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1 Introduction 1
2 Clinical assessment and monitoring 3
3 Cardiovascular management 11
4 Respiratory management 20
5 Fluid, electrolyte and renal management 28
6 Management of sepsis 34
7 Postoperative nutrition 39
8 Information for discussion with
patients and carers 44
9 Development of the guideline 45
Abbreviations 48
Annexes 49
References 52
August 2004
COPIES OF ALL SIGN GUIDELINES ARE AVAILABLE BY CALLING 0131 247 3664 OR ONLINE AT WWW.SIGN.AC.UK
KEY TO CONSENSUS AND EVIDENCE STATEMENTS
CONSENSUS STATEMENTS
LEVELS OF EVIDENCE
GRADES OF RECOMMENDATION
Note: The grade of recommendation relates to the strength of the evidence on which the
recommendation is based. It does not reflect the clinical importance of the recommendation.
B A body of evidence including studies rated as 2++, directly applicable to the target
population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C A body of evidence including studies rated as 2+, directly applicable to the target
population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
SIGN consents to the photocopying of this guideline for the purpose of implementation in NHSScotland
Scottish Intercollegiate Guidelines Network
Royal College of Physicians
9 Queen Street, Edinburgh EH2 1JQ
www.sign.ac.uk
SIGN IS FUNDED BY NHS QUALITY IMPROVEMENT SCOTLAND
1 INTRODUCTION
1 Introduction
1.1 THE NEED FOR GUIDANCE
Over the past five years, annual reports from the Scottish Audit of Surgical Mortality (SASM)
have highlighted problems in perioperative management of patients. These include failure to
predict or recognise clinical decline, failure to involve consultants at an early stage and failure to
appreciate the consequences of not acting promptly when decline is identified.1 SASM has
consistently highlighted variation in practice in postoperative care. Almost 2,000 patients die
following surgery in Scotland each year. In the vast majority, death is the inevitable consequence
of the disease process. However, it is likely that some 10,000 patients per year suffer major
complications after surgery and best practice guidelines might have an impact in this area.
As a consequence of these audits, SASM has called for the development of local and national
guidelines on the use of intensive care unit (ICU) and high dependency unit (HDU) resources
and in particular has suggested that the Scottish Intercollegiate Guidelines Network (SIGN) should
produce guidelines for postoperative management focusing on symptoms and signs of well-
known serious complications. The target audience for the guidelines would be nursing, allied
health care and trainee medical staff. It was suggested that a SIGN guideline could cover monitoring
of postoperative patients and the investigation and management of clinical deterioration in the
postoperative period.
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POSTOPERATIVE MANAGEMENT IN ADULTS
This guideline does not focus on postoperative pain management (an evidence based guideline
already exists in this area),7 indications for blood transfusion, the prophylaxis of surgical site
infection or venous thrombosis, nor the management of obstetric patients or pregnant women or
those patients with head injury or hip fracture (these are covered by separate SIGN guidelines,
see www.sign.ac.uk). The guideline excludes the management of children (<18 years of age).
The guideline is designed to be used principally by doctors, nurses, paramedical staff and students.
It can also serve as a teaching resource.
2
2 CLINICAL ASSESSMENT AND MONITORING
CS Anaesthetic and surgical staff should record the following items in the patients
case notes:
n any anaesthetic, surgical or intraoperative complications
n any specific postoperative instruction concerning possible problems
n any specific treatment or prophylaxis required (eg fluids, nutrition, antibiotics,
analgesia, anti-emetics, thromboprophylaxis).
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POSTOPERATIVE MANAGEMENT IN ADULTS
2.2 ASSESSMENT
CS A postoperative assessment should be carried out when the patient returns from theatre.
This assessment may be carried out by the doctor responsible in the first instance for patient care,
usually the House Officer. When the doctor is unavailable or the case is minor and straightforward
a trained nurse could complete this assessment. The doctor should attend later to assess the
patient in person. Any departure from accepted physiological parameters (see sections 3-6) requires
the attendance of the doctor as a matter of urgency.
CS Doctors immediately responsible for patients should ensure that a contact/pager number
is available to the nursing staff on the ward.
4
2 CLINICAL ASSESSMENT AND MONITORING
CS If the nurse responsible for the care of the patient becomes unavailable for discussions
with other members of the care team, they should pass on all pertinent information to
another member of nursing staff who then assumes responsibility for that patient.
A structured care plan may aid the exchange of information between healthcare professionals.
Physical examination of the patient is different from the routine examination of patients
preoperatively. In the routine situation, the doctor has time to carry out a structured examination
which includes the variables described below. In the emergency setting, the standard airways,
breathing and circulation or ABC approach would be followed. The focus, in postoperative
assessment, is on circulatory volume status, respiratory function and level of consciousness.
Table 1 shows a checklist for the first postoperative assessment.
Having assessed the patient, the doctor should legibly record the findings in the notes at the
same time. Any specific problems should be recorded and a management plan developed. The
interval after which the patient should be reassessed should also be chosen at this stage.
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POSTOPERATIVE MANAGEMENT IN ADULTS
Appropriate lighting should be used in order to visualise the jugular venous pressure. The height
of the JVP should specify the marker used; clavicle, sternal angle etc. 13
Proformas, which provide tick boxes to speed the recording of information after the postoperative
assessment, may be useful.
6
2 CLINICAL ASSESSMENT AND MONITORING
CS Patients with the following risk factors for deterioration should be reassessed within two
hours of the first postoperative assessment:
n ASA grade ³3
n emergency or high risk surgery
n operation out of hours.
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POSTOPERATIVE MANAGEMENT IN ADULTS
2.4 MONITORING
CS The doctor completing the initial postoperative assessment should consider the monitoring
regimen and appropriate level of care required for the next 24 hours in collaboration
with the nursing team.
8
2 CLINICAL ASSESSMENT AND MONITORING
Continuous oxygen saturation and electrocardiography (ECG) may be carried out by automatic
equipment. Patients requiring advanced monitoring or frequent detailed assessments may be
more appropriately cared for in a level 2 setting.15
CS Patients requiring the frequent monitoring of multiple variables should be considered for
care at level 2 or above.
CS n Any patient with circulatory disturbance should be catheterised and the urine output
measured hourly
n Consider catheterisation in patients with no urine production after four hours.
