Postoperative management in adults

Scottish Intercollegiate Guidelines Net work

Postoperative management in adultsA practical guide to postoperative carefor clinical staff

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

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COPIES OF ALL SIGN GUIDELINES ARE AVAILABLE BY CALLING 0131 247 3664 OR ONLINE AT WWW.SIGN.AC.UK

© Scottish Intercollegiate Guidelines NetworkISBN 1 899893 09 1First published 2004

SIGN consents to the pho to cop y ing of this guideline for the purpose of implementation in NHSScotland

Scottish Intercollegiate Guidelines NetworkRoyal College of Physicians9 Queen Street, Edinburgh EH2 1JQ

www.sign.ac.uk

SIGN IS FUNDED BY NHS QUALITY IMPROVEMENT SCOTLAND

KEY TO CONSENSUS AND EVIDENCE STATEMENTS

CONSENSUS STATEMENTS

CS Statements developed from structured discussion, informed by any existing evidence and the group’s clinical experience, and validated using a formal scoring system.

LEVELS OF EVIDENCE

1++ High quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias

1+ Well conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias

1 - Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias

2++ High quality systematic reviews of case control or cohort studies High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal

2+ Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal

2 - Case control or cohort studies with a high risk of confounding or bias and a signifi cant risk that the relationship is not causal

3 Non-analytic studies, eg case reports, case series

4 Expert opinion

GRADES OF RECOMMENDATION

Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not refl ect the clinical importance of the recommendation.

A At least one meta-analysis, systematic review of RCTs, or RCT rated as 1++

and directly applicable to the target population; or

A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results

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+

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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 topredict or recognise clinical decline, failure to involve consultants at an early stage and failure toappreciate the consequences of not acting promptly when decline is identified.1 SASM hasconsistently highlighted variation in practice in postoperative care. Almost 2,000 patients diefollowing surgery in Scotland each year. In the vast majority, death is the inevitable consequenceof the disease process. However, it is likely that some 10,000 patients per year suffer majorcomplications 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 nationalguidelines on the use of intensive care unit (ICU) and high dependency unit (HDU) resourcesand in particular has suggested that the Scottish Intercollegiate Guidelines Network (SIGN) shouldproduce guidelines for postoperative management focusing on symptoms and signs of well-known serious complications. The target audience for the guidelines would be nursing, alliedhealth care and trainee medical staff. It was suggested that a SIGN guideline could cover monitoringof postoperative patients and the investigation and management of clinical deterioration in thepostoperative period.

1.2 DEVELOPING A CONSENSUS GUIDELINE

The evidence of variation in practice and the repeated calls for guidance in this area clearlyindicated the need for a guideline. SIGN however, has always developed evidence based guidelines,and the lack of a strong evidence base of effective practice meant that postoperative managementwould not be suitable for guideline development using standard SIGN methodology. Instead, itwas proposed to develop a guideline using consensus techniques.2-6 Initial systematic searcheswere used to identify any relevant evidence and this was critically appraised using standard SIGNmethodology. The evidence base was not extensive and was often confined to specific patientgroups. The evidence that was appraised was used, together with the clinical experience of theguideline development group, to inform the formal consensus methods that were used to developrecommendations. These are presented in the form of �consensus statements�. More details ofthe methodology are given in section 9.

1.3 REMIT OF THE GUIDELINE

The remit of the guideline was determined by the guideline development group, who usedformal consensus techniques to prioritise their answers to the question �What treatment decisionsand evaluation criteria do you think are important in postoperative care?�

This guideline covers:

1. Early identification of at-risk patients

2. Monitoring in the postoperative period

3. Early recognition, investigation, and management of clinical deterioration

4. Identification of key physiological requirements in the postoperative period

5. Referral to expert care

6. Nutrition in the postoperative period.

POSTOPERATIVE MANAGEMENT IN ADULTS

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This guideline does not focus on postoperative pain management (an evidence based guidelinealready exists in this area),7 indications for blood transfusion, the prophylaxis of surgical siteinfection or venous thrombosis, nor the management of obstetric patients or pregnant women orthose 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.

1.4 ETHOS OF THE GUIDELINE

1.4.1 A TEAM APPROACH

In 1974 Professor P F Jones dedicated his book Emergency Abdominal Surgery8 to:

�The Night Watch - my registrar colleagues over the years in recognition of their hard won skillsand judgement, their concern for their patients and their continued dedication to emergencycare.�

Then, as now, registrars were supported by teams of junior doctors, nurses and paramedical staff.Much has changed over the years but the basic concept of a team approach to patient careremains. Each member of the team has a role to play in the normal process of recovery fromsurgery and the early identification and treatment of any deterioration in the condition of thepatient.

This guideline complements the team approach by concentrating on the fundamentals of goodpatient care and encouraging a simple, didactic and consistent approach.

The guideline is not intended to supplant specialist medical care but to help inexperiencedclinicians differentiate between those patients who are recovering normally and those in whomthere is cause for concern. The distinction between the two is often difficult and the guidelineemphasises early referral for senior or specialist advice where there is any doubt.

1.4.2 FOCUSING ON POSTOPERATIVE MANAGEMENT

The guideline concentrates on the postoperative period and does not address concepts such asoptimisation or protective strategies instituted preoperatively. The development group recognisesthat the postoperative period is only one part of the journey of care but, as reported by SASM,this is perceived to be an area where the need for guidance is paramount.1

Much has been said about the �Golden Hour� after trauma when decisions taken can have asignificant effect on outcome. There may well be a �Platinum 24 Hours� after surgery whenpatients are particularly vulnerable and where decision making has similar importance. Thisguideline is designed to assist trainee staff in making decisions even if that decision is to call foradvice. The guideline development group recommends that surgical units develop protocols thatmake it clear when it is time to call for advice.

1.5 STATEMENT OF INTENT

This guideline is not intended to be construed or to serve as a standard of care. Standards of careare determined on the basis of all clinical data available for an individual case and are subject tochange as scientific knowledge and technology advance and patterns of care evolve. Adherenceto guideline recommendations will not ensure a successful outcome in every case, nor shouldthey be construed as including all proper methods of care or excluding other acceptable methodsof care aimed at the same results. The ultimate judgement regarding a particular clinical procedureor treatment plan must be made by the appropriate healthcare professional(s) in light of theclinical data presented by the patient and the diagnostic and treatment options available. It isadvised however that significant departures from the national guideline or any local guidelinesderived from it should be fully documented in the patient�s case notes at the time the relevantdecision is taken.

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2 Clinical assessment and monitoring

2.1 INTRODUCTION

Optimal management of patients throughout the postoperative phase requires appropriate clinicalassessment and monitoring. In contrast with assessment of emergencies, which focuses on theinitial diagnosis and stabilisation after the patient has developed a complaint, postoperative carerequires pre-emptive management. Regular assessment, selective monitoring and timelydocumentation are key to postoperative care.

This section of the guideline describes a model of care that establishes a minimum standard ofpractice in postoperative patient care.

2.1.1 DISCHARGE FROM POSTANAESTHETIC RECOVERY

The following criteria must be fulfilled before a patient can be discharged from the recoveryroom:9

n the patient is fully conscious, responding to voice or light touch, able to maintain a clearairway and has a normal cough reflex

n respiration and oxygen saturation are satisfactory (10-20 breaths per minute and SpO2>92%)n the cardiovascular system is stable with no unexplained cardiac irregularity or persistent

bleeding. The patient�s pulse and blood pressure should approximate to normal preoperativevalues or should be at a level commensurate with the planned postoperative care

n pain and emesis should be controlled and suitable analgesic and anti-emetic regimens shouldbe prescribed

n temperature should be within acceptable limits (>36°C)n oxygen and fluid therapy should be prescribed when required.

Prior to discharge, recovery staff should record in the notes that patients have met these criteria.

If the patient does not achieve these criteria they should be assessed by the anaesthetist responsiblefor either the procedure or postanaesthetic recovery with a view to upgrade to level 2 or 3 care(see section 2.1.2).

CS Anaesthetic and surgical staff should record the following items in the patient�scase notes:

n any anaesthetic, surgical or intraoperative complicationsn any specific postoperative instruction concerning possible problemsn any specific treatment or prophylaxis required (eg fluids, nutrition, antibiotics,

analgesia, anti-emetics, thromboprophylaxis).

2 CLINICAL ASSESSMENT AND MONITORING


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2.1.2 LEVELS OF CARE

Postoperative care is provided in several different locations depending on the level of monitoringor organ support that is required. At any time it may become appropriate to move a patient to asetting in which a different level of care can be provided. The review of adult critical careservices10 recommends that the existing classification of ward, HDU and ICU, be replaced by aclassification of care that focuses on the level of care required by the patient, regardless oflocation. The following definitions of care have been used throughout this guideline:

Level 0 - formerly ward

Appropriate for patients

n who have had minor surgeryn whose needs can be met through normal ward care

Level 1 - formerly ward


n at risk of their condition deterioratingn recently relocated from immediate postanaesthetic recoveryn whose needs can be met on a surgical ward with additional advice and support from a critical

care team

Level 2 � formerly HDU


n requiring more detailed observation or intervention including support for a single failingorgan system

n �stepping down� from a higher level of care

Level 3 - formerly ICU


n requiring advanced respiratory support alonen requiring basic respiratory support together with support of at least two organ systemsn requiring complex support for multi-organ failure.

2.2 ASSESSMENT

2.2.1 THE FIRST POSTOPERATIVE ASSESSMENT � WHEN AND WHO?

The first postoperative assessment should take place immediately after surgery on return to theward. It provides a baseline against which the patient�s condition may subsequently be assessedand identifies any problems that may have occurred on transfer from the operating department.

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 straightforwarda trained nurse could complete this assessment. The doctor should attend later to assess thepatient in person. Any departure from accepted physiological parameters (see sections 3-6) requiresthe attendance of the doctor as a matter of urgency.

CS Doctors immediately responsible for patients should ensure that a contact/pager numberis available to the nursing staff on the ward.

AB IT SOLUTIONS

Highlight

AB IT SOLUTIONS

Highlight

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2.2.2 THE FIRST POSTOPERATIVE ASSESSMENT � HOW?

The first assessment reviews the intraoperative course, past medical history, medications andallergies. The nurse responsible for the care of the patient should inform the doctor of any otherinformation concerning deterioration or incident during the patient�s transit from theatre.

CS If the nurse responsible for the care of the patient becomes unavailable for discussionswith other members of the care team, they should pass on all pertinent information toanother 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 patientspreoperatively. In the routine situation, the doctor has time to carry out a structured examinationwhich includes the variables described below. In the emergency setting, the standard �airways,breathing and circulation� or ABC approach would be followed. The focus, in postoperativeassessment, is on circulatory volume status, respiratory function and level of consciousness.Table 1 shows a checklist for the first postoperative assessment.

CS The first postoperative assessment should determine:

n intraoperative history and postoperative instructionsn circulatory volume statusn respiratory statusn mental status.

The conscious level is often difficult to assess. The AVPU (Fully Alert, responsive to Verbal orPain, or Unresponsive) examination is a simple screening test and has been widely used inemergency patient management. The abbreviated mental test (AMT), using 10 key questions, isuseful in acutely confused postoperative patients.11,12 The Glasgow Coma Scale (GCS) is ratherinsensitive for confused patients, however, GCS 12 or less constitutes a medical emergency andshould be discussed with senior doctors prior to management at level 2 or 3 (see Annex 1 fordetails of these scales).

Common causes of postoperative confusion include:

n sepsis (eg infection of chest, urinary tract, wound, intravenous cannula site, or intra-abdominalcollection)

n sedative drugsn hypoxaemian hypercarbian hypoglycaemian acute neurological eventn myocardial infarctionn urinary retentionn alcohol/drug withdrawaln hepatic encephalopathyn biochemical abnormality (eg urea, sodium, potassium, calcium, thyroid function,

liver function).

CS If an acute confusional state is present, exclude treatable causes by appropriate history,physical examination and investigations.

Having assessed the patient, the doctor should legibly record the findings in the notes at thesame time. Any specific problems should be recorded and a management plan developed. Theinterval after which the patient should be reassessed should also be chosen at this stage.



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Table 1: The first postoperative assessment

Checklist for the first postoperative assessment

Review intraoperative history and postoperative instructions

n past medical historyn medicationsn allergiesn intraoperative complicationsn postoperative instructionsn recommended treatment and prophylaxis.

Complete a respiratory status assessment

n oxygen saturationn effort of breathing/use of accessory musclesn respiratory raten trachea - central or not?n symmetry of respiration/expansionn breath soundsn percussion note.

Complete a circulatory volume status assessment

n hands - warm or cool, pink or palen capillary return � less than two seconds or not?n pulse raten pulse volumen pulse rhythmn blood pressure (see section 3.3)n conjunctival pallorn jugular venous pressure (JVP, see below)n urine colour and rate of production (see section 5.6)n drainage from drains, wounds and nasogastric tubes.

Complete a mental status assessment

n Patient conscious and normally responsive (AVPU)n If abnormal determine whether confusion is present (AMT)n If abnormal determine GCS, oxygen saturation and blood glucose.

In addition to the physical assessment, record:

n any significant symptoms, such as chest pain or breathlessnessn pain and adequacy of pain control.

Following specialist surgery it may be necessary to assess additional factors.

Appropriate lighting should be used in order to visualise the jugular venous pressure. The heightof 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 postoperativeassessment, may be useful.

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2.2.3 ADDITIONAL ASSESSMENTS

The initial postoperative assessment will determine how frequently reassessment of the patient isrequired. Patients who display any abnormal physiological variables, in addition to severe pain,must be reassessed more frequently than patients who are stable and comfortable.

Surgery out-of-hours in patients who are American Society of Anesthesiologists (ASA) physicalstatus grade ≥3 (see Annex 2) has been shown to be an independent risk factor for postoperativeemergencies requiring intensive care team attendance. Thirty per cent of these emergencies occurwithin the first six postoperative hours.14

CS Patients at risk of deterioration require frequent assessment.

CS Patients with the following risk factors for deterioration should be reassessed within twohours of the first postoperative assessment:

n ASA grade ³3n emergency or high risk surgeryn operation out of hours.

2.3 TREATMENT AND PROPHYLAXIS

The following postoperative treatment and prophylaxis options should be discussed preoperativelywith the appropriate members of the clinical team:

n adequate pain controln venous thromboembolism prophylaxisn antibiotic prophylaxisn continuation of current medications (these, and in particular cardiorespiratory treatments,

should be continued wherever possible)n substitution of current medication (eg diabetic control, steroid therapy)n prophylaxis for postoperative nausea and vomitingn ability of patients to take drugs by mouthn pressure area management.

