- Email: [email protected]
Recovery room scorecard
Recovery room scorecard J Antonio Aldrete,
MD
J Antonio Aldrete, M D , is professor and chairman,
These thoughts came to mind many times, prompting us to search the literature for previous guidelines. Although we encountered two guidelines, in both a complete neurological examination was needed before any decision was made. In searching further, we came upon a condition similar to that of a patient recovering from surgery and anesthesia - the condition of the newborn recently delivered. Newborns have been evaluated for the last 20 years with the Apgar score, a system of evaluating physiological function on a scale of 1-10. It was decided, then, to modify this method and apply it to the recovery room situation in the hope that it would be descriptive, useful and would not require that personnel would have to learn a list of signs in addition to the excessive indices they already had memorized.
Department of Anesthesiology, University of Louisville School of Medicine. H e earned his doctor of medicine from the National University of Mexico.
Physical signs and their criteria for assessment:
How many times have you heard the report of a nurse or a doctor describing the patient’s physical condition on arrival in the recovery room saying “he is doing well,” “he is in poor condition,” “he is asleep,” or “he is still deeply anesthetized?” Other common expressions are: “the blood pressure is unstable,” “the color is not good,” “he is restless,” and so on. All of thse expressions applied to one patient alone would not fairly and completely describe his physical condition. Nor would they provide the nurse with a guideline on how closely to observe the patient. Finally, in a majority of the hospitals it is up to the nurse to decide when to discharge the patient from the recovery room to the ward - a decision that is made mostly on experience, but without well-established objective criteria.
79
1. Activity. Muscle activity was assessed by observing the ability of the patient to move his extremities either spontaneously or on command. If he was able to move all four limbs, a score of two was given. When only two were moved, this index was graded as one, and if none of the extremities was moved the score was zero. 2. Respiration. Respiratory efficiency was evaluated in a form that would permit as accurate and objective assessment as possible, without the need of complicated gadgetry of sophisticated physical tests. When patients were able to breathe deeply and cough, a score of two was given. If the respiratory effort was limited, or splinting, or if dyspnea was apparent, only one point was awarded. If no spontaneous respiratory activity was evident, the patient received a score of zero. 3. Circulation. This index has been probably the most difficult to evaluate by a simple sign. We elected to use changes of arterial blood pressure from the preanesthetic level. As gross as it may be, blood pressure is still considered a reliable clinical tool for evaluating circulation. Furthermore, it is monitored throughout the anesthetic state and is one of the first physical signs taken a t arrival in the recovery room in practically every hospital. The grading system was arbitrarily chosen and will probably be subject to revision as further experience is gained. When the systolic arterial blood pressure was between plus or minus 20% of the preanesthetic level (as obtained by the RivaRocci method), the patient received a score of two. However, if the same index was between or - 20 % and or - 50% of the same control
+
80
+
level, a grade of one was given. When this alteration was + or - 50% or more‘ of the original reading, the score was zero.
4. Consciousness. Full alertness, evidenced by the patient’s ability to answer questions, was considered as a completely awake state and graded as two. If patients were aroused only when called by name, they received one point, or zero if auditory stimulation failed to elicit a response. Painful stimulation was discarded, as even decerebrated patients might react to it, and because it is not a desirable maneuver to repeat frequently, and finally because development of a consistent and reliable method would be difficult. 5. Color. In contrast to evaluation of the newborn, color was an objective sign relatively easy to judge. When the patients appeared to have an obviously normal skin color, a score of two was given. In those cases in which normal pigmentation of the skin prevented an accurate evaluation, the color of the oral mucosa was observed. When frank cyanosis was present, zero was awarded. It should be noted, however, that this latter discoloration would be difficult to assess in the anemic, desaturated patient. Any alteration from the normal skin appearance not obviously cyanosis received one point; this included pale, “dusky,” or “blotchy” discoloration, as well as jaundice. Although some patients might have had these color alterations preoperatively, their presence in the postoperative period suggests an abnormal state that might require closer attention (Fig 1).
Accumulated experience: We have had over four years of experience
AORN Journal
LAlIJISVILLE GENERAL HOSPITAL RECOVERY ROOM RECORD
An es t h es i a : OR B/P
Pre-Op B/P AIRWAY:
By :
Complications:
O.T.
