Observation 1 patient after anesthesia. Postoperative period: care after anesthesia
On an outpatient basis, before releasing the patient after surgery and anesthesia, the doctor must make sure that the adequacy of his reactions and behavior is restored. This should be based on assessment of the general condition of the patient and his psychophysiological functions. Immediately after anesthesia, the patient is placed in a horizontal position in the ward or postoperative observation room. After regaining consciousness ask questions about well-being. In the presence of lethargy, weakness, nausea, the patient should lie more long time. For each patient, it is necessary to find out how he orients himself in space and time by asking him a few simple questions. Quite often, special tests are used for these purposes, for example testBidway, - disappearance of postoperative drowsiness and restoration of orientation (E. Garry et al., 1977). The patient's responses are evaluated on a 5-point system:
4 points - the patient does not respond to the verbal command and pain stimulation;
3 points - the patient responds to pain stimulation, but does not make contact;
2 points - the patient responds to a verbal command and responds to pain stimulation, but does not orient himself in space and time;
1 point - the patient responds to all forms of stimulation, is well oriented in time and space, but feels drowsy;
0 points - the patient is well oriented in space and time, there is no drowsiness.
After the above phenomena disappear, check the recovery motor coordination. It is necessary to make sure that there is no nystagmus, check the stability in the Romberg position, conduct a finger-nasal test, note the absence of ataxia when walking with closed and open eyes. The patient must be fully oriented and stable in relation to the functions of the vital organs, not experience nausea, the urge to vomit, be able to move around, drink and urinate.
They also determine the clarity and speed of thinking, attention and orientation in the environment. To do this, you can use a special Bourdon test(crossing out a given letter in 10 lines of regular book text) or Garatz test(writing 5-7 three-digit numbers, and each subsequent one must begin with the last digit of the previous one). Correct or with an insignificant number of errors and a fairly quick performance of these tests indicates a complete restoration of attention and orientation.
Pain is eliminated by the appointment of analgesics per os. After that, the patient must be escorted home and on the first day he must be under control. The patient should also be instructed to: contact the clinic in case of complications; stop drinking alcohol, as well as driving a car and using any technical devices during the first 24 hours, since it is impossible to accurately predict the full recovery of all body functions. An appropriate entry must be made in the individual outpatient record - the main medical and legal document.
In stationary conditions, the possibility of monitoring and monitoring the patient after undergoing intubation anesthesia is more favorable. Directly from the operating room after awakening and extubation of the patient, it is advisable to transfer to special awakening wards, organized in the conditions of the intensive care unit and anesthesiology, where he stays for 2-3 hours under the dynamic supervision of specialists until complete recovery from anesthesia with a guarantee of restoration of vital parameters of homeostasis of the body and elimination of possible complications associated with general anesthesia. If necessary (after extensive, prolonged or traumatic surgical interventions in maxillofacial region) with a probable threat of development early complications on the part of the vital functions of the body or their instability, it is advisable to transfer the patient from the operating room (in agreement with the operating surgeon and anesthesiologist) to the wards intensive care using technical means of monitoring on days 1–3 (sometimes in such cases, extubation is performed only in intensive care units after complete compensation of the patient's condition). Subsequently, for further specialized treatment, the patient is transferred to the department of maxillofacial surgery, where, along with the main treatment, prevention of the development of post-anesthetic complications is also carried out (alkaline oil inhalations, physiotherapy exercises, control analyzes of body homeostasis parameters are prescribed).
After undergoing neuroleptanalgesia or short-term intravenous anesthesia, the patient in a stable compensated state can be transferred from the operating room immediately to the wards of the maxillofacial surgery department under the supervision of the attending physicians and the medical staff on duty.
In preparation for local anesthesia attention should be paid to the patient, explain to him about the advantages of local anesthesia. In a conversation with the patient, it is necessary to convince him that the operation will be painless if the patient reports the appearance of pain in time, which can be stopped by adding an anesthetic. The patient must be carefully examined, especially the skin, where local anesthesia will be performed, since this type of anesthesia cannot be performed with pustular diseases and skin irritations. The patient needs to find out allergic diseases especially allergic to anesthetics. Before anesthesia, measure blood pressure, body temperature, count the pulse. Before premedication, ask the patient to empty bladder. 20-30 minutes before the operation, premedicate: inject 0.1% atropine solution, 1% promedol solution and 1% diphenhydramine solution 1 ml intramuscularly in one syringe. The purpose of premedication is to reduce the emotional arousal of the patient, neurovegetative stabilization, prevention allergic reactions, decrease in secretion of glands, decrease in response to external stimuli Barykina N.V., Zaryanskaya V.G. Nursing in surgery. - Rostov-on-Don "Phoenix", 2013-S.98 .. After the sedation, bed rest must be strictly observed until the end of local anesthesia.
After local anesthesia, it is necessary to lay the patient in the position required by the nature of the operation. If there are violations of the general condition (nausea, vomiting, pallor skin, lowering blood pressure, headache, dizziness), then lay the patient down without a pillow.
After any type of anesthesia, the patient should be observed for two hours: measure blood pressure and body temperature, count the pulse, examine the postoperative bandage. In case of complications, it is necessary to provide medical care and call a doctor immediately.
With a drop in blood pressure, it is necessary to lay the patient horizontally, inject intramuscularly 1-- ml of cordiamine, prepare before the doctor arrives 1% mezaton solution, 0.2% norepinephrine solution, 5% glucose solution, 0.05% strophanthin solution or 0.06% corglycone solution, prednisolone or hydrocortisone.
