Post-Operative Recovery and Pain Relief

Springer London Berlin Heidelberg New York Barcelona Budapest Hong Kong Milan Paris Santa Clara Singapore Tokyo

R. Eltringham, W. Casey and M. Durkin

Post-Operative Recovery and Pain Relief With 43 Figures

t Springer

Roger J. Eltringham, MB, ChB, FRCA Michael Durkin, MBBS, FRCA William F. Casey, MB, ChB, FRCA, MA

Department of Anaesthesia, Gloucestershire Royal Hospital, Gloucester GLl 3NN, UK

ISBN-13: 978-3-540-76078-8 DOl: 10.1007/978-1-4471-0899-3

e-ISBN-13: 978-1-4471-0899-3

British Library Cataloguing in Publication Data Eltringham, Roger

Post-operative recovery and pain relief 1. Postoperative care 2. Analgesia I. Title II. Durkin, Michael III. Casey, William Francis 617.9'19

ISBN 3540760784

Library of Congress Cataloging-in-Publication Data Eltringham, Roger, 1939-

Post-operative recovery and pain relief 1 R. Eltringham. W. Casey, and M. Durkin.

p. cm. Rev. ed. of: Post-anaesthetic recovery 1 Roger Eltringham ... let

al.). 2nd ed. 1989. Includes bibliographical references and index.

1. Postoperative care. 2. Postoperative pain. 3. Post anesthesia nursing. I. Casey, W. (Williaml, 1949- . II. Durkin, MichaeL III. Post-anaesthetic recovery. IV. Title.

IDNI.M: 1. Postanesthesia Nursing. 2. Recovery Room--nurses' instruction. 3. Postoperative Care--nurses' instruction. 4. Postoperative Complications--prevention & control--nurses' instruction. 5. Pain, postoperative--therapy--nurses' instruction. WY 154 E51pa 1997) RD51.E58 1997 617'.919--dc21 DNLM/DLC 97-14221 for Library of Congress CIP

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Preface

Recent advances in anaesthesia and monitoring have enabled patients who, a few years ago, would have been considered unfit for surgery, now to undergo increasingly complex and lengthy operations in safety.

However, if the good work done by anaesthetists and surgeons in the operating theatre is not to be in vain, high standards of monitor­ing and patient care must be continued into the critical early post­operative phase when patients are recovering from the immediate effects of their anaesthetic and surgery, and before they are fit to return to general wards. The Medical Defence Societies, the Royal Colleges and a series of reports from the National Confidential Enquiry into Perioperative Deaths have all stressed the vital import­ance of having appropriate recovery facilities whenever and wherever surgery is performed.

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 irretrievable situation is reached.

This book describes the major problems that may be encountered and suggests how they may be avoided by careful monitoring, vigilant nursing and sound organisation. The behaviour of patients during recovery is influenced by their pre-operative medical condition, by drugs they may receive both pre- and intra-operatively and by the nature of the surgery they have undergone. Sections of the book devoted to each of these areas have been extensively revised to ensure they reflect current best practice.

The section on pain management and regional anaesthesia has been expanded with discussion of patient-controlled analgesia (PCA), continuous epidural narcotic and local anaesthetic infusions, and pleural blockade. We are delighted to have been joined by Dr Jane Brown, one of our consultant anaesthetist colleagues, who has re­written the chapter on Day Surgery to emphasise its ever-increasing importance.

Sue Andrewes, who made immense contributions to the first two editions of this book, is no longer in clinical practice and has decided not to contribute to this edition. We wish to acknowledge that, with-

v

vi Preface

out her skill and assistance, this book would never have appeared and we wish her and her husband well in their retirement.

We hope that this book will continue to provide a readily available source of practical information not only to nursing staff working in operating theatres and post-operative care units, but also to those working in surgical units, as well as house officers (residents) and junior anaesthetists.

Gloucester, 1997 Roger J. Eltringham Michael A. Durkin

William F. Casey

Contents

Chapter 1 The Role of the Recovery Room ................................................. 1 Introduction ....................................................................................................................... 1 Designing a Post-anaesthesia Care Unit.. ............................................................. l Equipment ........................................................................................................................... 2

Equipment Required at Each Recovery Bay .................................................. 3 Cardiorespiratory Equipment .............................................................................. 3 Paediatric Equipment ............................................................................................... 4 Miscellaneous Equipment ...................................................................................... 4 Drugs and Intravenous Fluids ............................................................................. 5

Safety ...................................................................................................................................... 5 Pollution ......................................................................................................................... 5 Blood-borne Infections ........................................................................................... 5