N.T.
ORAL
TRACH
30
IN
ArovsaDIc on cillmq = I NOI responamg = 0 P,"* Pale. dusky, Ololchy. Iaundoced. Other CYlnotlr
K
3
f
K
n
n
0
sm v
A Y v1
n 3
60
1
90
rvr
I
INTAKE Running
.v.
Catheter
CONSCIOUSNESS
. Lcvine =2
=I
Other
COI.0"
'0
I
I
I
I
I
250 240 230 220 210 200 190 180 170 160 150 140 130 120 110 100 90 80 70 60
260 240 230
220 210 200 190 180 170 160 150 140 130 120 110 100 90 80 70 60 50 40 30
50 40 30
5 Y
K
20
20
10
0 TCLlD
10
0
EQUIPMENT
LGH - 3 3 3
1
- Rev. 1-27-72
March. 2973
Min-
om-
IN
= 2
Fully l W l Y e
Cannula
MINIJTES
POST ANESTHESIA RECOVERY SCORE
Y
T-Tube
Mask
07
0
1
MEDICATIONS
NURSES NOTES
with this method of scoring, and it has proven to be both practical and easy to apply. The advantages we have noted are as follows: 1. It permits objective evaluation of the physical condition of patients as they arrive in the recovery room. 2. It offers close follow-up of the progress, favorable or unfavorable, of patients as they recover from anesthesia and surgery.
3. It provides a criteria for discharge of patients from the recovery room.
4. It proves useful in assessing the surveillance and practices of anesthesia personnel in training. 5. It can be used to compare the recovery time from two similar anesthetic agents.
6. It is applicable to patients recovering from drug overdosage, cardiopulmonary arrest, and other problems. 7. It is easy to perform and integrate into usual recovery room forms. 8. It compels nurses to look at patients.
9. Seldom is a score of eight attained with four two’s, thus indicating an interrelationship between signs. 10. Recovery room nurses react favorably to it.
11. Residents make an effort to obtain higher scores. 12. Patients with scores of seven or less must remain in the recovery room or be transferred to intensive care units.
82
13. Ideally, every patient should have a score of ten before discharge to a ward.
14. It is reliable, practical, easy to learn, and feasible to apply in any circumstances. There are disadvantages as well: 1. It takes 15 seconds to perform and write. 2. It does not include urinary output, bleeding at the operative site, or cardiac arrhythmias. 3. The preanesthetic blood pressure may not be representative of the patient’s postoperative status. At any rate, in most every institution where the score has been used it was enthusiastically adopted by the recovery room nursing personnel, and by the anesthesiologists and surgeons involved who were concerned with the lack of standardization in evaluating patients recovering from anesthesia and surgery. This acceptance has been uniform, regardless of the anesthetic technic or the duration of the surgical procedure. Ideally, every patient should receive a score of ten before being discharged; however, we might encounter patients such as paraplegics or those with chronic vascular congestion of the face who would never attain a ten. Nevertheless, these patients should at least be able to attain a score of eight or nine and under these circumstances, that should be accepted. This method has been adopted in nearly 70 hospitals in the United States and in as many in other countries. There are already eight publications dealing with experiences with the score under different circumstances.l-RWe have found that the
AORN Journul
score has other applications as well. It can be used to determine the recovery and awakening time of patients receiving two intravenous or inhalational anesthetics, and in patients recovering from cardiopulmonary arrest or in the intensive care unit. The need to survey the patients repeatedly and score them obliges the nurses to watch them closer, touch them, and initiate the "stir up"
regimen early by asking the patients to take deep breaths, cough and move their extremities. Although in the future some of the signs may be modified, nevertheless, the score as a whole has thus far provided an excellent way to assess patients when they come into the recovery room and to follow their progress. Finally, it provides an objective basis on which to decide when to discharge them to the ward.
REFERENCES Aldrete, J A and D Kryulik. "Unmetado de valoraci& del estado fisico en el periodo postanestksico," Revista Mexicana de Anestesiologia, 18 ( l 9 6 9 ) , 17-19.
Beatty, GF and JA Aldrete. "A method for evaluating patients recovering from anesthesia," Journal of the American Association of Nurse Anesthetists, I 9 7 I, p p 290-30 I.
