Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
Resusciation and Anaesthesia
Resuscitation and Preparation for Anaesthesia and Surgery
Management of emergencies and cardiopulmonary resuscitation
Other conditions requiring urgent attention
Intravenous access
Fluids and drugs
Drugs and resuscitation
Preoperative assessment and investigations
Anaesthetic issues in the emergency situation
Important medical conditions for the anaesthetist
Practical Anaesthesia
General anaesthesia
Anaesthesia during pregnancy and for operative  delivery
Pediatric anaesthesia
Conduction anaesthesia
Specimen anaesthetic techniques
Monitoring the anaesthetized patient
Postoperative management
Anaesthetic infrastructure and supplies
Equipment and supplies for different level hospitals
Anaesthesia and oxygen
Fires, explosions and other risks
Care and maintenance of equipment
Postoperative Management
 

> IN RECOVERY
> POSTOPERATIVE EXTUBATION
> PAIR MANAGEMENT AND TECHNIQUES
> POSTOPERATIVE FLUID MANAGEMENT
> INTENSIVE CARE UNIT



POSTOPERATIVE EXTUBATION

Some patients are extubated on the table, others in recovery and still others in the intensive care unit, sometimes even after several days. If you expect that a prolonged period of intubation will follow postoperatively, select a suitable non-irritant tube for starting the case.

In general, it is better to extubate the patient yourself at the end of surgery, on the table when he or she is fully awake, with good suction and oxygenation and under controlled conditions. You can also monitor the airway, breathing and vital reflexes in the immediate post-extubation period. If you have a pulse oximeter connected, it must not be removed until the patient has been extubated and remains well oxygenated on room air.

Self extubation by the patient might cause some damage to the larynx as the cuff will not be deflated and there may also be secretions in the pharynx that normally would have been sucked away. However, self extubation is usually a harmless event and shows at least that the patient is awake and has good muscle power. The LMA is sometimes taken out in theatre with suction or sometimes left for the patient himself to pull out when fully awake.

When to leave the endotracheal tube in place

Always bear in mind that an tracheal tube left in place for several hours has the potential to become blocked. This will happen more quickly if the tube is small, there are secretions, pus or blood in the lungs or if nursing care is inadequate. As a general rule, you can expect any tracheal tube to become blocked within 24 hours.

A blocked tracheal tube = a dead patient.


Situations when you should leave the tracheal tube in place or delay extubation include:

:: Airway problems
Patients with potential airway problems such as major maxillofacial surgery or trauma, large thyroidectomies or other swelling in the airway may sometimes be left intubated for the first overnight period in case there is swelling that might cause airway obstruction
Decide in advance whether to leave the tube in and give a sedative and opiate analgesic so that it is tolerated otherwise the patient’s coughing or attempts to self-extubate will cause more difficulties
than intubation solves
 
:: Haemodynamically unstable patients: very sick patients from haemorrhage or sepsis who:
Do not fully recover
Might need ventilation
Suffer cardiovascular collapse in the postoperative period

:: Hypoxic patients who might need ventilation
:: Patients who do not wake up as planned:
In general, do not extubate an unconscious patient after surgery or
one who shows no cough reflex when moving the tube in the trachea
Wait until the patient is breathing (not breath-holding or biting
the tube) and shows a gag reflex and, ideally, opens his or her eyes.
 



Nasogastric/orogastric tube


All emergency cases have potentially full stomachs. At the end of surgery, there should be a nasogastric tube in place; the stomach may, in any case, have been emptied during the operation. An orogastric tube is very easy to pass under anaesthesia, but further intestinal contents reflux into the stomach and may regurgitate at extubation.

Neonates

Neonates are at special risk for apnoeic attacks in the hours and days postoperation. A neonatal ventilator and the necessary postoperative care are unlikely to be available. The anaesthetist may choose to leave the neonate intubated so that the nursing staff can hand ventilate when required. On the other hand, it is common in a neonatal emergency for there to be secretions in the chest which will thicken in the postoperative period and block a size 3 tube very easily. The choice is not easy.



> IN RECOVERY
> POSTOPERATIVE EXTUBATION
> PAIR MANAGEMENT AND TECHNIQUES
> POSTOPERATIVE FLUID MANAGEMENT
> INTENSIVE CARE UNIT



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