POSTOPERATIVE CARE

Emergence and Extubation

Initial surgery in a trauma patient is followed by a period of monitoring and ongoing treatment in which the anesthesiologist is closely involved, either in the postanesthesia care unit (PACU) or in the ICU. The adequacy of post-traumatic resuscitation must be confirmed, as outlined earlier, and diagnostic studies of the secondary survey completed. Reversal of the effects of general anesthesia is highly desirable, particularly in patients with an altered level of consciousness or other evidence of TBI before surgery. Change in mental status from the preoperative baseline is an indication for repeat cranial CT and a search for possible metabolic or toxic derangements.^[219]

Although it is imperative to assess neurologic function postoperatively, early extubation of a trauma patient should not be taken for granted. Many patients will require continued ventilator support because of CNS trauma, direct pulmonary or chest wall trauma, massive transfusion, upper airway edema, or ongoing intoxication. Table 63-17 lists the criteria for extubation after urgent or emergency trauma surgery; if there is any doubt about the patient's ability to meet these criteria, it is appropriate to transport the patient to the PACU or ICU with the endotracheal tube in place. Appropriate analgesic medication should be administered, with sedation if necessary, and the patient allowed to stabilize further. Twelve to 24 hours of support allows for confirmation of successful resuscitation and surgical repair, hemodynamic equilibration, titration of appropriate analgesia, and resolution of intoxication. Many patients can be extubated easily and safely at this time; those who cannot are at high risk for the development of MOSF—heralded by the development of post-traumatic ARDS—and will usually require days to weeks of subsequent intensive care.