Anaesthesia — Postoperative Care and Acute Pain, NMC MBBS licence examination syllabus (Nepal Medical Council).
The operation is over and the anaesthetist has gone. The drugs have not, and for the next several hours they are still doing what they were given to do.
The other anaesthesia chapters cover the period before and during an operation. This one covers afterwards — which, for most newly qualified doctors, is the part they are actually responsible for.
The airway comes first, and it fails quietly. A drowsy patient's tongue falls back and obstructs without drama. Snoring in a patient recovering from anaesthesia is not sleep — it is partial obstruction, and it is a sign to act on rather than a sound to ignore. Position, a simple airway manoeuvre and oxygen come before any investigation.
Breathing is depressed for longer than the operation lasted. Opioids and anaesthetic agents outlast the procedure, and their effect can deepen once the stimulation of surgery stops. The respiratory rate falls before the oxygen saturation does, particularly in a patient receiving oxygen — which is why counting the rate matters more than watching the monitor.
The saturation is a late warning in a patient on oxygen. Supplemental oxygen keeps the number acceptable while ventilation is already inadequate, so the first sign of trouble is a slow respiratory rate and a patient who is difficult to rouse. NMCAS03 makes the same point about sedation, and it is the same physiology.Circulation: bleeding is what has to be excluded. A rising pulse usually precedes a falling blood pressure, and a young patient compensates well until they suddenly do not. A tachycardia in the hours after surgery deserves an explanation rather than a fluid bolus and a hope.
Postoperative fever is common, and the day it appears narrows the cause more efficiently than any test.
In the first day or two, fever is often not infection at all — the surgical insult itself produces one — and where there is a source it is usually the lungs, from shallow breathing and retained secretions in someone who is in pain and reluctant to cough.
A few days on, look at the urine and at anything indwelling. The useful question is: what is still in this patient that was not there before the operation? A cannula, a catheter, a drain — each is a route in.
Later, or in a fever that returns after settling, the wound and the operative site come to the front: a collection, or a leak. This is the pattern that most needs examining rather than treating empirically.
Analgesics act at different points, so combining them relieves pain better than escalating any one of them — and it allows less opioid, whose adverse effects rise with the dose. That is the whole argument for combination analgesia, and it is worth understanding rather than memorising as a ladder.
Give analgesia regularly rather than only on request. Pain that is allowed to build is harder to control than pain that is prevented, and a patient who must ask each time will often wait until it is severe.
Expected postoperative pain follows a shape: worst early, improving day by day, with the analgesic requirement falling.
Pain that worsens, moves, or changes character is not the operation. A leak, a collection, ischaemia of bowel or limb, and compartment syndrome all announce themselves this way. So does a wound infection.The practical rule follows from that: a rising analgesic requirement is a reason to examine the patient, not a reason to increase the dose. Escalating analgesia without examining is how a leak is masked until the patient is septic. NMCOR01 makes the same point about compartment syndrome, where pain out of proportion is the earliest sign.
An hour after surgery, a patient is snoring loudly with a normal saturation on oxygen. This is partial airway obstruction, not sleep. Reposition, use an airway manoeuvre, and reassess — the saturation is being held up by the oxygen and will fall late.
On the second postoperative day a patient has a fever and is not coughing because it hurts. The commonest early source is the lungs, and the underlying problem is analgesia. Treating the pain lets the patient breathe deeply and cough.
A patient's abdominal pain was settling and has now become severe and constant, with a rising pulse. A change in character with a rising analgesic requirement — examine, and consider a leak. More analgesia alone would obscure it.
Four hours after surgery a young patient has a pulse that has been climbing steadily; the blood pressure is still normal. Compensated bleeding until proven otherwise. The normal pressure is reassuring only until it is not.
Snoring and sleeping. After anaesthesia, snoring is obstruction.
A normal saturation and adequate ventilation. Oxygen keeps the number acceptable while the respiratory rate tells the truth.
Early fever and infection. Fever in the first day or two is often the surgical insult itself; late or returning fever is the one that points to a collection.
More pain and more analgesia needed. Sometimes. But pain that has changed character is a new diagnosis first.
Airway, breathing, circulation — in that order, in the first hours.
Respiratory rate falls before saturation, especially on oxygen. Count it.
A rising pulse before a falling pressure — think bleeding.
Fever: early is often the lungs or the surgery; later is the wound, a collection or a leak. Clot at any point.
Combine analgesics and give them regularly — better relief, less opioid, fewer complications.
Pain that worsens or changes character — examine the patient rather than raising the dose.
Create a free account to tick topics off, take notes as you read, watch the video lessons and get a day-by-day study plan built around your exam date.
Loading…