Perianesthesia care

As with any procedure, the surgeon and anesthesia care provider should give the perianesthesia nurse a full report on the anesthesia used and the procedure performed. With every procedure, the surgeon will write an operative note, which describes the procedure performed, viscera removed, drains present, and any other relevant intraoperative findings or complications. This action assists those who are caring for the patient in an assessment of the wounds, dressings, and expected drainage.

Care of the patient with nasogastric or intestinal tubes

Anesthesia and manipulation of the viscera during surgery cause gastric and colonic peristalsis to diminish or disappear completely for up to 5 days after surgery. Nasogastrointestinal or nasogastric tubes can be used after surgery to prevent the sequelae of this hypomotility. Edema at the operative site also can result in temporary obstruction.

If gastric decompression is needed, short tubes are generally used; long intestinal tubes are no longer used. Short tubes used include the Levin and the plastic Salem sump, which is a double-lumen nasogastric tube and is the most commonly used tube. The double lumen prevents excessive negative pressure from developing when the tube is connected to suction. To benefit from the double-lumen tube, however, it is important that the lumen to air is not obstructed and is “sumping,” or the tube will become obstructed by sucking on the gastric wall.¹

When the patient returns from the operating suite with a nasogastric tube in place, the nurse must ascertain why the tube was placed, where it was placed, and whether it should be connected to suction or to straight-gravity drainage. The physician often orders the tube to be connected to low-pressure intermittent suction (20 to 80 mm Hg). Usually only low-pressure intermittent suction is used, because excessive negative pressure in either the stomach or the bowel pulls the mucosa into the lumen of the tube and can cause traumatic ulcers. For double-lumen nasogastric tubes, continuous suction at 40 to 60 mm Hg is usually ordered and is necessary for the tube to function properly. Keeping the open lumen above the midline improves functioning of the double-lumen tube.

Esophagus

Surgery on the esophagus includes repair of hiatal hernia and various forms of tracheoesophageal fistulas, excision of esophageal diverticula, treatment of stenosis of the lower end of the esophagus, esophagomyotomy, esophagectomy, and antireflux procedures.

Postoperative care depends on the kind of incision used to expose the operative site: abdominal, thoracic, or laparoscopic. Surgery on the esophagus frequently involves a thoracic incision. Care for the patient after a thoracic incision is discussed in Chapter 34. Procedures involving the esophagus are performed with general anesthesia.

On arrival to the PACU, the patient should be placed in a semi-Fowler position. This position aids in the drainage of blood from the pleural space and prevents tension from impinging on the suture lines. The incision is generally long (from the tip of the scapula to the seventh or eighth rib area) and painful. Analgesics must be given in adequate doses to promote rest and adequate respiratory effort. An interpleural or epidural catheter often is in place for postoperative analgesia. Patient-controlled analgesia may be used.

A nasogastric tube is in place and should be cared for as previously discussed. The nurse should not manipulate the tube. Chest tubes should be managed as discussed in Chapter 34. A large, sterile dressing should be in place and should be checked frequently for drainage and reinforced as necessary. Excessive bloody drainage should be reported to the surgeon.

Stomach

Surgery on the stomach involves procedures to treat the complications of ulcers (e.g., pyloroplasty, gastric resection, gastrectomy), removal of portions of the stomach for malignant disease, and rerouting of the gastrointestinal system at this point to treat pyloric obstruction. In addition, gastric restrictive procedures for the treatment of clinically severe obesity (bariatric surgery) are also performed commonly (see Chapter 45). These procedures can be conducted as both open and laparoscopic procedures. All postoperative care of the patient is generally the same, and anesthesia is general.

After surgery, the patient should be placed in a semi-Fowler position to relieve tension on the abdominal wall suture line, to prevent aspiration, and to promote drainage. When the patient’s condition is hemodynamically stable, the obese patient (e.g. a patient requiring bariatric surgery) may benefit from positioning in a reverse Trendelenburg position at 45 degrees to maximize respiratory effort and decrease the effects of the abdominal weight interfering with adequate ventilatory effort. For open procedures, the abdominal incisions are fairly high, long, and painful; particular attention must be paid to pulmonary toilet. This patient must be encouraged more often than any other to expand the lungs and to cough and must generally have assistance to change position. Assistance in splinting the wound with the hands or with a firm pillow is usually appreciated by the patient. These procedures generally produce considerable postoperative pain, and analgesics should be used generously but judiciously. Patient-controlled or continuous epidural analgesia may be effective for upper abdominal incisional and visceral pain. Patients who have diagnosed or may have obstructive sleep apnea or obesity hypoventilation syndrome are extremely sensitive to opioid analgesics.² Cautious administration and vigilant monitoring are essential, especially in these patients, to avoid respiratory depression and complications.

