Back To Search Results

Aldrete Scoring System

Editor: Selma Ishag Updated: 7/8/2023 10:04:09 PM

Definition/Introduction

Postanesthetic recovery begins with the discontinuation of anesthetic agents and continues until the complete return of preanesthetic physiology. Patients who have received intraoperative general, regional, or monitored anesthesia care are commonly admitted to the postanesthesia care unit (PACU) as they recover from anesthesia.

The PACU is traditionally structured into 2 phases based on the level of care provided. Phase I care is characterized by close patient monitoring with a high nursing ratio and is fully equipped to respond to any potential complications during the immediate recovery period. Phase II care is primarily targeted at preparing patients for discharge.[1][2][3]

To enhance the quality and consistency of evaluating the progress of postoperative patients and providing appropriate medical care, there has been a historical need for an effective PACU assessment tool. Multiple scoring systems were experimented with, but many had to be abandoned because of concerns about their objectivity, practicality, or reliability.[4][5][6] In 1970, two anesthesiologists from the Denver Veterans Hospitals developed a quantitative scoring system based on the Apgar Score System used for neonates at delivery.[4][7] This quantitative scoring system was the original Aldrete Scoring System, also known as the Postanesthetic Recovery Score (PARS).

The Aldrete Scoring System consists of 5 clinically relevant parameters reflecting physiological recovery from anesthesia: muscle activity, respiration, circulation, consciousness, and color. Each category is assigned a score of 0, 1, or 2, with a maximum possible total score of 10.[4] With the introduction, gradual integration, and standardization of pulse oximetry in the late 1980s, Aldrete substituted pulse oximeter readings for the color parameter in 1995, recognizing the subjective nature of assessing hypoxemia using only mucous membrane or nailbed color (Table 1. The Aldrete Scoring System).[8][9] A score of 8 or higher indicates that a patient is suitable for discharge from the PACU.[8][9]

Since its initial description, the Aldrete scoring system has gradually become one of the most popular and well-established metrics in the PACU. The Aldrete scoring system has been extensively validated in various surgical and anesthetic contexts to determine the suitability of postoperative patients for transitioning to the next level of care with less intensive nursing assessment and monitoring, such as the hospital ward, Phase II PACU, or home.[8][9]

Table 1. The Aldrete Scoring System

 Variable

 Assessment Interpretation

 Score

 Activity

 Able to move all extremities voluntarily or on command

 Able to move two extremities voluntarily or on command

 Unable to move extremities voluntarily or on command

 2

 1

 0

 Respiration

 Able to breathe deeply and cough freely

 Dyspnea or limited breathing

 Apneic or on the mechanical ventilator

 2

 1

 0

 Circulation

 Blood pressure +/- 20% or less of the preanesthetic level

 Blood pressure +/- 20% to 49% of the preanesthetic level

 Blood pressure +/- 50% or more of the preanesthetic level

 2

 1

 0

 Consciousness

 Fully awake

 Arousable on calling

 Not responding

 2

 1

 0

 Oxygenation

 Able to maintain O2 saturation >92% on room air

 Needs supplemental O2 to maintain O2 saturation >90%

 O2 saturation <90% even with supplemental oxygen

 2

 1

 0

Issues of Concern

Register For Free And Read The Full Article
Get the answers you need instantly with the StatPearls Clinical Decision Support tool. StatPearls spent the last decade developing the largest and most updated Point-of Care resource ever developed. Earn CME/CE by searching and reading articles.
  • Dropdown arrow Search engine and full access to all medical articles
  • Dropdown arrow 10 free questions in your specialty
  • Dropdown arrow Free CME/CE Activities
  • Dropdown arrow Free daily question in your email
  • Dropdown arrow Save favorite articles to your dashboard
  • Dropdown arrow Emails offering discounts

Learn more about a Subscription to StatPearls Point-of-Care

Issues of Concern

The Aldrete scoring system is valuable for measuring physiological recovery from anesthesia. However, the emphasis on physiological factors may not be enough to address certain postoperative complications that do not cause significant deviations in the scoring system but still require extended PACU care or additional medical attention, such as arrhythmias not yet resulting in hemodynamic compromises, hypothermia or hyperthermia, uncontrolled pain, or severe nausea and vomiting.[8] Therefore, consideration of the overall clinical picture and factors beyond the Aldrete scoring system is necessary to ensure proper patient care. Additionally, concerns have been raised regarding the applicability and efficacy of the Aldrete scoring system as a clinical assessment tool in ambulatory surgical settings.

