Postoperative Care, Complications, and Postoperative Nausea and Vomiting
Postoperative problems are predictable
PACU care prioritizes airway, breathing, circulation, pain, nausea, temperature, and urine output. Common complications include hypoxemia, hypoventilation, aspiration, laryngospasm, bleeding, hypertension, arrhythmia, shivering, malignant hyperthermia, anaphylaxis, and delirium. PONV risk uses Apfel factors: female sex, nonsmoker, history of PONV or motion sickness, and postoperative opioids. Multimodal prophylaxis beats repeated same-class rescue. Discharge criteria include stable vital signs, adequate pain control, no respiratory compromise, and ability to ambulate.
Traps: pulse oximetry can be normal with inadequate ventilation, especially on supplemental oxygen. Do not treat agitation with more sedation before ruling out hypoxemia, pain, urinary retention, or emerging delirium. Malignant hyperthermia presents with hypercapnia, rigidity, tachycardia, and acidosis-give dantrolene and stop triggers. Anaphylaxis may present as hypotension without rash.
Worked example: a healthy nonsmoking woman with prior PONV receives postoperative opioids. Apfel score is 3–4; give two or three prophylactic agents from different classes, minimize opioids, and use regional analgesia if possible.
Rule of thumb: in the PACU, first ask whether the patient is ventilating and perfusing before reaching for an antiemetic or sedative.