Postoperative Care and Perioperative Complications
Postoperative items test structured recovery and the complications that kill in the first 24 hours. Airway, breathing, circulation, pain, nausea and temperature form the frame.
Recovery and discharge
- Aldrete score of 9 or more (activity, respiration, circulation, consciousness, oxygen saturation) with stable vital signs before PACU discharge.
- PONV risk by Apfel: female sex, non-smoker, history of PONV or motion sickness, postoperative opioids. A score of 3–4 warrants three or four prophylactic agents.
- Agents: ondansetron 4 mg, dexamethasone 4–8 mg, droperidol 0.625–1.25 mg, aprepitant; TIVA reduces baseline risk.
Complications
- Residual curarisation: train-of-four ratio below 0.9 in PACU; reverse with neostigmine 0.03–0.07 mg/kg (maximum 5 mg) plus glycopyrrolate, or sugammadex.
- Laryngospasm and negative-pressure pulmonary oedema; aspiration; atelectasis.
- Postoperative delirium (hyperactive or hypoactive) versus postoperative cognitive dysfunction; screen, then treat pain, hypoxia, sepsis and urinary retention.
- Myocardial infarction peaks in the first 1–3 days; use troponin surveillance in high-risk patients.
Worked example
A 40-year-old non-smoking woman with previous PONV receiving intraoperative and postoperative opioids has an Apfel score of 4. Give ondansetron plus dexamethasone plus droperidol, choose TIVA and regional analgesia, minimise opioids, and keep rescue therapy from a different class.
Traps
Assuming a normal oxygen saturation excludes residual block; treating PACU hypotension as hypovolaemia when it may be epidural sympathectomy or bleeding; ignoring hypothermia, which worsens bleeding and infection.