Patients with complex needs often require enhanced levels of care. Invasive cardiovascular
monitoring, including the use of indwelling central venous or arterial cannulae, is usually restricted
to level 2 or level 3 care.
Patients who are initially admitted to the postoperative ward or to areas providing level 1 or 2
care may require a higher level of care thereafter. Patients who show cardiovascular instability or
respiratory difficulty should be considered very early in the postoperative course to be candidates
for level 2 or 3 care.
CS Trends in the physiological data, rather than absolute numbers, should be reported to
assist in the detection of deteriorating patients before a severe physiological compromise
occurs.
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POSTOPERATIVE MANAGEMENT IN ADULTS
CS n The ultimate responsibility for patient care lies with the consultants providing surgical
and anaesthetic care
n Junior doctors should assume only the responsibility appropriate to their training and
experience
n Where a junior doctor feels that they may exceed their personal responsibilities or
capabilities, they have a duty of care to discuss the patient with a more senior doctor
in the same clinical team.
10
3 CARDIOVASCULAR MANAGEMENT
3 Cardiovascular management
3.1 INTRODUCTION
In general, maintaining a patients heart rate and blood pressure within normal limits will result
in a satisfactory outcome. However, there are no clinical studies to indicate what is normal with
respect to heart rate and blood pressure for individual patients in the postoperative period.
Surgery is associated with a stress response that persists postoperatively.16 Anaesthesia modifies
the stress response, which can be further modified by the use of techniques such as regional
anaesthesia or use of high dose opioids. During anaesthesia heart rate and blood pressure are
maintained within appropriate limits at the discretion of the anaesthetist. On emergence from
anaesthesia this damping down of the stress response is lost and heart rate and blood pressure
rise in the postoperative period.
3.2.1 BRADYCARDIA
A heart rate below 50 beats per minute may be normal in a patient who is otherwise well. If the
blood pressure is well maintained, the simplest strategy is to observe the patient closely over the
next few hours.
In some patients a slow heart rate can reduce blood pressure as a result of reduced cardiac output
(cardiac output = heart rate x stroke volume).
Correcting the slow heart rate with a vagolytic agent (eg intravenous glycopyrronium bromide
0.2-0.4 mg or atropine sulphate 0.3- 0.6 mg) should restore the blood pressure and allow time
for the cause of the low blood pressure and heart rate to be deduced. If the blood pressure does
not respond to the increase in heart rate then other possible causes should be considered, such as
blood loss (see Table 4).
3.2.2 TACHYCARDIA
Heart rates over 100 beats per minute may be well tolerated by fit patients but may indicate a
clinical problem. Sustained tachycardia is particularly dangerous for patients who have documented
ischaemic heart disease or risk factors for ischaemic heart disease as myocardial oxygen supply
cannot be increased (see section 3.4).
Tachycardia associated with high blood pressure may simply be the consequence of pain and
anxiety and appropriate analgesia may be all that is required. If elevated rates and pressure are
maintained despite good analgesia, senior advice should be sought.
In hypovolaemic patients tachycardia may precede development of hypotension. Hypotension
indicates severe hypovolaemia caused by fluid deficit and in the context of recovery from surgery,
acute blood loss should be excluded. Assessment of fluid balance is mandatory at this stage (see
section 5).
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POSTOPERATIVE MANAGEMENT IN ADULTS
CS Postoperative blood pressure should always be reviewed with reference to the preoperative
and intraoperative assessments.
3.3.1 HYPOTENSION
Hypotension is defined as either a systolic blood pressure of less than 100 mm Hg or as a fall of
at least 25% from the patients normal pressure.
Hypotension is relatively common postoperatively and may be drug induced (eg residual effects
of anaesthesia, epidural or opioids) or may represent fluid deficit. Table 4 lists broad categories
for the assessment of hypotension.
Hypotension should not be allowed to persist unless the clinician is absolutely sure that no
important pathological process is taking place. If in doubt senior advice should be sought.
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3 CARDIOVASCULAR MANAGEMENT
Assessment of hypotension
3.3.2 HYPERTENSION
Hypertension is common in the postoperative period as a result of a number of factors including
the stress response, pain, anxiety and failure to continue medication perioperatively.
Postoperative hypertension is associated with bleeding, cerebral events and myocardial ischaemia
especially if the heart rate is also elevated.
Treatment of Hypertension
Beta blockers and intravenous (IV) nitrates are effective for the control of postoperative
2+
hypertension.23,24
CS If patients are hypertensive, ensure that they are receiving adequate analgesia. If
hypertension persists seek specialist medical advice and review the level of care.
C Beta blockers and IV nitrates may be used safely and effectively in postoperative
hypertension.
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POSTOPERATIVE MANAGEMENT IN ADULTS
Clinical factors
High risk surgery (see Table 6 for definitions)
History of ischaemic heart disease
History of congestive heart failure
History of cerebrovascular disease
Preoperative insulin treatment
Preoperative creatinine >180 micromol/l.
The rates of major cardiac complications postoperatively with 0,1,2,3 or more risk factors were
0.5%, 1.3%, 4% and 9% respectively.
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3 CARDIOVASCULAR MANAGEMENT
Patient and procedure-associated risk factors should be taken into account preoperatively when
planning any surgical procedure. Clinicians caring for patients postoperatively need to appreciate
the level of risk and any clinical factors which may influence that risk.
CS Clinicians caring for patients postoperatively must be aware of clinical factors which
increase risk to the patient and how these interact with the risks imposed by the surgical
procedure.
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n identify and correct underlying factors such as hypoxia, hypovolaemia, electrolyte imbalance
and sepsis (see sections 4, 5 and 6)
n seek expert advice for patients showing cardiovascular instability and review level of care
n seek expert advice where the diagnosis or management of an arrhythmia is in doubt as DC
cardioversion is the first option where tachyarrhythmia results in haemodynamic deterioration
n A 12 lead ECG should be obtained before and after DC shock or pharmacological cardioversion
and a rhythm strip obtained during drug intervention if possible
n Multiple or inappropriate drug therapy can be dangerous.
16
3 CARDIOVASCULAR MANAGEMENT
CS Seek expert help early in the management of serious or potentially serious arrhythmias
and reconsider the level of care.
Helpful algorithms for the management of acute tachyarrhythmias and bradyarrhythmias can be
found in the European Resuscitation Guidelines 2000.51
CS Seek expert help early when perioperative conduction defects result in bradycardia
unresponsive to atropine.
