Postanesthesia Care and Pain Management
Recovery and analgesia
The Postanesthesia Care and Pain Management domain tests PACU monitoring, discharge readiness, opioid and nonopioid analgesia, regional techniques and complications. The exam expects systematic assessment and safe titration.
- PACU monitoring: airway, breathing, circulation, consciousness, pain, temperature, nausea, urine output and surgical site. Use continuous SpO2 and intermittent vital signs.
- Discharge: Aldrete score at least 9 (or institutional equivalent), stable vitals, controlled pain, no nausea, able to ambulate if required, responsible escort.
- Pain: multimodal - acetaminophen, NSAIDs when not contraindicated, opioids titrated to effect, regional blocks, PCA. Assess sedation and respiratory rate before each opioid dose.
- PONV: ondansetron 4 mg, dexamethasone 4–8 mg, droperidol; use prophylaxis for high-risk patients.
- Opioid-induced respiratory depression: support airway, give naloxone 40 mcg increments, monitor for renarcotization.
Worked example
In PACU, a patient is drowsy with RR 6/min and SpO2 88% after fentanyl. The reasoning: stimulate, open airway, give 100% O2, and administer naloxone 40 mcg IV, repeating every 2–3 minutes. Titrate to adequate ventilation, not full wakefulness, because abrupt reversal causes pain and hypertension. Observe for recurrent sedation.
Traps that cost marks
Do not discharge on a single normal vital sign set. Do not ignore sedation scores; sedation precedes respiratory depression. Do not treat pain with repeated IM meperidine in renal impairment.