A nasogastric tube is in place and should be cared for as discussed previously. Small volumes of bloody drainage from the nasogastric tube can be expected for the first 2 to 3 hours, because bleeding at the anastomotic site is common in these procedures. However, bright red bleeding that does not decrease after this period or bleeding that becomes excessive (more than 75 mL/h) should be reported immediately to the surgeon. Observe the nasogastric tube and its drainage closely, because blood easily clots and clogs the tube. Notify the surgeon immediately if the tube stops draining or appears obstructed with blood. Because blood loss can be highly significant in this patient, cardiovascular status must receive careful scrutiny. Vital signs are checked frequently. If hypotension and tachycardia persist or maintain a downward trend, the surgeon should be notified.

Blood replacement may have to be instituted. Hemoglobin and hematocrit levels should be determined 4 to 6 hours after surgery, and the surgeon should be notified if the levels are significantly lower than previous determinations. Little or no drainage should be expected from the incision unless drains are in place. If drainage appears, the dressing should be reinforced and the surgeon notified. The nurse in the PACU should not replace the initial dressing unless so directed by the surgeon. Drains with copious output may need a drainage device applied over them to protect the patient’s skin and to allow for accurate measurement of drainage, but the surgeon should be notified first.

Urinary retention may be a problem after abdominal surgery if an indwelling balloon-tipped catheter is not in place. Accurate measurements of output should be ascertained. If a urinary catheter is not in place, the patient should be checked frequently for bladder distention, which can indicate an overfull bladder and urinary retention. If the patient is unable to void, a catheterization order should be obtained.

Small bowel

Operations on the small bowel include exploratory laparotomy with lysis of adhesions and resection for obstruction or perforation. Care after these procedures is essentially the same as that already mentioned. No excessive drainage from incisions should be noted unless drains have been placed. Fluid and electrolyte balance must be monitored carefully. Remember that the loss of sodium and bicarbonate ions is great, which results in imbalance, and that fluid losses during surgery may be significant, but fluid overload must be avoided.

The patient with an ileostomy enters the PACU with a bag in place over the stoma. The condition of the stoma should be pink and moist. Returns may be expected almost at once and should be recorded. Particular attention must be paid to this stoma, the drainage, and the collection device; no leakage onto the skin should be allowed because this causes significant skin irritation. Under the collection device, the peristomal skin is protected with a skin barrier that includes pectin-based and karaya-based wafers or paste.

Large bowel

Surgery on the large bowel includes appendectomy, colostomy, various types of colonic resection for removal of tumors or correction of other problems, total proctocolectomy with ileostomy or ileoanal anastomosis (Fig. 40-3), and abdominoperineal resection with permanent colostomy (Fig. 40-4). Most of these surgical procedures are performed with general anesthesia. On return to the PACU, patients are kept flat and on one side until the reflexes have returned; they may then assume a position of comfort unless otherwise specified by the surgeon. Specifically after abdominoperineal resection, patients should not have any direct pressure on their perineal wounds. Postoperative care is essentially the same as for small bowel surgery.

FIG. 40-3 Ileoanal anastomosis with J-pouch for treatment of ulcerative colitis.

(From Black JM, Hokanson Hawks JH: Medical-surgical nursing: clinical management for positive outcomes, ed 8, St. Louis, 2008, Saunders.)

FIG. 40-4 Large bowel procedures for resection of malignant disease. A, Anterior resection with primary anastomosis. B, Abdominoperineal (anteroposterior) resection with permanent colostomy. C, Proctosigmoidectomy with “pull through.”

(From Black JM, Hokanson Hawks JH: Medical-surgical nursing: clinical management for positive outcomes, ed 8, St. Louis, 2008, Saunders.)

If the patient returns from surgery with a colostomy, some special care is required. The colostomy usually does not start functioning immediately after surgery; however, spillage must be prevented from contaminating the incision or excoriating the skin. A pouch or collection device will be in place over the colostomy. The skin around the stoma should be protected with an appropriate skin barrier if drainage is present. The color and appearance of the stoma (it should be pink and moist) should be assessed and documented in the nursing record.