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POSTOPERATIVE MANAGEMENT IN ADULTS
CS Thrombolysis is not indicated in the management of perioperative MI, but all other
aspects are as for MI in any other setting.
3.10 HYPOTHERMIA
Hypothermia occurs in patients undergoing surgery because of anaesthetic-impaired
thermoregulation, cold operating environments, open body cavities and the administration of
unwarmed IV fluid.
Without active methods to retain or provide heat approximately half of all patients undergoing
surgery develop a core temperature of less than 36oC and in one third of patients the temperature
drops below 35oC.
In a prospective randomised controlled trial forced air warming, used both intraoperatively and
postoperatively, maintained a core temperature significantly higher than non-heated controls
(36.7 +/- 0.1oC versus 35.3 +/- 0.1oC, p = 0.0001).58
The maintenance of normothermia using a forced air warming technique intraoperatively and
postoperatively is also associated with fewer cardiac events (eg cardiac arrest, myocardial infarction
and/or unstable angina or ischaemia occurring in the first 24 hours postoperatively) in elderly
patients undergoing abdominal, vascular and thoracic surgery.58
3.11 OXYGENATION
Patients with coronary artery disease are at risk from ischaemia in the first few postoperative
days.
The effect of anaesthesia and analgesia on respiratory function predisposes patients to hypoxia
postoperatively. The potential for hypoxia may remain for up to five days postoperatively, 59 and
is increased at night.
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3 CARDIOVASCULAR MANAGEMENT
For most patients there is no consistent evidence regarding the relationship between hypoxia and
ischaemic events postoperatively. In high risk patients undergoing vascular surgery, new ischaemic
changes have been shown to be associated with a fall in oxygen saturation.60 Myocardial ischaemia
has been shown to be more likely when episodes of hypoxia are prolonged beyond five minutes
and are severe (SpO2<85%).61
See sections 4.3.3 and 4.5.2 for further information.
CS n Patients with coronary artery disease, or major risk factors for coronary artery disease,
should receive oxygen continuously until mobile.
n Oxygen saturation should be maintained above 92%.
NB None of these signs are specific for cardiac failure and must be assessed in the
clinical context.
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POSTOPERATIVE MANAGEMENT IN ADULTS
4 Respiratory management
4.1 INTRODUCTION
Pulmonary complications are an important and common cause of postoperative morbidity and
mortality and are particularly common after major abdominal and thoracic surgery. Reported
incidence varies from about 20-75%,62-64 perhaps because of inconsistent diagnostic criteria. If
patients at risk can be recognised, it may be possible to modify some risk factors before elective
surgery to reduce the rate of these complications. Early recognition of developing respiratory
complications with appropriate interventions may improve outcome. Failure to recognise pulmonary
complications may result in rapid deterioration leading to death.
Treatment must be based on an accurate assessment of the patient. In some cases no specific
treatment is required but in others rapid and aggressive treatment is required to prevent death.
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4 RESPIRATORY MANAGEMENT
4.3.1 ANALGESIA
Compared with systemic opioids, neuroaxial blockade after surgery can reduce pulmonary
complications; epidural opioids (RR 0.53 95% CI 0.2-1.33), epidural local anaesthetics (RR
0.58 95%CI 0.42-0.80), and intercostal nerve blocks (RR 0.47 95% CI 0.12-1.22).71
A large multicentre comparison of high risk patients having abdominal surgery found that analgesia
with epidural after surgery did not improve survival (5.1% vs 4.3%) or major morbidity.72 Only
one of eight categories of morbid end points in individual systems (respiratory failure) occurred
1+
less frequently in patients managed with epidural techniques (23% vs 30%, p=0.02). In this
study, the term respiratory failure is a pooled end point covering need for prolonged intubation
or reintubation, or a PaO2 ≤ 50 mm Hg or a PaCO2 ≥ 50 mm Hg on room air. These criteria may
not all be clinically relevant.
CS Oxygen therapy should be used in those patients at high risk of postoperative complications,
or who are hypoxaemic following surgery (SpO2< 92%).
21
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4.4.1 INTRODUCTION
The widely accepted methods of monitoring patients have not generally been subject to evidence
based assessment. An RCT of 20,802 patients found no difference in the incidence of postoperative
complications between those routinely monitored with pulse oximetry and those not routinely 1+
monitored. Monitored patients had significantly more episodes of hypoxaemia identified and
had fewer episodes of ECG detected myocardial ischaemia. 79,80 No other trials of routine monitoring
were identified.81
4.4.3 OBSERVATION
Simple measures are most appropriate in view of the absence of evidence of efficacy of more
sophisticated measures.82
The following indicate the possible development of respiratory complications:
n respiratory rate <10 or >25 breaths per minute
n pulse rate >100 beats per minute
n reduced conscious level and/or confusion.
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Clinical assessment of the chest should be performed. Adventitial sounds on breathing are common
and need not indicate significant disease but major abnormalities such as gross pulmonary collapse
and pleural effusions are easily detectable.
CS Respiratory rate, pulse rate and conscious level should be monitored routinely to identify
postoperative respiratory complications.
4.4.4 INVESTIGATIONS
Specific and non-specific investigations are available and should be used as indicated clinically.
n Pulse oximetry. It may be difficult to obtain a satisfactory signal if peripheral circulation is
poor. Patients receiving supplemental oxygen may have adequate oxygen saturation despite
hypoventilation and hypercapnia.
n Arterial blood gas analysis (ABG). ABG is essential in the assessment of any patient with
suspected respiratory complications. ABG accurately defines the degree of respiratory failure
and differentiates between metabolic and respiratory acidosis.
n Chest X-ray. Chest X-rays should be used to diagnose or exclude major collapse, pulmonary
embolism and pleural problems such as effusions, pneumothorax or haemothorax. Routine
X-rays are of limited value, even in patients who have had thoracic surgical procedures.83
Small areas of atelectasis are common but not necessarily significant. Diffuse pulmonary
infiltrates may be caused by conditions such as cardiac failure, infection and ARDS.
n CT scan. Valuable in the accurate assessment of pulmonary masses, pulmonary embolism or
major pleural disease such as empyema. It has no place in the routine management of
postoperative pulmonary complications.
n Bacteriology. Sputum culture is of value in planning appropriate antibiotic therapy. Specimens
taken by endobronchial suction may be used.
n ECG. Significant respiratory compromise may relate to a primary cardiac event, and so all
patients who are investigated for pulmonary complications should also have an ECG.
