The recovery from major surgery can be divided into three phases: (1) an immediate, or postanesthetic, phase; (2) an intermediate
phase, encompassing the hospitalization period; and (3) a convalescent phase.
During the first two phases, care is principally directed at maintenance
of homeostasis, treatment of pain, and prevention and early detection
of complications. The convalescent phase is a transition period
from the time of hospital discharge to full recovery. The trend
toward earlier postoperative discharge after major surgery has shifted
the venue of this period.
The primary causes of early complications and death following major surgery are acute pulmonary, cardiovascular, and fluid derangements.
The postanesthesia care unit (PACU) is staffed by specially trained
personnel and provided with equipment for early detection and treatment
of these problems. All patients should be monitored in this specialized
unit initially following major procedures unless they are transported
directly to an intensive care unit. While en route from the operating
room to the PACU, the patient should be accompanied by a physician
and other qualified attendants. In the PACU, the anesthesiology
service generally exercises primary responsibility for cardiopulmonary
function. The surgeon is responsible for the operative site and
all other aspects of the care not directly related to the effects
of anesthesia. The patient can be discharged from the recovery room
when cardiovascular, pulmonary, and neurologic function have returned
to baseline, which usually occurs 1–3 hours following operation.
Patients who require continuing ventilatory or circulatory support
or who have other conditions that require frequent monitoring are
transferred to an intensive care unit. In this setting, nursing
personnel specially trained in the management of respiratory and
cardiovascular emergencies are available, and the staff-to-patient
ratio is higher than it is on the wards. Monitoring equipment is available
to enable early detection of cardiorespiratory derangements.
Detailed treatment orders are necessary to direct postoperative care. The transfer of the patient from OR to PACU requires reiteration
of any patient care orders. Unusual or particularly important orders should
also be communicated to the nursing team orally. The nursing team must
also be advised of the nature of the operation and the patient’s
condition. Errors in postoperative orders, including medication
errors and omission of important orders, are diminished by electronic order
entry systems that can contain postoperative order sets. Postoperative orders
should cover the following:
Blood pressure, pulse, and respiration should be recorded frequently until stable and then regularly until the patient is discharged
from the recovery room. The frequency of vital sign measurements thereafter
depends upon the nature of the operation and the course in the PACU.
When an arterial catheter is in place, blood pressure and pulse
should be monitored continuously. Continuous electrocardiographic
monitoring is indicated for most patients in the PACU. Any major
changes in vital signs should be communicated to the anesthesiologist and