The nurse must clearly and correctly carry out nursing process by stages:
1. Nursing examination and assessment of the patient's situation.
Since local anesthesia still has a small percentage of complications, the nurse needs to find out if there are any contraindications to this type of anesthesia.
In a conversation with the patient, she explains the purpose and benefits of local anesthesia, obtaining consent for its implementation. Having collected the necessary subjective and objective information about the patient's health status, the nurse must conduct an analysis, fill out the documentation in order to use it as a basis for comparison in the future.
2. Diagnosing or identifying the patient's problems.
During local anesthesia, the following nursing diagnoses can be made:
I decrease in motor activity associated with the introduction of local anesthetic solutions;
I nausea, vomiting associated with the emerging complication.
I pain associated with the restoration of sensitivity after surgery;
I fear of possible complications.
After the formation of all nursing diagnoses, the nurse sets their priority Barykina N.V., Zaryanskaya V.G. Nursing in surgery. - Rostov-on-Don "Phoenix", 2013-p.100..
3. Planning necessary assistance the patient and the implementation of the nursing intervention plan.
Introduction.
CARE OF THE PATIENT AFTER ANESTHESIA
anesthesia(ancient Greek Να′ρκωσις - numbness, numbness; synonyms: general anesthesia, general anesthesia) - an artificially induced reversible state of inhibition of the central nervous system, in which loss of consciousness, sleep, amnesia, pain relief, relaxation of skeletal muscles and loss of control occur over some reflexes. All this occurs with the introduction of one or more general anesthetics, the optimal dose and combination of which is selected by the anesthesiologist, taking into account the individual characteristics of a particular patient and depending on the type of medical procedure.
From the moment the patient enters the ward from the operating room, the postoperative period begins, which lasts until discharge from the hospital. In this period nurse should be especially careful. An experienced, observant nurse is the closest assistant to the doctor; the success of treatment often depends on her. In the postoperative period, everything should be aimed at restoring the patient's physiological functions, at the normal healing of the surgical wound, and at preventing possible complications.
Depending on the general condition of the operated patient, the type of anesthesia, and the characteristics of the operation, the ward nurse ensures the desired position of the patient in bed (raises the foot or head end of the functional bed; if the bed is ordinary, then takes care of the headrest, cushion under the legs, etc.).
The room where the patient comes from the operating room must be ventilated. Bright light in the room is unacceptable. The bed should be placed in such a way that it is possible to approach the patient from any side. Each patient receives special permission from the doctor to change the regimen: in different dates allowed to sit down and stand up.
Basically, after non-cavitary operations of moderate severity, with good health, the patient can get up near the bed the next day. The sister should follow the first rise of the patient from the bed, not allow him to leave the ward on his own.
Care and monitoring of patients after local anesthesia
It should be noted that some patients have hypersensitivity to novocaine, in connection with which they may experience general disorders after surgery under local anesthesia: weakness, drop in blood pressure, tachycardia, vomiting, cyanosis.
cyanosis - the most important feature hypoxia, but its absence does not mean that the patient does not have hypoxia.
Only careful monitoring of the patient's condition allows you to recognize the beginning of hypoxia in time. If oxygen starvation is accompanied by carbon dioxide retention (and this happens very often), then the signs of hypoxia change. Even with significant oxygen starvation, blood pressure may remain high and the skin pink.
Cyanosis- bluish coloration of the skin, mucous membranes and nails - appears when every 100 ml of blood contains more than 5 g% of reduced (i.e., not associated with oxygen) hemoglobin. Cyanosis is best identified by the color of the ear, lips, nails, and the color of the blood itself. The content of reduced hemoglobin can be different. In anemic patients, who have only 5 g% of hemoglobin, cyanosis does not occur in the most severe hypoxia. On the contrary, in full-blooded patients, cyanosis appears at the slightest lack of oxygen. Cyanosis can be not only due to a lack of oxygen in the lungs, but also due to acute cardiac weakness, in particular cardiac arrest. If cyanosis occurs, immediately check the pulse and listen to the heart sounds.
arterial pulse- one of the main indicators of work of cardio-vascular system. Examine in places where the arteries are located superficially and are accessible to direct palpation.
More often, the pulse is examined in adults on the radial artery. For diagnostic purposes, the pulse is also determined on the temporal, femoral, brachial, popliteal, posterior tibial and other arteries. To calculate the pulse, you can use automatic blood pressure monitors with pulse readings.
The pulse is best determined in the morning, before meals. The ward should be calm and not talk while counting the pulse.
With an increase in body temperature by 1 ° C, the pulse increases in adults by 8–10 beats per minute.
The voltage of the pulse depends on the value of arterial pressure and is determined by the force that must be applied until the pulse disappears. At normal pressure, the artery is compressed with a moderate effort, therefore, the pulse of moderate (satisfactory) tension is normal. At high pressure, the artery is compressed by strong pressure - such a pulse is called tense. It is important not to make a mistake, since the artery itself may be sclerosed. In this case, it is necessary to measure the pressure and verify the assumption that has arisen.
If the artery is sclerosed or the pulse is poorly felt, measure the pulse on the carotid artery: feel the groove between the larynx and the lateral muscles with your fingers and press lightly.
At low pressure, the artery is squeezed easily, the voltage pulse is called soft (non-stressed).