4.5 TREATMENT
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Oxygen therapy
Oxygen can be delivered by a large number of different devices. 100% oxygen can only be
supplied by endotracheal intubation and positive pressure ventilation. The highest inspired
concentration that can be supplied by external devices is about 70% with a mask and reservoir
bag. A 60% ventimask can reliably supply sufficient oxygen for most patients with respiratory
insufficiency.84 A selection of fixed performance devices (ie providing a fixed FiO2) are available,
allowing delivery of an FiO2 appropriate to individual patients.
Hudson masks and nasal catheters with a foam collar allow better PaO2 than nasal catheters, but
there is no difference in oxygen saturation between the three devices.85 Hudson masks, when
used with low flow oxygen, may result in hypercapnia due to inadequate ventilation. Nasal
catheters are better tolerated and therefore compliance is better.86
In a normally hydrated patient humidification of oxygen is not necessary unless the patient is
intubated with an endotracheal tube or has a tracheostomy.
Patients with type 2 respiratory failure due to chronic obstructive pulmonary disease (COPD)
have chronic CO2 retention and are dependent on hypoxic drive. They should be given whatever
FiO2 is necessary to return their SpO2 to its usual level.
CS Oxygen should be given to patients with hypoxaemia using a device that is best tolerated
to achieve the necessary SpO2. In normally hydrated patients humidification is unnecessary.
Failure to maintain an SpO2 >90% or PaO2 >8.0 kPa is an indication to consider assisted
ventilation.
Antibiotics
Patients fulfilling the diagnostic criteria for respiratory infection (see section 4.4.2) should be
treated with appropriate antibiotics, based on local protocols and represcribed later on the basis
of the results from sputum culture.87 Any patient in whom aspiration may be suspected should
receive additional cover for anaerobic organisms. Continued monitoring of sputum bacteriology
is necessary as treatment failure is associated with development of drug resistance and change in
bacteria.87
CS Patients with evidence of respiratory infection should receive antibiotics based initially
on local protocols and modified later on the basis of the results from sputum culture. If
aspiration of intestinal contents is suspected additional cover for anaerobic organisms
should be given.
24
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CS Opioid overdose should be treated with oxygen, airway maintenance, ventilatory support
if necessary, and immediate anaesthetic or critical care specialist advice.
Assisted ventilation
In patients who develop respiratory failure assistance with breathing may be necessary. Assisted
ventilation is required when a patient develops hypercapnia and occasionally for severe hypoxaemia
(see section 4.4.2. for definitions).
Accepted criteria for ventilation are:
In a patient receiving FiO2 of 0.6:
n PaCO2 >6.6kPa
n PaO2 < 8.0kPa
n Respiratory rate >25 breaths/min.
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Following general anaesthetic, a patients functional residual capacity may be lowered, particularly
following upper abdominal or thoracic surgery. Reduction in lung volume reduces lung compliance,
increases airway resistance and may lead to atelectasis.
The aims of postoperative physiotherapy are to:
n facilitate re-expansion of atelectasis
n maintain adequate ventilation
n assist with the removal of bronchial secretions
n encourage early mobility
n promote return to preoperative functional levels.
A combination of these approaches may help to maintain respiratory function and prevent early
postoperative respiratory complications. Other treatment techniques are available for patients
with more complex needs. There should be a multidisciplinary approach to the promotion of
optimal positioning and early mobilisation.
Adequate analgesia prior to physiotherapy will allow more patients to participate in treatment.
Local treatment protocols may be in place for specific patient groups.
26
4 RESPIRATORY MANAGEMENT
Retention of sputum is common and assistance with breathing and positioning helps expectoration.
Additional use of humidification in patients with very viscid secretions may help expectoration.
Patients with evidence of collapse or decreased lung volume on X-ray, and those who have had
recent abdominal surgery may also benefit from physiotherapy.
Postoperative pain, particularly in upper abdominal or chest surgery, may cause difficulty with
deep breathing and coughing. Both are essential in the treatment of respiratory infections, making
appropriate positioning of the patient important. Patients often find the sitting position helpful
for breathing. This is also a more comfortable position in patients with respiratory distress.
CS The patient should be encouraged to sit up and should be given sufficient analgesia,
which may include epidural anaesthesia, to allow breathing exercise and coughing.
CS Patients with collapse or decreased lung volume or who have undergone recent thoracic
or abdominal surgery should be considered for physiotherapy.
27
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CS The basal requirements for young adults are approximately 30 ml/kg/day of water, 1.0-
1.4 mmol/kg/day of sodium and 0.7-0.9 mmol/kg/day of potassium.
Given that fat is relatively metabolically inert and that the percentage of fat relative to lean mass
tends to increase with age, the standard calculations above are particularly likely to overestimate
the basal needs of the obese, the elderly and women.
28
5 FLUID, ELECTROLYTE AND RENAL MANAGEMENT
CS Elderly patients should be observed closely as they are more likely to have overt or covert
cardiac, respiratory or renal disease and to have less reserve. Clinical signs may be less
reliable in these patients.
5.3 PROPHYLAXIS
The ideal way of tackling problems with fluid and electrolyte balance is to avoid them in the first
place. Appropriate monitoring strategies are discussed in section 2.4. The patients fluid status
and electrolyte balance need to be estimated, taking into consideration:
n unusual losses as the result of the surgical problem prior to assessment
n continuing surgical-related losses
n usual maintenance needs
n vasodilating effects of epidural analgesia.
CS Assess hypotensive patients with epidurals to exclude fluid deficit. It should not be assumed
that the hypotension is due to the epidural.
29
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CS Accurate assessment of fluid and electrolyte status can be difficult and the treatment of a
particular patient must be individualised and reviewed frequently in the light of the
response to treatment.
CS Volume depletion should be avoided as this can lead to poor perfusion and problems
such as anastomotic breakdown, cerebral damage, renal failure and multiple organ failure.
30
5 FLUID, ELECTROLYTE AND RENAL MANAGEMENT
5.6 OLIGURIA
Oliguria is defined as urine volume of less than 0.5 ml/kg/hr for two consecutive hours. The
appropriate response depends on the cause and whether it is associated with impaired renal
function.