Aldrete, JA. €valuation of the postanesthetic recovery score b y the a c i d base and blood gas studies. Fifth W o r l d Congress o f Anesthesio-
Figueroa, M. "The postanesthetic recovery score: a second look," Southern Medical Journal, 6 (July, 1972) 791-5.
logists, Abstract F2 10, Excerpta Medica, 1972, p 42.
Molina, FJ, e t al. La escala Aldrete:
un nuevo
Congreso Argentino de Buenos Aires, Argentina, 1971,
metado para evaluar a1 paciente en e l periodo post-anest6sico. X l l l Congreso Argentino de Anestesiologia, Buenos Aires, Argentina, 1971, p p 564-565.
Aldrete, JA and D Kroulik. "A postanesthetic recovery score," Anesthesia and Analgesia, 49 ( I970), 924-933.
Perez-Tamayo, L, e t al. "Valoraci6n de la recuperacio'n postanestgsica en gionecoobstetricia," Revista Mexicana de Anestesiologia, I 9 ( l970), 123-13 I.
. Yaloracibn de la recuperacibn postanestkica. Anestesiologia, pp, 421-424.
Xlll
Luser cu+s blood loss A significant decrease i n blood loss i s obtained when a carbon dioxide laser i s used t o cut liver tissue, compared t o the cold knife or electric knife, the clinical congress of the American College of Surgeons was told. A group from the Universty o f Cincinnati Medical Center reported that one of the major attributes o f the laser i s the minimal amount of tissue needed t o absorb the beam. Ninety-nine percent i s absorbed within less than 0.5 millimeters o f tissue depth. This means that at any given power, such an amount of tissue must be evaporated before the beam cuts deeper. I n comparing postoperative liver function i n animals undergoing partial liver resection, the authors found that the carbon dioxide laser cut livers return t o normal as soon as those cut with the cold knife or electric knife. "We are impressed enough with the laser that we are also evaluating blood loss following the excision o f acute thermal burns and the ability o f autografts t o take and survive on recipient beds," said James P Fidler, MD, FACS. "The work i s currently performed in patients and early results are encouraging." Liver injuries, and particularly partial resections, are often associated with a marked amount o f bleeding using the knife, he said.
March 1973
83
MD
J Antonio Aldrete, M D , is professor and chairman,
These thoughts came to mind many times, prompting us to search the literature for previous guidelines. Although we encountered two guidelines, in both a complete neurological examination was needed before any decision was made. In searching further, we came upon a condition similar to that of a patient recovering from surgery and anesthesia - the condition of the newborn recently delivered. Newborns have been evaluated for the last 20 years with the Apgar score, a system of evaluating physiological function on a scale of 1-10. It was decided, then, to modify this method and apply it to the recovery room situation in the hope that it would be descriptive, useful and would not require that personnel would have to learn a list of signs in addition to the excessive indices they already had memorized.
Department of Anesthesiology, University of Louisville School of Medicine. H e earned his doctor of medicine from the National University of Mexico.
Physical signs and their criteria for assessment:
How many times have you heard the report of a nurse or a doctor describing the patient’s physical condition on arrival in the recovery room saying “he is doing well,” “he is in poor condition,” “he is asleep,” or “he is still deeply anesthetized?” Other common expressions are: “the blood pressure is unstable,” “the color is not good,” “he is restless,” and so on. All of thse expressions applied to one patient alone would not fairly and completely describe his physical condition. Nor would they provide the nurse with a guideline on how closely to observe the patient. Finally, in a majority of the hospitals it is up to the nurse to decide when to discharge the patient from the recovery room to the ward - a decision that is made mostly on experience, but without well-established objective criteria.
