Postoperative Care and Pain Management
What this domain tests
Postoperative items test safe recovery, effective analgesia, and prevention of complications such as PONV, respiratory depression, and delirium.
Core rules
- PACU discharge: Aldrete score ≥9 with stable vital signs; assess airway, breathing, circulation, consciousness, pain, nausea, urine output, and temperature.
- PONV: Apfel score (female, nonsmoker, history, postoperative opioids). Prophylaxis includes ondansetron 4 mg, dexamethasone 4-8 mg, droperidol 0.625-1.25 mg, and scopolamine; use multimodal therapy for high risk.
- Multimodal analgesia: acetaminophen, NSAIDs when safe, regional blocks, gabapentinoids in selected patients, and opioids as rescue; reduce opioid doses in the elderly and in OSA.
- PCA: demand-only, no basal rate in opioid-naive patients; monitor sedation with POSS and use capnography in high-risk patients.
- Opioid tolerance: continue the baseline opioid, use multimodal analgesia, and expect higher requirements; do not withhold opioids.
- ERAS: early ambulation, early enteral nutrition, carbohydrate loading, opioid-sparing analgesia, and normothermia.
Worked example
A 45-year-old nonsmoking woman with prior PONV and planned postoperative opioids has an Apfel score of 4. She receives total IV anesthesia with propofol, ondansetron 4 mg, dexamethasone 8 mg, and droperidol 0.625 mg. The reasoning is that each class blocks a different receptor and baseline risk above 60% warrants at least two prophylactic agents, not rescue alone.
Traps
Using a single antiemetic for high-risk patients; ordering a basal PCA rate in an opioid-naive patient; missing hypoventilation because the respiratory rate is normal (sedation is the earliest sign); ignoring NSAID contraindications; discharging before temperature and pain are controlled.
Key points
- Aldrete score ≥9 is required for PACU discharge.
- Apfel score guides multimodal PONV prophylaxis.
- Avoid basal PCA rates in opioid-naive patients.
- Sedation, not respiratory rate, is the earliest sign of opioid-induced hypoventilation.
- ERAS emphasizes opioid-sparing analgesia and early mobilization.