If you have struggled hard to save a patient in the theatre, it is tragic to lose him in the ward afterwards. If you are working under difficult conditions, postoperative care can be at least as difficult as surgery. You will find an ICU (intensive care unit), like that in Primary Anaesthesia, very useful for any ill patient, and particularly for someone who is recovering from a severe operation (A 19.1). The staff of even the simplest ICU should be able to check his vital signs, keep an accurate fluid balance, and watch for postoperative bleeding. If he is recovering from a major operation, he will need need very careful monitoring, and frequent visits from you. If the nurses there are not yet fully trained, you will need to do much of this monitoring yourself. If you don't have an ICU, gather critically ill patients near the nurse's station in an ordinary ward, so that the senior nurse can watch them. The list below of the things she should check is a long one, but most of the checks are quick. Postoperative care is also discussed in Primary Anaesthesia (A 4.6). Above all, try to anticipate complications before they occur.
POSTOPERATIVE CARE THE RECOVERY POSITION. Nurse the patient on his side in the recovery position (A 4-5), with the foot of his bed raised if his blood pressure is low. Turn him 2-hourly.
MONITORING. All patients should be carefully watched, but only a few need careful measurement of their vital signs. The most useful observations are those of the pulse rate, blood pressure, consciousness, skin temperature, peripheral perfusion, and urinary output. If a patient is critically ill, make sure that, during the first few hours, some competent person checks: (1) His level of consciousness. (2) The pattern of his respiration. (3) His peripheral circulation[md]the warmth of his extremities. (4) The capillary circulation in his nail beds, and (5) his pulse. (6) His temperature. (7) His urine output. (8) His degree of pain, and any changes in it. (9) Any bleeding and discharge from his wound. (10) Abdominal distension. His blood pressure need only be measured if these other signs indicate that it might be abnormal, or if he is old, very ill, or has had major surgery.
The nurses in the ICU must be on the look out for: (1) a falling blood pressure and a rising pulse rate, (2) respiratory depression and arrest (A 3.4 and 4.5), (3) bronchospasm (A 3.3), (4) failure of the nasogastric suction to work properly, and (5) the aspiration of gastric contents (A 16.3).
Later, as he recovers, their attention can change to: (1) Maintaining nasogastric suction. (2) Coughing and breathing exercises.
INTRAVENOUS FLUIDS should be managed as in A 15.5. If there is any doubt about the adequacy of fluid replacement, be sure to monitor his urine output. Only a very ill patient needs an indwelling catheter; remove it when it is not absolutely necessary. A Paul's tube is often adequate in men.
If you did not adequately replace the blood he lost at the operation, he will have diluted his blood by the first day, so measure his haemoglobin or his haematocrit, and transfuse him if he is in danger.
NASOGASTRIC SUCTION will prevent the aspiration of vomit; it will remove gas and fluid and relieve distension. Manage it as in Section 4.9.
BOWELS. If he is on a traditional high-residue diet, he will probably have no difficuty with his bowels once any ileus he may have had has subsided. He is more likely to have difficulty if he is on a on a ''Western' type of low-residue diet. If he has passed flatus, but no stool by the fifth day, consider giving him a rectal suppository.
PAIN. If he is in severe pain, give him half the standard dose of intravenous pethidine or morphine (A 2-4) initially. Give the other half ten minutes later if the first was not enough. A useful method is to add further doses to his intravenous fluids 4 hourly (A 8.9). Or, better, run it in continuously with his intravenous fluids. This makes sure that he gets it all the time without having to call the nurses. Intramuscular drugs are not absorbed rapidly enough. 20 mg of morphine 8 hourly is an average dose for a fit adult. Give half or a quarter of this if he is very sick, thin or malnourished. By 3 to 5 days he should have no need of injectable opioids, so taper them off, and occasionally, if necessary, replace them by an oral opioid.
OTHER DRUGS. (1) Don't give him a hypnotic for 5[nd]7 days, it will not help him while he is in pain. (2) Don't give him an antiemetic without looking for a cause. It may help him if he has an inoperable carcinoma. (3) Continue his perioperative antibiotics only if necessary (2.9). Otherwise, don't give him an antibiotic, unless he has an established infection.
AMBULATION. Encourage him to move his legs in bed. If possible, get him up and about early. Dependent immobile legs have a higher incidence of deep vein thrombosis (rare in the developing world) than raised ones. This is more likely to occur sitting still in a chair than sitting still in bed.