Oliguria should not be regarded as a diagnosis but as a sign requiring explanation. It is not
appropriate to artificially increase the urine output in a hypovolaemic patient using diuretics.
These should be reserved for patients who are fluid overloaded. Dopamine has been widely used
in the past in the hope of preventing acute renal failure, but the overwhelming evidence from
studies in critically ill patients is that it is not beneficial.
Oliguria associated with normal pre-existing renal function, cardiovascular stability and an alert
patient is unlikely to require intervention unless it persists for four hours or more. If associated
with other symptoms or signs suggestive of fluid depletion it should be treated initially with a
fluid challenge. Careful monitoring is required in patients with poor cardiac function.
Colloid is preferred as the effect is more readily apparent, but crystalloid, such as normal saline,
can also be used. In a normal adult, 250 ml colloid should be given over 30 minutes. It is
essential to assess the response in terms of haemodynamics and subsequent urine output. If there
is no improvement, this may be repeated once. If this does not produce improvement then
consideration should be given to the measurement of central venous pressure. Smaller volumes
may be appropriate in the frail elderly and those with cardiovascular disease.
CS Oliguria is defined as urine volume of less than 0.5 ml/kg/hr for two consecutive hours.
The appropriate response depends on the cause and whether there is pre-existing renal
impairment.
CS Oliguria in an alert patient, that is associated with normal pre-existing renal function
and cardiovascular stability, is unlikely to require intervention unless it persists for four
hours or more.
CS Diuretics should not be used to treat oliguria and should be reserved for fluid overload.
31
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5.7 SODIUM
5.7.1 HYPONATRAEMIA
Hyponatraemia does not by itself indicate saline deficiency and is most commonly due to excess
water. Antidiuretic hormone (ADH) secretion is increased after surgery and if excess water is
given (as 5% dextrose) then hyponatraemia may be induced. If hyponatraemia is associated with
volume depletion then there must be a degree of sodium deficiency. The estimation of the degree
of volume excess or volume depletion requires clinical assessment in addition to biochemical
estimates. Very low levels of serum sodium (110-120 mmol/L or less) can produce symptoms
such as stupor, coma or fits and constitute a medical emergency. Over-vigorous correction of
severe hyponatraemia is also dangerous. Patients with hyponatraemia should be managed by
medical staff with appropriate experience.
5.7.2 HYPERNATRAEMIA
In patients with hypernatraemia, clinical assessment of the patient may add little to the
biochemical assessment, as water depletion initially leads to volume losses from the intra-
cellular rather than the extracellular space. The signs and symptoms of water depletion tend to be
non- specific, particularly where the sensation of thirst is impaired by the surgical or medical
situation.
5.8 POTASSIUM
Potassium levels in the blood are not a good indicator of total body potassium. However, abnormal
blood levels, and in particular hyperkalaemia may precipitate cardiac arrest, and an ECG is an
important adjunct when deciding the potential ill effects of potassium abnormalities in an
individual postoperative patient.
Protocols for the emergency treatment of potassium abnormalities are described in standard
emergency medicine texts. Most hospitals will also have local protocols which should be referred
to. It is important to correct hypoxia and institute ECG monitoring.
5.8.1 HYPOKALAEMIA
Chronic hypokalaemia indicates a significant deficit in total body potassium, which may be
several hundred millimoles. The clinical effects of hypokalaemia include skeletal muscle weakness,
ileus, and cardiac arrhythmias. It can also potentiate the adverse effects of digoxin.
Acute hypokalaemia can result from shift of potassium into cells due to, for example, alkalosis,
insulin or beta adrenergic stimulation (including nebulised beta agonists).
True potassium deficiency in postoperative patients may result from:
n inadequate replacement
n renal losses
n endocrine abnormalities
n upper and lower GI losses (the actual loss of potassium from the upper GI tract is small, but
the loss of chloride causes alkalosis which promotes the movement of potassium into cells
and increases renal excretion).
32
5 FLUID, ELECTROLYTE AND RENAL MANAGEMENT
Not only does alkalosis cause hypokalaemia, but hypokalaemia can cause alkalosis.
Treatment of hypokalaemia should first focus on removing avoidable causes. Unless there is true
potassium deficiency, it is seldom necessary to replace potassium at a rate of greater than 10-20
mmol/hr. Faster administration usually requires a central line and careful monitoring and should
by undertaken in an environment which provides level 2 care. Concentrated solutions of potassium
are intensely irritant to peripheral veins and can cause tissue necrosis if they extravasate.
When correcting severe or persistent hypokalaemia, also ensure that magnesium is not deficient.
Magnesium deficiency leads to increased renal loss of potassium.
5.8.2 HYPERKALAEMIA
Emergency treatment of hyperkalaemia may include IV calcium chloride, which must be titrated
slowly, IV calcium gluconate, nebulised beta agonists (such as salbutamol) or IV 50 ml 50%
dextrose with 10 units of shortacting insulin.
CS Metabolic acidosis is usually due to poor tissue perfusion but can also be caused by
excessive administration of saline. A total venous bicarbonate of less than 20 mmol/L or
a base deficit of greater than 4 mmol/L may indicate cause for concern, particularly if the
trend is towards progressive acidosis. Expert opinion should be sought.
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6 Management of sepsis
6.1 INTRODUCTION
Sepsis is the systemic inflammatory response to infection and represents a progressive response
to infection leading to a generalised inflammatory reaction in organs remote from the initial
insult and eventually to end-organ dysfunction and/or failure (see Table 13 for list of definitions).
The development of systemic sepsis in a postoperative patient marks a serious decline in their
condition. If associated with shock or organ dysfunction (sepsis syndrome) mortality is between
20 and 40%. Clearly identifying patients at risk and taking appropriate prophylactic measures is
vital. Once a patient has developed sepsis syndrome however, the principles of early identification,
immediate resuscitation, moving the patient up to the appropriate level of care (level 2 or 3),
identifying the primary source, use of early and appropriate antibiotics and undertaking appropriate
surgical drainage are the mainstays of treatment.
Sepsis
SIRS plus documented site of infection
Severe sepsis
Sepsis associated with organ dysfunction, hypoperfusion or hypotension (septic shock).
Hypoperfusion and perfusion abnormalities may include, but are not limited to, lactic
acidosis, oliguria or an acute alteration in mental state.
There is little evidence to demonstrate how these factors influence or predict outcome.
