Post-anaesthetic Recovery: A Practical Approach

201 Pages·1989·5.46 MB·English

by  Roger Eltringham MB

Roger Eltringham· Michael Durkin
Sue Andrewes . William Casey
Post-anaesthetic
Recovery
A Practical Approach
Second Edition
Foreword by Luke M. Kitahata
With 38 Figures
Springer-Verlag
London Berlin Heidelberg New York
Paris Tokyo Hong Kong
Roger Eltringham, MB, ChB, FFA RCS
Michael Durkin, MB, BS, FFA RCS
William Casey, MB, ChB, FFARCS
Consultant Anaesthetists, Gloucestershire Royal Hospital,
Great Western Road, Gloucester GLi 3NN, UK
Sue Andrewes RGN, RSCN
Formerly Nursing Officer, Recovery Unit,
Whipps Cross Hospital, London Ell 1N R, UK
ISB~-13:978-3-540-19555-9
British Library Cataloguing in Publication Data
Eltringham, Roger
Post-anaesthetic recovery.-2nd ed.
I. Medicine. Anaesthesia. Monitoring 1. Eltringham, Roger 617'.96
ISB~-13:978-3-540-19555-9 e-ISB~-13:978-1-4471-1693-6
001: 10.1007/978-1-4471-1693-6
Library of Congress Cataloging-in-Publication Data
Post-anaesthetic recovery: a practical approach/Roger Eltringham ... ret al.];
foreword by Luke M. Kitahata.-2nd ed.
p. cm. Rev. ed. of: Post-anaesthetic recovery/Roger Eltringham, Michael Durkin,
Sue Andrewes. 1983. Includes bibliographies and index.
ISB~-13:978-3-540-19555-9 (U.S.)
I. Anesthesia-Complications and sequelae. 2. Postoperative care. 1. Eltringham,
Roger, 1939- . [D~LM: I. Anesthesia-nurses' instruction. 2. Postoperative
Care--nurses'instruction. 3. Postoperative Complications-prevention & control
nurses'instruction. 4. Recovery Room-nurses' instruction. WY 154 P857]
RD82.5.P67 1989 6IT.919-dcI9 DNLM/DLC.
for Library of Congress 89-6032
CIP
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© Springer-Verlag Berlin Heidelberg 1983, 1989
First published 1983; Second edition 1989
The use of registered names, trademarks etc. in this publication does not imply, even
in the absence of a specific statement, that such names are exempt from the relevant
laws and regulations and therefore free for general use.
Product Liability: The publisher can give no guarantee for information about drug
dosage and application thereof contained in this book. In every individual case the
respective user must check its accuracy by consulting other pharmaceutical literature.
Filmset by Macmillan India Limited, Bangalore 560025
2128/3916-54321 Printed on acid-free paper
To Lorna Eltringham,
Richard Andrewes
and
Sue Durkin
Foreword to the Second Edition
The need for continued vigilance in the post-anaesthetic recovery
period following general or regional anaesthesia is paramount. This
book brings together in one volume the major issues that one should
consider in the management of the patient during this period.
Improvements in modern surgical techniques continue to stimulate
great advances in anaesthetic management. Large groups of patients
who until recently would not have been candidates for surgery are now
able to benefit from such surgery because of improved knowledge of
anaesthetic pharmacology, the physiology of pain transmission and
cardiopulmonary monitoring.
The first chapter concentrates on the organisation of the recovery
room; it deals with management from the standpoint of the United
Kingdom but is equally applicable to the rest of the world. The nursing
and medical procedures for normal recovery are discussed in Chapter 2.
In the later chapters there is a comprehensive review of complications
in the post-anaesthetic period and a discussion of specific aspects of
recovery from specialised surgical procedures. Finally, a unique chap
ter deals with the pre-operative factors that will affect the recovery
period. Additions to the first edition include chapters covering methods
of pain relief, day case surgery and the various monitoring techniques
now available for use in the recovery room.
The authors have succeeded in bringing together a rational plan for
the management of many problems which routinely affect a patient's
recovery from anaesthesia. They have done this in a problem-solving
fashion with the emphasis on reaching a management decision as a
result of careful clinical examination and monitoring. It is evident that
all personnel involved in the recovery of the patient from anaesthesia
need a concise, clinical and relevant book from which they can obtain
advice. There is no doubt that this is just such a book, and it will
provide for nurses, doctors and all those involved in the field a practical
guide to this often neglected critical period following anaesthesia.
Luke M. Kitahata, MD, PhD
Professor of Anesthesiology
Yale University, USA
Preface to the Second Edition
Developments in surgery have enabled more ambitious operations to
be attempted than ever before, while similar advances in anaesthesia
and monitoring have meant that many patients who were previously
considered unfit now undergo surgery.