Staffing .................................................................................................................................. 6 Continuing Education and Training ...................................................................... 7 Policies and Protocols .................................................................................................... 8

References and Bibliography ................................................................................ 8

Chapter 2 Normal Recovery ................................................................................. 9 Physiology of the Elimination of Drugs Used During Anaesthesia ......... 9

Volatile Agents ............................................................................................................ 9 Intravenous Induction Agents ............................................................................. 9 Suxamethonium .......................................................................................................... 9 Non-depolarising Muscle Relaxants .............................................................. 10 Analgesics ................................................................................................................... 10

Progress of Normal Recovery ................................................................................. 10 Stage IV: Medullary Paralysis ............................................................................ 11 Stage III: The Stage of Surgical Anaesthesia .............................................. 11 Stage II: The Stage of Excitement. ................................................................... 11 Stage I: The Stage of Analgesia ......................................................................... 12

Care-plan Nursing ........................................................................................................ 12 Reception of the Patient ............................................................................................. 13 Basic Nursing Position and Safety ........................................................................ 14 Routine Observations ................................................................................................. 14 Assessment of Colour ................................................................................................. 15

Peripheral and Central Cyanosis ..................................................................... 15 Assessment of Respiratory Function ................................................................... 16 Assessment of Cardiovascular Function ........................................................... 16

Tissue Perfusion ....................................................................................................... 16

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viii Contents

Pulse Measurement ................................................................................................ 17 Doppler Ultrasonic Recorder ............................................................................ 17 Blood Pressure Measurement ........................................................................... 18 Sphygmomanometer and Stethoscope ......................................................... 18 Oscillotonometer ..................................................................................................... 19 Automatic Blood-pressure Recording .......................................................... 19 Direct Arterial Pressure Measurement.. ....................................................... 20

Assessment of Level of Consciousness ............................................................... 23 Recognition of Blood Loss ........................................................................................ 24 Maintenance of the Airway ...................................................................................... 24 Insertion of Oropharyngeal Airway ..................................................................... 25 Insertion of Nasopharyngeal Airway .................................................................. 26 Suction of the Upper Airway ................................................................................... 27 Care of the Intubated Patient.. ................................................................................ 28

Endotracheal Suction ............................................................................................ 28 Extubation ................................................................................................................... 28

Care of the Patient with a Laryngeal Mask Airway (LMA) ....................... 29 The Ventilated Patient ................................................................................................ 29 Oxygen Therapy ............................................................................................................. 30 Administration of Oxygen ........................................................................................ 30 Maintenance of Fluid Balance ................................................................................ 33 Intravenous Fluid Therapy ...................................................................................... 34 Intravenous Infusions ................................................................................................. 34 Intravenous Infusion Drip Rates ........................................................................... 34 Intravenous Injections ............................................................................................... 35 Blood Transfusion ........................................................................................................ 35 Drainage Systems .......................................................................................................... 37 Record Keeping and Charting ................................................................................ 38 Criteria for Discharge ................................................................................................. 42

Discharge to a W ard ............................................................................................... 42 Discharge to Intensive Care or High-dependency Unit.. ..................... 43

Transfer of Patient to Ward Staff.. ........................................................................ 43 References and Bibliography ............................................................................. 43

Chapter 3 Pain Relief and Local Anaesthesia ......................................... 4S Introduction .................................................................................................................... 45 Gate-control Theory of Pain .................................................................................... 45 Methods of Pain Relief ............................................................................................... 47

Analgesic Drugs ....................................................................................................... 47 Patient -controlled Analgesia ............................................................................. 49 Balanced Analgesia ................................................................................................. 49 Local Anaesthetic Techniques .......................................................................... 53 Management of Toxic Reactions ...................................................................... 54 Local Anaesthetic Agents .................................................................................... 55

Specific Local Anaesthetic Blocks ......................................................................... 56 Spinal Blockade ........................................................................................................ 56 Epidural Blockade ................................................................................................... 57 Caudal Blockade ...................................................................................................... 60 Local Infiltration ...................................................................................................... 61 Intercostal Nerve Blockade ................................................................................ 61

Contents ix

Intrapleural Blockade ............................................................................................ 61 Inguinal Field Blockade ........................................................................................ 62 Penile Nerve Block ................................................................... ; .............................. 62 Brachial Plexus Blockade ..................................................................................... 62 Intravenous Regional Anaesthesia (Bier's Block) ................................... 63 Digital Nerve Blockade ......................................................................................... 64 Femoral Nerve Blockade ...................................................................................... 64

Patient Management in the P ACU ........................................................................ 65 References and Bibliography ............................................................................. 65

Cha pter 4 Complications ..................................................................................... 67 Respiratory Complications ...................................................................................... 67

