Just because a patient is out of the operating room doesn’t mean we’re out of the woods. In fact, most deaths occur after, not during surgery: 50 percent of canine and 60 percent of feline deaths occur in the postop period.
It is important to avoid becoming complacent, despite the busyness of the day. Here are 10 steps to improve the care given to your postop patients.
The proper time to extubate is often based on a widespread misconception, sometimes called the “two swallow” rule. This is a very unfortunate urban legend that can lead patients to serious trouble.
“Two swallows” may not mean that the patient is alert enough to continue swallowing and breathing efficiently on its own. The more appropriate time to extubate is when a patient is alert, preferably has lifted its head up at least once, and begins to chew. The next challenge it to pull the tube before the patient chews it in half. Ideally, each patient recovering from anesthesia and/or surgery should be under direct supervision of a technician until extubation. We still need to remain alert afterward: Being extubated doesn’t mean that recovery is over. It is just one step of the process.
Walking away from a patient after extubation may be risky.
Monitoring vitals (TPR, mucous membranes, capillary refill time) every five to 10 minutes is a simple way to assess a patient. Heart and lungs should be auscultated. Monitoring might also include ECGs, blood pressure and pulse oximetry.
Vital signs should be documented, just as if the patient were still under anesthesia. If things go wrong, it is important to know where we started and where the trend is going to effectively treat any abnormality.
Optimal body functions require optimal body temperature, yet most patients wake up hypothermic after anesthesia. This in turn can affect blood pressure, infection rate and metabolism. There are many warming devices available to help hypothermic patients. The same devices should be used during surgery.
As long as patients are hypothermic (<100 degrees Fahrenheit), their temperature should be taken every 30 minutes. This could be done even more often, e.g. every 15 minutes, in small patients, who could quickly become hyperthermic while unsupervised.
4. Eye Lube
We all know to place sterile lubrication on the cornea after induction. However, many patients may not blink effectively postop, which can lead to ulcerations, especially in brachycephalic breeds. A wise precaution is to apply more sterile eye lube during recovery.
5. Cardiac Function
Heart auscultation and pulse palpation are easy to monitor while patients recover. If hypotension or hemorrhage were a concern during surgery, blood pressure should be closely monitored during recovery until it becomes repeatedly normal.
If a patient has a heart murmur, fluid rate adjustment and lung auscultation should be performed.
6. IV Fluids
Patients recovering from surgery may benefit from intravenous fluids. Yet they are often disconnected, and the IV catheter might be removed, as soon as they leave the OR. Fluids help correct fluid and electrolyte imbalances caused by sickness, fluid loss or hemorrhage. They help prevent dehydration due to postop anorexia. They also help with drug metabolism and kidney function.
In addition, having access to a patient vein can be a life-saver in case of emergency. Last but not least, IV fluids can be used as part of your pain management in the form of a constant rate infusion (CRI).
7. Pain management
Periodically assess a patient’s pain level and treat as needed.
Most practices have embraced the importance of pre-emptive pain management. It should continue beyond the OR. There are countless modalities we can choose, depending on the patient and the procedure, including opioids, CRIs and anti-inflammatory drugs. Antibiotics A classic antibiotic protocol starts with IV cefazolin given 30 minutes before skin incision (i.e. often at the time of induction). Cefazolin is then given IV every 90 minutes as long as the patient is under anesthesia. If indicated, the drug is then given IV every eight hours postop until the patient can take antibiotics by mouth.
8. Emergency Preparedness
Re-intubation equipment and emergency drugs should always be available near a recovery area. But in specific cases, it is wise to have them next to the patient.
This includes any brachycephalic breed, patients recovering from neck and throat surgery and any critical patient who may arrest.
This is where a nurturing and observant technician makes all the difference in the world. Something as simple as repositioning a patient or emptying the bladder can drastically improve comfort.
From giving medications and monitoring vitals at the right times, to keeping patients and bedding clean, dry and comfortable, nursing care is a full time job. Experience and good observational skills are critical to pick up on subtle changes and to notify the doctor before a crisis occurs.
How can you accomplish this when there are so many other things to do? One solution may be to have a dedicated technician for recovery patients if you have a busy surgery schedule. In fact, this should include all anesthetic procedures, including dentals.
Even if you don’t have a big case load, the technician in charge of the anesthesia could remain in charge of the patient until it is deemed safely recovered.
10. When to Discharge?
After some short procedures, you may be able to send the patient home within a few hours, as long as the patient is fully awake, i.e. normothermic, responsive, comfortable and able to walk. Fancier procedures and critical patients may require longer hospitalization and overnight care, which should be fully understood by the owner.