An empty, relaxed pulse is called a small filiform. Thermometry. As a rule, thermometry is carried out 2 times a day - in the morning on an empty stomach (between 6 and 8 am) and in the evening (between 16-18 hours) before the last meal. During these hours, you can judge the maximum and minimum temperatures. If you need a more accurate idea of the daily temperature, you can measure it every 2–3 hours. The duration of temperature measurement with a maximum thermometer is at least 10 minutes.
During thermometry, the patient should lie down or sit.
Places for measuring body temperature:
Armpits;
Oral cavity (under the tongue);
Inguinal folds (in children);
Rectum (debilitated patients).
Care and supervision of patients after general anesthesia
The post-anesthetic period is no less important stage than anesthesia itself. Most of the possible complications after anesthesia can be prevented by proper patient care and meticulous implementation of doctor's prescriptions. A very important stage of the post-anesthetic period is the transportation of the patient from the operating room to the ward. It is safer and better for the patient if he is taken from the operating room to the ward on the bed. Repeated shifting from the table to the gurney, etc., can cause respiratory failure, cardiac activity, vomiting, and unnecessary pain.
After anesthesia, the patient is placed in a warm bed on his back with his head turned or on his side (to prevent the retraction of the tongue) for 4-5 hours without a pillow, covered with heating pads. The patient should not be awakened.
Immediately after the operation, it is advisable to put a rubber ice pack on the area of the surgical wound for 2 hours. The application of gravity and cold to the operated area leads to squeezing and narrowing of small blood vessels and prevents the accumulation of blood in the tissues of the surgical wound. Cold soothes pain, prevents a number of complications, lowers metabolic processes, making it easier for tissues to tolerate circulatory failure caused by the operation. Until the patient wakes up and regains consciousness, the nurse should be near him relentlessly, observe general condition, appearance, blood pressure, pulse, respiration.
Transportation of the patient from the operating room. Delivery of the patient from the operating room to the postoperative ward is carried out under the guidance of an anesthesiologist or nurse of the postoperative ward. Care must be taken not to cause additional trauma, not to displace the applied bandage, not to break the plaster cast. From the operating table, the patient is transferred to a stretcher and transported to the postoperative ward on it. A gurney with a stretcher is placed with its head end at a right angle to the foot end of the bed. The patient is picked up and placed on the bed. You can put the patient in another position: the foot end of the stretcher is placed at the head end of the bed and the patient is transferred to the bed.
Preparing the room and bed. At present, after complex operations under general anesthesia, patients are placed in the intensive care unit for 2-4 days. In the future, depending on the condition, they are transferred to the postoperative or general ward. The ward for postoperative patients should not be large (maximum for 2-3 people). The ward should have a centralized supply of oxygen and the entire set of tools, apparatus and medications for resuscitation.
Typically, functional beds are used to give the patient a comfortable position. The bed is covered with clean linen, an oilcloth is placed under the sheet. Before laying the patient, the bed is warmed with heating pads.
Care of the patient in the event of vomiting after anesthesia
In the first 2-3 hours after anesthesia, the patient is not allowed to drink or eat.
Help with nausea and vomiting
Vomiting is a complex reflex act that leads to the eruption of the contents of the stomach and intestines through the mouth. In most cases, it is a protective reaction of the body, aimed at removing toxic or irritating substances from it.
If the patient is vomiting:
1. Sit the patient down, cover his chest with a towel or oilcloth, bring a clean tray, basin or bucket to his mouth, you can use vomit bags.
2. Remove dentures.
3. If the patient is weak or forbidden to sit, position the patient so that his head is lower than his body. Turn his head to one side so that the patient does not choke on vomit, and bring a tray or basin to the corner of his mouth. You can also put a towel, folded several times, or a diaper to protect the pillow and linen from soiling.
4. During vomiting, be near the patient. Lay the unconscious patient on their side, not on their back! It is necessary to introduce a mouth expander into his mouth so that during vomiting with closed lips there is no aspiration of vomit. After vomiting, immediately remove the dishes with vomit from the room so that a specific smell does not remain in the room. Let the patient rinse with warm water and wipe his mouth. In very weakened patients, each time after vomiting, it is necessary to wipe the mouth with a gauze cloth moistened with water or one of the disinfecting solutions (boric acid solution, a clear solution of potassium permanganate, 2% sodium bicarbonate solution, etc. .).
Vomiting "coffee grounds" indicates stomach bleeding.
Anesthesia(pain relief) is a series of procedures designed to relieve the patient from pain. Anesthesia is performed by an anesthesiologist, but in some cases by a surgeon or dentist. The type of anesthesia is chosen, first of all, depending on the type of operation (diagnostic procedure), the patient's health status and existing diseases.
Epidural anesthesia
Epidural anesthesia consists in the supply of anesthetic into the epidural space using a thin polyethylene catheter with a diameter of approximately 1 mm. Epidural and spinal anesthesia belong to the group of so-called. central blocks. This is a very effective technique, providing a deep and long-lasting blockade without the use of general anesthesia. Epidural anesthesia is also one of the most effective forms of pain management, including postoperative pain.
Epidural anesthesia is the most popular pain relief during childbirth. Its advantage is that the woman in labor does not feel painful contractions, so she can relax, calm down and concentrate on childbirth, and with a caesarean section, the woman remains conscious and the pain after childbirth decreases.
