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
Central venous pressure should be recorded periodically in the early postoperative period if the operation has entailed large blood
losses or fluid shifts, and invasive monitoring is available. A Swan-Ganz
catheter for measurement of pulmonary artery wedge pressure is indicated
under these conditions if the patient has compromised cardiac or
The anesthetic record includes all fluid administered as well as blood loss and urine output during the operation. This record
should be continued in the postoperative period and should also
include fluid losses from drains and stomas. This aids in assessing
hydration and helps to guide intravenous fluid replacement. A bladder
catheter can be placed for frequent measurement of urine output.
In the absence of a bladder catheter, the surgeon should be notified
if the patient is unable to void within 6–8 hours after operation.
Other Types of Monitoring
Depending on the nature of the operation and the patient’s preexisting conditions, other types of monitoring may be necessary. Examples include measurement of intracranial pressure and level of consciousness
following cranial surgery and monitoring of distal pulses following
vascular surgery or in patients with casts.
In the early postoperative period, the patient may remain mechanically ventilated or be treated with supplemental oxygen by mask or nasal
prongs. These orders should be specified. For intubated patients,
tracheal suctioning or other forms of respiratory therapy must be specified
as required. Patients who are not intubated should do deep breathing exercises
frequently to prevent atelectasis.
Position in Bed and Mobilization
The postoperative orders should describe any required special positioning of the patient. Unless doing so is contraindicated,
the patient should be turned from side to side every 30 minutes
until conscious and then hourly for the first 8–12 hours
to minimize atelectasis. Early ambulation is encouraged to reduce venous
stasis; the upright position helps to increase diaphragmatic excursion. Venous
stasis may also be minimized by intermittent compression of the
calf by pneumatic stockings.
Patients at risk for emesis and pulmonary aspiration should have nothing by mouth until some gastrointestinal function has returned
(usually within 4 days). Most patients can tolerate liquids by mouth
shortly after return to full consciousness.
Administration of Fluid and Electrolytes
Orders for postoperative intravenous fluids should be based on maintenance needs and the replacement of gastrointestinal losses
from drains, fistulas, or stomas.
Drain care should be included in the postoperative orders. Details such as type and pressure of suction, irrigation fluid and frequency,
and skin exit site care should be specified. The surgeon should
examine drains frequently, since the character or quantity of drain
output may herald the development of postoperative complications
such as bleeding or fistulas.
Orders should be written for antibiotics, analgesics, gastric acid suppression, deep vein thrombosis prophylaxis, and sedatives.
If appropriate, preoperative medications should be reinstituted.
Careful attention should be paid to replacement of corticosteroids
in patients at risk, since postoperative adrenal insufficiency may
be life threatening. Other medications such as antipyretics, laxatives,
and stool softeners should be used selectively as indicated.
Laboratory Examinations and Imaging
Postoperative laboratory and radiographic examinations should be used to detect specific abnormalities in high-risk groups. The
routine use of daily chest radiographs, blood counts, electrolytes, and
renal or liver function panels is not useful.