Postoperatively, consider the need for:

n physiotherapyn nutrition team consultation (see section 7.5.4)n oral hygiene.

CS Local protocols should be established for:

n drug treatment of pre-existing cardiovascular and respiratory disordersn treatment of postoperative nausea and vomiting.

In patients with persistent vomiting, exclude gastrointestinal obstruction before providing drugtreatment for vomiting.



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2.4 MONITORING

2.4.1 ROUTINE MONITORING

Monitoring allows the collection of routine data so that trends may be established, assisting inthe detection of deterioration or improvement. This is vital for an objective assessment of apatient�s response to treatment.

In general, the anaesthetist will recommend a monitoring regimen for the first few hours aftersurgery, which would normally include:

n temperaturen pulse raten blood pressuren respiratory raten pain assessment (resting and moving)n urine output (postoperative voiding)n peripheral oxygen saturation.

Experienced nurses will usually institute an appropriate regimen after this initial period, dependingon local practice. If any problems are encountered, the frequency of monitoring may be increased.

Monitoring will be most frequent initially (eg every 15 minutes for the first hour), becoming lessfrequent over time (eg every 30 minutes for the next two hours, and hourly for a period thereafter).

The frequency and exact content of the assessment should be tailored to the individual patientand not all parameters will need to be measured at all time points. Excess data collection in wellpatients is confusing, time consuming and may prevent patients sleeping properly. Conversely,lack of monitoring in patients who may deteriorate can lead to late detection of serious problems.

CS The doctor completing the initial postoperative assessment should consider the monitoringregimen and appropriate level of care required for the next 24 hours in collaborationwith the nursing team.

CS Documenting numerical data in graphical form facilitates the assessment of trends.(see example in Annex 3)

NB The monitoring of nutritional status and support is discussed in section 7.5.3.

2.4.2 ADDITIONAL MONITORING

Patients with, for example, pre-existing cardiorespiratory disease or who have had longer, morephysiologically stressful operations may need additional, more frequent or continuous monitoring(see Table 2). These patients may require a setting other than the routine ward for a higher levelof care.

Table 2: Suggested additional monitoring

Additional monitoring requirements dependent on clinical status

ECGHourly urine volumesArterial blood pressureCentral venous pressureArterial blood gasesDrainage from woundsHaematologyBiochemistry

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Continuous oxygen saturation and electrocardiography (ECG) may be carried out by automaticequipment. Patients requiring advanced monitoring or frequent detailed assessments may bemore appropriately cared for in a level 2 setting.15

CS Patients requiring the frequent monitoring of multiple variables should be considered forcare at level 2 or above.

CS n Any patient with circulatory disturbance should be catheterised and the urine outputmeasured hourly

n Consider catheterisation in patients with no urine production after four hours.

Patients with complex needs often require enhanced levels of care. Invasive cardiovascularmonitoring, including the use of indwelling central venous or arterial cannulae, is usually restrictedto level 2 or level 3 care.

Patients who are initially admitted to the postoperative ward or to areas providing level 1 or 2care may require a higher level of care thereafter. Patients who show cardiovascular instability orrespiratory difficulty should be considered very early in the postoperative course to be candidatesfor level 2 or 3 care.

2.4.3 RULES AND TRIGGERS FOR MONITORING AND INTERVENTION

Patient monitoring is most useful when the doctor and nurse responsible for care agree:

n specific criteria that should prompt a call to the doctorn specific time points (eg half hourly, hourly) for the reporting of trends, whether or not the

parameters being monitored fall within abnormal levels.

CS Trends in the physiological data, rather than absolute numbers, should be reported toassist in the detection of deteriorating patients before a severe physiological compromiseoccurs.

2.5 DAILY CLINICAL ASSESSMENT

Successful management of patients in the postoperative period requires routine assessment untildischarge.

Repeated clinical assessment is key to early detection of deterioration but, depending on theclinical condition of the patient, does not need to be as detailed as the initial assessment.

Surgical patients are usually seen once or twice a day on the ward round and their status must bedocumented. Clear clinical notes must be kept and an entry made every time a patient is reviewed.This assessment is the most complete opportunity to ensure that the patient is progressing in asatisfactory manner. Each daily assessment is an opportunity to modify the monitoring regimenso as best to provide data for clinical decision making.

CS n Postoperative monitoring should be continued on a daily basis

n The monitoring regimen should be reviewed daily so as best to provide data forclinical decision making

n Any change in a monitoring regimen should prompt reassessment of the level of care.



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2.6 THE ROLE OF SENIOR MEDICAL STAFF

Where junior doctors have difficulty managing a patient, or in admitting a patient to a specialcare area, it is essential to discuss the patient with the responsible senior doctors. Training inpostoperative care may influence outcome.9

CS n The ultimate responsibility for patient care lies with the consultants providing surgicaland anaesthetic care

n Junior doctors should assume only the responsibility appropriate to their training andexperience

n Where a junior doctor feels that they may exceed their personal responsibilities orcapabilities, they have a duty of care to discuss the patient with a more senior doctorin the same clinical team.

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3 Cardiovascular management

3.1 INTRODUCTION

In general, maintaining a patient�s heart rate and blood pressure within normal limits will resultin a satisfactory outcome. However, there are no clinical studies to indicate what is normal withrespect 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 modifiesthe stress response, which can be further modified by the use of techniques such as regionalanaesthesia or use of high dose opioids. During anaesthesia heart rate and blood pressure aremaintained within appropriate limits at the discretion of the anaesthetist. On emergence fromanaesthesia this damping down of the stress response is lost and heart rate and blood pressurerise in the postoperative period.

3.2 HEART RATE

Most patients will tolerate a postoperative heart rate of between 50 and 100 beats per minute. Aheart rate outside these limits may indicate that all is not well with the patient.

3.2.1 BRADYCARDIA

A heart rate below 50 beats per minute may be normal in a patient who is otherwise well. If theblood pressure is well maintained, the simplest strategy is to observe the patient closely over thenext 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 bromide0.2-0.4 mg or atropine sulphate 0.3- 0.6 mg) should restore the blood pressure and allow timefor the cause of the low blood pressure and heart rate to be deduced. If the blood pressure doesnot respond to the increase in heart rate then other possible causes should be considered, such asblood 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 aclinical problem. Sustained tachycardia is particularly dangerous for patients who have documentedischaemic heart disease or risk factors for ischaemic heart disease as myocardial oxygen supplycannot be increased (see section 3.4).

Tachycardia associated with high blood pressure may simply be the consequence of pain andanxiety and appropriate analgesia may be all that is required. If elevated rates and pressure aremaintained despite good analgesia, senior advice should be sought.

In hypovolaemic patients tachycardia may precede development of hypotension. Hypotensionindicates 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 (seesection 5).

3.3 BLOOD PRESSURE

The Sixth Joint National Committee on Detection, Evaluation and Treatment of High BloodPressure gives a classification of blood pressure.17 Note that this is a general classification and isnot specific to patients undergoing surgery (see Table 3).

3 CARDIOVASCULAR MANAGEMENT


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Table 3: Classification of Blood Pressure

Category Systolic Pressure (mm Hg) Diastolic Pressure (mm Hg)

Optimal <120 <80Normal 120-129 80-84High Normal 130-139 85-89

Hypertension (mm Hg)

Stage 1 140-159 90-99Stage 2 160-179 100-109Stage 3 180-209 110-119Stage 4 >210 >120

The American College of Cardiology/American Heart Association (ACC / AHA) guidelines18

recommend deferring surgery if the diastolic pressure is above 110 mm Hg and systolic is above180 mm Hg.

Antihypertensive medication should be continued during the postoperative period for patientswith known and treated hypertension, as unplanned withdrawal of treatment can result in reboundhypertension.

In practice, the decision to give antihypertensive drugs must be made for each patient, takinginto account their normal blood pressure, and their postoperative blood pressure.

For some patients, after major surgery, this may require a change from oral to parenteraladministration. The advice of the clinical pharmacist should be sought about equivalent dosagesor suitable alternatives to oral preparations.

Many patients on admission to hospital have elevated systolic pressure with normal diastolicpressure. Once settled into the ward environment systolic pressure often falls to normal. Aroundhalf of those aged over 60 years have isolated systolic hypertension.19 A linear relationship existsbetween increasing admission systolic pressure and the risk of postoperative silent ischaemia.20 Aclear association between admission arterial pressure and major perioperative cardiac complicationshas not however been demonstrated.21,22

CS Postoperative blood pressure should always be reviewed with reference to the preoperativeand 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 ofat least 25% from the patient�s normal pressure.

Hypotension is relatively common postoperatively and may be drug induced (eg residual effectsof anaesthesia, epidural or opioids) or may represent fluid deficit. Table 4 lists broad categoriesfor the assessment of hypotension.

Hypotension should not be allowed to persist unless the clinician is absolutely sure that noimportant pathological process is taking place. If in doubt senior advice should be sought.

CS Further assessment is required for patients with:

n heart rate below 50 beats per minuten heart rate above 100 beats per minuten blood pressure below 100 mm Hg systolic.

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Table 4: Assessment of hypotension

Assessment of hypotension

Observe if: Seek further advice if:

Awake or easily rousable Drowsy or unrousable

Comfortable Distressed

Normal preoperative BP Hypertensive preoperatively

Warm Cold

Well perfused (capillary refill <2 seconds) Capillary refill >2 seconds

Heart rate 50-100bpm Heart rate >100 or <50 bpm

Passing urine (>0.5 ml/kg/hr) Oliguric (<0.5 ml/kg/hr)

No obvious bleeding Signs of bleeding (drains, wounds, haematoma)

3.3.2 HYPERTENSION

Hypertension is common in the postoperative period as a result of a number of factors includingthe stress response, pain, anxiety and failure to continue medication perioperatively.

Postoperative hypertension is associated with bleeding, cerebral events and myocardial ischaemiaespecially if the heart rate is also elevated.

Treatment of Hypertension

Beta blockers and intravenous (IV) nitrates are effective for the control of postoperativehypertension.23,24

CS If patients are hypertensive, ensure that they are receiving adequate analgesia. Ifhypertension persists seek specialist medical advice and review the level of care.

CS Patients on regular antihypertensive medication should normally be maintained on thismedication perioperatively. If the patient becomes hypotensive then it may be appropriateto discontinue some drugs.

C Beta blockers and IV nitrates may be used safely and effectively in postoperativehypertension.

3.4 MYOCARDIAL ISCHAEMIA

Patients with ischaemic heart disease or risk factors for ischaemic heart disease represent aspecial group in whom the maintenance of heart rate and blood pressure within �normal limits�may not prevent perioperative myocardial ischaemia (MI). They do not always increase myocardialoxygen supply to match an increased myocardial oxygen demand. An estimated 30% of patientsundergoing surgery in the United States have ischaemic heart disease or risk factors for ischaemia.25

It is reasonable to assume that the population is similar in Scotland.

3.4.1 MYOCARDIAL ISCHAEMIA IN THE POSTOPERATIVE PERIOD

Myocardial ischaemia in the first 48 hours after an operation is the single most important predictorof serious cardiac events (including cardiac death, myocardial infarction, unstable angina,congestive heart failure and serious arrhythmias).26-28 Ischaemia is common, occurring in up to48% of those at risk (see Tables 5 and 6).29,30 It is most likely to be silent although there may bean association with elevated heart rates.26,27 Ischaemia which persists for over two hours is likelyto result in a significant cardiac event.31-34


2+

2+


14

Factors affecting supply and demand of myocardial oxygen include:

n release of pro-inflammatory mediatorsn hypercoagubilityn diminished fibrinolytic activityn endothelial dysfunctionn atherosclerotic plaque instabilityn fluctuating adrenergic activityn plasma catecholamine levelsn body temperaturen pulmonary dysfunctionn fluid balancen pain.

It used to be considered that the peak incidence for perioperative myocardial infarction was thethird postoperative day. Recent studies using biochemical markers and serial ECGs suggest thatinfarction occurs earlier, either on the day of surgery or during the first postoperative day. 35

Most infarctions are non-Q wave in nature suggesting the cause is prolonged ischaemia ratherthan rupture of an atheromatous plaque. However, one small study in patients who died followingperioperative myocardial infarction described similar pathological features - plaque haemorrhage,rupture and thrombosis, as is seen with non-operative MI.36

In unselected groups of patients undergoing surgery the risk of perioperative infarction is lessthan 2%. In patients with ischaemic heart disease, undergoing major surgery, the rate is over 5%.Risk is determined both by patient factors and the nature of the surgery, with patients undergoingmajor vascular surgery facing the highest risks. Despite advances in detection and treatment,mortality after infarction remains high, with rates ranging from 17% to over 50%.37

The long term risk over two years of having an adverse cardiac outcome increases by 2.8 fold(95% CI 1.6-4.9) in patients with postoperative ischaemia and 14 to 24 fold (CI 7.5-53) inpatients with postoperative infarction or unstable angina.25,38 For patients who leave hospitalalive, event free survival decreases from 93% to 78% when compared with patients with noepisodes of myocardial ischaemia.38

All patients who suffer adverse cardiac events should be referred for assessment by cardiologistsand consideration of cardiac risk reducing strategies for the longer term.

3.4.2 ASSESSING THE RISK OF POSTOPERATIVE CARDIAC COMPLICATIONS

The ACC/AHA guidelines on perioperative cardiovascular evaluation for non-cardiac surgeryinclude a full discussion of preoperative assessment.18 In the perioperative period, the RevisedCardiac Risk Index is a useful tool. It stratifies risk based on the presence of a number of clinicalfactors, thus informing an appropriate patient management plan (see Tables 5 and 6).18,39

Table 5: Revised Cardiac Risk Index

Clinical factors

High risk surgery (see Table 6 for definitions)History of ischaemic heart diseaseHistory of congestive heart failureHistory of cerebrovascular diseasePreoperative insulin treatmentPreoperative creatinine >180 micromol/l.

The rates of major cardiac complications postoperatively with 0,1,2,3 or more risk factors were0.5%, 1.3%, 4% and 9% respectively.

