The modern surgeon is involved with the management of a patient from preoperative evaluation, through the conduct of the operation into the postoperative care period and often into generating a long-term plan. As the operating surgeon, he/she is best situated to apply evidence-based scientific knowledge and a deep understanding of potential complications to that patient’s care. The recovery from major surgery can be divided into three phases:
An immediate, or postanesthetic phase
An intermediate phase, encompassing the hospitalization period
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 IMMEDIATE POSTOPERATIVE 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 functions 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. Careful review of order sets is still warranted, as individual patients require specialized attention. Postoperative orders should cover the following.