Indications for the use of epidural anesthesia
operations on lower limbs especially if they are very painful, e.g. replacement hip joint, operations on the knee joint;
operations on blood vessels - coronary artery bypass surgery of the femoral vessels, aortic aneurysms. Lets on long-term treatment postoperative pain, rapid re-operation, if the first failed, fights thrombus formation;
removal operations varicose veins veins of the lower extremities;
operations on abdominal cavity- usually together with mild general anesthesia;
serious operations on the chest (thoracosurgery, i.e. lung operations, cardiac surgery);
urological operations, especially in the lower urinary tract;
the fight against postoperative pain;
Today, epidural anesthesia is the most advanced and effective method dealing with pain after surgery or during childbirth.
Complications and contraindications for epidural anesthesia
Every anesthesia carries a risk of complications. Proper preparation of the patient and the experience of the anesthesiologist will help to avoid them.
Contraindications for epidural anesthesia:
lack of patient consent;
infection at the puncture site - microorganisms can enter the cerebrospinal fluid;
blood clotting disorders;
infection of the body;
some neurological diseases;
violations of the water and electrolyte balance of the body;
unstabilized arterial hypertension;
severe congenital heart defects;
unstabilized ischemic disease hearts;
serious changes in the vertebrae in the lumbar region.
Side effects of epidural anesthesia:
lowering blood pressure is enough frequent complication, but appropriate monitoring of the patient's condition allows it to be avoided; a decrease in blood pressure is most felt by patients in whom it is elevated;
back pain at the injection site; pass within 2-3 days;
"Patchwork" anesthesia - some areas of the skin may remain unpained; in this case, the patient is given another dose of anesthetic or a strong analgesic, sometimes general anesthesia is used;
arrhythmia, including bradycardia;
nausea, vomiting;
delay and complication of urination;
point headache - appears due to a puncture of the hard shell and leakage of cerebrospinal fluid into the epidural space;
hematoma in the area of anesthetic injection, with concomitant neurological disorders - in practice, a complication is very rare, but serious;
inflammation of the brain and spinal membranes.
Point headache should only occur with spinal anesthesia, because only then does the anesthetist deliberately pierce the dura to inject the anesthetic into the subdural space behind the dura. At correct execution epidural anesthesia headaches do not appear, because the hard shell remains intact. Point headache occurs with different frequency, more often in young people and women in labor; appears within 24-48 hours after anesthesia and lasts 2-3 days, after which it disappears on its own. The cause of a point headache is the use of thick puncture needles - the thinner the needle, the less likely this complication is. Analgesics are used to treat acupressure headaches. The patient must lie down. In some cases, an epidural patch is performed using the patient's own blood. Some anesthesiologists recommend lying quietly for several hours after surgery and anesthesia.
These standards apply to all types of anesthesia care, although appropriate life-sustaining measures are preferred in emergencies. These standards may be supplemented at any time at the discretion of the responsible anesthesiologist. They are aimed at providing qualified care to patients, however, their observance cannot serve as a guarantee of a favorable treatment outcome. These standards are subject to revision from time to time due to advances in technology and practice. They apply to all types of general, regional and controlled anesthesia. In certain rare or unusual circumstances 1) some of these monitoring methods may not be clinically feasible and 2) appropriate use of the described monitoring methods may not prevent adverse clinical developments. Short breaks in continuous monitoring may be unavoidable (note that "permanent" is defined as "regularly and frequently repeated in constant rapid succession", while "continuous" means "continuous, without any interruption in time"). Under compelling circumstances, the responsible anesthesiologist may waive requirements marked with an asterisk (*); if such a decision is made, a record of this (including justification) should be made in medical card. These standards are not intended for use in the management of pregnant women during labor or pain management.
STANDARD I
Qualified anesthesia personnel must be present in the operating room during the entire time of all types of general, regional anesthesia and controlled anesthesia care.
Target:
Due to the rapid change in the patient's condition during anesthesia, qualified anesthesia personnel must be constantly present in the operating room to monitor the patient's condition and provide anesthesia care.
Where personnel may be exposed to direct, known hazards, such as exposure to x-rays, periodic monitoring of the patient from a distance may be required. Certain precautions must be taken during monitoring. If any new emergency requires the temporary absence of the anesthesiologist responsible for administering anesthesia, he should decide how important this emergency is compared to the condition of the patient under anesthesia, and appoint a specialist who will be responsible for administering anesthesia during his absence. .
STANDARD II
During all types of anesthesia, it is necessary to constantly assess the oxygenation, ventilation, circulation and temperature of the patient.
oxygenation
Target:
Ensuring an adequate concentration of oxygen in the inhaled gas mixture and blood during all types of anesthesia.
Methods:
1. Inhaled gas mixture: at any time general anesthesia using a breathing apparatus, it is necessary to determine the oxygen concentration in the breathing circuit with an oxygen analyzer that gives an alarm when the oxygen concentration is low.*
2. Blood oxygenation: Quantitative methods of oxygenation assessment, such as pulse oximetry, should be used for all types of anesthesia.
Ventilation
Target:
Ensuring adequate ventilation of the patient during all types of anesthesia.
Methods:
1. Adequate ventilation should be ensured in each patient during general anesthesia, which must be constantly evaluated. Although qualitative clinical features, such as excursion chest, observation of the breathing bag and auscultation of the lungs, however, quantitative monitoring of CO₂ and / or volume of exhaled gas is mandatory.