2+

2+

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3.4.3 PROCEDURE-ASSOCIATED RISK

Table 6: Surgical procedures stratified by cardiac risk level

HIGH RISK PROCEDURES reported cardiac risk >5%

Emergency major operations, particularly in the elderlyAortic and other major vascular surgeryPeripheral vascular surgeryAnticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss

INTERMEDIATE RISK PROCEDURES reported cardiac risk generally <5%

Carotid endarterectomyHead and neck surgeryIntraperitoneal and intrathoracic surgeryOrthopaedic surgeryProstate surgery

LOW RISK PROCEDURES reported cardiac risk generally<1%

Endoscopic proceduresSuperficial proceduresCataract surgeryBreast surgery

Patient and procedure-associated risk factors should be taken into account preoperatively whenplanning any surgical procedure. Clinicians caring for patients postoperatively need to appreciatethe level of risk and any clinical factors which may influence that risk.

CS Clinicians caring for patients postoperatively must be aware of clinical factors whichincrease risk to the patient and how these interact with the risks imposed by the surgicalprocedure.

3.5 MEDICAL TREATMENT TO REDUCE PERIOPERATIVE CARDIAC RISK

Several studies have demonstrated that beta blockers are effective in reducing perioperativeischaemia.40-43 Although caution has been expressed in the general use of prophylactic betablockade,44 reviews suggest that perioperative blockade reduces the incidence of both ischaemiaand MI in patients undergoing high risk surgery.45,46

CS Clinicians caring for patients postoperatively must be aware of potential optimisationstrategies instituted preoperatively that should be continued into the postoperative period.

B Beta blockers should be continued perioperatively in patients previously taking thesedrugs for coronary disease, congestive heart failure, hypertension or arrhythmias.

3.6 ARRHYTHMIAS AND CONDUCTION DEFECTS

3.6.1 SUPRAVENTRICULAR ARRHYTHMIAS

Supraventricular arrhythmias (SVAs) have been reported to occur in 7.6% of patients undergoingmajor non-cardiac surgery25 and in 10.2% of surgical ICU patients.26 They occur most commonlyin the elderly, those with previous cardiorespiratory disease and those undergoing thoracic, vascularor abdominal surgery. The occurrence of SVA is associated with a marked increase in mortality,morbidity and length of stay.

SVAs are often a sign of underlying morbidity such as anastomotic leakage and can be regardedas a marker for increased morbidity.


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3.6.2 VENTRICULAR ARRHYTHMIAS

Ventricular arrhythmias occur most commonly in patients with preoperative arrhythmias, smokersand those with a history of heart failure. Non-sustained ventricular arrhythmias do not appear tohave prognostic significance and, when occurring without other signs or symptoms of myocardialischaemia or infarction, may not require aggressive monitoring or treatment during the perioperativeperiod.47

3.6.3 GENERAL MANAGEMENT OF ARRHYTHMIAS

n identify and correct underlying factors such as hypoxia, hypovolaemia, electrolyte imbalanceand sepsis (see sections 4, 5 and 6)

n seek expert advice for patients showing cardiovascular instability and review level of caren 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 deteriorationn A 12 lead ECG should be obtained before and after DC shock or pharmacological cardioversion

and a rhythm strip obtained during drug intervention if possiblen Multiple or inappropriate drug therapy can be dangerous.

3.6.4 MANAGEMENT OF SPECIFIC ARRHYTHMIAS

Atrial fibrillation (AF)

Chronic - maintain rate control, preferably using the drug treatment found to be effective pre-operatively. Oral therapy may need to be converted to parenteral perioperatively.

New-onset - may be managed by DC cardioversion, pharmacological conversion to sinus rhythmor rate control. Rate control is indicated where AF has been present for >48hrs, due to theincreasing risk of systemic embolus in the non-anticoagulated patient. New-onset AF has a highrate of spontaneous conversion to sinus rhythm (about 50% at 24hrs).48

Pharmacological conversion

n amiodarone hydrochloride is well tolerated in ill patients and may be the drug of choice. Thestandard IV regimen is 300 mg over 1 hour followed by an infusion of 900 mg over the next24 hours preferably using a central venous catheter. A higher dose regimen such as 125 mg/hr IV (max 3 g) may achieve higher 24 hour conversion rates.49 This higher dose regimenshould only be considered following expert advice.

n class 1c drugs such as flecainide acetate and propafenone hydrochloride have potentiallyserious adverse effects and should be avoided, particularly in patients with cardiac disease.

n IV magnesium sulphate has been reported to be superior to conventional-dose amiodaronehydrochloride in surgical and non-surgical ICU patients and can be considered as an alternativeto amiodarone in the critically ill patient.50 The dosing regimen is 8 mmol (2g) intravenouslyover 10 to 15 minutes repeated once if necessary. A maintenance infusion of 0.1mmol/kg/hour should only be considered following expert advice.

Rate control

n verapamil hydrochloride and diltiazem hydrochloride can effectively control heart rate inpatients presenting with fast AF

n beta blockade with IV esmolol hydrochloride can effectively control heart rate in patientspresenting with fast AF

n verapamil hydrochloride and beta blockers should not be used together because of the risk ofsevere hypotension and asystole

n IV digoxin has a relatively slow onset of action and is less effective than other agentsn uncontrolled studies of acute AF suggest that IV amiodarone hydrochloride may also be

effective in controlling the ventricular rate in patients who are critically ill.

Atrial flutter should be managed in a similar manner to atrial fibrillation.

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Supraventricular tachycardia (SVT)

Adenosine (3-12 mg) and verapamil hydrochloride (5-10 mg) IV are equally effective in thetermination of regular narrow-complex paroxysmal supraventricular tachycardia. Adenosine hasthe advantage of brief duration of action and less hypotension. It may be associated with a highrelapse rate in critically ill patients. Verapamil hydrochloride and beta blockers should not beused concurrently.

Ventricular tachycardia (VT)

The occurrence of ventricular ectopic beats or non-sustained ventricular tachycardia does notappear to have prognostic significance and, in the absence of signs or symptoms of myocardialischaemia, may not require aggressive monitoring or treatment. In haemodynamically unstablepatients, VT is most effectively treated by DC cardioversion. Inappropriate or ineffective drugtreatment may worsen the situation.

IV anti-arrhythmic drugs may be used in haemodynamically stable patients. The EuropeanResuscitation Council (ERC) guidelines51 recommend amiodarone hydrochloride or lidocainehydrochloride as the drugs of choice for monomorphic VT and magnesium sulphate (IV 8 mmol,or 4 ml, 50% over 10-15 min)52 for polymorphic VT.

CS Seek expert help early in the management of serious or potentially serious arrhythmiasand reconsider the level of care.

CS The occurrence of supraventricular arrhythmias should provoke a search for underlyingcauses such as hypoxia, hypovolaemia, electrolyte abnormality, sepsis or drug toxicity.

CS DC shock should be considered as a first treatment option where there is haemodynamicdeterioration as a result of a tachyarrhythmia.

Helpful algorithms for the management of acute tachyarrhythmias and bradyarrhythmias can befound in the European Resuscitation Guidelines 2000.51

3.7 CONDUCTION DEFECTS

In general, the indications for pacing in the perioperative situation are no different from those inthe nonsurgical context, as stated in the ACC/AHA guidelines53 for implantation of pacemakersand antiarrhythmia devices.

CS Seek expert help early when perioperative conduction defects result in bradycardiaunresponsive to atropine.

Implanted Pacemakers and defibrillators

Patients with implanted pacemakers and defibrillators should have their device checked by acardiologist before and after surgical procedures.

3.8 PERIOPERATIVE MYOCARDIAL INFARCTION

Perioperative MI (PMI) carries a high risk of both short and long term morbidity. It is usuallysilent in presentation with non-specific ECG changes.

Troponin I has been shown to be a sensitive and specific method for the diagnosis of PMI invascular and spinal surgery patients.54 Troponin T has been shown to be a marker for PMI inpatients with CAD or CAD risk factors undergoing non-cardiac surgery.55,56

Serial troponin measurements during the preoperative, intraoperative and postoperative periodsmay identify myocardial injury, reflect the degree of injury and help in categorising subsequentrisk.

Patients who sustain perioperative MI should not receive thrombolytic agents. In all other respectsthey should be managed as in any other setting, receiving aspirin 300 mg orally, but monitoredin a setting with immediate specialist input.



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CS Where perioperative MI is diagnosed or suspected early specialist medical advice shouldbe sought.

CS Patients with high clinical risk of perioperative MI undergoing high or intermediate-riskprocedures should have:

n ECG at baseline, immediately following surgery and daily for the two subsequentdays

n cardiac troponin measurements 24 hours after surgery.

CS In patients without documented coronary disease, surveillance for perioperative MI shouldbe restricted to those who develop cardiac symptoms or signs.

CS Thrombolysis is not indicated in the management of perioperative MI, but all otheraspects are as for MI in any other setting.

3.9 ORAL ANTICOAGULANTS

Patients on warfarin sodium have increased risk of haemorrhage in the perioperative period.Warfarin sodium should normally be discontinued preoperatively and restarted as soon as isdeemed safe postoperatively. The SIGN guideline on Antithrombotic Therapy suggests that�surgeons intending to perform surgery or invasive procedures in patients receiving anticoagulanttherapy seek advice concerning the management of such therapy from a haematologist.�57

The guideline suggests that after warfarin sodium therapy is restarted following surgery it takesabout three days on average for the international normalised ratio (of the prothrombin time)(INR) to increase above 2.0.

3.10 HYPOTHERMIA

Hypothermia occurs in patients undergoing surgery because of anaesthetic-impairedthermoregulation, cold operating environments, open body cavities and the administration ofunwarmed IV fluid.

Without active methods to retain or provide heat approximately half of all patients undergoingsurgery develop a core temperature of less than 36oC and in one third of patients the temperaturedrops below 35oC.

In a prospective randomised controlled trial forced air warming, used both intraoperatively andpostoperatively, 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 andpostoperatively is also associated with fewer cardiac events (eg cardiac arrest, myocardial infarctionand/or unstable angina or ischaemia occurring in the first 24 hours postoperatively) in elderlypatients undergoing abdominal, vascular and thoracic surgery.58

CS Maintain normothermia in the postoperative period.

CS Active warming is appropriate for patients who are hypothermic postoperatively.

3.11 OXYGENATION

Patients with coronary artery disease are at risk from ischaemia in the first few postoperativedays.

The effect of anaesthesia and analgesia on respiratory function predisposes patients to hypoxiapostoperatively. The potential for hypoxia may remain for up to five days postoperatively, 59 andis increased at night.

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For most patients there is no consistent evidence regarding the relationship between hypoxia andischaemic events postoperatively. In high risk patients undergoing vascular surgery, new ischaemicchanges have been shown to be associated with a fall in oxygen saturation.60 Myocardial ischaemiahas been shown to be more likely when episodes of hypoxia are prolonged beyond five minutesand 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%.

3.12 CARDIAC FAILURE

Even patients with stable cardiac failure may not tolerate anaemia, tachycardia or intravascularvolume shifts. Features of cardiac failure are shown in Table 7. Patients on drug treatment forestablished cardiac failure should have their medication continued throughout the perioperativeperiod where possible. It may be necessary to use an IV loop diuretic where oral intake is notpossible.

If cardiac failure is suspected in the postoperative period:

n examine patient thoroughlyn assess IV fluid regimen and drugsn order ECG and chest X-rayn request specialist advice for assessment and possible echocardiogramn if patient in acute distress consider IV furosemide 40-80 mg.

Table 7: Features of cardiac failure

FEATURES OF LEFT HEART FAILURE include

lung crepitationsdyspnoeapulmonary oedema on chest X-raygallop rhythm

FEATURES OF RIGHT HEART FAILURE include

peripheral oedemaraised JVPhepatic enlargement and occasionally tenderness

PRECIPITATING FACTORS

acute myocardial infarction or ischaemiaarrhythmia (including loss of heart rate control in patients with established atrial fibrillation)anaemiafluid overloadpulmonary thromboembolismdrugs added, eg non-steroidal anti-inflammatory drugsdrugs omitted, eg diuretics

NB None of these signs are specific for cardiac failure and must be assessed in theclinical context.



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4 Respiratory management

4.1 INTRODUCTION

Pulmonary complications are an important and common cause of postoperative morbidity andmortality and are particularly common after major abdominal and thoracic surgery. Reportedincidence varies from about 20-75%,62-64 perhaps because of inconsistent diagnostic criteria. Ifpatients at risk can be recognised, it may be possible to modify some risk factors before electivesurgery to reduce the rate of these complications. Early recognition of developing respiratorycomplications with appropriate interventions may improve outcome. Failure to recognise pulmonarycomplications may result in rapid deterioration leading to death.

Treatment must be based on an accurate assessment of the patient. In some cases no specifictreatment is required but in others rapid and aggressive treatment is required to prevent death.

4.2 RISK FACTORS

A number of risk factors for postoperative pulmonary complications have been identified: 65-70

n duration of anaesthesia66

n nasogastric intubation66,67

n type of surgery65

n functional status65

n ASA >2 68,69

n age >59 68,70

n body mass index >25 kg/m2 68 or BMI >27 kg/m2 70

n weight loss65

n smoking history within last eight weeks65,70

n upper abdominal incisions68,70

n chronic bronchitis65,68

n presence of cancer68

n stroke65

n increased blood urea65

n transfusion65

n emergency surgery65

n smoking, alcohol, and long term steroid use65

n intermittent positive pressure ventilation (IPPV) >1 day67

n impaired cognitive function65,70

n preoperative stay >4 days.65

The evidence supporting some of these risk factors is tenuous and may be circumstantial:

n patients requiring IPPV may already have pulmonary complicationsn patients requiring prolonged preoperative stay may have other problems and may also have

an ASA >1n cognitive function may be impaired before operation or may develop as a result of the

intervention and be caused by pulmonary complications.

Other risk factors for which there is no specific evidence include oesophageal problems such aspharyngeal pouch, hiatus hernia, achalasia and intestinal obstruction.

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4.3 REDUCING POSTOPERATIVE PULMONARY COMPLICATIONS

4.3.1 ANALGESIA

Compared with systemic opioids, neuroaxial blockade after surgery can reduce pulmonarycomplications; epidural opioids (RR 0.53 95% CI 0.2-1.33), epidural local anaesthetics (RR0.58 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 analgesiawith epidural after surgery did not improve survival (5.1% vs 4.3%) or major morbidity.72 Onlyone of eight categories of morbid end points in individual systems (respiratory failure) occurredless frequently in patients managed with epidural techniques (23% vs 30%, p=0.02). In thisstudy, the term �respiratory failure� is a pooled end point covering need for prolonged intubationor reintubation, or a PaO2 ≤ 50 mm Hg or a PaCO2 ≥ 50 mm Hg on room air. These criteria maynot all be clinically relevant.