Advancements in surgical and anesthetic techniques and the rise in healthcare expenses have led to more diagnostic and therapeutic procedures being performed in the outpatient setting. Recent studies indicate that increasingly diverse and complex procedures are being performed on less healthy patients discharged home on the day of the procedure.[10][11][12][13][14] Physiologic recovery from anesthesia is a complex process that extends over several days; ambulatory surgical patients' discharge criteria should assess readiness for PACU discharge and ensure safe discharge home.[12][15][8]

Although the original Aldrete scoring system has proven valuable in determining suitability for discharge from the PACU, the scoring system does not address common postprocedural issues such as pain, nausea and vomiting, and surgical site bleeding. Assessing and managing these issues before patients are discharged home is imperative to ensure their safety, reduce unexpected hospital readmissions, and promote patient satisfaction.[16][17][18] The Aldrete scoring system was expanded in 1995 to include 5 additional criteria specific to the outpatient surgical setting; this expansion is the Modified Aldrete Score for ambulatory surgeries. These criteria, which include dressing appearance, severity of pain, ability to walk, ability to tolerate oral fluids, and ability to urinate, are each assigned a score between 0 and 2 (Table 2. The Modified Aldrete Scoring System for Ambulatory Surgeries). A cumulative score of 18 or more indicates that the patient is fit for discharge and can safely return home.[9]

Another major discharge scoring tool for ambulatory surgery patients was developed during this period. The initial Post Anesthetic Discharge Scoring System (PADSS) included five criteria: vital signs; activity and mental status; pain, nausea, or vomiting; surgical bleeding; and intake and output.[15] However, subsequent revisions of PADSS removed the oral fluid intake and voiding before discharge criteria; there was a lack of clinical evidence supporting their impact on reducing adverse outcomes.[16][18] PADSS has proven effective and reliable in facilitating the early discharge of average-risk surgical outpatients from the PACU without compromising their safety (Table 3. The Postanesthetic Discharge Scoring System). High-risk patients still require individualized assessment.[19][20][21]

Table 2. The Modified Aldrete Scoring System for Ambulatory Surgeries

 Variable

 Assessment Interpretation

 Score

 Activity

 Able to move all extremities voluntarily or on command

 Able to move two extremities voluntarily or on command

 Unable to move extremities voluntarily or on command

 2

 1

 0

 Respiration

 Able to breathe deeply and cough freely

 Dyspnea or limited breathing

 Apneic or on a mechanical ventilator

 2

 1

 0

 Circulation

 Blood pressure +/- 20% or less of the preanesthetic level

 Blood pressure +/- 20% to 49% of the preanesthetic level

 Blood pressure +/- 50% or more of the preanesthetic level

 2

 1

 0

 Consciousness

 Fully awake

 Arousable on calling

 Not responding

 2

 1

 0

 Oxygenation

 Able to maintain O2 saturation >92% on room air

 Needs supplemental O2 to maintain O2 saturation >90%

 O2 saturation <90% even with supplemental oxygen

 2

 1

 0

 Dressing

 Dry and clean

 Wet but marked and not increasing

 A growing area of wetness

 2

 1

 0

 Pain

 No pain

 Mild pain handled by oral medication

 Severe pain requiring parenteral medication

 2

 1

 0

 Ambulation

 Able to stand up and walk straight

 Vertigo when erect

 Dizziness when supine

 2

 1

 0

 Fast-feeding

 Able to drink fluids

 Nauseated

 Nausea and vomiting

 2

 1

 0

 Urine output

 Has voided

 Unable to void but comfortable

 Unable to void and uncomfortable

 2

 1

 0

Table 3. The Postanesthetic Discharge Scoring System (PADSS)