It is essential that standards of patient care during surgery are
continued post-operatively until the depressant effects of anaesthesia
have worn off and it is safe for patients to return to the wards or to their
homes. The importance of adequate supervision by well-trained nurs
ing staff in properly equipped surroundings has been recognised by
the introduction of recovery rooms in most hospitals. Despite this,
many patients still emerge from anaesthesia in wards or departments
where they are supervised by inexperienced nursing staff in unfamiliar
surroundings.
Recovery from anaesthesia may be accompanied by a variety of
dangerous and potentially fatal complications, many of which can be
avoided by the detection of early warning signs and the institution
of appropriate therapy before an irreversible situation is allowed to
develop.
This book describes the major complications liable to be encountered
and suggests how they may be avoided by careful monitoring, vigilant
nursing and sound organisation. The patient's behaviour at recovery is
influenced by his pre-operative condition, by drug therapy pre- and
intra-operatively and by the nature of the surgery, and sections have
been devoted to these aspects since a basic understanding of them is
essential in anticipating events in the recovery room.
In this second edition, there is a chapter on pain management that
includes information on both the advantages and the problems that
may be encountered when local anaesthetic blocks are used. There are
also new chapters on the special considerations that apply to recovery
nursing in day care units and on the role of monitoring equipment in
the recovery room.
Throughout the text drugs have been referred to by their British
Pharmacopoeia name with the US equivalent in parentheses when this
is different. In Appendix A common brand names are also included.
x Preface to the Second Edition
For clarity, throughout this book, it is assumed that patients and
doctors are male and that nurses are female. No slight is intended to
members of either gender, and we trust no one will be offended by this
usage.
It is hoped that this book will provide a readily available source of
practical information not only for nursing staff but also for junior
anaesthetists and house surgeons and for all those involved in the care
of patients in the immediate post-operative period.
Acknowledgements
The authors are indebted to their many medical and nursing colleagues
in Bristol, Gloucester and at Whipps Cross Hospital, London for their
help and encouragement in the preparation of this work. In particular
we appreciate the help given by Tony Bennett, Geoffrey Burton, Paul
Thornton and Sheila Willatts, consultant anaesthetists from Bristol,
and Mike Gear and Reggie Merryweather, consultant surgeons, Philip
Kingston, consultant haematologist, and Steve Wilkinson, consultant
physician, all from Gloucester and to Lynda Taylor for infection control
update.
We are grateful to Patricia Stone, Marion Heath and Jean Blake, all
pharmacists, for their painstaking work in checking the drug names
and their American equivalents, to Steve Catchpole and Sue Durkin for
the illustrations, and to Dick Andrewes for repeatedly typing the
manuscripts and indexing.
We express also our gratitude to Michael Jackson and Wendy Darke
of Springer-Verlag and to the late and very sadly missed John Farman
of Addenbrooke's Hospital, Cambridge, for their helpful advice
throughout the preparation of the manuscript.
Finally, a special word of thanks is due to Prof. Harold Carron of the
University of Virginia who offered invaluable advice during the prep
aration of this work and whom we failed to acknowledge in the first
edition. Our sincere apologies and grateful thanks.
Gloucester and Loughton Roger Eltringham
1989 Michael Durkin
Sue Andrewes
William Casey
Contents
Chapter 1. Organisation.................................................................. I
Role of the Recovery Room ............ ............................................... 1
Site .................................................................................................. 2
Reception Area............................................................................ 2
Relationship with an Intensive Therapy Unit............................. 3
Windows...................................................................................... 3
Design ............................................................................................. 3
Number of Bays .................................................................. ........ 3
Space per Bed...................................................... ........................ 3
Lighting ....................................................................................... 4
Power Outlet Points .......................................... .......................... 4
Communication Systems ............................................................. 5
Te1ephones................................................................................... 5
Noise Levels ................................................................................ 5
Heating and Ventilation .............................................................. 6
Equipment....................................................................................... 6
Safety .............................................................................................. 8
Pollution .................................... ............... ................................... 8
Fire Risk...................................................................................... 9
Infection Control and Staff Protection ............ ........................... 9
Advice for Recovery Staff......................................................... 10
Anti-static Precautions ...... ............... ......................................... 12
Routine Cleaning....................................................................... 12
Flooring.......................................... .......................................... 12
Equipment Disinfection and Sterilisation ................................. 13
Staffing .......................................................................................... 13
The Senior Nurse ...................................................................... 13
Nurse-Patient Ratio .................................................................. 14
Twenty-four Hour Staffing........................................................ 15
Staff Training ............................................................................ 15
Nurse-Doctor Collaboration .................................................... 16
Policies of a Recovery Unit .......................................................... 17
Further Reading............................................................................ 18
xii Contents
Chapter 2. Normal Recovery......................................................... 21
Physiology of the Elimination of Anaesthetic Gases......................... 21
Progress of Normal Recovery ....................................................... 22
Care Plan Nursing ........................................................................ 23
Reception of the Patient ............................................................... 24
Basic Nursing Position and Safety ............................................... 25