2. After tracheal intubation, it is necessary to verify the correct position of the endotracheal tube in the trachea by clinical assessment and determination of CO₂ in the exhaled gas mixture. Continuous determination of end-tidal CO₂ should be carried out from the moment of intubation to extubation or transfer to the recovery room using quantitative methods such as capnography, capnometry or mass spectrometry.
3. When ventilation is provided by a breathing apparatus, continuous use of a monitor is required to detect leaks in the breathing circuit. It should give an audible alarm.
4. When performing regional and monitored anesthesia, it is necessary to assess the adequacy of ventilation, at least through constant monitoring of clinical signs.
Circulation
Target:
Ensuring adequate blood circulation in the patient during all types of anesthesia.
Methods:
1. For each patient during anesthesia, continuous monitoring of the ECG should be carried out from the beginning of anesthesia until the moment the patient is transferred from the operating room.*
2. Each patient should have their blood pressure and heart rate measured and assessed at least every five minutes during anesthesia.*
3. In each patient during anesthesia, it is necessary, in addition to the above, to constantly assess the circulatory function using at least one of the following methods: palpation of the pulse, auscultation of the heart, monitoring of the intra-arterial pressure curve, ultrasound monitoring peripheral pulse, plethysmography or oximetry.
Body temperature
Target:
Maintaining an appropriate body temperature during all types of anesthesia.
Methods:
Devices for monitoring the patient's body temperature should be easily accessible and ready for use. Temperature should be measured if a change is expected or suspected.
STANDARDS FOR REGIONAL ANESTHESIA IN OBSTETRICS
These standards refer to the administration of regional anesthesia or analgesia when local anesthetics administered to a woman during labor or delivery. They are aimed at providing qualified assistance, but cannot serve as a guarantee of a favorable outcome. Since the drugs and equipment used in anesthesia can change, these standards need to be interpreted in each institution. They are subject to revision from time to time due to developments in technology and practice.
STANDARD I
Regional anesthesia should only be initiated and administered in a facility where appropriate resuscitation equipment and facilities are available and ready for use. medications, which may be required to eliminate problems associated with the administration of anesthesia.
The list of resuscitation equipment should include: oxygen source and suction equipment to maintain patency respiratory tract and tracheal intubation, positive pressure ventilation devices, and medicines and equipment for cardiopulmonary resuscitation. Depending on local possibilities, the list can be expanded.
STANDARD II
Regional anesthesia must be performed by a licensed physician and carried out by him or under his supervision.
The physician must obtain permission to perform and further manage the administration of anesthesia in obstetrics, as well as to manage the complications associated with anesthesia.
STANDARD III
Regional anesthesia should not be performed before: 1) examination of the patient by a qualified specialist; and 2) maternal, fetal, and labor frequency evaluations by an obstetrician who is prepared to manage the delivery and manage any complications associated with it.
Under certain circumstances, as determined by the department protocol, qualified personnel may perform an initial pelvic examination of the woman. The doctor responsible for caring for a pregnant woman should be informed of her condition so that he can decide on further actions, taking into account the risk.
STANDARD IV
Intravenous infusion should begin prior to the start of regional anesthesia and be maintained throughout its duration.
STANDARD V
When performing regional anesthesia during labor or delivery through the birth canal, it is necessary that a qualified specialist monitor the vital signs of the woman in labor and the fetal heart rate, and also register them in medical records.
Additional monitoring appropriate clinical condition woman in labor and the fetus, is carried out according to indications. If extensive regional blockade is performed for complicated vaginal delivery, standards for basic anesthetic monitoring should be applied.
STANDARD VI
The administration of regional anesthesia for caesarean section requires the application of basic anesthetic monitoring standards and the ability to immediately call in a doctor specializing in obstetrics.
STANDARD VII
In addition to the anesthetist supervising the mother, it is necessary to have qualified personnel who will take responsibility for resuscitation of the newborn.
The primary responsibility of the anesthesiologist is to provide care for the mother. If this anesthetist is required to a short time has been involved in caring for a newborn, the benefit that these actions can bring to the child must be weighed against the risk to the mother.
STANDARD VIII
When performing regional anesthesia, it is necessary to be able to attract a qualified specialist who will deal with the medical treatment of complications associated with anesthesia until the moment when the condition after anesthesia becomes satisfactory and stable.
STANDARD IX
All patients during recovery period after regional anesthesia, appropriate anesthetic support should be provided. After caesarean section and/or extensive regional blockade, post-anesthetic management standards should apply.
1. The post-anesthesia care unit (PONS) should be prepared to receive patients. Its layout, equipment and personnel must meet all regulatory requirements.
2. If a department other than the OPNI is used, the woman should be given equivalent care.
STANDARD X
Liaison should be established with a physician capable of treating complications and performing cardiopulmonary resuscitation in the postanesthetized patient.
STANDARDS OF MANAGEMENT AFTER ANESTHESIA
(Approved October 12, 1988, last amended October 19, 1994)
These standards apply to the provision of post-anesthesia care in all departments. These may be supplemented at the discretion of the responsible anesthesiologist. The standards are aimed at providing qualified care to patients, but cannot guarantee a favorable outcome of treatment. These standards are revised from time to time as technology and practice evolve. Under compelling circumstances, the responsible anesthesiologist may waive requirements marked with an asterisk (*); if such a decision is made, an entry (including justification) should be made in the medical record about this.
STANDARD I
All patients after general, regional or monitored anesthesia should be provided with appropriate care.