Variable

 Assessment Interpretation

 Score

 Vital Signs

 Within 20% of the preoperative baseline

 20 to 40% of the preoperative baseline

 40% of the preoperative baseline

 2

 1

 0

 Ambulation

 Steady gait, no dizziness, consistent with preoperative level

 Requires assistance

 Unable to ambulate or assess

 2

 1

 0

 Nausea and vomiting

 Minimal: no treatment is required

 Moderate: treatment effective

 Severe: treatment not effective

 2

 1

 0

 Pain

 VAS = 0–3: the patient has minimal or no pain before discharge

 VAS = 4–6: the patient has moderate pain

 VAS = 7–10: the patient has severe pain

 2

 1

 0

 Surgical bleeding

 Minimal: does not require dressing changes needed

 Moderate: up to two dressing changes with no further bleeding

 Severe: more than three dressing changes and continues to bleed

 2

 1

 0

Abbreviations: VAS, visual analog scale

The modified Aldrete scoring system and the PADSS are frequently used in the PACU to assist decision-making for Phase I discharge and discharge from Phase II to home, respectively. However, the use of modern anesthetic techniques and agents with short-lasting effects coupled with further cost-saving incentives have promoted the emergence and acceptance of fast-track recovery for clinically suitable patients undergoing select types of surgeries such as ophthalmology or orthopedic procedures.[22] In this fast-track recovery pathway, a postsurgical outpatient is evaluated by an anesthesia provider against a set of well-defined criteria before leaving the operating room. If deemed eligible, the patient will bypass the traditional Phase I care and move directly to Phase II recovery.

Given its niche in early postoperative recovery assessment, the Aldrete scoring system was examined for its potential use in the fast-track pathways; concerns remained due to its primary focus on vital signs and wakefulness. Therefore, the Aldrete scoring system was expanded to include factors commonly delaying ambulatory discharge, such as pain and emetic symptoms, creating the Ambulatory Surgery Fast Track Discharge Criteria (Table 4 - The Ambulatory Surgery Fast-Track Discharge Criteria).[14][22] A score of 12 or higher, with each category scoring a minimum of 1 point, indicates eligibility for the fast-track program to bypass Phase I recovery.[22]Further studies suggest that when applied to carefully selected patients having undergone a particular type of surgery, the fast-track criteria can safely triage patients directly to Phase II recovery with a reduced hospital stay.[23][24]

Table 4. The Ambulatory Surgery Fast-Track Discharge Criteria

 Variable

 Assessment Interpretation

 Score

 Level of consciousness

 Awake and oriented

 Arousable with minimal stimulation

 Responsive only to tactile stimulation

 2

 1

 0

 Physical activity

 Able to move all extremities on command

 Some weakness in the movement of extremities

 Unable to voluntarily move extremities

 2

 1

 0

 Hemodynamic stability

 Blood pressure +/- 15% of baseline MAP value

 Blood pressure +/- 30% of baseline MAP value

 Blood pressure +/- 50% of baseline MAP value

 2

 1

 0

 Respiratory stability

 Able to breathe deeply

 Tachypnea with a good cough

 Dyspneic with a weak cough

 2

 1

 0

 Oxygen saturation status

 Maintain value >90% on room air

 Requires supplemental O2 (nasal prongs)

 Saturation <90% on supplemental O2

 2

 1

 0

 Pain

 Absent or mild discomfort

 Moderate to severe pain controlled with IV analgesia

 Persistent severe pain

 2

 1

 0

 Emetic symptoms

 None or mild nausea with no active vomiting

 Transient vomiting or retching

 Persistent moderate to severe nausea and vomiting

 2

 1

 0

Abbreviations: MAP, mean arterial pressure

Clinical Significance

The Aldrete scoring system has significantly contributed to the safety and quality of care for postoperative patients over the past 40 years by revolutionizing the approach to gauging postoperative recovery in a simple, reliable, and reproducible way based on common physiological parameters. Together with its numerically scaled evaluation mechanism, the Aldrete scoring system employs a uniform quantitative assessment of the recovery process and discharge readiness regardless of anesthetic and surgical types, which has been shown to improve patient outcomes.[25]

Before the origination of the Aldrete scoring system, there were many inconsistencies and practice variations in the process of deciding when to transfer a patient through different phases of postoperative care and eventually to discharge to home or a step-down unit. The Aldrete scoring system facilitated decision-making on appropriate levels of postoperative care and resources available while ensuring patient safety.