4.3.2 POSTOPERATIVE FLUID BALANCE

Following surgery the capacity to excrete fluid is reduced. Fluid accumulation, particularly in thelungs, may result in oedema. Cardiac and pulmonary complications and mortality afterpneumonectomy are more common if fluid balance is strongly positive73 and this associationalso appears to be relevant after non-thoracic surgery.74 Fluid balance following surgery must bevery carefully controlled to avoid excess fluid accumulation (see section 5).

4.3.3 OXYGEN THERAPY

Oxygen is often given to patients after surgery but good evidence supporting its routine use isscarce. The theoretical concern that nitrous oxide excretion may cause postoperative hypoxia hasnot been substantiated.75 One study has shown that increasing FiO2 after operation reduces theincidence of wound infection.76 Hypoxaemia is common after surgery and is caused by impairedgas exchange and impaired ventilatory control. Episodes of minor hypoxaemia after surgery arecommon but are of doubtful significance. Routine use of oxygen in fit patients after uncomplicatedsurgery, with SpO2 values over 92% has not been shown to reduce the incidence of hypoxaemia.77

Hypoxaemia in the postanaesthesia recovery room is not related to general postoperativemorbidity.78 The threshold for adverse effects of hypoxaemia in individual patients however, isunknown and all patients should receive oxygen in the early postoperative period.

The following groups of patients are at risk of persistent hypoxaemia and should receive prolongedmonitoring and oxygen therapy:

n obese patientsn patients who have undergone thoracic or upper abdominal surgeryn patients with acute and chronic pulmonary diseasen patients receiving sedative drugs and opiates.

In some patients oxygen delivery to the tissues may be impaired despite a normal PaO2. Thisincludes patients with:

n hypovolaemian hypotensionn myocardial ischaemian cerebral ischaemian anaemian increased oxygen consumption (eg pyrexia)n sickle cell disease.

These patients should also receive prolonged monitoring and oxygen therapy.

CS Oxygen therapy should be used in those patients at high risk of postoperative complications,or who are hypoxaemic following surgery (SpO2< 92%).

4 RESPIRATORY MANAGEMENT

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4.4 MONITORING AND DIAGNOSIS

4.4.1 INTRODUCTION

The widely accepted methods of monitoring patients have not generally been subject to evidencebased assessment. An RCT of 20,802 patients found no difference in the incidence of postoperativecomplications between those routinely monitored with pulse oximetry and those not routinelymonitored. Monitored patients had significantly more episodes of hypoxaemia identified andhad fewer episodes of ECG detected myocardial ischaemia. 79,80 No other trials of routine monitoringwere identified.81

4.4.2 DIAGNOSTIC CRITERIA

The generally accepted diagnostic criteria for respiratory failure, pulmonary infections, acuterespiratory distress syndrome (ARDS) and acute lung injury are as follows:

Respiratory failure

n Type 1 PaO2 < 8kPa (60 mm Hg), PaCO2 <6.6kPa (50 mm Hg)n Type 2 PaO2 < 8kPa (60 mm Hg), PaCO2 >6.6kPa (50 mm Hg).

Atelectasis

n Pulmonary collapse clinically or on X-ray which may be subsegmental, segmental, lobar orpulmonary, without evidence of respiratory infection.

Respiratory infection

Any two of the following on two or more days:

n Pyrexia >38oCn Positive sputum culturen Positive clinical findingsn Abnormal chest X-ray � Atelectasis/infiltrates.

Acute respiratory distress syndrome and acute lung injury:

n Acute onsetn Bilateral infiltrates on chest radiographyn Pulmonary artery capillary wedge pressure (PACWP) ≤18 mm Hg or the absence of clinical

evidence of left heart failuren Acute lung injury is considered to be present if PaO2 (kPa) / FiO2 is ≤ 40n ARDS is considered to be present if PaO2 (kPa) / FiO2 is ≤ 26.

4.4.3 OBSERVATION

Simple measures are most appropriate in view of the absence of evidence of efficacy of moresophisticated measures.82

The following indicate the possible development of respiratory complications:

n respiratory rate <10 or >25 breaths per minuten pulse rate >100 beats per minuten reduced conscious level and/or confusion.

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Clinical assessment of the chest should be performed. Adventitial sounds on breathing are commonand need not indicate significant disease but major abnormalities such as gross pulmonary collapseand pleural effusions are easily detectable.

CS Respiratory rate, pulse rate and conscious level should be monitored routinely to identifypostoperative respiratory complications.

CS The following indicate the possible development of respiratory complications:

n Respiratory rate <10 or>25 breaths per minuten Pulse rate >100 beats per minuten Reduced conscious level.

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 ispoor. Patients receiving supplemental oxygen may have adequate oxygen saturation despitehypoventilation and hypercapnia.

n Arterial blood gas analysis (ABG). ABG is essential in the assessment of any patient withsuspected respiratory complications. ABG accurately defines the degree of respiratory failureand differentiates between metabolic and respiratory acidosis.

n Chest X-ray. Chest X-rays should be used to diagnose or exclude major collapse, pulmonaryembolism and pleural problems such as effusions, pneumothorax or haemothorax. RoutineX-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 pulmonaryinfiltrates 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 ormajor pleural disease such as empyema. It has no place in the routine management ofpostoperative pulmonary complications.

n Bacteriology. Sputum culture is of value in planning appropriate antibiotic therapy. Specimenstaken by endobronchial suction may be used.

n ECG. Significant respiratory compromise may relate to a primary cardiac event, and so allpatients who are investigated for pulmonary complications should also have an ECG.

CS n Patients in whom there is a suspicion of postoperative pulmonary complications shouldhave an arterial blood gas analysis, a sputum culture and ECG.

n Chest X-ray should be performed on suspicion of major collapse, effusions,pneumothorax or haemothorax.

n Other investigations should be used only if there are specific indications.

4.5 TREATMENT

4.5.1 TREATING ATELECTASIS

Atelectasis is common after surgery, particularly pulmonary and upper abdominal surgery.Prevention and clearance of atelectasis is important to prevent secondary infection. In mostcases no specific treatment is required beyond normal mobilisation and breathing exercises.Hypoxia requires oxygen therapy as described in section 4.5.2. Very occasionally wherephysiotherapy fails to effectively treat extensive lobar or pulmonary collapse, therapeuticbronchoscopy and bronchial suction may be necessary as the collapsed lung contains no air withwhich to cough out the mucus plugs.

4.5.2 TREATING RESPIRATORY INFECTION

Treatment should aim to maintain oxygenation, clear blocked airways, expand collapsed alveoliand clear infection.



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Oxygen therapy

Oxygen can be delivered by a large number of different devices. 100% oxygen can only besupplied by endotracheal intubation and positive pressure ventilation. The highest inspiredconcentration that can be supplied by external devices is about 70% with a mask and reservoirbag. A 60% ventimask can reliably supply sufficient oxygen for most patients with respiratoryinsufficiency.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, butthere is no difference in oxygen saturation between the three devices.85 Hudson masks, whenused with low flow oxygen, may result in hypercapnia due to inadequate ventilation. Nasalcatheters are better tolerated and therefore compliance is better.86

In a normally hydrated patient humidification of oxygen is not necessary unless the patient isintubated 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 whateverFiO2 is necessary to return their SpO2 to its usual level.

Table 8: Equipment used for oxygen delivery

Type of mask Characteristics of system Rate or concentrationof oxygen delivery

Nasal catheters (± foam) Low flow system 2-4 litre/minVariable performance

Hudson mask Low flow system 4-8 litre/minVariable performance

Venturi mask with venturi jet High flow system 24,28,35,40,60% oxygenFixed performance

Venturi mask attached to High flow system 28,35,40,60% oxygenhumidification system Fixed performance

Reservoir mask High flow system 70% oxygenFixed performance

CS Oxygen should be given to patients with hypoxaemia using a device that is best toleratedto 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 assistedventilation.

Antibiotics

Patients fulfilling the diagnostic criteria for respiratory infection (see section 4.4.2) should betreated with appropriate antibiotics, based on local protocols and represcribed later on the basisof the results from sputum culture.87 Any patient in whom aspiration may be suspected shouldreceive additional cover for anaerobic organisms. Continued monitoring of sputum bacteriologyis necessary as treatment failure is associated with development of drug resistance and change inbacteria.87

CS Patients with evidence of respiratory infection should receive antibiotics based initiallyon local protocols and modified later on the basis of the results from sputum culture. Ifaspiration of intestinal contents is suspected additional cover for anaerobic organismsshould be given.

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4.5.3 TREATMENT OF RESPIRATORY FAILURE

Respiratory failure may be purely a ventilatory problem and in the postoperative period this maybe due to one of a variety of drugs. It is important to identify drug related problems as specificantidotes are available.

Drugs

Many drugs depress ventilation. Specific antagonists are available for the commoner suppressantdrugs namely opioids, neuromuscular blocking agents and benzodiazepines. Specific respiratorystimulants may also be appropriate. It is important to remember that antagonists usually have ashorter action than agonists and dosage may have to be repeated. Antagonists such as naloxonehydrochloride or flumazenil should be given carefully because acute reversal can cause acutepain, withdrawal symptoms, or fits.

CS Opioid overdose should be treated with oxygen, airway maintenance, ventilatory supportif necessary, and immediate anaesthetic or critical care specialist advice.

CS Benzodiazepine overdose should be treated with oxygen, airway maintenance, ventilatorysupport if necessary, and immediate specialist advice.

CS Hypoventilation due to CNS depression not responsive to specific antagonists is anindication for specialist anaesthetic or critical care referral.

Assisted ventilation

In patients who develop respiratory failure assistance with breathing may be necessary. Assistedventilation 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 >6.6kPan PaO2 < 8.0kPan Respiratory rate >25 breaths/min.

CS Patients developing respiratory failure should be referred to a critical care specialist tobe assessed for possible assisted ventilation. The referral should be timely as hypoxia orhypercapnia may lead rapidly to cardiorespiratory arrest.

4.6 ROLE OF PHYSIOTHERAPY

Physiotherapy is widely used before and after surgery. As this is an under-researched area, limitedhigh quality evidence is available. In addition, the evidence that was identified addresses techniquesthat tend not to be used in current practice. Further research regarding the role of postoperativephysiotherapy would be beneficial.

Although evidence for its efficacy is variable, physiotherapy may be useful in patients with:

n decreased lung volumen sputum retentionn increased work of breathingn reduced exercise tolerance.



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Following general anaesthetic, a patient�s functional residual capacity may be lowered, particularlyfollowing 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 atelectasisn maintain adequate ventilationn assist with the removal of bronchial secretionsn encourage early mobilityn promote return to preoperative functional levels.

A combination of these approaches may help to maintain respiratory function and prevent earlypostoperative respiratory complications. Other treatment techniques are available for patientswith more complex needs. There should be a multidisciplinary approach to the promotion ofoptimal positioning and early mobilisation.

4.6.1 TREATMENT OPTIONS

Table 9: Summary of common physiotherapy treatments

Effect required Treatments available

Increase lung volume PositioningThoracic expansion exercisesControlled mobilisationActive exercise programmeMechanical aids, eg incentive spirometer,intermittent positive pressure breathing (IPPB)

Clear secretions Systemic hydration/humidificationAirway clearance techniquesThoracic expansion exercisesMobilisationManual techniquesMechanical aidsSuction

Reduce work of breathing Rest and sleepPositioningBreathing control exercisesBreathing re-educationMechanical aids/assisted ventilation

Adequate analgesia prior to physiotherapy will allow more patients to participate in treatment.

Local treatment protocols may be in place for specific patient groups.

4.6.2 REDUCING POSTOPERATIVE PULMONARY COMPLICATIONS

Postoperative pulmonary complications have been reduced from 60% to 19% with simplesupervised breathing exercises in patients undergoing upper abdominal surgery88 and majorabdominal surgery (from 27% to 6%, p<0.001), with the addition of resistance training in highrisk patients.89

Devices such as incentive spirometers have not been consistently shown to be better than standardbreathing exercises.90

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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 hadrecent abdominal surgery may also benefit from physiotherapy.

Postoperative pain, particularly in upper abdominal or chest surgery, may cause difficulty withdeep breathing and coughing. Both are essential in the treatment of respiratory infections, makingappropriate positioning of the patient important. Patients often find the sitting position helpfulfor 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 sputum retention should be assessed by a physiotherapist.

CS Patients with collapse or decreased lung volume or who have undergone recent thoracicor abdominal surgery should be considered for physiotherapy.

4.6.3 OUT OF HOURS SERVICES

Most hospitals also operate an out of hours respiratory physiotherapy service for emergencies,with local guidelines giving details of service provision.91 Table 10 gives a guide to when out ofhours physiotherapy may be appropriate.

Table 10: When to use out of hours physiotherapy services

CRITERIA FOR EMERGENCY CALL-OUTS

The patient has a condition that is amenable to physiotherapy which has either:n deterioratedn or is likely to deteriorate without intervention before the daytime service resumes

PROBLEMS WHICH MAY BE HELPED BY PHYSIOTHERAPY

Secretion retention which is compromising ventilationAcute lobar collapseAcute aspiration

DO NOT CALL FOR

Respiratory compromise due to pain, until pain is controlledSputum retention due to dehydration, until patient is rehydratedBronchospasmPulmonary embolismReduced lung volume due to pleural effusionPulmonary oedema/fluid overload



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5 Fluid, electrolyte and renal management

5.1 INTRODUCTION

There is surprisingly little primary research on this important topic. There are studies based onspecialist populations, including those in ICU, and on preoperative optimisation. Many of thesestudies are small and have methodological flaws. The guideline development group did not feelthat the results of trials in different populations could be used as evidence to guide managementof the postoperative patients covered by this guideline.

Acute renal failure can be defined in terms of creatinine clearance or a rise in serum creatininefrom the baseline value. Creatinine clearance is seldom measured in postoperative patients anddecisions are generally made on the basis of serum creatinine. Patients may have serum creatininewithin the normal laboratory range and still have significant impairment of function. This isparticularly the case in patients who are debilitated or elderly.

The SIGN guideline on perioperative blood transfusion for elective surgery provides guidance onthe use of packed cells in the postoperative period.92

5.1.1 BASAL REQUIREMENTS IN THE POSTOPERATIVE PATIENT

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 masstends to increase with age, the �standard� calculations above are particularly likely to overestimatethe basal needs of the obese, the elderly and women.

5.1.2 PRINCIPLES OF FLUID BALANCE

As in any patient, the standard principles of fluid balance in the postoperative patient are:

n to correct any pre-existing deficitn to supply basal needsn to replace unusual losses (eg from the pre-existing surgical problem, surgical drains, pyrexia)n to use the oral route where possible; there is often an unnecessary delay in commencing oral

intake after surgery.