79
1. Activity. Muscle activity was assessed by observing the ability of the patient to move his extremities either spontaneously or on command. If he was able to move all four limbs, a score of two was given. When only two were moved, this index was graded as one, and if none of the extremities was moved the score was zero. 2. Respiration. Respiratory efficiency was evaluated in a form that would permit as accurate and objective assessment as possible, without the need of complicated gadgetry of sophisticated physical tests. When patients were able to breathe deeply and cough, a score of two was given. If the respiratory effort was limited, or splinting, or if dyspnea was apparent, only one point was awarded. If no spontaneous respiratory activity was evident, the patient received a score of zero. 3. Circulation. This index has been probably the most difficult to evaluate by a simple sign. We elected to use changes of arterial blood pressure from the preanesthetic level. As gross as it may be, blood pressure is still considered a reliable clinical tool for evaluating circulation. Furthermore, it is monitored throughout the anesthetic state and is one of the first physical signs taken a t arrival in the recovery room in practically every hospital. The grading system was arbitrarily chosen and will probably be subject to revision as further experience is gained. When the systolic arterial blood pressure was between plus or minus 20% of the preanesthetic level (as obtained by the RivaRocci method), the patient received a score of two. However, if the same index was between or - 20 % and or - 50% of the same control
+
80
+
level, a grade of one was given. When this alteration was + or - 50% or more‘ of the original reading, the score was zero.
4. Consciousness. Full alertness, evidenced by the patient’s ability to answer questions, was considered as a completely awake state and graded as two. If patients were aroused only when called by name, they received one point, or zero if auditory stimulation failed to elicit a response. Painful stimulation was discarded, as even decerebrated patients might react to it, and because it is not a desirable maneuver to repeat frequently, and finally because development of a consistent and reliable method would be difficult. 5. Color. In contrast to evaluation of the newborn, color was an objective sign relatively easy to judge. When the patients appeared to have an obviously normal skin color, a score of two was given. In those cases in which normal pigmentation of the skin prevented an accurate evaluation, the color of the oral mucosa was observed. When frank cyanosis was present, zero was awarded. It should be noted, however, that this latter discoloration would be difficult to assess in the anemic, desaturated patient. Any alteration from the normal skin appearance not obviously cyanosis received one point; this included pale, “dusky,” or “blotchy” discoloration, as well as jaundice. Although some patients might have had these color alterations preoperatively, their presence in the postoperative period suggests an abnormal state that might require closer attention (Fig 1).
Accumulated experience: We have had over four years of experience
AORN Journal
LAlIJISVILLE GENERAL HOSPITAL RECOVERY ROOM RECORD
An es t h es i a : OR B/P
Pre-Op B/P AIRWAY:
By :
Complications:
O.T.
N.T.
ORAL
TRACH
30
IN
ArovsaDIc on cillmq = I NOI responamg = 0 P,"* Pale. dusky, Ololchy. Iaundoced. Other CYlnotlr
K
3
f
K
n
n
0
sm v
A Y v1
n 3
60
1
90
rvr
I
INTAKE Running
.v.
Catheter
CONSCIOUSNESS
. Lcvine =2
=I
Other
COI.0"
'0
I
I
I
I
I
250 240 230 220 210 200 190 180 170 160 150 140 130 120 110 100 90 80 70 60
260 240 230
220 210 200 190 180 170 160 150 140 130 120 110 100 90 80 70 60 50 40 30
50 40 30
5 Y
K
20
20
10
0 TCLlD
10
0
EQUIPMENT
LGH - 3 3 3
1
- Rev. 1-27-72
March. 2973
Min-
om-
IN
= 2
Fully l W l Y e
Cannula
MINIJTES
POST ANESTHESIA RECOVERY SCORE
Y
T-Tube
Mask
07
0
1
MEDICATIONS
NURSES NOTES
with this method of scoring, and it has proven to be both practical and easy to apply. The advantages we have noted are as follows: 1. It permits objective evaluation of the physical condition of patients as they arrive in the recovery room. 2. It offers close follow-up of the progress, favorable or unfavorable, of patients as they recover from anesthesia and surgery.
3. It provides a criteria for discharge of patients from the recovery room.
4. It proves useful in assessing the surveillance and practices of anesthesia personnel in training. 5. It can be used to compare the recovery time from two similar anesthetic agents.
6. It is applicable to patients recovering from drug overdosage, cardiopulmonary arrest, and other problems. 7. It is easy to perform and integrate into usual recovery room forms. 8. It compels nurses to look at patients.
9. Seldom is a score of eight attained with four two’s, thus indicating an interrelationship between signs. 10. Recovery room nurses react favorably to it.
11. Residents make an effort to obtain higher scores. 12. Patients with scores of seven or less must remain in the recovery room or be transferred to intensive care units.