1. After anesthesia, patients should be admitted to the Post-Anesthetic Surveillance Unit (OPN) or to another unit capable of providing the same qualified care. All patients after anesthesia should be admitted to the DRCU or its equivalent, except in special cases, due to the order of the responsible anesthesiologist.
2. Medical aspects the provision of care in the DPNS should be governed by rules that are reviewed and approved by the Department of Anesthesiology.
3. The layout, equipment, and personnel of the OPNS must meet all regulatory requirements.
STANDARD II
A patient who is being transported to the DRCU should be accompanied by a member of the anesthesia team who is aware of their condition. During transportation, constant monitoring and necessary medical treatment of the patient should be carried out, corresponding to his condition.
STANDARD III
After the patient has been delivered to the DRCU, the patient's condition should be reassessed, and the accompanying anesthesia team member should verbally communicate the patient's information to the DRCU nurse in charge.
1. The condition of the patient upon admission to the emergency department should be reflected in the medical records.
2. Information about the preoperative condition of the patient and the nature of the provision of surgical / anesthetic care should be transferred to the nurse of the OPNN.
3. A member of the anesthesia team must remain in the EDNS until the nurse in that department takes over the responsibility of caring for the patient.
STANDARD IV
The PDNS should continuously assess the patient's condition.
1. The patient must be observed and monitored by methods appropriate to his condition. Special attention attention should be paid to monitoring oxygenation, ventilation, circulation and body temperature. Quantitative oxygenation methods such as pulse oximetry should be used in initial recovery from all types of anesthesia.* It is not necessary to use this method in parturient women recovering from regional anesthesia for labor pain relief and vaginal delivery.
2. The course of the post-anesthetic period must be accurately reflected in the medical records. It is desirable to use an appropriate scoring system for assessing the condition of each patient upon admission, after a certain period of time (before discharge) and at discharge.
3. The overall medical direction and coordination of patient care in the DOI is the responsibility of the anesthesiologist.
4. Patients with AKI should be provided with ongoing care from a specialist in the management of complications and cardiopulmonary resuscitation.
STANDARD V
The physician is responsible for transferring the patient from the anesthesia care unit.
1. The discharge criteria used must be approved by the medical staff of the anesthesiology department. They can be different depending on whether the patient is transferred to one of the departments of the hospital, to the intensive care unit, to the short stay unit, or is discharged home.
2. In the absence of a discharge physician, the PDNS nurse must decide whether the patient's condition meets the discharge criteria. The name of the physician taking responsibility for the discharge of the patient must be included in the medical records.
If the operation was not accompanied by severe complications and the tactics of the anesthesiologist were correct, the patient should wake up immediately after completion of the operation, as soon as the drug is turned off.
If the operation was long and anesthesia was carried out with ether, then the supply is reduced even in the second half so that by the end of it the anesthesia weakens to a level close to awakening. From the moment when the surgeon starts suturing the wound cavity, the supply of the narcotic substance stops completely. Without turning off the apparatus, the oxygen supply is increased to 5-6 liters per minute with the simultaneous opening of the exhalation valve. The beginning of the awakening of the patient is determined by the anesthesiologist, depending on the course of the surgical intervention and the characteristics of the course of anesthesia. The skill and experience of the anesthesiologist tell him at what point it is necessary to turn off the apparatus.
Proper management of the patient in the post-anesthetic period is no less important than the anesthesia itself and the operation. Particularly responsible is the transition from the artificial maintenance of the most important functions of the body, which is carried out by an anesthesiologist, to the natural activity of the body after anesthesia. With the correct course of the operation and anesthesia, as well as with the correct withdrawal from it, by the end of the operation, the patient fully recovers active spontaneous breathing. The patient responds to irritation of the trachea with a tube, consciousness is restored, he fulfills the request of the anesthesiologist to open his eyes, stick out his tongue, etc. During this period, the patient is allowed to be extubated. If anesthesia was carried out through a tube passed through the mouth, then before the onset of extubation, it is necessary to prevent biting of the tube with the teeth. For this, mouth expanders and dental spacers are used. Extubation is most often performed at a certain moment, when the tone of facial muscles is clearly restored, the pharyngeal and laryngeal reflexes are clearly restored, and the patient begins to wake up and react to the tube as if it were a foreign body.
Before removing the tube from the trachea, as already mentioned, mucus and sputum should be carefully aspirated from the oral cavity, endotracheal tube and trachea.
The decision to transfer the patient from the operating room to the ward is determined by his condition.
The anesthesiologist must make sure that breathing is adequate and that there are no violations of the function of the cardiovascular system. Respiratory failure most often results from the residual action of muscle relaxants. Another cause of acute respiratory failure is the accumulation of mucus in the trachea. Inhibition of the act of breathing sometimes depends on oxygen starvation (hypoxia) of the brain with low blood pressure and a number of other reasons.
If, at the end of the operation, the patient's blood pressure, pulse and respiration are satisfactory, when there is full confidence that there will be no complications, he can be transferred to the postoperative ward. At low blood pressure, insufficiently deep breathing with signs of hypoxia, patients should be detained in the operating room, since the fight against complications in the ward always presents significant difficulties. Moving the patient to the ward in conditions of respiratory and circulatory disorders can lead to serious consequences.
Before delivering the operated patient to the ward, he should be examined. If the patient is wet from sweat or contaminated during the operation, it is necessary to wipe him thoroughly, change his underwear and carefully transfer to a gurney.
