Edgard M.

Simon, MD Department of Anesthesiology UP-Philippine General Hospital

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Airway patency, vital signs, and oxygenation should be checked immediately on arrival Blood pressure, pulse rate, and respiratory rate measurements are routinely made at least every 5 mins for 15 mins or until stable and every 15 mins thereafter Pulse oximetry should be monitored continuously in all patients recovering from general anesthesia, or at least until they regain consciousness

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Occurrence of hypoxemia does NOT necessarily correlate with level of consciousness Neuromuscular function should be assessed clinically At least one temperature measurement should be obtained Additional monitoring includes pain assessment, nausea/vomiting, and fluid input/ output

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All patients recovering from general anesthesia should receive 30-40% oxygen during emergence because transient hypoxemia can develop even in healthy patients (increased risk in patients with underlying pulmonary dysfunction or those undergoing upper abdominal/thoracic procedures and should be constantly monitored with pulse oximetry) Deep breathing and coughing should be encouraged periodically

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Heavily sedated or hemodynamically unstable patients should receive supplemental oxygen Sensory and motor levels should be periodically recorded Blood pressure should be closely monitored Bladder catheterization may be necessary in some patients

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Visual Analog Scale Adequate analgesia vs. excessive sedation Respiratory depression of opioids may not manifest until 20-30 mins after IV administration Risk of delayed respiratory depression with epidural morphine still present within 12-24 hours after administration!

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Pain is often manifested as postoperative restlessness Serious systemic disturbances (such as hypoxemia, acidosis, or hypotension), bladder distension, or surgical complication (hemorrhage) should also be considered May also be due to adverse drug effects

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Postoperative nausea and vomiting (PONV) occurs in 20-30% of patients Etiology is usually multifactorial: anesthetic agents, type of procedure, patient factors Also a common complaint at the onset of hypotension following spinal/epidural anesthesia May be treated with pharmacologic and nonpharmacologic agents

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Patient factors
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Surgical procedures
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Young age Female Large body habitus Previous PONV Motion sickness General anesthesia Drugs (opioids, volatile agents, etc.)
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Anesthetic techniques
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Strabismus surgery Ear surgery Laparoscopy Orchiopexy Ovum retrieval Tonsillectomy Postoperative pain Hypotension

Postoperative factors
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Shivering may occur as a result of intraoperative hypothermia or effects of anesthetic agents Most important cause of hypothermia is redistribution of heat from the body core to the peripheral compartments Cold ambient temperature in the OR, prolonged exposure of a large wound, use of large amounts of unwarmed IV fluids or high flows of unhumidified gases can be contributory

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Nearly all anesthetics, especially volatile agents, decrease normal vasoconstrictive response to hypothermia May also be due to regional anesthesia, sepsis, drug allergy, or transfusion reaction Intense shivering can cause rise in oxygen consumption, carbon dioxide production, and cardiac output, which may be poorly tolerated by patients with preexisting pulmonary or cardiac impairment, leading to increased incidence of myocardial ischemia, arrythmias, increased transfusion requirements, and increased duration of muscle relaxant effects

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May be treated with warming lights or heating blankets May also be treated pharmacologically (meperidine, tramadol, sedation)