There is a longstanding conflict between �wet� and �dry� schools, particularly with regard toprevention of complications and correction of pre-existing deficits. The �wet� school offers evidencethat some patients benefit from aggressive preoperative fluid loading as part of a �pre-optimisation�strategy (guided by invasive monitoring). The �dry� school contends that, due to stress-relatedchanges in endocrine function, many patients do better with restriction of water and sodiumintake. The advocates of both approaches often include them as part of a package of perioperativecare.

This guideline is concerned with postoperative care and not with these overall strategies. Theevidence base for fluid management in the postoperative setting is poor, but it is important toavoid hypovolaemia in the early postoperative phase.

5.1.3 ROLE OF INVASIVE MONITORING

Invasive monitoring of central venous pressure may help in assessing fluid balance status, especiallyin high risk patients (eg the elderly). The assessment of trends, particularly in response to a fluidchallenge, is more important than a single reading.

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CS Invasive monitoring should be considered to assess fluid balance status, particularly inhigh risk patients.

CS Elderly patients should be observed closely as they are more likely to have overt or covertcardiac, respiratory or renal disease and to have less reserve. Clinical signs may be lessreliable in these patients.

5.2 RISK FACTORS

Risk factors for postoperative fluid or electrolyte disturbance could relate to:

n the surgical conditionn medical problems complicating the surgical conditionn pre-existing medical problems (eg renal, cardiac or hepatic disease)n medications such as diureticsn problems of limited homeostasis in older patients making them susceptible both to over- and

under-loading of fluids and electrolytes.

The following patients are particularly at risk:

n the elderlyn those with pre-existing cardiovascular diseasen those with pre-existing cerebrovascular diseasen those with pre-existing renal diseasen those who have suffered perioperative myocardial ischaemia or infarctionn those who have suffered large perioperative fluid losses.

5.3 PROPHYLAXIS

The ideal way of tackling problems with fluid and electrolyte balance is to avoid them in the firstplace. Appropriate monitoring strategies are discussed in section 2.4. The patient�s fluid statusand electrolyte balance need to be estimated, taking into consideration:

n unusual losses as the result of the surgical problem prior to assessmentn continuing surgical-related lossesn usual maintenance needsn vasodilating effects of epidural analgesia.

CS Be aware that preoperative bowel preparation or prolonged preoperative fasting mayresult in covert hypovolaemia, which may become evident only in the early postoperativeperiod.

CS Assess hypotensive patients with epidurals to exclude fluid deficit. It should not be assumedthat the hypotension is due to the epidural.

CS Avoid excessive administration of fluids to hypotensive patients with epidural anaesthesiawho are well perfused. This can cause fluid overload which may only become manifestwhen the epidural infusion is stopped.

5.4 DETECTION OF OVERT CLINICAL PROBLEMS

Patients should be monitored for problems such as:

n hypotensionn tachycardian oligurian signs of fluid overload (such as pulmonary oedema)n more subtle signs such as confusion or tachypnoea.

5 FLUID, ELECTROLYTE AND RENAL MANAGEMENT

AB IT SOLUTIONS

Highlight


30

Hypotension, tachycardia, oliguria, confusion and tachypnoea may all be indications ofhypovolaemia but also have other causes, including sepsis and primary cardiac problems.Whenever a postoperative patient is hypovolaemic, it is vital to consider blood loss, and toactively exclude this before attributing hypovolaemia to another cause. Management should beappropriate to the identified causal factor.

CS Accurate assessment of fluid and electrolyte status can be difficult and the treatment of aparticular patient must be individualised and reviewed frequently in the light of theresponse to treatment.

5.5 MANAGEMENT OF VOLUME DEPLETION AND OVERLOAD

5.5.1 VOLUME DEPLETION

Volume depletion can lead to poor tissue perfusion and this can result in both morbidity andmortality.

The specific consequences are:

n anastomotic breakdownn cerebral damagen renal failuren multiple organ failure.

Table 11: Volume depletion

Possible causes of volume depletion

n unrecognised or uncorrected preoperative hypovolaemia (including effects of fasting)n inadequate intra- or postoperative replacement, bearing in mind:

n third space losses (fluid sequestration in the gut or peritoneal cavity, oedema)n drain lossesn fistulaen polyuric renal failuren hyperventilationn pyrexian nasogastric aspirate

n haemorrhagen inappropriate use of diuretics.

CS Volume depletion should be avoided as this can lead to poor perfusion and problemssuch as anastomotic breakdown, cerebral damage, renal failure and multiple organ failure.

5.5.2 VOLUME OVERLOAD

Volume overload can lead to pulmonary and tissue oedema. Pulmonary oedema can beimmediately life threatening. Tissue oedema can lead to poor tissue perfusion, failure to absorbenteral feed, and failure to eat.

AB IT SOLUTIONS

Highlight

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Table 12: Volume overload

Possible causes of volume overload

Excessive fluid administration due to:n overestimation of loss (drain or third space losses)n failure to recognise deteriorating renal functionn failure to recognise deteriorating cardiac function.

CS Volume overload should be avoided.

5.6 OLIGURIA

Oliguria is defined as urine volume of less than 0.5 ml/kg/hr for two consecutive hours. Theappropriate response depends on the cause and whether it is associated with impaired renalfunction.

Oliguria should not be regarded as a diagnosis but as a sign requiring explanation. It is notappropriate 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 usedin the past in the hope of preventing acute renal failure, but the overwhelming evidence fromstudies in critically ill patients is that it is not beneficial.

Oliguria associated with normal pre-existing renal function, cardiovascular stability and an alertpatient is unlikely to require intervention unless it persists for four hours or more. If associatedwith other symptoms or signs suggestive of fluid depletion it should be treated initially with afluid 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 isessential to assess the response in terms of haemodynamics and subsequent urine output. If thereis no improvement, this may be repeated once. If this does not produce improvement thenconsideration should be given to the measurement of central venous pressure. Smaller volumesmay 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 renalimpairment.

CS Oliguria in an alert patient, that is associated with normal pre-existing renal functionand cardiovascular stability, is unlikely to require intervention unless it persists for fourhours or more.

CS If oliguria is associated with other symptoms or signs suggestive of fluid depletion itshould be treated initially with a fluid challenge.

CS In all cases of oliguria it is important to exclude obstruction of the urinary tract orurinary catheter.

CS Diuretics should not be used to treat oliguria and should be reserved for fluid overload.

CS Dopamine should not be used to treat oliguria or to prevent renal failure.



32

5.7 SODIUM

5.7.1 HYPONATRAEMIA

Hyponatraemia does not by itself indicate saline deficiency and is most commonly due to excesswater. Antidiuretic hormone (ADH) secretion is increased after surgery and if excess water isgiven (as 5% dextrose) then hyponatraemia may be induced. If hyponatraemia is associated withvolume depletion then there must be a degree of sodium deficiency. The estimation of the degreeof volume excess or volume depletion requires clinical assessment in addition to biochemicalestimates. Very low levels of serum sodium (110-120 mmol/L or less) can produce symptomssuch as stupor, coma or fits and constitute a medical emergency. Over-vigorous correction ofsevere hyponatraemia is also dangerous. Patients with hyponatraemia should be managed bymedical staff with appropriate experience.

CS Assess volume status in hyponatraemic patients, as it is more commonly due to excesswater rather than sodium deficiency.

CS Severe hyponatraemia (Na<120 mmol/L) constitutes a medical emergency and should bemanaged by experienced medical staff.

5.7.2 HYPERNATRAEMIA

In patients with hypernatraemia, clinical assessment of the patient may add little to thebiochemical 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 benon- specific, particularly where the sensation of thirst is impaired by the surgical or medicalsituation.

CS Hypernatraemia most commonly indicates a total body deficiency of water and is anindication for prompt assessment and intervention, especially when levels exceed 155mmol/L.

5.8 POTASSIUM

Potassium levels in the blood are not a good indicator of total body potassium. However, abnormalblood levels, and in particular hyperkalaemia may precipitate cardiac arrest, and an ECG is animportant adjunct when deciding the potential ill effects of potassium abnormalities in anindividual postoperative patient.

Protocols for the emergency treatment of potassium abnormalities are described in standardemergency medicine texts. Most hospitals will also have local protocols which should be referredto. 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 beseveral 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 replacementn renal lossesn endocrine abnormalitiesn 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 cellsand increases renal excretion).

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Not only does alkalosis cause hypokalaemia, but hypokalaemia can cause alkalosis.

Treatment of hypokalaemia should first focus on removing avoidable causes. Unless there is truepotassium deficiency, it is seldom necessary to replace potassium at a rate of greater than 10-20mmol/hr. Faster administration usually requires a central line and careful monitoring and shouldby undertaken in an environment which provides level 2 care. Concentrated solutions of potassiumare 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.

CS Hypokalaemia is a common problem and can delay postoperative recovery. Hypokalaemiashould be avoided, or corrected, with appropriate supplementation. Magnesiumsupplementation may also be required.

5.8.2 HYPERKALAEMIA

Emergency treatment of hyperkalaemia may include IV calcium chloride, which must be titratedslowly, IV calcium gluconate, nebulised beta agonists (such as salbutamol) or IV 50 ml 50%dextrose with 10 units of shortacting insulin.

CS Hyperkalaemia is a medical emergency and senior help should be obtained.

5.9 ACID/BASE BALANCE

Acute acid/base problems in the postoperative period are commonly due to respiratory/ventilationproblems (see section 4). Metabolic acidosis is usually due to poor tissue perfusion but can alsobe due to renal failure, or rarely, can be caused by excessive administration of 0.9% saline whichhas a high chloride concentration.93 If large volumes of crystalloid are required then Hartmann�ssolution is preferable. A total venous bicarbonate of less than 20 mmol/L or a base deficit ofgreater than four may indicate cause for concern, particularly if the trend is adverse.

CS Metabolic acidosis is usually due to poor tissue perfusion but can also be caused byexcessive administration of saline. A total venous bicarbonate of less than 20 mmol/L ora base deficit of greater than 4 mmol/L may indicate cause for concern, particularly if thetrend 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 responseto infection leading to a generalised inflammatory reaction in organs remote from the initialinsult 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 theircondition. If associated with shock or organ dysfunction (sepsis syndrome) mortality is between20 and 40%. Clearly identifying patients at risk and taking appropriate prophylactic measures isvital. 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 appropriatesurgical drainage are the mainstays of treatment.

Table 13: Definitions of sepsis

Systemic inflammatory response syndrome: SIRS

The response is defined by the presence of two or more of the following:n temperature >380C or <360Cn heart rate >90 beats/minn respiratory rate >20 breaths/min or PaCO2 <4.3kPan white cell count >12,000 cells/mm3 , <4,000 cells/mm3 , or >10% immature forms.

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, lacticacidosis, oliguria or an acute alteration in mental state.

6.2 RISK FACTORS FOR INFECTION

Several studies have identified a series of risk factors for postoperative infection, outlined inTable 14. Minimising the risk of infection in such patients is logical and should be an integralpart of their care pathway.

Table 14: Risk factors for postoperative infection

complicated surgery, eg total gastrectomy > than other gastroduodenal procedures94

prolonged operation time94-96

blood transfusions94,95

hypothermiaincreasing age95,97

presence of remote infection96,98 or faecal contamination98

male sex98

poor physical status of patient,98 malnutrition, immunocompromise, severe underlying diseaseemergency surgery95

use of invasive procedures (urinary catheter, chest tubes, nasogastric tube passage)95

prolonged intravascular cannulationprolonged postoperative stay96

patients receiving chemotherapy or radiotherapy, immunosuppressants, steroidssevere trauma or burns

There is little evidence to demonstrate how these factors influence or predict outcome.

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6.3 PROPHYLAXIS

6.3.1 ANTIBIOTIC PROPHYLAXIS

Antibiotic prophylaxis in surgery has previously been reviewed by SIGN (for recommendationssee SIGN guideline on Antibiotic Prophylaxis in Surgery).99

CS Prophylactic antibiotics should be administered to appropriate groups of patients to reducethe risk of developing postoperative sepsis.

6.3.2 HAND WASHING

Hand washing is widely recognised as an important but underused measure to prevent nosocomialinfections.100 Guidelines exist for handwashing techniques.101 The following statements are basedon these guidelines:

1. Hands (when visibly soiled) must be washed thoroughly with soap and water.

2. Hands must be cared for by hand washing with soap and water or by hand antisepsis withalcohol based handrubs (if hands are not visibly soiled):

a) before and after patient contactb) after contact with a source of micro-organisms (body fluids and substances, mucous

membranes, non-intact skin, inanimate objects that are likely to be contaminated)c) after removing gloves.

3. Hand antisepsis, achieved by hand washing or surgical scrub with antimicrobial-containingsoaps or detergents or by use of alcohol based antiseptic handrubs, is recommended in thefollowing instances:

a) before the performance of invasive procedures such as surgery or the placement ofintravascular catheters, indwelling urinary catheters, or other invasive devices

b) when persistent antimicrobial activity on the hands is desiredc) when it is important to reduce numbers of resident skin flora in addition to transient

micro-organisms.

CS Hand washing with soap and water or with alcoholic cleansing agents should be performedbefore and after patient contact.

CS Strict hand antisepsis must be achieved before the performance of invasive proceduressuch as surgery or the placement of intravascular catheters, indwelling urinary catheters,or other invasive devices.

Other aspects of hand care and protection:

Glove use

n gloves should be used as an adjunct to, not a substitute for, handwashingn gloves should be used for hand-contaminating activitiesn gloves should be removed and hands washed when hand-contaminating activity is completed,

when the integrity of the gloves is in doubt, and between patientsn gloves may need to be changed during the care of a single patient, for example when moving

from one procedure to anothern disposable gloves should be used only once and should not be washed for reusen gloves made of other materials should be available for personnel with sensitivity to usual

glove material (such as latex), and for use in patients with a similar sensitivity.

Behaviour and compliance

Efforts to improve hand washing practice should be multifaceted and should include continuingeducation and feedback to staff on behaviour or infection surveillance data. Unit clinical andadministrative staff should be involved in the planning and implementation of strategies toimprove compliance and hand washing.

6 MANAGEMENT OF SEPIS


36

CS Gloves should be used for hand-contaminating activities.

CS Gloves made from a range of materials should be available for personnel with sensitivityto standard glove material, and for use in patients with a similar sensitivity.

