Synopsis
Recognise and manage early physiological deterioration after adult anaesthesia, complete a structured handover and apply explicit discharge criteria before transfer from the post-anaesthesia care unit.
- Keep one-to-one trained recovery care until the patient controls the airway, has stable respiration and circulation, and can communicate appropriately; instability requires direct anaesthetic review.
- Continue ECG, pulse oximetry, blood pressure and waveform capnography after general anaesthesia as indicated; capnography continues while an artificial airway remains and until verbal responsiveness is re-established.
- Do not discharge to a routine ward until consciousness, airway reflexes, breathing, oxygenation and circulation are satisfactory and pain, nausea, vomiting and temperature are acceptably controlled.
Key red flags
Stridor, paradoxical breathing, absent airflow, falling consciousness, recurrent obstruction or increasing oxygen requirement needs immediate airway assessment and anaesthetic help.
Slow or shallow ventilation, unexpected sedation or failure to regain consciousness may reflect opioid effect, residual anaesthesia, metabolic disturbance or neurological injury and must not be dismissed as normal sleep.
Weak cough, reduced tidal movement, diplopia, inability to sustain head lift or a low quantitative train-of-four ratio raises concern for residual neuromuscular block.
Hypotension, tachycardia, cool peripheries, increasing drain output or abdominal distension can indicate occult postoperative haemorrhage.
Chest pain, new arrhythmia, pulmonary oedema, severe hypertension or unexplained hypoxaemia warrants urgent cause-directed evaluation.
New focal neurological loss, prolonged unresponsiveness, seizure or severe agitation disproportionate to context requires immediate medical review.
Snoring, tracheal tug, paradoxical movement or poor air entry may improve with repositioning and airway manoeuvres; stridor or silent obstruction is more urgent.
Reduced respiratory effort, shallow breaths, rising carbon dioxide and drowsiness can precede desaturation, particularly when oxygen is being administered.
Hypotension with tachycardia, pallor, cool skin, reduced urine output or increasing blood loss suggests hypovolaemia or haemorrhage until assessed.
Reasoning priorities
Confirm ventilation and detect obstruction, apnoea or circuit disconnection while an artificial airway remains or verbal response is absent.
Loss or change of waveform requires immediate patient and equipment assessment; supplemental oxygen can delay an oximetry warning.
Worked reasoning
An adult in PACU snores, has paradoxical chest movement and becomes less responsive after opioid analgesia.
- Call for help, open the airway with positioning and jaw support, give oxygen and assess airflow, respiratory effort, waveform capnography, saturation and circulation.
- Use an airway adjunct and assisted ventilation if required; verify effectiveness from chest movement, capnography, airway pressure and leak rather than assuming a selected mode delivers an adequate breath.
- Review anaesthetic and opioid exposure, residual neuromuscular block, temperature and metabolic causes; titrate reversal only when the relevant cause is identified and continue airway support.
- Keep the patient in an appropriately staffed monitored area after improvement because obstruction or drug effect may recur, and revise the ward analgesia and observation plan. Continue ECG, pulse oximetry, blood-pressure measurement and waveform capnography through recovery until the artificial airway has been removed and the patient responds verbally.