34
6 MANAGEMENT OF SEPIS
6.3 PROPHYLAXIS
CS Hand washing with soap and water or with alcoholic cleansing agents should be performed
before and after patient contact.
CS Strict hand antisepsis must be achieved before the performance of invasive procedures
such as surgery or the placement of intravascular catheters, indwelling urinary catheters,
or other invasive devices.
35
POSTOPERATIVE MANAGEMENT IN ADULTS
CS Gloves made from a range of materials should be available for personnel with sensitivity
to standard glove material, and for use in patients with a similar sensitivity.
CS Urine and blood cultures should be obtained whenever there is reason to suspect systemic
sepsis.
CS If clinical signs are unclear, appropriate radiological investigations should be used for
the diagnosis of intra-abdominal infection.
36
6 MANAGEMENT OF SEPIS
6.5 MANAGEMENT
Once a patient has been identified to be septic, further diagnosis and treatment usually occur in
parallel. Immediate care demands assessment of airways, breathing and circulation (the ABCs).
The patient will often be hypovolaemic and hypoxaemic and the presence of these changes
demands at least the administration of oxygen and establishment of intravenous access with
volume expansion using either colloid or crystalloid. Patients with sepsis syndrome need careful
monitoring and, in general, require level 2 care. Once a patient has been examined fully and
initial diagnostic tests undertaken, antibiotics should be given as early as possible and are generally
prescribed on a best guess basis for the clinical scenario.
CS If the cause of sepsis is unknown, treatment should be with broad spectrum antibiotics,
guided by local protocols.
CS The results from microbiological specimens should be reviewed regularly and antibiotics
changed as necessary.
6.5.2 SURGERY
Surgical approaches to the treatment of infection have evolved through principal and tradition
and few have been evaluated by randomised controlled trials. Localised collections of pus generally
need either operative or percutaneous drainage and dead tissue should be excised.
Severe pulmonary sepsis may require bronchoscopy and toilet of the bronchial tree. Early
intervention in necrotising soft tissue infection has been shown to reduce mortality compared to
historical controls in some case series.111
Abdominal sepsis, if localised, can be managed initially with antibiotics or percutaneous drainage,
but generally the primary source of sepsis must be treated surgically (eg anastomotic leakage).
Meticulous attention to peritoneal toilet with copious lavage is essential. The role of planned
second-look laparotomy is still not clear. There are no randomised controlled trials comparing
percutaneous and operative drainage techniques. Case series show that percutaneous drainage is
as effective as conventional surgery for the drainage of intra-abdominal collections.112,113
37
POSTOPERATIVE MANAGEMENT IN ADULTS
CS Patients with multiple collections or with failure of percutaneous drainage should have
open surgery.
38
7 POSTOPERATIVE NUTRITION
7 Postoperative nutrition
7.1 INTRODUCTION
For normally nourished patients, the primary objective of postoperative care is restoration of
normal GI function to allow adequate food intake and rapid recovery. Malnourished patients are
at increased risk of postoperative complications and mortality, yet artificial nutritional support
can be associated with major complications.114
This section discusses a number of key issues that should be addressed if restoration of oral food
intake is to be achieved quickly and safely.
CS Patients should not be fasted for any longer than necessary, either for investigations or
surgery.
CS Hospitals should provide appetising food and assist patients to eat, if this is needed.
39
POSTOPERATIVE MANAGEMENT IN ADULTS
CS Malnourished patients with benign disease requiring surgery should receive postoperative
nutritional support by the appropriate route.
40
7 POSTOPERATIVE NUTRITION
CS Mild or moderately malnourished cancer patients should proceed with surgery and only
receive artificial nutritional support if specifically indicated.
CS All malnourished cancer patients should be considered for nutritional advice and oral
supplements in the postoperative period and for a period following discharge.
CS Nutritional replacement should be discussed with a dietitian and tailored to the patients
requirements.
CS Enteral nutrition is the preferred method of postoperative nutritional support and should
be used if possible.
Patients with partial gut failure and who are catabolic, eg with necrotising pancreatitis or ongoing
intra-abdominal sepsis, may benefit from artificial nutritional support in the postoperative period.
In the presence of partial gut function either combined TPN/EN, or if possible, full enteral
feeding, is the method of choice.
CS For patients with ongoing postoperative complications enteral nutrition should be used
whenever possible, combined with parenteral nutrition where necessary, to meet nutritional
needs.
41
POSTOPERATIVE MANAGEMENT IN ADULTS
CS Enteral nutrition should be provided by the simplest technique possible. The feeding
should be given in such a way as to interfere minimally with the normal stimuli to
eating.
42
7 POSTOPERATIVE NUTRITION
Status Markers
Biochemistry Electrolytes, urea, blood glucose, urinalysis, liver
function tests (twice weekly)
Fluid balance Fluid charts, weight
Nutritional status Weight, nitrogen balance (once weekly)
Nutritional intake Nursing records, food and fluid charts
CS Nutritional and metabolic status should be assessed regularly and the nutritional
prescription modified as necessary.
43
POSTOPERATIVE MANAGEMENT IN ADULTS
44
9 DEVELOPMENT OF THE GUIDELINE
SIGN FACILITATORS
Miss Gemma Healy Assistant Information Officer, SIGN
Dr Moray Nairn Programme Manager, SIGN
Dr Safia Qureshi Programme Director, SIGN
ACKNOWLEDGEMENTS
Dr Joris Berwaerts Medicines Control Agency, London
Mr Ross Carter Consultant General Surgeon, Glasgow Royal Infirmary
Mrs Jane McCready Senior Staff Nurse, Victoria Infirmary, Glasgow
45
POSTOPERATIVE MANAGEMENT IN ADULTS
Canadian Practice Guidelines Infobase, the Australian National Health and Medical Research
Council, the New Zealand Guidelines programme, and the UK Health Technology Assessment
programme. Searches were also conducted on the search engines Citeline, Medical World Search,
Echidna, Medisearch and Google, and all suitable links followed up. Database searches were
conducted from 1993-2001 on the Cochrane Library, Medline, Embase and CINAHL. The Medline
version of the main search strategies is available on the SIGN website, in the section covering
supplementary guideline material. The main searches were supplemented by literature identified
by individual members of the development group. All selected papers were appraised using
standard methodological checklists before conclusions were considered as evidence.
Only clearly appropriate consensus statements, with a median score of 7-9, are used as consensus
statements in this guideline.