Fluid and electrolyte balance must be monitored carefully. Some blood-tinged urine can be expected after colectomy, because retractors used in surgery may have caused contusions of the bladder; however, gross blood can indicate that the bladder was more severely injured. If ureteral catheters were used during surgery, this will also cause bloody urine. Dressings should remain dry unless drains were placed in the wound. If drains were placed, some bloody drainage may be expected, and dressings should be reinforced as necessary. Drainage that soaks through the dressings is considered excessive and must be reported to the surgeon.

Incisions may be left open to heal with delayed primary closure or secondary intent if there was significant contamination at the time of surgery. Abdominal wounds for bowel surgery may be contaminated (e.g., traumatic penetrating injuries, colostomies) with an increased risk of infection. For a delayed primary closure, the wound is left open, protected with moist gauze, and, when it is clean and red, closed with sutures that were placed during the original surgery and left slack. The cleanliness of the wound and the health of the granulation tissue in the wound generally determine the best time for closure.

Lower rectum and anus

Surgery on the lower rectum and anus includes excision of pilonidal cysts, rectal fissures, fistulas, rectal abscesses, tumors, and hemorrhoids. Perianesthesia nursing care is the same as for any patient who undergoes local, regional, or general anesthesia. Dressings should be checked frequently for excessive drainage and bleeding. The incisions may be closed, but often are packed to facilitate drainage of infected material and aid in healing. Urinary retention can be a problem because the proximity of the bladder and operative site can make urination difficult. Pain can be severe, but patients are often embarrassed by the location of the operative site and might not ask for analgesia. The nurse should be alert to signs and symptoms of pain and discomfort and administer analgesia as necessary for relief.

Liver

Surgery on the liver includes biopsy, excision of tumors, major resection, repair of traumatic lacerations, and liver transplant.

Percutaneous liver biopsy is a common procedure that is usually performed in the endoscopy suite, although the patient may be taken to the operating suite and may return to the PACU for a short period of observation. Postoperative care depends on the type of anesthesia used; anesthesia is usually local, but may involve other types if the patient cannot or will not cooperate. The patient should remain positioned on the right side for at least 2 hours after the procedure. Vital signs should be determined frequently: every 10 to 15 minutes for the first hour and every 30 minutes for the second hour. Complications include hemorrhage from penetration of a blood vessel and peritonitis from accidental puncture of the biliary tree. If the patient’s vital signs begin a downward trend or if the patient reports severe abdominal pain or becomes febrile, the surgeon should be notified immediately.

Open or laparoscopic surgery on the liver for the excision of tumors or the repair of lacerations is done with general anesthesia and, if open, involves a fairly long upper abdominal vertical or bilateral subcostal oblique (chevron) incision. Liver transplantation may be indicated in patients with end-stage liver disease, fulminant acute liver failure, hepatocellular carcinoma, and pediatric metabolic liver diseases when a patient meets established criteria.³ The transplanted liver may be from a living donor or cadaver. All care previously discussed for patients after general anesthesia and upper abdominal incisions applies. Respiratory care is of paramount importance. The liver is an extremely vascular organ. It is difficult to suture; gross bleeding is common and often involves large blood losses, especially when surgery is necessitated by traumatic injury or large resection. Large drains of the suction (grenade or bulb) type are placed in the region of the laceration or excision of the tumor and are brought through separate sites to the skin surface. For the first 8 hours, expect approximately 100 to 250 mL of serosanguineous drainage from the drains.

Coagulation studies must be performed frequently and monitored closely, because many patients have coagulation abnormalities that develop during and after liver surgery. Specific coagulation factors may be administered, according to the results of the coagulation tests. Phosphate levels must also be monitored closely after major liver resection.

Vital signs must be assessed frequently, and any downward trend should be reported to the surgeon at once. Blood replacement or hemostasis may be inadequate. Rapid infusions of fluid replacements may be needed, especially after extensive liver resection or transplant. Occasionally, this patient also has a T-tube in place in the common bile duct (Fig. 40-5). This tube should be attached to straight-gravity drainage, and accurate measurements of the output should be made. A nasogastric tube is often in place and should receive care as discussed previously. Pain may be severe, and opioid analgesics or epidural analgesia are necessary to promote rest and respiratory effort.

FIG. 40-5 T-tube placement in common bile duct.

(From Black JM, Hokanson Hawks JH: Medical-surgical nursing: clinical management for positive outcomes, ed 7, St. Louis, 2005, Saunders.)

