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Tom Sharon
The first two hours of recovery are crucial


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After the Operation
Recovering from the Anesthesia

After the surgical patients survive the worrisome experience called surgery, the first two hours of recovery are also precarious. This is why there is a special unit called the postanesthesia recovery unit (PACU), the former name for which was the recovery room. The first danger is the possibility of trauma during the transfer of the patient from the operating table to the recovery bed. The usual procedure is to have the surgical team grab the sheet that is under the patient and use it to hoist the unconscious patient onto the stretcher at the count of three. Sometimes it is a smooth transition, but often the movement is a jerky one, and the patient comes down on the stretcher with a thud. I have always viewed this practice as cavalier and dangerous. Most internal stitches used to close the nicks in bleeding arteries are made of catgut and can easily snap with movement, resulting in internal bleeding. When this happens, the discovery of it might be too late. The best scenario would still require going back to the operating room to be reopened.

A fifty-three-year-old man I'll call George went in for an arterial bypass in the right leg to counter a blocked artery behind the knee. The lower leg was not getting sufficient circulation and was beginning to turn colors. The operation was successful, George's right lower leg was showing normal color and was warm to touch, and there was a strong pulse in the foot and ankle. The transfer from the table to recovery bed did not go well. The team did not have good support under the affected leg, and they dragged it along and bounced it slightly while they moved him over. The surgeon said, "Hey! Be careful!" He might as well have said, "Don't do that again," because it was after the fact. After that, no one gave the incident another thought.
 
In the two weeks that followed, George's right leg deteriorated. First, the pulse became diminished and then nonexistent. The foot was cold to touch. The calf muscle swelled up and became hot and hard. This was obviously a blood collection that no one was paying any attention to until one of the nurses complained to the chief of surgery, which caused the vascular surgery residents to come running. They took George back to the operating room and reopened the leg. Apparently, some of the graft sutures had snapped, and the graft was leaking into the calf muscle from the time of the traumatic transfer to the recovery bed. George's leg ultimately developed gangrene, and he underwent amputation. Notwithstanding all the missed opportunities to save the leg, the primary cause was the faulty transfer.
 
The only way to assure a nontraumatic transfer is to use a transfer device known as a Hoyer lift. The nurses simply place a canvas hammock under the patient before surgery and then attach it to a hydraulic lift. The lift then transfers the patient over to the bed and gently eases him or her down. One or two people can safely accomplish the entire task. It is safer for the patient and prevents staff from injuring themselves in the process. The hydraulic devices are already available in most hospitals. It is a simple matter to change policy to implement its use in the operating room. It is already in use for patients who weigh hundreds of pounds. I advocate its mandatory routine use in the operating rooms of all hospitals for all patients. It might take a couple of minutes longer to complete the transfer, as opposed to four people hurriedly doing one of those "everybody on three" routines, so people will undoubtedly meet this idea with some resistance. Nonetheless, the extra time would be a good investment if it avoids traumatizing a fresh postoperative patient. Although we are not likely to be successful in changing the current standards for transfer, you can request that your surgeon insist on using a Hoyer lift to transfer you from the operating table. If your surgeon agrees to it, he or she has the authority to make it happen.
 
The first hour in the PACU is the most crucial period. The nurse is required to do a complete assessment with full vital signs every fifteen minutes, followed by half-hour intervals after the first hour. He or she will adjust this interval depending on whether the patient remains stable. This is the place where the nurse must check the patient thoroughly and frequently for any complications from the anesthesia, such as nausea and vomiting.
 
One of the greatest risks immediately after surgery is choking, because people often vomit as soon as they regain consciousness due to the effects of the drugs. The staff cannot allow patients to heave while lying on their backs, so they must maintain a constant vigil and turn patients on their sides or at least turn their heads to one side at the first sign of vomiting. This is where family members can help. They should become involved in requesting a brief conversation with the PACU nurse to say, "I'm so worried because I hear about the possibility of people choking on their vomit. Please watch carefully so this does not happen".
 
Many hospitals allow one or two immediate family members to stay with the patient in the PACU at the charge nurse's discretion. If this is true in your case, then it would be a good idea to be there. If any vomiting occurs, the nurse or physician must turn the patient as far as possible to one side. The visitor must not attempt any intervention except for calling out for assistance if there is no staff at the bedside when the vomiting begins.
 
The other risks of complications are the same as in the lCU.

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