46
9 DEVELOPMENT OF THE GUIDELINE
47
POSTOPERATIVE MANAGEMENT IN ADULTS
Abbreviations
ABC Airways, breathing, circulation
ABG Arterial blood gases
ACC/AHA American College of Cardiology/American Heart Association
ADH Antidiuretic hormone
AF Atrial fibrillation
ALI Acute lung injury
ARDS Acute respiratory distress syndrome
ASA American Society of Anesthesiologists
AVPU Alert, verbal, painful, unresponsive
BMI Body mass index
CAD Coronary artery disease
CHF Chronic heart failure
CI Confidence intervals
COPD Chronic obstructive pulmonary disease
CS Consensus statement
CT Computed tomography
ECG Electrocardiogram
FiO2 Fractional concentration of oxygen in inspired gas
GCS Glasgow coma score
GI Gastrointestinal
GTN Glyceryl trinitrate
HDU High dependency unit
ICD Implantable cardioverter defibrillators
ICU Intensive care unit
INR International normalised ratio (of the prothrombin time)
IPPB Intermittent positive pressure breathing
IPPV Intermittent positive pressure ventilation
JVP Jugular venous pressure
LBBB Left bundle branch block
LVH Left ventricular hypertrophy
MI Myocardial infarction
NG Nasogastric
NSAID Non-steroidal anti-inflammatory drug
OR Odds ratio
PaCO2 Arterial carbon dioxide partial pressure (measured from a blood gas sample)
PaO2 Arterial oxygen partial pressure (measured from a blood gas sample)
PAWCP Pulmonary artery wedge capillary pressure
RCT Randomised controlled trial
RR Relative risk
SASM Scottish Audit of Surgical Mortality
SIGN Scottish Intercollegiate Guidelines Network
SIRS Systemic inflammatory response syndrome
SpO2 Oxygen saturation measured by a pulse oximeter
SaO2 Oxygen saturation from a blood gas sample
SVA Supraventricular arrhythmia
SVT Supraventricular tachycardia
TPN Total parenteral nutrition
VT Ventricular tachycardia
48
ANNEXES
Annex 1
Assessing Conscious Level
THE AVPU SCALE
A - Alert The patient is alert, awake, responsive to voice and oriented to person,
time, and place.
V - Verbal The patient responds to voice, but is not fully oriented to person, time,
or place.
P Painful The patient does not respond to voice, but does respond to a painful
stimulus, eg pinching the skin.
U - Unresponsive The patient is unresponsive to both verbal and painful stimuli.
Age
Time to nearest hour
An address, eg 42 West Street, to be repeated at the end of the test
Month
Year
Name of place
Date of birth
Year first world war started
Name of present monarch
Count backwards from 20 to 1
TOTAL SCORE
Scores: 8-10 normal; 7 probably abnormal; <6 abnormal
49
POSTOPERATIVE MANAGEMENT IN ADULTS
Annex 2
American Society of Anesthesiologists Physical Status
Classification System
ASA 1 A normal healthy patient
ASA 2 A patient with mild systemic disease
ASA 3 A patient with severe systemic disease
ASA 4 A patient with severe systemic disease that is a constant threat to life
ASA 5 A moribund patient who is not expected to survive without the operation
ASA 6 A declared brain-dead patient whose organs are being removed for donor purposes
50
ANNEXES
Annex 3
Example of a Postoperative Monitoring Chart
This is an example chart only. These parameters will not be suitable for all patients and should be adjusted
in line with local protocols.
DATE
Postoperative Monitoring Chart
Name Hosp. Number DOB Weight Consultant
TIME
40
39.5
39
38.5
38
37.5
TEMPERATURE 37
36.5
36
35.5
35
210
200
BLOOD 190
PRESSURE 180
170
ADMISSION 160
BP 150
140
130
Plus 30% 120
110
Example
100
Less 30% 90
80
70
60
50
CVP
170
160
150
140
130
120
110
HEART RATE 100
90
80
70
60
50
40
30
20
SaO2
FiO2 (l/min or %)
40
35
30
25
RESP. RATE 20
15
10
5
0
URINE >0.5mls/kg
Volume <0.5mls/kg
NEUROLOGICAL AWAKE
STATE VERBAL
PAIN
UNRESP
Pain score
BM
DR CALLED
51
POSTOPERATIVE MANAGEMENT IN ADULTS
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54
RESPIRATORY MANAGEMENT CARDIOVASCULAR MANAGEMENT (Contd.) SEPSIS
Patients in whom there is a suspicion of postoperative pulmonary Postoperative blood pressure should always be reviewed with Hand washing with soap and water or with alcoholic cleansing
complications should have an arterial blood gas analysis, a sputum reference to the preoperative and intraoperative assessments agents should be performed before and after patient contact.
culture and ECG. Further assessment is required for patients with: Early identification and appropriate treatment of sepsis improves
Chest X-ray should be performed on suspicion of major collapse, § heart rate < 50 and > 100 bpm outcome.
effusions, pneumothorax or haemothorax. § blood pressure <100 mm Hg systolic. Urine and blood cultures should be obtained whenever there is
Other investigations should be used only if there are specific reason to suspect systemic sepsis.
Patients on regular antihypertensive medication should normally be
indications. maintained on this medication perioperatively. If the patient becomes If the cause of sepsis is unknown, treat with broad spectrum
Oxygen should be given to patients with hypoxaemia using a device hypotensive then it may be appropriate to discontinue some drugs. antibiotics, guided by local protocols.
that is best tolerated to achieve the necessary SpO2. Beta blockers and IV nitrates may be used safely and effectively in Results from microbiological specimens should be reviewed
In normally hydrated patients humidification is unnecessary. postoperative hypertension. regularly and antibiotics changed as necessary.
Failure to maintain an SpO2 >90% or PaO2 >8.0 kPa is an Beta blockers should be continued perioperatively in patients A course of antimicrobial treatment should generally be limited
indication to consider assisted ventilation. previously taking these drugs for coronary disease, congestive heart to 5-7 days. Fungi and atypical organisms can contribute to sepsis
failure, hypertension or arrhythmias. syndrome, so take cultures and prescribe appropriately.