Routine Observations........... ... ............... ........... ........................... 26
Assessment of Colour. ... .......... ...... ....... ......... ... ........ .................... 26
Peripheral and Central Cyanosis.......................................... ..... 26
Assessment of Respiratory Function ...... ... ..... ... ...................... ..... 27
Assessment of Cardiovascular Function....................................... 27
Tissue Perfusion .... .......... ... .... ...... ....... .......... ............... ... .......... 27
Pulse Measurement................................................... ................. 28
Blood Pressure Measurement.................................................... 30
Assessment of Level of Consciousness ........ ......... .... .............. ...... 34
Recognition of Blood Loss ...................................... ... .................. 35
Maintenance of the Airway .......................................................... 35
Insertion of Oropharyngeal Airway.................................... .......... 36
Insertion of Nasopharyngeal Airway ...................... :..................... 37
Suction of Upper Airway.............................................................. 38
Care of the Intubated Patient ....................................................... 38
Endotracheal Suction ................................................................ 38
Extubation ................................................................................. 39
The Ventilated Patient .................................................................. 39
Oxygen Therapy.... ..... ........... ................ ......... .............. ................. 40
Administration of Oxygen ............................................................ 41
Maintenance of Fluid Balance .......................................... ............ 43
Intravenous Infusion Drip Rates.................................................. 44
Intravenous Fluid Therapy ........................................................... 44
Intravenous Infusions .............. ..................................................... 45
Intravenous Injections............................................... .................... 45
Blood Transfusion............ ............................................................. 45
Drainage Systems.......... ............................ ................... ................. 46
Record Keeping and Charting...................................................... 47
Criteria for Discharge ................................................................... 51
Transfer of Patient to Ward Staff................................................. 52
Further Reading................................................. ............. .............. 52
Chapter 3. Pain Relief and Local Anaesthesia .............................. 53
Introduction .................................................................................. 53
Gate Control Theory of Pain.................................................... 53
Methods of Pain Relief............ ....... ................... ............. .......... .... 55
Analgesic Drugs.. .......... .......... .... ............ .................... ........ ...... 55
Partial Antagonists.................................................................... 56
Patient Controlled Analgesia ................................................. ;.. 56
Contents xiii
Local Anaesthetic Techniques....................................................... 57
Management of Toxic Reactions .............................................. 58
Local Anaesthetic Agents.......................................................... 58
Specific Local Anaesthetic Blocks................................................. 59
Spinal Blockade......................................................................... 59
Epidural Blockade... ........ ... ......... ........... .... ...... ........ ....... ..... ..... 60
Caudal Blockade.. ...... .... ....... .......... ......... ...... ...... ..... ............. ... 61
Local Infiltration........ .... ....... ...... .... ........ ....... ..... .... ...... ....... ..... 61
Intercostal Nerve Blockade ....................................................... 61
Intrapleural Catheterisation ...................................................... 62
Inguinal Field Blockade........ ............ ....... ............ ..... ........ .... .... 62
Penile Nerve Blockade.. ...... ... ... ... .......... ................ ........... ........ 62
Brachial Plexus Blockade.... ....... ... ..... .......... ... ....... .... ...... ......... 63
Intravenous Regional Anaesthesia (Bier's Block) ..................... 63
Digital Nerve Blockade ............................................................. 64
Femoral Nerve Blockade........................................................... 64
Patient Management in the Recovery Unit .................................. 65
Further Reading............. ........... .................. ........... ........... .... .... .... 65
Chapter 4. Complications.. ......... ... .......... ....... ...... ....... ........... ....... 67
Respiratory Complications ...... ....... .......... ...... ......... .... ............ ....... 67
Upper Airway Obstruction ........................................................... 68
Inadequate Ventilation (Hypoventilation) .................................... 70
Hypoxaemia .................................................................................. 75
Bronchospasm ............................................................................... 76
Aspiration of Gastric Contents..................................................... 76
Chemical Pneumonitis (Mendelson's Syndrome)...................... 78
Pneumothorax and Haemothorax....... .... .... ..... ...... ........... ........ .... 78
Tension Pneumothorax ................................................................. 79
Cardiovascular Complications........................................................ 79
Hypotension .................................................................................. 79
Hypovolaemia ........................................................................... 80
Diminished Cardiac Output..... ......... ... .... ............. ......... ........ ... 81
Other Causes of Hypotension ................................................... 82
Hypertension ................................................................................. 82
Bradycardia.. ............... .... ...... ....... .......... ................... .... ..... ........... 83
Sinus Bradycardia ..................................................................... 83
Heart Block...... .... ............. ...... ......... ....... .......... .......... .............. 84
Tachycardia................................................................................... 85
Sinus Tachycardia ..................................................................... 85
Supraventricular and Ventricular Tachycardia ......................... 86
Dysrhythmias .. ....... .... ........ .... ........... ..... ........ ............... ..... ........ ... 87
Premature Atrial Contractions.................................................. 88
Premature Ventricular Contractions ......................................... 88
Atrial Fibrillation ...................................................................... 89
Cardiac Arrest............................................................................... 90