6.4 EARLY IDENTIFICATION

Early identification and management of sepsis is vital as the prompt administration of appropriateempirical antimicrobial therapy reduces by half the frequency with which shock develops inpatients with rapidly fatal, ultimately fatal and non-fatal diseases.102

6.4.1 CLINICAL FEATURES

The early clinical signs of sepsis are variable and often non-specific. Patients at high risk requirea high index of suspicion. One group at particular risk is that with an anastomosis of the GI tract.Anastomotic leakage carries a mortality rate of 20-50%.The list of clinical signs of sepsis inTable 15 has been adapted from Matot et al.103

Table 15: Clinical signs of sepsis

Fever/hypothermiaUnexplained tachycardiaUnexplained tachypnoeaSigns of peripheral vasodilationUnexplained hypotension/shockChanges in mental stateLeucocytosis/neutropeniaUnexplained alteration in renal or liver functionThrombocytopenia/ disseminated intravascular coagulationMetabolic acidosis

6.4.2 IDENTIFICATION OF SEPSIS

Early identification of systemic sepsis involves:

n focused clinical examination, for both a primary site of infection and the systemic sequelaeof sepsis

n examination for primary site of infection (guided by risk factors); exposure of surgical wounds,vascular access sites, pressure areas, injection sites. Wound swabs or specimens of drain fluidshould be obtained from the suspected wound infection. Examination of chest, examinationof urine. Microscopy and/or dipstix testing for nitrites may give an early indication of infection,before formal sensitivities from culture are available

n examination for systemic sequelae; include measurement of temperature, respiratory rate,heart rate, blood pressure and laboratory investigation of neutrophil count104

n severity of sepsis may be assessed by looking for organ dysfunction which may be reflected byaltered platelet count, coagulation screen, renal function, liver function and C-reactive protein.

CS Early identification and appropriate treatment of sepsis improves outcome.

CS Urine and blood cultures should be obtained whenever there is reason to suspect systemicsepsis.

CS If clinical signs are unclear, appropriate radiological investigations should be used forthe diagnosis of intra-abdominal infection.

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6.4.3 DIAGNOSTIC PROCEDURES

No evidence was identified to inform timing of blood culture in relation to clinical signs. Expertopinion suggests that blood cultures should be taken as soon as possible following onset offever.105 Three samples, totalling 60 ml should be taken over a 24 hour period.

The accuracy of CT and ultrasonography for the diagnosis of intra-abdominal abscesses has beencompared.106 ,107 The accuracy of ultrasound ranges from 75-96% while CT correctly diagnoses71-100%. CT and ultrasonography may be complementary.

6.5 MANAGEMENT

Once a patient has been identified to be septic, further diagnosis and treatment usually occur inparallel. Immediate care demands assessment of airways, breathing and circulation (the �ABCs�).The patient will often be hypovolaemic and hypoxaemic and the presence of these changesdemands at least the administration of oxygen and establishment of intravenous access withvolume expansion using either colloid or crystalloid. Patients with sepsis syndrome need carefulmonitoring and, in general, require level 2 care. Once a patient has been examined fully andinitial diagnostic tests undertaken, antibiotics should be given as early as possible and are generallyprescribed on a best guess basis for the clinical scenario.

6.5.1 ANTIMICROBIAL THERAPY IN SEPSIS

Antimicrobial therapy is the cornerstone of management of patients with sepsis. Results fromanalysis of microbial specimens, and any proposed changed in antibiotic therapy may need to bereviewed with the consultant microbiologist. There are few comparative studies on the efficacyand safety of different antimicrobial regimens in non-neutropenic or postoperative patients.Treatment guidelines for patients with sepsis have been based on the results of large, multicentrestudies conducted in neutropenic cancer patients.108 Retrospective studies have shown that earlyadministration of appropriate, broad spectrum109 antibiotics reduces mortality.110

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 antibioticschanged as necessary.

CS A course of antimicrobial treatment should generally be limited to 5-7 days. It is importantto appreciate that fungi and atypical organisms can contribute to sepsis syndrome, and totake cultures and prescribe appropriately.

6.5.2 SURGERY

Surgical approaches to the treatment of infection have evolved through principal and traditionand few have been evaluated by randomised controlled trials. Localised collections of pus generallyneed either operative or percutaneous drainage and dead tissue should be excised.

Severe pulmonary sepsis may require bronchoscopy and toilet of the bronchial tree. Earlyintervention in necrotising soft tissue infection has been shown to reduce mortality compared tohistorical controls in some case series.111

CS Surgical intervention in the form of debridement or drainage of infected, devitalisedtissue should be undertaken as soon as possible following haemodynamic stabilisation.

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 plannedsecond-look laparotomy is still not clear. There are no randomised controlled trials comparingpercutaneous and operative drainage techniques. Case series show that percutaneous drainage isas effective as conventional surgery for the drainage of intra-abdominal collections.112,113

6 MANAGEMENT OF SEPIS


38

CS Percutaneous drainage following radiological identification should be considered forwell defined collections.

CS Patients with multiple collections or with failure of percutaneous drainage should haveopen surgery.

6.5.3 OTHER INTERVENTIONS

Obstruction of the biliary or urinary system must be relieved usually by endoscopic or percutaneousradiological means. Major sepsis associated with an infected prosthesis most commonly demandsremoval of the latter. It is essential to remain vigilant about the possibility of catheter-relatedsepsis, particularly in patients receiving level 2 or 3 care.

Short term, high concentration oxygen after surgery reduces wound infection.75

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7 Postoperative nutrition

7.1 INTRODUCTION

For normally nourished patients, the primary objective of postoperative care is restoration ofnormal GI function to allow adequate food intake and rapid recovery. Malnourished patients areat increased risk of postoperative complications and mortality, yet artificial nutritional supportcan be associated with major complications.114

This section discusses a number of key issues that should be addressed if restoration of oral foodintake is to be achieved quickly and safely.

7.2 AVOIDING ROUTINE NASOGASTRIC INTUBATION

To promote a return to normal dietary intake, the presence of a nasogastric (NG) tube should beavoided. Evidence from several randomised trials 115 and a meta-analysis 116 indicates thatavoiding routine nasogastric decompression after abdominal surgery significantly reduces theincidence of fever, atelectasis and pneumonia.

7.2.1 PROMOTION OF EARLY ORAL INTAKE

A meta-analysis of controlled trials (11 studies with 837 patients) of early enteral feeding versusnil by mouth after GI surgery, concluded there is no clear advantage to keeping patients nil bymouth after elective GI resection.117 Early feeding reduced both the risk of any type of infection(RR 0.72, 95%CI 0.54 � 0.98, p = 0.036) and the mean length of stay in hospital (number ofdays reduced by 0.84, 0.36 to 1.33 P = 0.001). The risk of vomiting increased in patients fedearly (RR 1.27, 95% CI 1.01 � 1.61, p=0.046).

For patients with an anastomosis in the upper GI tract, ingestion of solid food may have to bedelayed for several days (eg until contrast studies confirm an intact oesophageal anastomosis).Following colorectal operations where the GI tract remains functional (see section 7.2.4) solidfood can be commenced without adverse effect on the first postoperative day.118 Patients may findliquid supplements easier to take in the first instance.

CS Oral intake should be commenced as soon as possible after surgery.

7.2.2 PROVISION AND ACCESS TO APPETISING FOOD

Studies in hospital patients have shown that up to 20% of meals are missed while patients attendor are fasted for investigative or therapeutic interventions, whilst 40% of the content of mealsdelivered to the patient is discarded.119 The provision of appetising hospital food and access tosufficient nursing staff to help patients who have difficulty in eating is a key issue in helpingpatients return to a normal food intake.

CS Patients should not be fasted for any longer than necessary, either for investigations orsurgery.

CS Hospitals should provide appetising food and assist patients to eat, if this is needed.

7.2.3 NUTRITIONAL STATUS AND POSTOPERATIVE NAUSEA AND VOMITING

The control of postoperative nausea and vomiting is essential if patients are to resume normaloral fluid and dietary intake. The regular use of anti-emetics is advised.

CS Anti-emetics should be used as required in order to promote an early return oforal intake.

7 POSTOPERATIVE NUTRITION

1++

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7.2.4 PREVENTION OF POSTOPERATIVE ILEUS

The effect of early enteral feeding on ileus is controversial. No data were identified from randomisedclinical trials on the effect of laxatives on postoperative paralytic ileus.

7.2.5 USE OF ORAL SUPPLEMENTS

Patients who are malnourished either at the time of, or shortly following, major abdominal orvascular surgery have a more rapid recovery of nutritional status, physical function and quality oflife, if given nutritional advice and prescribed routine oral supplements in the immediatepostoperative period and following two months.120

The evidence supporting the short term routine use of oral supplements in patients who are notmalnourished is not clear.121,122

7.2.6 MULTIMODAL RECOVERY PROGRAMMES

Use of early oral or artificial enteral nutrition at a time when gastrointestinal function has notreturned to a suitable level can be associated with abdominal distension, vomiting and respiratoryembarrassment.123

Multimodal enhanced recovery programmes (with a focus on pain control, early mobilisationand promotion of gastrointestinal function) are associated with an early return of oral nutrition inthe postoperative period.124 ,125 Patient care pathways should be designed to take account of amultimodal approach.

7.3 NUTRITIONAL SUPPORT FOR MALNOURISHED PATIENTS

Protein/calorie undernutrition can vary from mild (eg <5% weight loss) to severe (eg >15%weight loss, BMI <18kg/m2, albumin <30 g/l) and can occur in patients undergoing surgery forbenign or malignant disease. The need for nutritional support should be considered in relation toeach patient�s nutritional status and surgical pathology. Patients who are identified as malnourishedshould be referred to the unit dietitian for further assessment and management.

7.3.1 MALNUTRITION AND SURGICAL RISK; SCREENING TOOLS

Patients who are malnourished are at increased risk of postoperative complications.126,127 A varietyof strategies have been suggested for screening patients for malnutrition in the community, but itis not clear whether their implementation reduces morbidity or mortality.

7.3.2 MALNUTRITION IN BENIGN DISEASE

There is no evidence that malnourished patients with benign disease and requiring surgery (egCrohn�s disease) benefit from prolonged preoperative artificial nutritional support. Such patientsare best treated by surgical correction of their pathology followed by intensive nutritional supportin the postoperative period.

CS Malnourished patients with benign disease requiring surgery should receive postoperativenutritional support by the appropriate route.

7.3.3 MALNUTRITION IN MALIGNANT DISEASE

There is some evidence to suggest that severely malnourished patients with cancer benefit fromperioperative total parenteral nutrition (TPN).128 This benefit does not pertain to cancer patientswith mild or moderate malnutrition, where a meta-analysis has shown that perioperative TPNhas no benefits in terms of mortality.129

Upper GI cancer patients are often given postoperative enteral feeding either via a jejunostomy orfine-bore nasoenteral feeding tube. This allows maintenance of nutritional status should thepatient develop a postoperative complication that retards normal progression towards oral nutrition(eg an anastomotic leak).

1+

1-

2+

2+

1+

41

A meta-analysis has demonstrated that enteral nutritional support supplemented withimmunomodulatory nutrients results in a significant reduction in the risk of developing infectiouscomplications but has no effect on mortality.130 The cost effectiveness of such a strategy has notbeen clearly established. Immunonutrition may be given preoperatively as well aspostoperatively.131

CS Mild or moderately malnourished cancer patients should proceed with surgery and onlyreceive artificial nutritional support if specifically indicated.

CS All malnourished cancer patients should be considered for nutritional advice and oralsupplements in the postoperative period and for a period following discharge.

7.4 ARTIFICIAL NUTRITIONAL SUPPORT

Generally, if oral nutrition is not re-established within five to seven days postoperatively, enteralor parenteral feeding should be considered.

7.4.1 ASSESSMENT OF NUTRITIONAL REQUIREMENTS

Energy and protein requirements depend on body composition, clinical status and mobility. Anestimation of requirements is 30 kcal/kg/day and 1.0 g protein/kg/day for the average patient.Few patients require more than 2,200 kcal/day. Additional calories are unlikely to be usedeffectively and may constitute a metabolic stress.

Daily biochemical monitoring must be undertaken when initially refeeding the chronically severelymalnourished patient because of the dangers of hypokalaemia and hypophosphataemia. Nutritionalrequirements should be determined in consultation with a dietitian.

CS Nutritional replacement should be discussed with a dietitian and tailored to the patient�srequirements.

7.4.2 ENTERAL OR PARENTERAL NUTRITION?

Postoperative nutritional support has potentially serious complications. Enteral nutrition usesthe physiological route of nutrient intake, is cheaper and is generally safer, and should be thepreferred method of nutritional support, in the presence of a functioning gastrointestinal tract.

CS Enteral nutrition is the preferred method of postoperative nutritional support and shouldbe used if possible.

Patients with partial gut failure and who are catabolic, eg with necrotising pancreatitis or ongoingintra-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 enteralfeeding, is the method of choice.

CS For patients with ongoing postoperative complications enteral nutrition should be usedwhenever possible, combined with parenteral nutrition where necessary, to meet nutritionalneeds.


1+


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7.5 ARTIFICIAL NUTRITIONAL TECHNIQUES

7.5.1 ENTERAL NUTRITION

Nasogastric feeding

The most appropriate route of enteral tube feeding for patients who require short term support (egless than four weeks) is via a fine-bore nasogastric tube.

Gastrostomy

Gastrostomy (endoscopic, radiological or surgical) should be reserved for mid-to long-term feeding.It is more comfortable than nasogastric feeding and has a lower risk of tube misplacement orblockage. Major indications include neurological disorders and head and neck cancer.Contraindications include sepsis, ascites and clotting disorders.

Jejunostomy

Tubes may be placed surgically or endoscopically. The most common indication is followingmajor upper gastrointestinal surgery. The jejunostomy is sited at the time of surgery and can beused for feeding within 12 hours of surgery.

Administration

Most surgical patients can tolerate a standard whole protein feed (1 kcal/ml). A peptide orelemental formula can be considered in patients with significant malabsorption. Patients aregenerally started with 30-50 ml/hour, increasing within 24-48 hours until prescribed targets arereached. If supplementation of an inadequate oral intake is required, then overnight feeding for8-12 hours may be sufficient and allows the patient to be mobile during the day. A pump shouldbe used to control the rate of feed delivery, avoiding the abdominal cramps and bloating associatedwith bolus feeding.

CS Enteral nutrition should be provided by the simplest technique possible. The feedingshould be given in such a way as to interfere minimally with the normal stimuli toeating.

