A patient in the PACU after laparoscopic appendicectomy has SpO₂ 87% on 4 L/min nasal prongs. On examination, respiratory rate is 6/min with a see-saw pattern, he is difficult to arouse, and there is bilateral miosis. What is the diagnosis and immediate treatment?
- A Laryngospasm — administer succinylcholine 1 mg/kg IV and reintubate
- B Residual neuromuscular blockade — administer sugammadex 200 mg IV
- C Opioid-induced respiratory depression — administer naloxone 40 mcg IV titrated to restore respiration while preserving analgesia ✓
- D Pulmonary embolism — urgent CT pulmonary angiogram
Explanation
The classic triad of opioid toxicity is miosis (pinpoint pupils), CNS depression (unrousable), and respiratory depression (rate <10/min with paradoxical breathing). Treatment is naloxone (competitive opioid antagonist) titrated carefully in 20–40 mcg increments to restore ventilatory drive without precipitating acute pain, hypertension, pulmonary oedema, or cardiac arrhythmias. Succinylcholine/reintubation may be needed if pharmacological reversal fails. Residual NMB would show normal pupils and consciousness with decreased muscle strength. Laryngospasm presents with stridor and silence, not bradypnoea with miosis.
Reference: Morgan & Mikhail's Clinical Anesthesiology, 6th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.