Despite its limitations in the ambulatory surgery setting and the fast-track recovery pathway, the Aldrete scoring system undoubtedly played an essential role in promoting the establishment of a standard of care to ensure safe patient discharge or transfer of care after surgery while balancing the need for efficient utilization of healthcare resources. Currently, the Aldrete scoring system often serves as the core basis for developing institution-specific discharge guidelines or protocols to assist decision-making and improve patient outcomes in the PACU in many hospitals worldwide.

Although an effective discharge tool such as the Aldrete scoring system or PADSS provides consistent quality care and more efficient use of resources, the discharge criteria are integral but insufficient for a complete final evaluation; the criteria should not substitute for common sense and the clinical judgment of a healthcare professional. Careful consideration must still be given in unique circumstances, such as those characterized by postoperative complications, neurological injuries, temperature disturbances, and neuraxial anesthesia complications.[21] Additionally, safe, high-quality postanesthetic care must be individualized, accounting for the medical history and comorbidities, surgical- and anesthesia-related factors, and socioeconomic circumstances that directly or indirectly impact postoperative recovery.

Nursing, Allied Health, and Interprofessional Team Interventions

The PACU plays a crucial role in providing monitoring, support, and interventions to minimize complications for postoperative patients. The postoperative period is characterized by rapid changes in patient status, making it essential to adopt a multidisciplinary approach that leverages the unique skills and perspectives of each healthcare professional involved in postanesthetic care.

For instance, PACU nurses are responsible for monitoring patient recovery, assessing readiness for discharge using criteria like the Aldrete score, collaborating with physicians for diagnosis and treatment, coordinating care with respiratory therapists and pharmacists, and providing aftercare instructions and education to patients and their families.

PACU anesthesiologists oversee medical practice, diagnose and manage postoperative complications, administer cardiopulmonary resuscitation, collaborate with other medical specialties as needed, and ensure safe patient discharge to home or an appropriate level of care.

Respiratory therapists closely collaborate with PACU nurses and anesthesiologists to manage respiratory treatment and airway-related issues, including the use of respiratory devices, nebulization treatments, and mechanical ventilation for patients with preexisting respiratory conditions or acute postoperative respiratory insufficiencies.

Pharmacy personnel prepare and deliver discharge medications and instruct patients on proper medication use.

Additionally, the PACU may involve other medical specialists as required, such as surgeons addressing chest tubes, drains, or surgical site bleeding, or ophthalmologists evaluating corneal abrasions.

Effective interprofessional collaboration and communication are vital to facilitate early and safe discharge or transition of care from the PACU. This ensures minimal complications, shorter hospital stays, and improved patient outcomes and satisfaction. [Level 5] All healthcare team members contribute their valuable expertise toward delivering high-quality, patient-centered care.

In summary, by optimizing the use of discharge criteria like the Aldrete score and fostering collaborative teamwork, the PACU can achieve early and safe patient discharge or transition of care, leading to improved outcomes and patient satisfaction. 