Signs of Hypoxaemia ............................................................................................. 67 Signs of Hypercarbia .............................................................................................. 67 Upper Airway Obstruction ................................................................................. 68 Inadequate Ventilation (Hypoventilation) ................................................. 70 Hypoxaemia ............................................................................................................... 75 Bronchospasm .......................................................................................................... 76 Aspiration of Gastric Contents ......................................................................... 77 Pneumothorax and Haemothorax .................................................................. 78 Tension Pneumothorax ........................................................................................ 79

Cardiovascular Complications ............................................................................... 80 Hypotension ............................................................................................................... 80 Hypertension ............................................................................................................. 83 Bradycardia ................................................................................................................ 83 Tachycardia ................................................................................................................ 85 Dysrhythmias ............................................................................................................ 87 Cardiac Arrest ........................................................................................................... 90 Initial Management ................................................................................................ 92

Miscellaneous Complications ................................................................................. 93 Delayed Return of Consciousness ................................................................... 93 Restlessness, Excitement and Delirium ....................................................... 96 Nausea and V omiting ............................................................................................ 97 Shivering ...................................................................................................................... 98 Convulsions ................................................................................................................ 99 Hypothermia ............................................................................................................ 100 Hyperthermia .......................................................................................................... 101 Malignant Hyperthermia ................................................................................... 102 Blood Transfusion Reactions .......................................................................... 103 Problems Associated with Massive Blood Transfusion ...................... 104 Failure of Coagulation ......................................................................................... 106 Oliguria ....................................................................................................................... 109 References and Bibliography ........................................................................... 111

Chapter 5 Recovery in Different Branches of Surgery ................. 113 Emergency Surgery .................................................................................................... 113

Surgery for Trauma .............................................................................................. 113 Surgery in the Accident Department.. ......................................................... 114

Gastroenterology ......................................................................................................... 114 Endoscopy ................................................................................................................. 114

x Contents

Upper Gastrointestinal Tract Bleeding ....................................................... 115 Surgery for Intestinal Obstruction or Peritonitis .................................. 115 Bowel Surgery .......................................................................................................... 115

Orthopaedic Surgery ................................................................................................. 116 Plaster Casts ............................................................................................................. 116 Traction ...................................................................................................................... 117 Reduction of Fractures ....................................................................................... 117 Hip Operations ....................................................................................................... 117 Fractured Vertebrae ............................................................................................. 118

Obstetrics and Gynaecology .................................................................................. 118 Caesarian Section .................................................................................................. 118 Evacuation of Retained Products of Conception; Suction

Termination of Pregnancy .......................................................................... 119 Laparoscopy ............................................................................................................. 119 Hysterectomy .......................................................................................................... 120

Ear, Nose and Throat Surgery ............................................................................... 120 Tonsillectomy .......................................................................................................... 120 Laryngoscopy .......................................................................................................... 121 Tracheostomy .......................................................................................................... 121 Operations on the Nose ...................................................................................... 122 Middle-ear Surgery ............................................................................................... 123

Thyroid Surgery ........................................................................................................... 123 Airway Problems ................................................................................................... 123 Thyroid Crisis or Storm ..................................................................................... 124

Dental and Faciomaxillary Surgery .................................................................... 124 Post-operative Bleeding ..................................................................................... 124 Wiring of the Jaw ................................................................................................... 125 Fracture of the Zygomatic Arch ..................................................................... 125 Mentally Handicapped Patients ..................................................................... 125

Ophthalmic Surgery ................................................................................................... 125 Position ....................................................................................................................... 126 Intra-ocular Pressure (lOP) ............................................................................. 126 Pupil Size ................................................................................................................... 126 Analgesia ................................................................................................................... 126 Drug Interactions .................................................................................................. 126

Neurosurgery ................................................................................................................ 126 Thoracic Surgery ......................................................................................................... 130

Bronchoscopy .......................................................................................................... 130 Thoracotomy ................................................................................................................. 131

Pain Relief ................................................................................................................. 132 Vascular Surgery ......................................................................................................... 133

Pain Relief. ................................................................................................................ 134 Genito-urinary Surgery ............................................................................................ 135

Prostatectomy ......................................................................................................... 135 Nephrectomy.: ......................................................................................................... 136 Circumcision ........................................................................................................... 137

Paediatric Surgery ....................................................................................................... 137 Maintenance of Airway and Adequacy of Ventilation ........................ 137 Maintenance of Adequate Cardiovascular Function ........................... 139 Temperature Regulation .................................................................................... 140

Contents xi

Fluid Balance ........................................................................................................... 141 References and Bibliography ........................................................................... 141