Spleen

Surgery on the spleen involves general anesthesia and removal of the organ, with either an open or laparoscopic technique. The spleen is removed because of rupture from trauma; accidental trauma from associated surgery; diseases that cause damage, such as mononucleosis and malaria; a variety of hematologic diseases; left-sided portal hypertension; and hypersplenism. If the procedure is done with an open technique, a midline or left subcostal incision is used. Postoperative care for the patient after splenectomy is the same as that for the patient after repair of a lacerated liver. Dressings should remain dry and intact. A drain may be placed in the subdiaphragmatic space to prevent the collection of blood under the diaphragm and to detect unrecognized injury to the pancreas that may have occurred.

The perianesthesia nurse should know the circumstances that lead to the patient’s splenectomy. If it was necessitated by trauma, the nurse must be particularly alert for signs that indicate development of unrecognized complications from the accident. Vital signs should be determined frequently, and trends should be watched, especially those that indicate progressive bleeding. Neurologic signs should be checked, and the patient should be assessed carefully for any signs of injury to the extremities. Any dysrhythmia should be reported, because it can indicate cardiac injury.

Pancreas

Surgery on the pancreas is difficult and technically demanding. It involves general anesthesia, and care for these patients is the same as for other postoperative patients.

Postoperative care of the patient after a pancreaticoduodenectomy (Whipple procedure) requires particular attention to drains and catheters. All postoperative care for the abdominal surgery patient applies. Surgeons should augment their reports to the nurse by explaining exactly what procedure was performed, where drains or wound catheters were placed, and how to care for them. Surgeons should brief the nurse on expected drainage and what should be considered excessive. As with all abdominal surgeries, intravenous lines and intravenous therapy have already been initiated.

All respiratory, cardiac, and renal functioning must be monitored carefully, and the surgeon should be notified of any untoward signs. If frequent arterial blood gas analysis is needed for this patient, an arterial line should be in place for this purpose. Blood gas analysis yields valuable information about the patient’s respiratory acid-base status. Urine output should be determined hourly, and at least 0.5 to 1 mL/kg/h should be expected.

Frequent assays of blood glucose levels should be ordered for all patients after pancreatic surgery. Most of these patients need to receive intravenous insulin during the postoperative period. Generally, insulin doses are titrated to maintain the blood glucose levels between 140 and 180 mg/dL in the critical care setting and at less than 140 mg/dL in the noncritical care setting.⁴ The insulin aids in preventing hyperglycemia.

Large fluctuations in serum glucose levels or acid-base balance can precipitate electrolyte abnormalities in these patients. Potassium and calcium levels, in particular, should be monitored closely.

Biliary tract

Surgery on the biliary tract includes exploration for removal of stones from the gallbladder and the ducts and removal of the gallbladder. It can also include repair of biliary tract injuries and resection for malignant disease or benign strictures. Anesthesia is general, regional, or a combined technique. For cholecystectomy, the procedure is performed with a laparoscope, the patient has an umbilical incision and three small subcostal incisions for instruments (Fig. 40-6); if performed open, the incision is either a right subcostal or a midline incision. On return to the PACU, the patient is placed in a semi-Fowler position. All tubes must be cared for appropriately. A nasogastric tube is typically placed during surgery and is often removed when the operative procedure ends. A T-tube is placed in the common bile duct if the common duct was opened during surgery. This tube is usually connected to straight-gravity drainage to a bile bag. Careful attention must be paid to maintaining the patency of this tube and its attachment to the patient; the surgeon needs to be called immediately if the tube is dislodged.

FIG. 40-6 Placement of laparoscope and instrument ports for laparoscopic cholecystectomy.

(Redrawn from Malt RA: The practice of surgery, Philadelphia, 1993, Saunders.)

Bile drainage should be carefully measured and accurately reported. Between 200 and 500 mL of bile drainage can be expected within a 24-hour period. Dressings should remain dry and intact and should be reinforced as necessary to keep the surrounding skin dry.

As with all upper abdominal incisions, pain is a challenge, and analgesics (intermittent, continuous, or patient-controlled), epidural analgesia, and relaxation exercises should be used to promote rest and respiratory effort. Any downward trend in vital signs, excessive bleeding from the incision, or bleeding noted in the bile drainage from the T-tube should be reported to the surgeon. Bleeding from the cystic artery is a rare but serious complication and can lead to hemodynamic deterioration in the patient.

After laparoscopic cholecystectomy, the patient may have one of the most stable conditions of any seen in the PACU. Any patient with unexplained pain, oliguria, or hypotension should be immediately discussed with the surgeon. Complications of gas embolism, deep vein thrombophlebitis, subcutaneous emphysema, injuries to major vessels and intestine, and bile leakage all have been reported after laparoscopic procedures. Right shoulder pain is often experienced because of the referred pain from a nerve running up from the diaphragm; however, this resolves fully within 72 hours.