References


[1]

Fang L, Wang Q, Xu Y. Postoperative Discharge Scoring Criteria After Outpatient Anesthesia: A Review of the Literature. Journal of perianesthesia nursing : official journal of the American Society of PeriAnesthesia Nurses. 2023 Jan 18:():. pii: S1089-9472(22)00600-1. doi: 10.1016/j.jopan.2022.11.008. Epub 2023 Jan 18     [PubMed PMID: 36670045]


[2]

Yamaguchi D, Morisaki T, Sakata Y, Mizuta Y, Nagatsuma G, Inoue S, Shimakura A, Jubashi A, Takeuchi Y, Ikeda K, Tanaka Y, Yoshioka W, Hino N, Ario K, Tsunada S, Esaki M. Usefulness of discharge standards in outpatients undergoing sedative endoscopy: a propensity score-matched study of the modified post-anesthetic discharge scoring system and the modified Aldrete score. BMC gastroenterology. 2022 Nov 4:22(1):445. doi: 10.1186/s12876-022-02549-7. Epub 2022 Nov 4     [PubMed PMID: 36333660]


[3]

McLaren JM, Reynolds JA, Cox MM, Lyall JS, McCarthy M, McNoble EM, Petersen VR. Decreasing the length of stay in phase I postanesthesia care unit: an evidence-based approach. Journal of perianesthesia nursing : official journal of the American Society of PeriAnesthesia Nurses. 2015 Apr:30(2):116-23. doi: 10.1016/j.jopan.2014.05.010. Epub     [PubMed PMID: 25813297]


[4]

Aldrete JA, Kroulik D. A postanesthetic recovery score. Anesthesia and analgesia. 1970 Nov-Dec:49(6):924-34     [PubMed PMID: 5534693]


[5]

CARIGNAN G, KEERI SZANTO M, LAVELLEE JP. POSTANESTHETIC SCORING SYSTEM. Anesthesiology. 1964 May-Jun:25():396-7     [PubMed PMID: 14156584]


[6]

Steward DJ. A simplified scoring system for the post-operative recovery room. Canadian Anaesthetists' Society journal. 1975 Jan:22(1):111-3     [PubMed PMID: 1109700]


[7]

APGAR V. A proposal for a new method of evaluation of the newborn infant. Current researches in anesthesia & analgesia. 1953 Jul-Aug:32(4):260-7     [PubMed PMID: 13083014]


[8]

Aldrete JA. Modifications to the postanesthesia score for use in ambulatory surgery. Journal of perianesthesia nursing : official journal of the American Society of PeriAnesthesia Nurses. 1998 Jun:13(3):148-55     [PubMed PMID: 9801540]


[9]

Aldrete JA. The post-anesthesia recovery score revisited. Journal of clinical anesthesia. 1995 Feb:7(1):89-91     [PubMed PMID: 7772368]

Level 3 (low-level) evidence

[10]

McLemore EC, Lee L, Hedrick TL, Rashidi L, Askenasy EP, Popowich D, Sylla P. Same day discharge following elective, minimally invasive, colorectal surgery : A review of enhanced recovery protocols and early outcomes by the SAGES Colorectal Surgical Committee with recommendations regarding patient selection, remote monitoring, and successful implementation. Surgical endoscopy. 2022 Nov:36(11):7898-7914. doi: 10.1007/s00464-022-09606-y. Epub 2022 Sep 21     [PubMed PMID: 36131162]


[11]

Young S, Osman B, Shapiro FE. Safety considerations with the current ambulatory trends: More complicated procedures and more complicated patients. Korean journal of anesthesiology. 2023 Mar 10:():. doi: 10.4097/kja.23078. Epub 2023 Mar 10     [PubMed PMID: 36912006]


[12]

Marshall SI, Chung F. Discharge criteria and complications after ambulatory surgery. Anesthesia and analgesia. 1999 Mar:88(3):508-17     [PubMed PMID: 10071996]


[13]

Marxen T, Shauly O, Losken A. The Safety of Same-day Discharge after Immediate Alloplastic Breast Reconstruction: A Systematic Review. Plastic and reconstructive surgery. Global open. 2022 Jul:10(7):e4448. doi: 10.1097/GOX.0000000000004448. Epub 2022 Jul 20     [PubMed PMID: 35924002]

Level 1 (high-level) evidence

[14]

Joshi GP, Vetter TR. Unanticipated Hospital Admission After Ambulatory Surgery: The Devil Is in the Details. Anesthesia and analgesia. 2020 Aug:131(2):494-496. doi: 10.1213/ANE.0000000000004947. Epub     [PubMed PMID: 32665499]


