07 / Anaesthesia · Recovery
The first hour
Most of what goes wrong after an anaesthetic declares itself in the first sixty minutes, and the recovery nurse who calls early is doing the job correctly. 12 calls, each with a first move.
Photograph: Stefan Bellini, CC0, via Wikimedia Commons.
The first hour
The recovery nurse calls you. First move?
A 32-year-old woman, non-smoker, retching after a laparoscopic gynaecological procedure; ondansetron was given at the end of the case.
BP 108/64, HR 92, SpO2 98 percent
Nausea and vomiting
Apfel score: count, then plan
Risk in 24 hours
39%
2 factors
Moderate risk: two agents from different classes, given at the right times, and an opioid-sparing plan.
- Dexamethasone 4 to 8 mg, at induction: it takes hours to work. A single dose does not affect wound healing or glucose meaningfully in most patients.
- Ondansetron 4 mg, at the end of surgery. QT prolongation with other prolonging drugs; give it slowly.
- Droperidol 0.625 to 1.25 mg, at the end of surgery. Low dose is effective and safe; the boxed warning came from doses many times higher.
- Cyclizine 50 mg, slowly, at the end or in recovery. Tachycardia and a burning vein if pushed fast; avoided in severe heart failure.
- Total intravenous anaesthesia, instead of volatile in the high-risk patient. Propofol is antiemetic in itself; removing the volatile and the nitrous oxide is worth about a third of the risk.
- Regional block, fluids, and less opioid, throughout. The interventions that treat the cause rather than the symptom.
Ready to leave recovery?
The modified Aldrete score
Activity
Respiration
Circulation
Consciousness
Oxygen saturation
0/10
Score every line.
Pain, multimodally
The ladder, every rung at once
- 1Paracetamol: 1 g four times a day (15 mg/kg if under 50 kg)The base of everything. Opioid-sparing by about a fifth, and safe in almost everyone.
- 2A non-steroidal: Ibuprofen 400 mg three times a day, or ketorolac 15 to 30 mg intravenouslyAdds as much again, unless the kidneys, the stomach, asthma or the surgeon's bleeding risk say no.
- 3Local anaesthetic: Wound infiltration, a plane block, or a nerve block or catheterThe rung that removes the need for most of the opioid, and the nausea that comes with it.
- 4Opioid, titrated: Morphine 1 to 2 mg intravenously every five minutes in recovery until comfortable, then oral or a patient-controlled pumpTitrated to effect, on top of the rest, never instead of it. The dose that works is the dose; there is no right number.
- 5Adjuncts: Ketamine in small doses, gabapentinoids in selected patients, clonidine or dexmedetomidineFor the opioid-tolerant, the chronic pain patient and the surgery known to hurt. Each has a cost.
Going home today
Day-case discharge
- Vital signs stable for an hour and within 20 percent of baseline
- Awake, orientated and able to walk without dizziness
- Pain controlled on oral analgesia
- Nausea controlled; drinking is not mandatory
- No bleeding from the wound
- Voided, after a spinal or perineal surgery
- A responsible adult to escort them home and stay overnight
- Written instructions and a number to ring, with the drugs and their timings