7.5.2 PARENTERAL NUTRITION

Peripheral intravenous feeding (eg via a cannula) should only be used in the short term. Centralvenous feeding, via either a peripherally inserted catheter (PIC line) or a catheter in a centralvein, is the preferred route. A dedicated central venous feeding line minimises infectivecomplications. However in suitable circumstances a triple lumen central line inserted underaseptic conditions and with a dedicated port for total parenteral nutrition can be used. Followinginsertion of a dedicated central or jugular line, a chest X-ray must be taken to exclude apneumothorax and confirm the position of the catheter tip at or near the junction of the superiorvena cava with the right atrium.

Mixtures of nutrients are usually combined in a single bag. Many pharmacies now use three orfour standard regimens. The solutions contain fixed amounts of energy and nitrogen, and typicallyprovide 1,800-2,400 kcals (50% glucose, 50% lipid) and 10-14 g nitrogen. The amount ofelectrolytes, vitamins and trace elements can be varied. In general, standard regimens are simpler,safer and cheaper than those prepared individually.

CS Parenteral nutrition should be provided through a dedicated intravenous catheter.

7.5.3 MONITORING NUTRITIONAL SUPPORT

Nutritional support should be monitored to detect feeding complications and assess the efficacyof the nutritional regimen. The measurements and frequency of monitoring depend on theindividual patient, the route and the stage of feeding. Daily monitoring should be carried out inthe unstable patient or a patient who has recently started nutritional support (see Table 16).

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Table 16: Monitoring nutritional support requirements

Status Markers

Biochemistry Electrolytes, urea, blood glucose, urinalysis, liverfunction tests (twice weekly)

Fluid balance Fluid charts, weightNutritional 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 nutritionalprescription modified as necessary.

7.5.4 NUTRITION TEAMS

A coordinated multidisciplinary team approach to nutritional support can reduce the incidenceof feeding complications and improve the overall quality of care.

CS Quality of nutritional support is enhanced by the use of dedicated nutrition teams.



44

8 Information for discussion with patientsand carers

8.1 EXAMPLE INFORMATION SHEET FOR DISCUSSION WITH PATIENTS

WHO WILL BE LOOKING AFTER YOU?

During your stay in hospital you will be cared for by a team of healthcare professionals,including, doctors, nurses, physiotherapists, pharmacists and occupational therapists.Decisions on your care will be made on a team basis with input from all membersunder the supervision of the consultants who are responsible for your care.

The main aim of the team caring for you is to ensure that your recovery from surgeryis uneventful and completed in the shortest time possible.

Before your operation you will be carefully assessed and this may reveal otherconditions requiring treatment. If so you may be started on new treatments whichmay have to be continued after the operation.

WHAT HAPPENS AFTER YOUR OPERATION?

Immediately after the operation your recovery from the anaesthetic and surgery willbe assessed by measuring your blood pressure, pulse rate, breathing rate, temperatureand the amount of oxygen in your blood. If you have had major surgery or haveother conditions such as heart disease you may require additional tests.

When your condition is stable you will be transferred from the recovery area to award, high dependency unit or intensive care unit depending on the type of careyou require. If you are taken to an intensive care unit or high dependency unit atfirst, then as your condition improves and you require less intensive observation, youmay then be cared for in a normal ward.

In the early phase of your recovery from your operation you may need to be verycarefully monitored, especially if you have undergone major surgery. You may findthat you are assessed quite frequently, and although you may find this disruptive, itis necessary to monitor your progress. The observations will be no more frequentthan necessary to ensure your well being. The monitoring is vital to detect any changesso that remedial actions may be taken at an early stage.

You may need oxygen treatment, usually from a mask or a tube in your nose, afteryour operation. If you have chest or heart problems, this may be needed for severaldays. In some cases, a tube (catheter) in your bladder will be used to measure howmuch urine is being produced, which helps show how well the kidneys are working.

Your care can also involve treatment to prevent blood clots (deep vein thrombosis),infections, and nausea.

COPING WITH PAIN

Many patients are concerned about having pain following surgery and your teamof carers will have a plan of how this will be controlled. It is important that you tellthem if you have pain as they wish to make your recovery as pain free as possible.

MOVING AND EATING AFTER YOUR OPERATION

Following your operation you will be encouraged to become as mobile as possibleas this helps to prevent complications such as blood clots or chest infection andspeeds recovery. You may receive instruction from the physiotherapist to help youwith your breathing. You will also be encouraged to eat and drink as soon as it isfeasible as maintaining your level of nutrition is an important aspect of recovery.

45

9 Development of the guideline

9.1 INTRODUCTION

This guideline was supported by a grant from the Chief Scientist�s Office which aimed to assessthe feasibility of applying formal consensus techniques to SIGN guideline development. Althoughintended to be fully developed by consensus techniques, the guideline is in fact a hybrid ofconsensus and evidence based methodology. This situation arose when it became clear thatseveral of the clinical issues which were chosen for inclusion in this guideline were supported bya robust evidence base and these were fed through the standard SIGN development process asdescribed in section 9.3. Following the systematic review of evidence, formal consensus wasthen applied to statements developed by specialist subgroups of the development group as describedin section 9.4.

Further details about SIGN�s standard evidence based methodology are contained in SIGN 50: Aguideline developer�s handbook available at www.sign.ac.uk

9.2 THE DEVELOPMENT GROUP

Dr Harry McFarlane (Co-chair) Consultant Anaesthetist, Aberdeen Royal InfirmaryMr Robert C Smith (Co-chair) Consultant in General Surgery,

Falkirk and District Royal InfirmaryMs Sarah Armstrong Associate Director of Nursing,

Forth Valley NHS Acute Hospital, FalkirkMr Ian Currie Clinical Lecturer in Surgery, Royal Infirmary of EdinburghDr Gordon Drummond Consultant Anaesthetist, Royal Infirmary of EdinburghProfessor Kenneth Fearon Professor of Surgical Oncology,

Royal Infirmary of EdinburghMiss Mary Glasgow Clinical Nurse Educator, Aberdeen Royal InfirmaryDr Graham Hilditch Specialist Registrar in Anaesthesia,

Glasgow Western InfirmaryMr Roland Ingram Consultant Orthopaedic Surgeon, Glasgow Royal InfirmaryDr Simon Mackenzie Consultant Anaesthetist, Royal Infirmary of EdinburghMs Morag Naysmith Principal Pharmacist, Western General Hospital, EdinburghDr David O�Neill Consultant Physician, Crosshouse Hospital, KilmarnockMr Christopher Rodger Research Fellow, Department of Coloproctology,

Glasgow Royal InfirmaryProfessor D Gwyn Seymour Professor of Medicine (Care of the Elderly),

University of AberdeenMiss Gail Thomson Senior 1 Physiotherapist, Royal Infirmary of Edinburgh

SIGN FACILITATORS

Miss Gemma Healy Assistant Information Officer, SIGNDr Moray Nairn Programme Manager, SIGNDr Safia Qureshi Programme Director, SIGN

ACKNOWLEDGEMENTS

Dr Joris Berwaerts Medicines Control Agency, LondonMr Ross Carter Consultant General Surgeon, Glasgow Royal InfirmaryMrs Jane McCready Senior Staff Nurse, Victoria Infirmary, Glasgow

9.3 SYSTEMATIC LITERATURE REVIEW

The evidence base for this guideline was synthesised in accordance with SIGN methodology. Asystematic review of the literature was conducted using an explicit search strategy devised by aSIGN Information Officer in collaboration with members of the development group. Internetsearches were conducted on the websites of the US National Guidelines Clearinghouse, the

9 DEVELOPMENT OF THE GUIDELINE


46

Canadian Practice Guidelines Infobase, the Australian National Health and Medical ResearchCouncil, the New Zealand Guidelines programme, and the UK Health Technology Assessmentprogramme. Searches were also conducted on the search engines Citeline, Medical World Search,Echidna, Medisearch and Google, and all suitable links followed up. Database searches wereconducted from 1993-2001 on the Cochrane Library, Medline, Embase and CINAHL. The Medlineversion of the main search strategies is available on the SIGN website, in the section coveringsupplementary guideline material. The main searches were supplemented by literature identifiedby individual members of the development group. All selected papers were appraised usingstandard methodological checklists before conclusions were considered as evidence.

9.4 CONSENSUS TECHNIQUES

Nominal group technique (NGT)132 was used to identify 125 items important to the managementof postoperative patients. Two further rounds of NGT reduced this list to 14 items which relatedto clinical assessment and monitoring, or cardiovascular; respiratory; fluid, electrolyte and renalor sepsis management. The items were used to develop a set of �key questions�, and used todevelop the search strategy which forms the basis of the evidence based arm of the methodology(see section 9.3).

The systematic review allowed the group to identify evidence gaps, that is, key questions thatcould not be answered using published evidence. For each of these questions a consensusstatement was prepared. The group reviewed the consensus statements and summaries of appraisedevidence and rated privately all consensus statements using a 9-point scale where:3

9 = extremely appropriate

5 = uncertain

1= extremely inappropriate

The group also listed all changes they would make to the consensus statement, based on boththeir interpretations of the literature review and their clinical experience.

An �appropriateness score� was calculated, which reflected the panel�s collective opinion on thesuitability of each consensus statement.

The appropriateness score for an individual statement is the median of the panel�s ratings. Thepanel is considered to be:

n in agreement over the appropriateness of a statement when no more than 3 of theindividual members� ratings are outside a 3-point region that includes the median rating

n disagreement occurs when 1 or more ratings is in the 1-3 region, and 1 or more inthe 7-9 region

n clearly appropriate statements will have a median of 7-9 without disagreementn clearly inappropriate statements will have a median of 1-3 without disagreementn equivocal statements - with a median of 4-6, or where there is disagreement on a

proper rating

Only �clearly appropriate� consensus statements, with a median score of 7-9, are used as consensusstatements in this guideline.

9.5 CONSULTATION AND PEER REVIEW

9.5.1 NATIONAL OPEN MEETING

A national open meeting is the main consultative phase of SIGN guideline development, atwhich the guideline development group presents their draft recommendations for the first time.A national open meeting for this report was held on 29th October 2002. The draft was alsoavailable on the SIGN website for a limited period to allow those unable to attend the meetingto contribute to the development of the guideline.

47

9.5.2 SPECIALIST REVIEWERS

The guideline was reviewed in draft form by a panel of independent expert referees. SIGN is verygrateful to the following experts:

Ms Dorothy Barber Nutrition Nurse Specialist, Aberdeen Royal InfirmaryMiss Shirley Brennan Final year medical student, University of AberdeenDr Martin Cameron Specialist Registrar in Obstetrics and Gynaecology,

Aberdeen Maternity HospitalProfessor Ian Campbell Consultant Physician, Victoria Hospital, KirkcaldyDr Matthew Checketts Consultant Anaesthetist, Ninewells Hospital, DundeeDr Malcolm Daniel Consultant in Anaesthesia and Intensive Care,

Glasgow Royal InfirmaryDr Pamela Doherty Specialist Registrar in Anaesthesia,

Falkirk and District Royal InfirmaryDr Dugald Glen Consultant Radiologist, Stirling Royal InfirmaryDr Paul Glen SHOIII / Research fellow,

Lister Department of Surgery, GlasgowMiss Susie Goodwin Final Year Medical Student, University of AberdeenMrs Kate Gordon Smith Practice Development Nurse,

Grampian University HospitalsMr John Graham Charge Nurse, Aberdeen Royal InfirmaryMrs Fiona Grant Practice Development Nurse, Stirling Royal InfirmaryDr Heather Hosie Consultant in Anaesthesia,

Southern General Hospital, GlasgowMrs Sandra Jamard Clinical Ward Manager, High Dependency Unit,

Stirling Royal InfirmaryMr Richard James Final Year Medical Student, University of AberdeenMr Ronald Kennan Consultant in General Surgery, Aberdeen Royal InfirmaryMs Caroline MacDonald Lecturer, School of Nursing and Midwifery,

Robert Gordon University, AberdeenMrs Heather Macgowan Surgical Co-ordinator, Surgical Unit,

Falkirk and District Royal InfirmaryDr Fergus Miller Consultant Anaesthetist, Ninewells Hospital, DundeeMr Aslam Mohammed Specialist Registrar in Orthopaedics,

Glasgow Royal InfirmaryProfessor Michael Mythen Portex Professor of Anaesthesia and Critical Care,

Institute of Child Health, LondonDr Alastair Nimmo Consultant in Anaesthesia, Royal Infirmary of EdinburghMr James Parris Final Year Medical Student, University of AberdeenDr John Reid Consultant Radiologist,

Borders General Hospital, RoxburghshireMr Chris Shearer Surgical Specialist Registrar, Victoria Infirmary, GlasgowMr Walter Simpson Lay Representative, GlendevonDr David Swann Consultant in Anaesthesia, Royal Infirmary of EdinburghMiss Gillian Thain Clinical Specialist in Respiratory Physiotherapy,

Aberdeen Royal InfirmaryProfessor Nigel Webster Professor and Honorary Consultant of Anaesthesia and

Intensive Care, Aberdeen Royal InfirmaryMiss Senga Welsh Charge Nurse, Intensive Care Area,

Falkirk and District Royal InfirmaryProfessor Tony Wildsmith Professor of Anaesthesia, University Department of

Anaesthesia, Ninewells Hospital andMedical School, Dundee

Dr John Wilson Clinical Lecturer, Clinical and Surgical Sciences,University of Edinburgh

9 DEVELOPMENT OF THE GUIDELINE


48

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

49

Annex 1Assessing 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 painfulstimulus, eg pinching the skin.

U - Unresponsive The patient is unresponsive to both verbal and painful stimuli.

THE ABBREVIATED MENTAL TESTCorrect answers to each question score one point

Age

Time to nearest hourAn address, eg 42 West Street, to be repeated at the end of the test

Month

Year

Name of placeDate of birth

Year first world war started

Name of present monarch

Count backwards from 20 to 1TOTAL SCORE

Scores: 8-10 normal; 7 probably abnormal; <6 abnormal

THE GLASGOW COMA SCALE AND SCORE

Feature Scale ScoreResponses Notation

Eye opening Spontaneous 4To speech 3To pain 2None 1

Verbal response Orientated 5Confused conversation 4Words (inappropriate) 3Sounds (incomprehensible) 2None 1

Best motor response Obey commands 6Localise pain 5Flexion - Normal 4

- Abnormal 3Extend 2None 1

TOTAL COMA �SCORE� 3/15 - 15/15

ANNEXES


50

Annex 2American Society of Anesthesiologists Physical StatusClassification 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

51

Annex 3Example of a Postoperative Monitoring ChartThis is an example chart only. These parameters will not be suitable for all patients and should be adjustedin line with local protocols.