Transferring the patient from the operating table should be done by skilled nurses under the guidance of a nurse or doctor. In shifting the patient, two or (when shifting very heavy, overweight patients) three persons participate: one of them covers the shoulder girdle, the second puts both hands under the pelvis and the third under the unbent knee joints. It is important to instruct inexperienced caregivers that they should all stand on one side of the patient when carrying.
When transporting from the operating room to the ward, it is imperative to cover the patient so that cooling does not occur (this is especially true for the elderly). When shifting the patient to a gurney or stretcher, and then to the bed, the position of the patient changes. Therefore, one must be very careful not to raise the upper body, and especially the head, too much, since with low blood pressure anemia of the brain and respiratory distress can occur.
The anesthetist and the doctor who observed the patient during the operation and anesthesia should enter the patient's room, observe how he is transferred from the gurney to the bed, and help to put him down correctly. The ward nurse must be aware of the nature of the surgical intervention and must also monitor the correct and comfortable position of the patient. After general anesthesia, the patient is laid completely flat on his back, without a pillow, and sometimes with his head down to prevent vomit from flowing into the airways.
If it is cold in the ward, then you need to cover the patient with heating pads, cover them warmly. In this case, overheating should not be allowed, since as a result increased sweating dehydration occurs.
The nurse must ensure that the patient, overlaid with heating pads, does not have a burn. She checks the temperature of the heating pad by touch, avoiding applying it directly to her body.
In the patient room, a constant supply of humidified oxygen is established. Pillows filled with oxygen should always be at the nurse's hand. In some surgical departments and clinics, special oxygen chambers are organized in which patients are placed after thoracic surgery. The oxygen tank is in the room or on ground floor, where there is a control panel, from there oxygen is sent through pipes to the wards and is supplied to each bed. Through a thin rubber tube inserted into the nasal passages, the patient receives a metered amount of oxygen. For humidification, oxygen is passed through the liquid.
Oxygen after surgery is necessary due to the fact that when the patient switches from breathing a mixture of drugs with oxygen to breathing in ambient air, acute oxygen starvation with cyanosis and palpitations. Inhalation of oxygen by patients significantly improves gas exchange and prevents the occurrence of hypoxia.
Most patients are transferred to the recovery room with a drip infusion of fluid or blood. When shifting the patient from the table to the gurney, it is necessary to lower the stand as much as possible, on which the vessels with the infused blood or solutions were located, so that the rubber tube is stretched as little as possible, otherwise, with careless movement, the needle may be pulled out of the vein and it will be necessary to again perform venipuncture or venesection on the other limb . An intravenous drip is often left until the morning of the next day. It is needed for the introduction of the necessary medicines, as well as for infusion of 5% glucose solution or saline. It is necessary to strictly take into account the amount of fluid administered, which should not exceed 1.5-2 liters per day.
If anesthesia was carried out according to the intubation method and the patient different reasons did not come out of the state of anesthesia, in these cases the tube is left in the trachea until the patient fully awakens. The patient is transferred from the operating room to the ward with the endotracheal tube not removed. Immediately after delivering it to the ward, a thin tube from the oxygen system is connected to the tube. It is necessary that in no case should it cover the entire lumen of the endotracheal tube. For the patient during this period, the most careful observation should be established, since it is possible serious complications due to biting of the tube, pulling it out with an inflated cuff or a tamponed oral cavity.
For those patients who need to continue the oxygen supply after surgery, it is recommended to replace the oral tube with a tube inserted through the nose. The presence of a tube allows you to remove sputum that accumulates in the trachea by sucking it through a thin tube. If, however, you do not monitor the accumulation of sputum and do not take measures to remove it, then the presence of a tube can only harm the patient, since it deprives him of the opportunity to get rid of sputum through coughing.
The nurse anesthetist who participated in the anesthesia should remain at the patient's bedside until full awakening occurs and the danger associated with the use of anesthesia has passed. Then she leaves the patient to the ward nurse, gives her the necessary information and appointments.
For the postoperative patient, it is always necessary to create favorable conditions. It is known that when a nurse is in the ward, the very fact that she is nearby brings relief to the patient. Sister relentlessly monitors the state of breathing, blood pressure, for the pulse and in case of changes immediately inform the anesthetist and surgeon. During this period, the patient should not be left unattended for a single minute, in view of the fact that unpleasant complications may arise associated both with the production of the operation itself and with anesthesia.
In the post-anesthetic period, in patients in a state of post-anesthetic sleep, when positioned on the back, tongue retraction is possible. Proper holding of the jaw is one of the responsible tasks of the anesthetist nurse. To prevent retraction of the tongue, and at the same time difficulty in breathing, the middle fingers of both hands wind up around the corner mandible and with light pressure push it forward and up. If before that the patient's breathing was wheezing, now it immediately becomes even and deep, cyanosis disappears.
Another danger a sister should be aware of is vomiting. A great danger for the patient is the ingress of vomit into the respiratory tract. After a long operation and anesthesia, the patient must be under continuous supervision of medical personnel. At the time of vomiting, it is necessary to support the patient's head, turn it to one side, substitute a barrel-shaped basin or a prepared towel in a timely manner, and then put the operated person in order. The sister should have tongs with gauze balls to wipe her mouth, or if there is none, then in case of vomiting, you need to put the end of the towel on your index finger and wipe the buccal space with it, freeing it from mucus. With nausea and vomiting, the patient should be warned to refrain from drinking for some time.
It should be remembered that all medications prevention of vomiting after anesthesia is ineffective, so the most faithful helpers in this are peace, clean air and abstinence from drinking.