Patients developing respiratory failure should be referred to
a critical care specialist to be assessed for possible assisted Be aware of clinical factors which increase risk to the patient and
ventilation. The referral should be timely as hypoxia or hypercapnia how these interact with the risks imposed by the surgical procedure. Systemic inflammatory response syndrome (SIRS) is defined as the
may lead rapidly to cardiorespiratory arrest. Seek expert help early in the management of serious or potentially presence of 2 or more of the following:
serious arrhythmias. Reconsider the level of care. § temperature >380C or <360C
Search for the underlying causes of any supraventricular § heart rate >90 bpm
Diagnosis of respiratory infection
arrhythmias, eg hypoxia, hypovolaemia, electrolyte abnormality, § respiratory rate >20 breaths/min or PaCO2 <4.3kPa
Any two of the following on two or more days: sepsis or drug toxicity. § white cell count >12,000 cells/mm3 , <4,000 cells/mm3 or
§ Pyrexia >380C Where perioperative MI is diagnosed or suspected early specialist >10% immature forms.
§ Positive sputum culture medical advice should be sought. When SIRS is present an infective cause should be sought first.
§ Positive clinical findings Maintain normothermia in the postoperative period.
§ Abnormal chest X-ray – Atelectasis/infiltrates
FLUID, ELECTROLYTE & RENAL MANAGEMENT NUTRITION
CARDIOVASCULAR MANAGEMENT Accurate assessment of fluid and electrolyte status can be difficult Oral intake should be commenced as soon as possible after surgery.
ASSESSMENT OF HYPOTENSION and the treatment of a particular patient must be individualised and
Nutritional replacement should be discussed with a dietitian and
reviewed frequently in the light of the response to treatment.
tailored to the patient's requirements.
Observe if: Seek further advice if: Volume depletion should be avoided as this can lead to poor
Enteral nutrition is the preferred method of postoperative
Awake or easily rousable Drowsy or unrousable perfusion and problems such as anastomotic breakdown, cerebral
nutritional support and should be used if possible.
damage, renal failure and multiple organ failure.
Comfortable Distressed Nutritional and metabolic status should be assessed regularly and
Diuretics should not be used to treat oliguria and should be
Normal preoperative BP Hypertensive preoperatively the nutritional prescription modified as necessary.
reserved for fluid overload.
Warm Cold Hyponatraemia is more commonly due to excess water than sodium
Well perfused (capillary Capillary refill > 2 seconds deficiency – assess volume status.
refill <2 seconds) Hypernatraemia most commonly indicates a total body deficiency of
Heart rate 50-100 bpm Heart rate >100 or <50 bpm water and is an indication for prompt assessment and intervention,
Given the lack of a strong evidence base of effective practice for
especially when levels exceed 155 mmol/L.
Passing urine (>0.5 ml/kg/hr) Oliguric (<0.5 ml/kg/hr) postoperative management this guideline has been developed using
Hypokalaemia can delay postoperative recovery - magnesium a combination of evidenced based and consensus techniques. Initial
No obvious bleeding Signs of bleeding (drains, supplementation may also be required. systematic searches identified any relevant evidence. The critically
wounds, haematoma) appraised evidence, together with the clinical experience of the
Hyperkalaemia is a medical emergency – obtain senior help.
guideline development group, informed the formal consensus methods
Metabolic acidosis is usually due to poor tissue perfusion but can that were used to develop recommendations. These are presented in
also be caused by excessive administration of saline. the form of “consensus statements”.
77
POSTOPERATIVE MANAGEMENT IN ADULTS: A PRACTICAL GUIDE TO POSTOPERATIVE CARE FOR CLINICAL STAFF
CHECKLIST FOR FIRST
PRINCIPLES OF POSTOPERATIVE POSTOPERATIVE ASSESSMENT SAMPLE MONITORING REGIMEN FOR FIRST
MANAGEMENT
FEW POSTOPERATIVE HOURS
� Past medical history
������ Medications
Optimal postoperative care requires: ����������
§ clinical assessment and monitoring ���������� Allergies
��
§ respiratory management ������������ Intraoperative complications
������������
�
§ cardiovascular management Postoperative instructions
§ fluid, electrolyte and renal management Recommended treatment & prophylaxis
§ control of sepsis
§ nutrition
Oxygen saturation
�����������
Only accept responsibility appropriate to your training and Effort of breathing/use of accessory muscles
experience. If in doubt ASK FOR HELP
������ Respiratory rate
���������� Trachea central or not?
DISCHARGE FROM THEATRE Symmetry of respiration/expansion
AND POSTANAESTHETIC RECOVERY Breath sounds
Percussion note
Anaesthetic and surgical staff should record the following
items in the patient’s case notes: Hands - warm or cool, pink or pale?
§ any anaesthetic, surgical or intraoperative complications Capillary return <2s or not?
§ any specific postoperative instruction concerning ������ Pulse rate, volume and rhythm
possible problems ������ Blood pressure
§ any specific treatment or prophylaxis required ����������
�
Conjunctival pallor
(eg fluids, nutrition, antibiotics, analgesia, anti-emetics,
thromboprophylaxis). Jugular venous pressure
Urine colour and rate of production
�
THE FIRST POSTOPERATIVE ASSESSMENT Drainage from drains, wounds & NG tubes
Patient conscious and normally responsive ?
A postoperative assessment should be carried out when the ������ (AVPU; Alert, Verbal, Painful, Unresponsive)
patient returns from theatre. ������ If abnormal determine:
Patients at risk of deterioration require frequent assessment. ���������� § if confusion is present (AMT) MONITORING
Patients with the following risk factors for deterioration § GCS, oxygen saturation and
should be reassessed within two hours of the first blood glucose Patients requiring the frequent monitoring of multiple variables
postoperative assessment:
should be considered for care at level 2 or above.
§ ASA grade ≥ 3
Trends in the physiological data, rather than absolute numbers,
§ emergency or high risk surgery
should be reported to assist in the detection of deteriorating patients
������
§ operation out of hours before a severe physiological compromise occurs.
Any significant symptoms eg chest pain,
The doctor completing the initial postoperative assessment breathlessness Postoperative monitoring should be continued on a daily basis.
should consider the monitoring regimen and appropriate level
Pain and adequacy of pain control The monitoring regimen should be reviewed daily so as best to
of care required for the next 24 hours in collaboration with the
nursing team. Following specialist surgery it may be provide data for clinical decision making.
necessary to assess additional factors. Any change in a monitoring regimen should prompt reassessment of
the level of care.