DATEPostoperative Monitoring Chart

Name Hosp. Number DOB Weight Consultant

TIME40

39.539

38.538

37.5TEMPERATURE 37

36.536

35.535

210200

BLOOD 190PRESSURE 180

170ADMISSION 160

BP 150140130

Plus 30% 120110100

Less 30% 9080706050

CVP170160150140130120110

HEART RATE 1009080706050403020

SaO2FiO2 (l/min or %)

40353025

RESP. RATE 201510

50

URINE >0.5mls/kg

Volume <0.5mls/kg

NEUROLOGICAL AWAKE

STATE VERBAL

PAIN

UNRESP

Pain score

BM

DR CALLED

Example

ANNEXES


52

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73 Moller AM, Pedersen T, Svendsen PE, Engquist A. Perioperative risk factors inelective pneuomonectomy: the impact of excess fluid balance. Eur J Anaesthesiol2002;19(1):57-62.

74 Brandstrup B, Tonnesen H, Beier-Holgersen R, Hjortso E, Ording H, Lindorff-Larsen K, et al. Danish Study Group on Perioperative Fluid Therapy. Effects ofintravenous fluid restriction on postoperative complications: comparison oftwo perioperative fluid regimens: a randomized assessor-blinded multicentertrial. Ann Surg. 2003;238(5):641-8.

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76 Greif R, Akca O, Horn EP, Kurz A, Sessler DI. Supplemental perioperativeoxygen to reduce the incidence of surgical-wound infection. OutcomesResearch Group. N Engl J Med 2000;342(3):161-7.

77 Gift AG, Stanik J, Karpenick J, Whitmore K, Bolgiano CS. Oxygen saturation inpostoperative patients at low risk for hypoxaemia: is oxygen therapy needed?Anaesth Analg 1995;80(2):368-72.

78 Moller JT, Wittrup M, Johansen SH. Hypoxemia in the post-anaesthesia careunit: an observer study. Anesthesiology 1990;73(5):890-5.

79 Moller JT, Pedersen T, Rasmussen LS, Jense PF, Pedersen BD, Ravlo O, et al.Randomized evaluation of pulse oximetry in 20,802 patients: I. Design,demography, pulse oximetry failure rate, and overall complication rate.Anesthesiology 1993;78(3):436-44.

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83 Graham RJ, Meziane MA, Rice TW, Agasthian T, Christie N, Gaebelein K, etal. Postoperative portable chest radiographs: optimum use in thoracic surgery.J Thorac Cardiovasc Surg 1998;115(1):45-52.

84 Campbell EJ, Minty KB. Controlled oxygen therapy at 60% concentration.Why and how. Lancet 1976;1(7971):1199-203.

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88 Roukema JA, Carol EJ, Prins JG. The prevention of pulmonary complicationsafter upper abdominal surgery in patients with noncompromised pulmonarystatus. Arch Surg 1988;123(1):30-34.

89 Fagevik Olsen M, Hahn I, Nordgren S, Lonroth H, Lundholm K. Randomizedcontrolled trial of prophylactic chest physiotherapy in major abdominal surgery.Br J Surg 1997;84(11):1535-8.

90 Davies BL, MacLeod JP, Ogilvie HM. The efficacy of incentive spirometers inpost-operative protocols for low-risk patients. Can J Nurs Res.1990;22(4):19-36.

91 Hough, A. Physiotherapy in respiratory care : a problem-solving approach torespiratory and cardiac management. 2nd ed. London:Chapman & Hall;1996.

92 Scottish Intercollegiate Guidelines Network (SIGN). Perioperative bloodtransfusion for elective surgery. Edinburgh: SIGN; 2001. (SIGN publicationno. 54). [cited 13 Jan 2004]. Available from url: http://www.sign.ac.uk/guidelines/fulltext/54/index.html

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94 Infectious problems after elective surgery of the alimentary tract: the influenceof peri-operative factors. The Norwegian Gastro-Intestinal Group (NORGAS).Curr Med Res Opin 1988;11(3):179-95.

95 Rebollo MH, Bernal JM, Llorca J, Rabasa JM, Revuelta JM. Nosocomial infectionsin patients having cardiovascular operations: a multivariate analysis of riskfactors. J Thorac Cardiovasc Surg 1996;112(4):908-13.

96 Velasco E, Thuler LC, Martins CA, Dias LM, Conalves VM. Risk factors forinfectious complications after abdominal surgery for malignant disease. Am JInfect Control 1996;24(1):1-6.

97 Earnshaw JJ, Slack RC, Hopkinson BR, Makin GS. Risk factors in vascular surgicalsepsis. Ann R Coll Surg Engl 1988;70(3):139-43.

98 Kingston RD, Walsh S, Robinson C, Jeacock J, Keeling F. Significant risk factorsin elective colorectal surgery. Ann R Coll Surg Engl 1995;77(5):369-71.

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101 Larson EL. APIC guideline for handwashing and hand antisepsis in health caresettings. Am J Infect Control 1995;23(4):251-69.

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104 Muckart DJ, Bhagwanjee S. American College of Chest Physicians/Society ofCritical Care Medicine Consensus Conference definitions of the systemicinflammatory response syndrome and allied disorders in relation to criticallyinjured patients. Crit Care Med 1997;25(11):1789-95.

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Diagnosis of respiratory infection

Any tw

o of the following on tw

o or more days:

§Pyrexia >

380C

§Positive sputum

culture§

Positive clinical findings§

Abnorm

al chest X-ray – Atelectasis/infiltrates

CA

RDIO

VA

SCU

LAR M

AN

AG

EMEN

TA

SSESSMEN

T OF H

YPOTEN

SION

Observe if:

Seek further advice if:

Aw

ake or easily rousable D

rowsy or unrousable

Com

fortable D

istressed

Norm

al preoperative BP H

ypertensive preoperatively

Warm

Cold

Well perfused (capillary

refi ll <2 seconds)

Capillary refi ll >

2 seconds

Heart rate 50-100 bpm

Heart rate >

100 or <50 bpm

Passing urine (>0.5 m

l/kg/hr) O

liguric (<0.5 m

l/kg/hr)

No obvious bleeding

Signs of bleeding (drains, w

ounds, haematom

a)

Patients in whom

there is a suspicion of postoperative pulmonary

complications should have an arterial blood gas analysis, a sputum

culture and EC

G.

Chest X-ray should be perform

ed on suspicion of major collapse,

effusions, pneumothorax or haem

othorax.

Other investigations should be used only if there are specific

indications.

Oxygen should be given to patients w

ith hypoxaemia using a device

that is best tolerated to achieve the necessary SpO2 .

In normally hydrated patients hum

idification is unnecessary.

Failure to maintain an SpO

2 >90%

or PaO2 >

8.0 kPa is an indication to consider assisted ventilation.

Patients developing respiratory failure should be referred to a critical care specialist to be assessed for possible assisted ventilation. The referral should be tim

ely as hypoxia or hypercapnia m

ay lead rapidly to cardiorespiratory arrest.

RESPIRATO

RY MA

NA

GEM

ENT

FLUID

, ELECTRO

LYTE & REN

AL M

AN

AG

EMEN

T

CA

RDIO

VA

SCU

LAR M

AN

AG

EMEN

T (Contd.)

Postoperative blood pressure should always be review

ed with

reference to the preoperative and intraoperative assessments

Further assessment is required for patients w

ith:§

heart rate < 50 and > 100 bpm§

blood pressure <100 mm

Hg systolic.

Patients on regular antihypertensive medication should norm

ally be m

aintained on this medication perioperatively. If the patient becom

es hypotensive then it m

ay be appropriate to discontinue some drugs.

Beta blockers and IV nitrates m

ay be used safely and effectively in postoperative hypertension.

Beta blockers should be continued perioperatively in patients previously taking these drugs for coronary disease, congestive heart failure, hypertension or arrhythm

ias.

Be aware of clinical factors w

hich increase risk to the patient and how

these interact with the risks im

posed by the surgical procedure.

Seek expert help early in the managem

ent of serious or potentially serious arrhythm

ias. Reconsider the level of care.

Search for the underlying causes of any supraventricular arrhythm

ias, eg hypoxia, hypovolaemia, electrolyte abnorm

ality, sepsis or drug toxicity.

Where perioperative M

I is diagnosed or suspected early specialist m

edical advice should be sought.

Maintain norm

othermia in the postoperative period.

Accurate assessm

ent of fluid and electrolyte status can be difficult and the treatm

ent of a particular patient must be individualised and

reviewed frequently in the light of the response to treatm

ent.

Volum

e depletion should be avoided as this can lead to poor perfusion and problem

s such as anastomotic breakdow

n, cerebral dam

age, renal failure and multiple organ failure.

Diuretics should not be used to treat oliguria and should be

reserved for fluid overload.

Hyponatraem

ia is more com

monly due to excess w

ater than sodium

deficiency – assess volume status.

Hypernatraem

ia most com

monly indicates a total body deficiency of

water and is an indication for prom

pt assessment and intervention,

especially when levels exceed 155 m

mol/L.

Hypokalaem

ia can delay postoperative recovery - magnesium

supplem

entation may also be required.

Hyperkalaem

ia is a medical em

ergency – obtain senior help.

Metabolic acidosis is usually due to poor tissue perfusion but can

also be caused by excessive administration of saline.

Systemic inflam

matory response syndrom

e (SIRS) is defined as the presence of 2 or m

ore of the following:

§tem

perature >38

0C or <

360C

§heart rate >

90 bpm§

respiratory rate >20 breaths/m

in or PaCO

2 <4.3kPa

§w

hite cell count >12,000 cells/m

m3 , <

4,000 cells/mm

3 or >

10% im

mature form

s.W

hen SIRS is present an infective cause should be sought first.

SEPSIS

NU

TRITION

Given the lack of a strong evidence base of effective practice for

postoperative managem

ent this guideline has been developed using a com

bination of evidenced based and consensus techniques. Initial system

atic searches identified any relevant evidence. The critically appraised evidence, together w

ith the clinical experience of the guideline developm

ent group, informed the form

al consensus methods

that were used to develop recom

mendations. These are presented in

the form of “consensus statem

ents”.

Hand w

ashing with soap and w

ater or with alcoholic cleansing

agents should be performed before and after patient contact.

Early identification and appropriate treatment of sepsis im

proves outcom

e.

Urine and blood cultures should be obtained w

henever there is reason to suspect system

ic sepsis.

If the cause of sepsis is unknown, treat w

ith broad spectrum

antibiotics, guided by local protocols.

Results from m

icrobiological specimens should be review

ed regularly and antibiotics changed as necessary.

A course of antim

icrobial treatment should generally be lim

ited to 5-7 days. Fungi and atypical organism

s can contribute to sepsis syndrom

e, so take cultures and prescribe appropriately.

Oral intake should be com

menced as soon as possible after surgery.

Nutritional replacem

ent should be discussed with a dietitian and

tailored to the patient's requirements.

Enteral nutrition is the preferred method of postoperative

nutritional support and should be used if possible.

Nutritional and m

etabolic status should be assessed regularly and the nutritional prescription m

odified as necessary.

POSTO

PERATIV

E MA

NA

GEM

ENT IN

AD

ULTS: A

PRAC

TICA

L GU

IDE TO

POSTO

PERATIV

E CA

RE FOR C

LINIC

AL STA

FF

77

Optim

al postoperative care requires:

§clinical assessm

ent and monitoring

§respiratory m

anagement

§cardiovascular m

anagement

§fluid, electrolyte and renal m

anagement

§control of sepsis

§nutrition

Only accept responsibility appropriate to your training and

experience. If in doubt ASK FO

R HELP

DISC

HA

RGE FRO

M TH

EATRE

AN

D PO

STAN

AESTH

ETIC REC

OV

ERY

Anaesthetic and surgical staff should record the follow

ing item

s in the patient’s case notes:

§any anaesthetic, surgical or intraoperative com

plications §

any specific postoperative instruction concerning possible problem

s§

any specific treatment or prophylaxis required

(eg fluids, nutrition, antibiotics, analgesia, anti-emetics,

thromboprophylaxis).

THE FIRST PO

STOPERA

TIVE A

SSESSMEN

T

A postoperative assessm

ent should be carried out when the

patient returns from theatre.

Patients at risk of deterioration require frequent assessment.

Patients with the follow

ing risk factors for deterioration should be reassessed w

ithin two hours of the first

postoperative assessment:

§A

SA grade ≥ 3

§em

ergency or high risk surgery§

operation out of hours

The doctor completing the initial postoperative assessm

ent should consider the m

onitoring regimen and appropriate level

of care required for the next 24 hours in collaboration with the

nursing team. PRIN

CIPLES O

F POSTO

PERATIV

E M

AN

AG

EMEN

T

CH

ECKLIST FO

R FIRST PO

STOPERA

TIVE A

SSESSMEN

T

Past medical history

Medications

Allergies

Intraoperative complications

Postoperative instructionsRecom

mended treatm

ent & prophylaxis

��

��

��

Oxygen saturation

Effort of breathing/use of accessory muscles

Respiratory rateTrachea central or not?Sym

metry of respiration/expansion

Breath soundsPercussion note

��

��

Hands - w

arm or cool, pink or pale?

Capillary return <

2s or not?Pulse rate, volum

e and rhythmBlood pressureC

onjunctival pallorJugular venous pressureU

rine colour and rate of productionD

rainage from drains, w

ounds & N

G tubes

��

��

��

Patient conscious and normally responsive ?

(AV

PU; A

lert, Verbal, Painful, U

nresponsive)

If abnormal determ

ine: §

if confusion is present (AM

T) §

GC

S, oxygen saturation and

blood glucose

��

��

Any significant sym

ptoms eg chest pain,

breathlessnessPain and adequacy of pain controlFollow

ing specialist surgery it may be

necessary to assess additional factors.

��

MO

NITO

RING

SAM

PLE MO

NITO

RING

REGIM

EN FO

R FIRST FEW

POSTO

PERATIV

E HO

URS

��Patients requiring the frequent m

onitoring of multiple variables

should be considered for care at level 2 or above.

Trends in the physiological data, rather than absolute numbers,

should be reported to assist in the detection of deteriorating patients before a severe physiological com

promise occurs.

Postoperative monitoring should be continued on a daily basis.

The monitoring regim

en should be reviewed daily so as best to

provide data for clinical decision making.

Any change in a m

onitoring regimen should prom

pt reassessment of

the level of care.

Documents

Postoperative management in adults