AS6.1-3 | Post-anaesthesia Recovery — Practice Quiz

The Aldrete score is the structured tool used in the PACU to document consciousness, oxygenation, circulation, activity, and respiration — providing a reproducible readiness-for-discharge baseline. It drives the protocol-driven monitoring that underpins AS6.1.

The modified Aldrete score (10-point scale) is applied on PACU arrival and serially thereafter; a score ≥9 is required for discharge. Oxygenation, circulation, consciousness, activity, and respiration are the five domains.

While temperature, ECG, and urine output have their place, the Aldrete score gives the structured, multi-parameter snapshot needed to benchmark the patient's status on PACU arrival and guide monitoring frequency. Temperature is checked but is not the immediate priority for guiding ongoing management.

Venturi masks are fixed-performance devices: the Venturi jet entrains a fixed ratio of room air, delivering a precise FiO2 (24, 28, 31, 35, 40, or 60%) regardless of patient breathing pattern. This is essential in COPD where over-oxygenation can blunt hypoxic drive.

Venturi mask = fixed-performance device. Match each device to its FiO2 range: nasal cannula 1–6 L/min gives ~24–44%; simple mask ~40–60%; non-rebreather ~60–90%; Venturi = fixed 24/28/31/35/40/60%.

Simple face masks deliver variable FiO2 (~40–60%), non-rebreathers can deliver ~60–90%, and nasal cannulae ~24–44% — all variable-performance. Only Venturi masks are fixed-performance. Giving a non-rebreather mask to a COPD patient risks CO2 retention.

In the PACU, the crash cart must be available within ten seconds of any bay and must be verified at the start of every nursing shift. This is an inviolable safety standard under AS6.2.

Crash cart = check every shift, document it. Contents include defibrillator, airways (ETT sizes, LMA, guedel), resuscitation drugs (adrenaline, atropine, amiodarone, sodium bicarbonate), suction, bag-valve-mask, laryngoscope, IV supplies, and 20% intralipid (for LAST).

Weekly checks are inadequate for a high-acuity environment where cardiac arrest can occur at any moment. Reactive checking (only after an event) is unacceptable. Nursing staff share responsibility for crash cart readiness.

20% Intralipid emulsion is the specific antidote for LAST (local anaesthetic systemic toxicity). It acts as a lipid sink, sequestering the lipid-soluble LA molecule away from cardiac tissue. It must be in every PACU crash cart.

LAST presents as perioral tingling, metallic taste, seizures, then cardiovascular collapse. Treatment: stop LA, airway management, 20% Intralipid 1.5 mL/kg bolus IV then infusion. Bupivacaine is the most cardiotoxic LA — high-concentration IV bupivacaine has no role in IVRA.

Atropine treats bradycardia; amiodarone treats ventricular arrhythmias (including VF after the 3rd shock); neostigmine reverses non-depolarising neuromuscular blockade. None specifically address LAST. 20% Intralipid is unique to LAST management.

Opioid-induced respiratory depression (OIRD) is managed with naloxone, but bolus 0.4 mg causes acute opioid reversal with hypertension, pulmonary oedema, and pain crisis. The correct approach is titration: 0.1–0.2 mg IV every 2–3 minutes to restore adequate ventilation while supporting the airway.

Three most time-critical PACU errors: (1) giving naloxone 0.4 mg as a bolus — always titrate 0.1–0.2 mg; (2) missing laryngospasm — look for stridor and paradoxical chest movement; (3) attributing hypotension to pain rather than haemorrhage.

A 0.4 mg naloxone bolus causes abrupt reversal and is an avoidable error in the PACU. Flumazenil reverses benzodiazepines, not opioids. Observation alone is unsafe with SpO2 82%. Jaw-thrust/bag-mask support is needed concurrently with naloxone titration.

Laryngospasm = adducted vocal cords causing functional airway obstruction. Classic signs: stridor (high-pitched inspiratory sound) and paradoxical chest movement (chest pulls in while abdomen goes out). Treatment: jaw thrust, 100% O2, positive-pressure ventilation — suxamethonium 0.5 mg/kg IV if incomplete (1–1.5 mg/kg if complete laryngospasm with zero flow).

Laryngospasm is the most critical immediate post-extubation complication. Recognise by stridor + paradoxical breathing. Management: CPAP jaw thrust, 100% O2; if incomplete → suxamethonium 0.5 mg/kg IV; if complete (zero flow) → 1–1.5 mg/kg IV.

Bronchospasm causes expiratory wheeze, not stridor, and no paradoxical movement. OIRD causes silent, slow breathing with pinpoint pupils, not stridor. Pulmonary aspiration is less acute. The stridor + paradoxical pattern after thyroid surgery is a classic laryngospasm scenario.

In the PACU, hypotension must FIRST exclude haemorrhage before attributing it to spinal sympathectomy. This is a key PACU principle from AS6.3 — tachycardia + pallor + anxiety suggests reduced circulating volume, not vasodilation alone (which typically gives bradycardia with hypotension).

PACU hypotension differential: hypovolaemia (haemorrhage), vasodilation (residual spinal/epidural, sepsis), cardiac (arrhythmia, AMI), anaphylaxis. Tachycardia + pallor = haemorrhage until proven otherwise. Do NOT attribute to spinal effect without surgical assessment.

Fluids empirically without ruling out haemorrhage can mask diagnosis. Spinal sympathectomy typically causes hypotension with compensatory bradycardia, not tachycardia. Anaphylaxis is possible but the scenario does not suggest allergic features (rash, bronchospasm). Haemorrhage must be excluded first.

The standard Aldrete discharge threshold is ≥9/10. The five domains scored 0–2 each are: activity (move 4 limbs = 2), respiration (deep breath/cough = 2), circulation (BP within 20% baseline = 2), consciousness (fully awake = 2), and oxygenation (SpO2 ≥92% room air = 2). All five domains matter.

Modified Aldrete score ≥9/10 for PACU discharge. Five domains (0–2 each): activity, respiration, circulation, consciousness, oxygenation. SpO2 ≥92% on room air scores 2; on supplemental O2 scores 1; <90% scores 0.

A score of 7 is insufficient. SpO2 ≥90% on supplemental oxygen scores only 1 on the oxygenation domain. 'Responsive to stimulation' is a score of 1, not 2, on consciousness. The threshold is ≥9 and must include room-air adequate oxygenation.