Chapter 6 Pre-existing Factors Affecting Recovery ........................ 143 Premedication ............................................................................................................... 143 Anaesthetic Technique ............................................................................................. 143

Intravenous Induction Agents ........................................................................ 143 Long-acting Inhalational Agents ................................................................... 144 Analgesic and Relaxant Technique ............................................................... 144 Regional Anaesthesia .......................................................................................... 144 Induced Hypotension .......................................................................................... 145 Ketamine .................................................................................................................... 145

Pre-operative Drug Therapy .................................................................................. 146 Anti-hypertensive Agents ................................................................................. 146 Monoamine Oxidase Inhibitors (MAOIs) ................................................. 146 Corticosteroids ....................................................................................................... 147 Insulin and Hypoglycaemic Agents ............................................................. 147 Anticoagulants ........................................................................................................ 147 Diuretics ..................................................................................................................... 147 Antibiotics ................................................................................................................. 148 Digoxin ....................................................................................................................... 148

Respiratory Disease ................................................................................................... 148 Chronic Bronchitis ............................................................................................... 148 Asthma ........................................................................................................................ 149

Cardiovascular Disease ............................................................................................ 149 Coronary Artery Disease ................................................................................... 149 Hypertension ........................................................................................................... 150 Cardiac Failure ....................................................................................................... 150 Pacemaker ................................................................................................................. 150

Neuromuscular Disease ........................................................................................... 151 Myasthenia Gravis ................................................................................................ 151 Muscular Dystrophy ............................................................................................ 152 Paraplegia .................................................................................................................. 152

Liver Disease ................................................................................................................. 152 Renal Disease ................................................................................................................ 153 Endocrine Disorders ................................................................................................. 154

Diabetes Mellitus ................................................................................................... 154 Thyroid Disease ........................................................................................................... 155

Hypothyroidism ..................................................................................................... 155 Hyperthyroidism ................................................................................................... 155

Phaeochromocytoma ................................................................................................ 155 Porphyria ........................................................................................................................ 156 Haematological Disease ........................................................................................... 156

Iron-deficiency Anaemia ................................................................................... 156 Haemophilia ............................................................................................................ 156 Sickle Cell Disease ................................................................................................. 157 Deficiency of Clotting Factors ......................................................................... 158

Musculoskeletal Disease .......................................................................................... 158 Rheumatoid Arthritis .......................................................................................... 158 Osteoporosis ............................................................................................................ 158

xii Contents

Ankylosing Spondylitis ....................................................................................... 159 Geriatric Patients ......................................................................................................... 159 Pregnancy ....................................................................................................................... 160 Malnourishment .......................................................................................................... 160 Obesity .............................................................................................................................. 160

References and Bibliography ........................................................................... 161

Chapter 7 Recovery and Day Surgery ....................................................... 163 Patient Selection .......................................................................................................... 163

Social Circumstances ........................................................................................... 163 Medical Factors ...................................................................................................... 164

Procedure Selection ................................................................................................... 164 Examples of Suitable Procedures .................................................................. 164

Pre-admission Clinic ................................................................................................. 1 65 Documentation ............................................................................................................ 166 Anaesthetic Management ....................................................................................... 166 Recovery from Anaesthesia ................................................................................... 167 Discharge from the Hospital ................................................................................. 167 Paediatrics ...................................................................................................................... 168

Management ............................................................................................................ 169 Post-anaesthetic Complications .......................................................................... 169

Pain ............................................................................................................................... 169 Regional or Local Anaesthesia ........................................................................ 169

General Anaesthesia .................................................................................................. 170 References and Bibliography ........................................................................... 171

Chapter 8 Monitoring ............................................................................... 173 ASA Classification ...................................................................................................... 174 Routine Monitoring ................................................................................................... 174 Respiratory System .................................................................................................... 175 Cardiovascular System ............................................................................................. 176 Metabolic Systems ...................................................................................................... 176 Neurological System .................................................................................................. 176 Specific Monitors ........................................................................................................ 177

Electrocardiograph (ECG) ................................................................................ 177 Arterial Pressure .......................................................................................................... 179

Invasive Methods .................................................................................................. 179 Non-invasive Methods ........................................................................................ 17 9

Pulmonary Artery Pressure ................................................................................... 180 Oxygen Saturation ...................................................................................................... 181 Neuromuscular Blockade ........................................................................................ 18 2 Carbon Dioxide Tension ......................................................................................... 183

References and Bibliography ........................................................................... 183

Appendix A Drugs Commonly Used in the PACU ................................ 185 Appendix B Translations of Standard Recovery Phrases ............. 191

Index ................................................................................................................................. 193