Introduction		Monitoring Equipment
Clinical Patient Monitoring		Discharge Criteria
Supplemental Oxygen Therapy		Reference

Introduction

The recovery room is the area where patients recover from the immediate effects of anaesthesia and surgery and provides a setting for the detection and treatment of early post-operative complications. These areas vary considerably in the level of staffing and monitoring available from the "ideal" fully staffed, fully equipped modern recovery facility to the somewhat less than perfect dimly lit corridor just outside theatre.

The commonest causes of recovery room mishaps all result from unidentified changes in a patient's airway, breathing or circulation and these can almost always be rectified if identified at an early stage.

In 1993 the Association of Anaesthetists of Great Britain and Ireland published recommendations for the provision of equipment necessary for a modern day recovery area. These are shown in table 1.

These facilities may not all be available in many recovery areas throughout the world and some thought is necessary to determine the relative merits of each item on this long list.

Certainly the two most important pre-requisites of any recovery area should be the provision of good lighting together with a suitably trained recovery nurse available to recover each unconscious patient on a one-to-one basis. The nurse must be available to stay with the patient constantly until awake and able to maintain their own airway.

Clinical patient monitoring

Clinical monitoring can be divided into assessment of airway, breathing and circulation. The patient's airway can be assessed by observing for signs of obstruction such as chest wall or supraclavicular inward movement on inspiration and/or the presence of noisy breathing. A patent airway is most easily maintained with the patient in the left lateral ('recovery') position (figure 1) as this allows the tongue and soft palate to fall forwards away from the oropharyngeal opening.

This will also prevent any blood or secretions pooling in the oropharynx and causing aspiration or laryngospasm. In patients at risk of further oropharyngeal soiling, drainage of secretions can be increased by placing a pillow beneath the patient's chest ('tonsillar position'). If the patient has to remain supine for any reason then the use of jaw thrust or an oropharyngeal (Guedel) airway can be invaluable in airway maintenance. Maintenance of a patent airway is probably the single most important aspect of immediate post-operative care. Although few patients in the UK are now taken to recovery with an endotracheal tube in-situ this depends to some extent on the anaesthetic agents available. Where slowly eliminated agents are used (ether and halothane) the endotracheal tube is sometimes best left in-situ until full return of the laryngeal reflexes. When to extubate is a matter of clinical judgment, but as a rule it is safer to leave the tube as long as possible as this ensures airway patency. In children it is common practice to wait until they can remove it themselves. Suctioning of the oropharynx should be performed before tube removal to avoid aspiration of any blood or mucus present. The anaesthetist should always be on hand until a patient is awake and maintaining their own airway in case of severe laryngospasm necessitating re-intubation.

Respiration can be assessed by monitoring abdominal excursion, chest movement or by feeling for expiration with a cupped hand at the patient's mouth or nose. Oxygenation can also be assessed to some degree by examining the patient's colour. A dusky, bluish hue suggests hypoxia, and is often most easily noted around the lips or tongue. This does, however, require natural daylight or good quality artificial lighting as some systems produce monochromatic light which makes the appreciation of colour difficult. Bradypnoea will usually be due to intra-operative opioid use and if so will be associated with pinpoint pupils. This may resolve spontaneously as the other anaesthetic agents are eliminated and the patient wakes up. If treatment is indicated (respiratory rate less than 8 bpm or hypoxia) then first try to rouse the patient and if this fails consider naloxone (400 microgram diluted into 10 ml saline administering 2 ml boluses intravenously). Where available doxapram (1 mg/kg) is a useful respiratory stimulant and will not reverse the analgesic effects of opioids. Tachypnoea can be associated with certain volatile agents (particularly ether), acidosis, hypovolaemia, pain, hypoxia or other respiratory problem.

Circulation can be assessed by palpating the pulse (thready pulse or tachycardia suggesting volume depletion) and by feeling the peripheries (cold poorly perfused hands also suggest hypovolaemia or hypothermia following long operations). Heart rate should normally be between 60-90 bpm. Bradycardia is usually associated with deep anaesthesia or vagally stimulating surgery and may need treating if the heart rate is less than 40-50bpm or if associated with hypotension (give atropine 200-400mcg). Tachycardia is likely to be due to poor pain control or hypovolaemia, but may rarely be due to atrial fibrillation or a supraventricular tachycardia. Primary treatment should be directed at the cause (morphine or a 250ml fluid challenge). As with respiratory monitoring it is useful to chart the heart rate and blood pressure so that trends over time can be more easily seen. A developing tachycardia is often an early sign of unrecognised blood loss. The wound site must also be observed every few minutes to ensure that any bleeding or haematoma formation is noted early. Drainage from surgical drains should also be charted.

Conscious level should be monitored by observing the return of reflexes such as the eyelash reflex, swallowing and the start of vocalisation and response to commands. Where the patient has undergone regional anaesthesia (spinal or epidural) the height of the block must be assessed until it is seen to be regressing. This is most easily tested by measuring the point at which cold can no longer be appreciated (using ethyl chloride or ice). It is safer not to sit these patients up too early as marked postural hypotension can occur.

Once the patient is vocalising and is reasonably awake pain levels should be assessed. Recovery nurses should be capable of administering intravenous analgesia and achieving adequate analgesia should be a primary goal once airway reflexes have returned. Pain is most easily treated by administering morphine 1-2 mg aliquots every 3-5 minutes until comfortable. It is very unusual to overdose patients using this regime, but intravenous naloxone should be available. See also  The Management of Postoperative Pain , Update in Anaesthesia 1997;7:2. 

(Continued ...)

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