82
13. Ideally, every patient should have a score of ten before discharge to a ward.
14. It is reliable, practical, easy to learn, and feasible to apply in any circumstances. There are disadvantages as well: 1. It takes 15 seconds to perform and write. 2. It does not include urinary output, bleeding at the operative site, or cardiac arrhythmias. 3. The preanesthetic blood pressure may not be representative of the patient’s postoperative status. At any rate, in most every institution where the score has been used it was enthusiastically adopted by the recovery room nursing personnel, and by the anesthesiologists and surgeons involved who were concerned with the lack of standardization in evaluating patients recovering from anesthesia and surgery. This acceptance has been uniform, regardless of the anesthetic technic or the duration of the surgical procedure. Ideally, every patient should receive a score of ten before being discharged; however, we might encounter patients such as paraplegics or those with chronic vascular congestion of the face who would never attain a ten. Nevertheless, these patients should at least be able to attain a score of eight or nine and under these circumstances, that should be accepted. This method has been adopted in nearly 70 hospitals in the United States and in as many in other countries. There are already eight publications dealing with experiences with the score under different circumstances.l-RWe have found that the
AORN Journul
score has other applications as well. It can be used to determine the recovery and awakening time of patients receiving two intravenous or inhalational anesthetics, and in patients recovering from cardiopulmonary arrest or in the intensive care unit. The need to survey the patients repeatedly and score them obliges the nurses to watch them closer, touch them, and initiate the "stir up"
regimen early by asking the patients to take deep breaths, cough and move their extremities. Although in the future some of the signs may be modified, nevertheless, the score as a whole has thus far provided an excellent way to assess patients when they come into the recovery room and to follow their progress. Finally, it provides an objective basis on which to decide when to discharge them to the ward.
REFERENCES Aldrete, J A and D Kryulik. "Unmetado de valoraci& del estado fisico en el periodo postanestksico," Revista Mexicana de Anestesiologia, 18 ( l 9 6 9 ) , 17-19.
Beatty, GF and JA Aldrete. "A method for evaluating patients recovering from anesthesia," Journal of the American Association of Nurse Anesthetists, I 9 7 I, p p 290-30 I.
Aldrete, JA. €valuation of the postanesthetic recovery score b y the a c i d base and blood gas studies. Fifth W o r l d Congress o f Anesthesio-
Figueroa, M. "The postanesthetic recovery score: a second look," Southern Medical Journal, 6 (July, 1972) 791-5.
logists, Abstract F2 10, Excerpta Medica, 1972, p 42.
Molina, FJ, e t al. La escala Aldrete:
un nuevo
Congreso Argentino de Buenos Aires, Argentina, 1971,
metado para evaluar a1 paciente en e l periodo post-anest6sico. X l l l Congreso Argentino de Anestesiologia, Buenos Aires, Argentina, 1971, p p 564-565.
Aldrete, JA and D Kroulik. "A postanesthetic recovery score," Anesthesia and Analgesia, 49 ( I970), 924-933.
Perez-Tamayo, L, e t al. "Valoraci6n de la recuperacio'n postanestgsica en gionecoobstetricia," Revista Mexicana de Anestesiologia, I 9 ( l970), 123-13 I.
. Yaloracibn de la recuperacibn postanestkica. Anestesiologia, pp, 421-424.
Xlll
Luser cu+s blood loss A significant decrease i n blood loss i s obtained when a carbon dioxide laser i s used t o cut liver tissue, compared t o the cold knife or electric knife, the clinical congress of the American College of Surgeons was told. A group from the Universty o f Cincinnati Medical Center reported that one of the major attributes o f the laser i s the minimal amount of tissue needed t o absorb the beam. Ninety-nine percent i s absorbed within less than 0.5 millimeters o f tissue depth. This means that at any given power, such an amount of tissue must be evaporated before the beam cuts deeper. I n comparing postoperative liver function i n animals undergoing partial liver resection, the authors found that the carbon dioxide laser cut livers return t o normal as soon as those cut with the cold knife or electric knife. "We are impressed enough with the laser that we are also evaluating blood loss following the excision o f acute thermal burns and the ability o f autografts t o take and survive on recipient beds," said James P Fidler, MD, FACS. "The work i s currently performed in patients and early results are encouraging." Liver injuries, and particularly partial resections, are often associated with a marked amount o f bleeding using the knife, he said.
March 1973
83