One of the frequent companions of the early postoperative period is pain. The pain expected in connection with the operation, especially in combination with the emotion of fear, was left behind. It would seem that, nervous system the patient after the completed operation should be in a state of complete rest. However, such a state in the postoperative period does not always occur, and here the pain factor associated with the operation begins to act with particular force.
Painful irritations, coming primarily from the surgical wound, are especially disturbing for patients in the first days after surgery. Pain has an adverse effect on everything physiological functions organism. To combat local pain, the operated seeks to maintain a fixed position, which causes excruciating tension in him. During operations on the organs of the chest and the upper floor of the abdominal cavity, pain limits the movement of the muscles involved in the breathing process. In addition, pain prevents the recovery of the cough reflex and expectoration of sputum, sometimes for many hours and days. This leads to the accumulation of mucus that clogs the small bronchi, as a result of which conditions are created for the development of pneumonia in the postoperative period, and in the next few hours after anesthesia and surgery, acute respiratory failure varying degrees. If the pain lasts for a long time, then painful irritations exhaust the patient, upset sleep and the activity of various organs. Therefore, the elimination of pain in the early postoperative period is the most important therapeutic factor.
To eliminate local pain in connection with the operation, there are many different techniques and means. In order to reduce the pain syndrome in the next few hours after the operation, before closing the chest, a paravertebral blockade is performed from the side of the parietal pleura of 2-3 intercostal nerves above and below the surgical wound. Such a blockade is carried out with a 1% solution of novocaine. For the prevention of pain in the area of surgical incisions of the chest and abdominal wall still on the operating table, an intercostal blockade of the nerve conductors is done with a 0.5-1% solution of novocaine.
In the first days after the operation, those operated on, mainly because of pain in the wound, and partly because of the uncertainty about the strength of the sutures or any other complications, are very cautious, timid and do not dare to change the position given to them.
From the first day after the operation, patients should actively breathe and cough up sputum in order to prevent pulmonary complications. Coughing promotes the expansion of the lungs and prepares patients for the motor regimen.
To eliminate postoperative pain, various narcotic and sedative drugs are widely used - morphine, promedol, scopolamine mixtures, and more recently, neuroplegics. After minimally invasive surgery pain significantly reduced by the use of these substances. However, in most cases (especially after very traumatic operations), the effect of drugs is ineffective, and their frequent use and overdose lead to respiratory and circulatory depression. Prolonged use of morphine leads to addiction, to drug addiction.
An effective method of dealing with postoperative pain was the use of therapeutic anesthesia proposed by professors B. V. Petrovsky and S. N. Efuni. Therapeutic anesthesia or self-narcosis according to the method of these authors is carried out in the postoperative period with nitrous oxide and oxygen in such proportions that are practically completely harmless. This mixture, even at a very high concentration of nitrous oxide (80%), is completely non-toxic. The method is based on the following principles:
- the use of a drug that does not have a depressing effect on the vital functions of the patient;
- ensuring sufficient pain relief in the postoperative period;
- normalization respiratory function and hemodynamic parameters;
- the use of nitrous oxide with oxygen, which does not excite the vomiting and cough centers, does not irritate the mucous membranes of the respiratory tract and does not increase the secretion of mucus.
The technique of self-narcosis briefly boils down to the following. After setting nitrous oxide and oxygen at a ratio of 3:1 or 2:1 on dosimeters, the patient is invited to pick up a mask from the anesthesia machine and inhale the gas mixture. Disappears after 3-4 minutes pain sensitivity(while maintaining tactile), consciousness becomes clouded, the mask falls out of the hands. With the return of consciousness, if the pain reappears, the patient himself reaches for the mask.
If the operation was performed under endotracheal anesthesia, then often small pains are felt when swallowing and talking. This is due to the presence of infiltration of the mucous membrane of the larynx (from the endotracheal tube), pharynx (from the tampon). In the presence of such phenomena, the patient's speech should be limited, various inhalations and gargling with an antiseptic solution should be used.
Care of the patient in the postoperative period has exclusively importance, not without reason there is an expression "the patient went out." In the organization of care and in its practical implementation, the nurse is directly involved. At the same time, accurate, timely and high-quality fulfillment of all doctor's prescriptions is very important.
The stay of patients in the postoperative ward in the first days requires especially careful monitoring by doctors. AT last years along with the surgeon, the anesthesiologist is also directly involved in the management of the immediate postoperative period, because in some cases it is much easier for him than for the surgeon to find out the causes of certain complications, and since the preoperative period, he carefully monitors the dynamics of the functional state of the patient. Along with this, the anesthesiologist is well acquainted with the measures for the prevention and treatment of the most common respiratory and cardiovascular disorders in patients.
Taking into account the possibility of acute respiratory failure, the anesthesiologist in the first postoperative hours should have everything necessary for tracheal intubation and artificial lung ventilation at the patient's bedside.
If respiratory failure becomes protracted, the patient cannot cough up sputum well - it becomes necessary to perform a tracheotomy. This small operation usually greatly improves the conditions for gas exchange. It not only allows you to reduce the harmful space of the respiratory tract, but also creates conditions for the suction of sputum from the bronchi. Through the tracheotomy cannula, controlled or assisted breathing can be undertaken at any time.
Blockage of the tracheotomy tube with a secret occurs when the patient has abundant sputum. Given that after a tracheotomy, the patient cannot effectively cough up sputum, it must be very carefully aspirated periodically.
