What is “critical care” at HSS?
Critical care refers to the constant, attentive medical care received by some HSS patients in the Post-Anesthesia Care Unit (PACU) after surgery.
Do all patients require critical care after spine surgery?
While not every patient requires critical care after spine surgery, those with major revision surgeries, front and back (anterior and posterior) surgeries, and those patients with complicated medical histories are more likely to spend their initial postoperative time in a critical care monitoring environment.
Often the goal is not to treat actual problems, but to avoid them through careful monitoring. For example, patients after an anterior cervical spine fusion, which is usually not associated with major blood loss, may be watched overnight to make sure that the postoperative swelling in their neck area does not cause any breathing problems.
What are reasons why patients require critical care after major spine surgery?
Patients undergoing major spine surgery often lose significant amounts of blood and require blood transfusions. Blood loss continues after surgery, although to a lesser extent, and requires close monitoring and often blood replacement. We often see blood clotting disturbances, electrolyte shifts, and effects on your breathing and cardiovascular systems, which, until they normalize, require a watchful eye and the ability to intervene in a timely manner.
All these goals can best be accomplished in an intensive care setting, which our recovery room (PACU) - with its monitoring capabilities and skilled staff - can provide. The particular reason why your anesthesiologist would like to keep you in the recovery room will be discussed with you and your family. While we can often anticipate your staying in the recovery room for monitoring even before surgery, certain events during the surgical procedure may influence this decision-making process.
What monitors, catheters and other equipment may be used?
During your stay in a critical care setting, you will be monitored with a blood pressure cuff, an electrocardiogram, and a pulse oximeter (a clip on your finger that measures the oxygen levels in your blood). Most patients will have an arterial line in place, which is a small catheter (similar to an IV) that sits in a small artery in your wrist, allowing us to continually measure your blood pressure. It also allows us to draw blood samples without having to stick you each time.
Depending on your operation and medical history, you may have a central venous line in your neck area, which is a special IV that is used to measure the pressure in your big veins, and gives us information about your blood volume. Similar to a tank gauge in a car, it allows us to better judge how much fluid to give you. We can also use this catheter to give you blood or medications. All the above-mentioned monitors and catheters will be removed before you leave the recovery room.
Also, you may require a Foley catheter (a tube that drains the urine from your bladder) and drains placed at the site of the operation during your surgery. Patients with procedures on the chest level may have a “chest tube,” which is a drain that evacuates air and fluid from your chest cavity that may have accumulated after surgery.
Will my breathing tube stay in after surgery?
General anesthesia (the type of anesthesia used for virtually all spine cases at HSS) usually requires your anesthesiologist to place a breathing tube in your windpipe to help you breathe during your surgery. There are many reasons why your anesthesiologist may decide to leave the breathing tube in place, as indicated by your medical situation at the end of surgery. The reasons for this may vary and often include:
What should I expect if the breathing tube stays in after surgery?
If the decision is made to keep the breathing tube in after your surgery, you will stay in our recovery room overnight and a breathing machine will help you breathe. This does not mean that you will not be able to breathe on your own, just that the machine will help as a backup. A number of measures will be taken to keep you comfortable during this time. You will remain sedated, and you will receive pain medicine usually administered by your nurse. However, if you are awake enough, you may use a pain pump that you will have control over – we call this patient-controlled analgesia (PCA).
Most patients do not recall a lot of details from their time with a breathing tube. At times it becomes necessary to lighten your sedation to do a brief examination that requires your ability to follow commands and to assess your progress. Be aware that because the breathing tube sits between your vocal cords, you will not be able to speak with the tube in place.
When does the breathing tube come out?
Your physician will conduct a number of tests to assess that you are ready to breathe on your own. These checks may include a simple blood test that lets us know how much oxygen your lungs transfer to your bloodstream, a test which requires you to take a deep breath and lets us know how strong your breathing muscles are, and a test that a allows us to check if your airway is open and not swollen anymore.
Once the decision is made to remove the breathing tube, sedation is discontinued, and we will wait for you to be awake enough to follow our instructions. Subsequently, we will suction your mouth to remove any secretions and then remove the breathing tube. An oxygen mask will be placed over your mouth and nose, and we will encourage you to take deep breaths and cough up any secretions you may have. It is crucial that you let us know if you have any pain, as this may make it difficult for you to breathe. You should expect to have a sore throat for a while after the removal of the breathing tube.
When do I leave the critical care area?
Your physician will review data on all your organ systems and determine if you are stable and ready to be discharged. This will usually require a stable blood pressure and heart rate, no - or slight - ongoing bleeding, and good breathing status.
Further, we want your pain to be controlled, and you should be awake enough to communicate any subjective complaints. If you meet these criteria and we deem it safe for you to go to a regular inpatient unit, invasive monitoring catheters will be removed, and your nurse will sign out to his/her colleague on the in-patient unit, who will be assigned to take care of you.
If, for whatever reason, any medical concerns arise after your discharge to the in-patient unit, you may be transferred back to the recovery room, where we have the appropriate capabilities to take care of you.
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