[15]

Chung F, Chan VW, Ong D. A post-anesthetic discharge scoring system for home readiness after ambulatory surgery. Journal of clinical anesthesia. 1995 Sep:7(6):500-6     [PubMed PMID: 8534468]

Level 1 (high-level) evidence

[16]

Awad IT, Chung F. Factors affecting recovery and discharge following ambulatory surgery. Canadian journal of anaesthesia = Journal canadien d'anesthesie. 2006 Sep:53(9):858-72     [PubMed PMID: 16960263]


[17]

Nanavati AJ, Prabhakar S. Fast-track surgery: Toward comprehensive peri-operative care. Anesthesia, essays and researches. 2014 May-Aug:8(2):127-33. doi: 10.4103/0259-1162.134474. Epub     [PubMed PMID: 25886214]


[18]

Apfelbaum JL, Silverstein JH, Chung FF, Connis RT, Fillmore RB, Hunt SE, Nickinovich DG, Schreiner MS, Silverstein JH, Apfelbaum JL, Barlow JC, Chung FF, Connis RT, Fillmore RB, Hunt SE, Joas TA, Nickinovich DG, Schreiner MS, American Society of Anesthesiologists Task Force on Postanesthetic Care. Practice guidelines for postanesthetic care: an updated report by the American Society of Anesthesiologists Task Force on Postanesthetic Care. Anesthesiology. 2013 Feb:118(2):291-307. doi: 10.1097/ALN.0b013e31827773e9. Epub     [PubMed PMID: 23364567]

Level 1 (high-level) evidence

[19]

Chung F. Discharge criteria--a new trend. Canadian journal of anaesthesia = Journal canadien d'anesthesie. 1995 Nov:42(11):1056-8     [PubMed PMID: 8590498]


[20]

Palumbo P, Tellan G, Perotti B, Pacilè MA, Vietri F, Illuminati G. Modified PADSS (Post Anaesthetic Discharge Scoring System) for monitoring outpatients discharge. Annali italiani di chirurgia. 2013 Nov-Dec:84(6):661-5     [PubMed PMID: 23165318]


[21]

Ead H. From Aldrete to PADSS: Reviewing discharge criteria after ambulatory surgery. Journal of perianesthesia nursing : official journal of the American Society of PeriAnesthesia Nurses. 2006 Aug:21(4):259-67     [PubMed PMID: 16935737]


[22]

White PF, Song D. New criteria for fast-tracking after outpatient anesthesia: a comparison with the modified Aldrete's scoring system. Anesthesia and analgesia. 1999 May:88(5):1069-72     [PubMed PMID: 10320170]


[23]

Rice AN, Douglas C, Bosarge H, Young G, Muckler VC, Vacchiano CA. Fast-Tracking Patients in an Academic Hospital to Increase Efficiency and Decrease Discharge Delays: A Process Improvement Plan. Journal of perianesthesia nursing : official journal of the American Society of PeriAnesthesia Nurses. 2021 Dec:36(6):615-621. doi: 10.1016/j.jopan.2021.04.005. Epub 2021 Oct 28     [PubMed PMID: 34688537]


[24]

Rice AN, Muckler VC, Miller WR, Vacchiano CA. Fast-tracking ambulatory surgery patients following anesthesia. Journal of perianesthesia nursing : official journal of the American Society of PeriAnesthesia Nurses. 2015 Apr:30(2):124-33. doi: 10.1016/j.jopan.2014.01.006. Epub 2014 Nov 28     [PubMed PMID: 25813298]

Level 2 (mid-level) evidence

[25]

Armstrong J, Forrest H, Crawford MW. A prospective observational study comparing a physiological scoring system with time-based discharge criteria in pediatric ambulatory surgical patients. Canadian journal of anaesthesia = Journal canadien d'anesthesie. 2015 Oct:62(10):1082-8. doi: 10.1007/s12630-015-0428-6. Epub 2015 Jul 7     [PubMed PMID: 26149598]

Level 2 (mid-level) evidence