Do not depend on the nursing staff in the postoperative period

In above all situations it is the duty of anaesthetist to leave full instructions or leave the nursing home after complete recovery and stable condition. Instruction not to remove the airway unless the patient removes it himself is not understood by the nursing staff. Six post-operative deaths have been recorded after a septum operation under GA. The anaesthetist must plan his anaesthesia in such a way that patient recovers complete consciousness at the end or leave the airway in the mouth or insist on surgeon to put small tubes in the nose reaching up to nasopharynx and then pack the nose. These tubes provide airway for emergency (better than no airway at all) and they provide excellent airway at night when the mouth closes and patient does not wake up suddenly choked and has to open the mouth to breathe. Patients are comfortable with tubes.
After planning for lighter anaesthesia at the end I carry out a simple test to find out whether patient has sufficiently recovered. I call it “Gharpure’s test”. Hold the lips of the patient together with both nasal cavities packed. If the patient struggles to open his mouth and succeeds he is in a safe state to be left alone. In patients when the “Safety” polyethylene tubes are put one can test the functioning by listening free breath from the post end (does not touch the post pharyngeal wall and blocks it.) The test can be applied in deeply sedated patients.
In patients who have been given spinal anaesthesia with long acting anaesthetic agents (Bipuvacaine) and surgery gets over in much earlier time (1-2) hours, the effect of the spinal continues for another 3-4 hours. The anaesthetist must instruct the nursing staff about hypotension continuing in postoperative period and its treatment. So many anaesthetist blame the drug. Death has been recorded in the postoperative period. Patient’s blood pressure during surgery is attended to during surgery by the anaesthetist and after surgery the patient is left all alone without instructions.
In smaller setup the commonest cause of postoperative deaths is inadequate reversal of muscle relaxant. Firstly no patient should be shifted from operation table if there is any doubt about his inability to breath. A conscious patient is not a guide for incomplete reversal. A restless patient is always due to hypoxia and not because of pain. A serial B.P. check up every 5 minutes must be done. A rising B.P. is surely sign of incomplete carbon dioxide elimination even though the patient appears pink. A patient who needs assisted respiration in postoperative period with bag and mask needs intubation. A patient who allows IPPR after reversal needs the IPPR.
In all patients with prolonged surgery or toxic patient the presence of qualified doctor is a must. Restlessness in postoperative period should not be translated into pain after surgery but the relevant cause must be found. All patients in whom Lasix was injected during or immediately after surgery, a catheter must be placed in the bladder. Sometimes even a qualified doctor may not be sufficient to understand the cause of restlessness and anaesthetist or operating surgeon must leave instructions rather than testing the intelligence of the house officer.
A diabetic patient on insulin must be under corrected and a small hyperglycaemia accepted rather than hypoglycemia. Covering alternate bottles of glucose 5% infusion with 10 units of soluble insulin is a better plan. Similarly patients with drugs for hypertension given after patient recovers completely and BP checked.
Infants intubated must be closely observed in postoperative period for
Good lusty cry and not a progressive hoarseness
Restless which is mainly hypoxic unless proved otherwise
Dusky colour of skin or mucous membrane. The commonest cause is laryngeal oedema and it calls for immediate treatment and preparation for tracheostomy if treatment fails.
Patients operated for major oral surgery like mandibular tumours of mouth and tongue and tumours of thyroid must be provided an airway at least 48 hours (nasal polyethylene tube with connection) this tube must be removed in the presence of the anaesthetist with all preparations for emergency intubations and IPPR or if found necessary do a tracheostomy. Instances of sudden death in postoperative period are witnessed and documented in such cases. A tongue sutured also prevents falling back of tongue in infants or cases of oral surgery.
All diabetic patients must be converted on soluble insulin regimen if the surgery is major. For minor surgery if the patient is settled on antidiabetic treatment should receive the treatment till previous day and on the day of the operation alternate pint of glucose 5% to be covered by injection Insulin 12 units subcutaneous. The patient goes back to his routine after he starts his oral feeds.
All hypertensives may continue their drug treatment till previous day and after BP check in the morning a dose of nifedepine 10 mg orally under the tongue may be given to check the sudden rise post operatively. All thyroid patients either receiving treatment for hypo or hyper must continue till the day of the surgery. Beta-blockers for thyrotoxicosis must be continued and noted and be informed.