Post-Anesthesia Visit: What to Assess and What to Ask

1. Airway and Respiratory

• Sore throat or hoarseness - occurs in 20-50% of patients after tracheal intubation, depending on laryngoscopy difficulty, intubation duration, and tube type (Barash, Cullen & Stoelting's Clinical Anesthesia, 9e)
• Stridor or signs of upper airway edema - especially after difficult or traumatic intubation; hematoma or edema can cause partial obstruction
• Dental damage - can occur during laryngoscopy or emergence; document any tooth or appliance injury and arrange dental referral
• Dysphagia - common after LMA use, oral airways, suctioning trauma, or any airway instrumentation
• Neck or jaw soreness - seen after facemask anesthetics

• Do you have a sore throat, hoarse voice, or difficulty swallowing?
• Did you notice any tooth damage or loose fillings?
• Is there any jaw or neck pain?
• Do you have any difficulty breathing, cough, or feel short of breath?

2. Neurological: Delirium and Cognitive Function

• Postoperative delirium - the most common surgical complication in older adults, occurring in 5-50% of elderly patients; it typically appears on postoperative days 1-3 but may already be evident in the PACU. Presents as fluctuating consciousness, disorientation, or agitation. Hypoactive subtype (quiet confusion) predominates and is often missed (Barash 9e).
• Postoperative cognitive dysfunction (POCD) - subtler decline in memory, concentration, and executive function; occurs at ~15% higher rate than controls even in younger patients, resolves within 3 months in most
• Residual neuromuscular blockade - patients may appear "recovered" by standard tests but report impaired swallowing, blurred vision, or perceived weakness
• Combativeness or confusion in the immediate postoperative period should prompt ruling out hypoxemia, hypoglycemia, hyponatremia, or inadequate analgesia before attributing it to emergence

• Are you feeling confused, disoriented, or having memory lapses?
• Do you feel mentally back to your baseline?
• Any unusual dreams, nightmares, or disturbing memories from the procedure?
• Do you feel muscle weakness, heaviness, or trouble swallowing?

3. Nerve and Positioning Injuries

• Peripheral nerve injury from positioning - can cause sensory or motor deficits; ulnar neuropathy is particularly common and may be related to subtle positioning issues
• Regional anesthesia nerve injury - rare but possible after neuraxial or peripheral nerve blocks
• Any new numbness, tingling, or weakness in a limb not explained by surgery
• Bruising or skin breakdown over pressure points (can indicate underlying nerve compression)

• Any numbness, tingling, or weakness in your arms, hands, legs, or feet?
• Do you have back pain or leg pain that feels different from surgical pain?
• Any new muscle weakness or difficulty with fine motor tasks?

4. Postdural Puncture Headache (after spinal/epidural)

• Positional headache (worse upright, better supine) - the hallmark; typically appears within 24-48 hours after spinal anesthesia
• More frequent after difficult blocks with multiple attempts or inadvertent dural puncture during epidural placement
• Neck stiffness, photophobia, tinnitus, or diplopia (rare but indicate large CSF leak)

• Do you have a headache that gets worse when you sit or stand up?
• Any neck stiffness, vision changes, or ringing in the ears?

5. Nausea, Vomiting, and GI Symptoms

• Postoperative nausea and vomiting (PONV) - one of the most common and distressing complications; higher risk in females, non-smokers, history of PONV/motion sickness, opioid use
• Prolonged ileus or abdominal distension (especially after abdominal procedures)
• Aspiration risk assessment if there was a documented airway event

• Have you been nauseated or vomiting since surgery?
• Were you able to tolerate fluids or food?
• Did anyone tell you there were any airway concerns during the procedure?

6. Pain and Analgesic Adequacy

• Adequacy of pain control - both at rest and with movement
• Side effects from opioids: pruritus, urinary retention, constipation, excessive sedation
• Efficacy of regional blocks: is the block wearing off appropriately? Any unexpected pain in the blocked region?
• Chronic pain risk - inadequately treated acute pain is a recognized risk factor for chronic post-surgical pain

• How is your pain being controlled? Is it adequate?
• Any itching from pain medications?
• Difficulty urinating?

7. Cardiovascular

• Hypertension or hypotension (documented in PACU or persistent after discharge)
• New arrhythmias
• Myocardial ischemia signs in high-risk patients (chest pain, dyspnea, new ECG changes)
• DVT risk: leg pain, swelling, especially after orthopedic or pelvic procedures

• Any chest pain, palpitations, or shortness of breath?
• Leg swelling or calf pain?

8. Temperature and Metabolic

• Fever - may indicate infection, malignant hyperthermia (MH) sequelae (rare but dangerous), or aspiration pneumonia
• Hypothermia (often present intraoperatively, should resolve)
• Malignant hyperthermia: if succinylcholine or volatile agents were used, watch for late fever, myoglobinuria, muscle pain, and elevated CK

• Have you had a fever since surgery?
• Any unusual muscle aches or dark-colored urine?

9. Awareness During Anesthesia

• Do you have any memories from during the surgery?
• Did you feel or hear anything during the procedure?
• Are you having nightmares or flashbacks?

10. Patient Satisfaction and Documentation

• Was the anesthetic experience as explained beforehand?
• Were their concerns addressed?
• Document any complications in the anesthesia record for quality assurance and medicolegal purposes

Quick Reference Summary Table