Postanesthesia Care

Head-down position is useful for hypovolemic patients

Head-up position is useful for patients with underlying pulmonary dysfunction

Lateral position is useful for patients at high risk for vomiting or upper airway bleeding (e.g., after tonsillectomy)

Postoperative Pain Control

• Most commonly treated with oral or parenteral opioids.

• Preoperative oral administration of nonsteroidal antiinflammatory drugs (NSAIDs), acetaminophen, and gabapentin or pregabalin may significantly reduce postoperative opioid requirements

• Selective cyclooxygenase-2 inhibitors such as celecoxib reduce the risk of NSAID-related platelet dysfunction and gastrointestinal hemorrhage.

• Rescue single-shot, continuous nerve blocks, or continuous epidural analgesia are used when moderate to severe postoperative pain is present or oral analgesia is not possible.

Agitation

• Before the recovering patient is fully responsive, pain is often manifested as postoperative restlessness.

• Differential diagnosis of postoperative agitation includes serious systemic disturbances (e.g., hypoxemia, respiratory or metabolic acidosis, hypotension), bladder distention, or a surgical complication (e.g., occult intraabdominal hemorrhage).

• Physostigmine, 1 to 2 mg intravenously (IV) (0.05 mg/kg in children), is most effective in treating delirium caused by atropine and scopolamine.

• Midazolam, 0.5 to 1 mg (0.05 mg/kg in children) is used in persistent agitation.

Nausea and Vomiting

• Risk factors for postoperative nausea and vomiting (PONV)

° Most common problem after general anesthesia, occurring in 30% to 40% of all patients

° The etiology of PONV is usually multifactorial, associated with anesthetic and analgesic agents, the type of surgical procedure, and intrinsic patient factors such as a history of motion sickness.

° Risk factors for postoperative nausea and vomiting

Patient factors: Young age; female gender, particularly if menstruating on the day of surgery or in first trimester of pregnancy; large body habitus; history of postoperative emesis; history of motion sickness; anesthetic techniques

General anesthesia: Opioids, volatile agents, neostigmine, surgical procedures, strabismus surgery, ear surgery, laparoscopy, orchiopexy, ovum retrieval, tonsillectomy, breast surgery

Postoperative factors: Postoperative pain, hypotension

• Prevention and treatment of PONV

° Propofol anesthesia decreases the incidence of PONV, and a preoperative history of smoking lessens the risk of PONV.

° Selective 5-hydroxytryptamine (serotonin) receptor 3 (5-HT₃) antagonists such as ondansetron 4 mg (0.1 mg/kg in children), granisetron 0.01–0.04 mg/kg, and dolasetron 12.5 mg (0.035 mg/kg in children) are effective.

° Transdermal scopolamine is effective but associated with side effects such as sedation, dysphoria, blurred vision, dry mouth, urinary retention, and exacerbation of glaucoma, particularly in elderly patients.

° Dexamethasone, 4 to 10 mg (0.10 mg/kg in children) is an antiemetic and provides a varying degree of analgesia and a sense of patient well-being.

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