Professional Documents
Culture Documents
77
Introduction
Cardiovascular management
11
Respiratory management
20
28
Management of sepsis
34
Postoperative nutrition
39
44
45
Abbreviations
48
Annexes
49
References
52
August 2004
COPIES OF ALL SIGN GUIDELINES ARE AVAILABLE BY CALLING 0131 247 3664 OR ONLINE AT WWW.SIGN.AC.UK
LEVELS OF EVIDENCE
1++
1+
1-
++
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-
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 reflect the clinical importance of the recommendation.
A
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+
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++
Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
SIGN consents to the photocopying of this guideline for the purpose of implementation in NHSScotland
Scottish Intercollegiate Guidelines Network
Royal College of Physicians
9 Queen Street, Edinburgh EH2 1JQ
www.sign.ac.uk
SIGN IS FUNDED BY NHS QUALITY IMPROVEMENT SCOTLAND
1 INTRODUCTION
Introduction
1.1
1.2
1.3
This guideline does not focus on postoperative pain management (an evidence based guideline
already exists in this area),7 indications for blood transfusion, the prophylaxis of surgical site
infection or venous thrombosis, nor the management of obstetric patients or pregnant women or
those patients with head injury or hip fracture (these are covered by separate SIGN guidelines,
see www.sign.ac.uk). The guideline excludes the management of children (<18 years of age).
The guideline is designed to be used principally by doctors, nurses, paramedical staff and students.
It can also serve as a teaching resource.
1.4
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 skills
and judgement, their concern for their patients and their continued dedication to emergency
care.
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 care
remains. Each member of the team has a role to play in the normal process of recovery from
surgery and the early identification and treatment of any deterioration in the condition of the
patient.
This guideline complements the team approach by concentrating on the fundamentals of good
patient care and encouraging a simple, didactic and consistent approach.
The guideline is not intended to supplant specialist medical care but to help inexperienced
clinicians differentiate between those patients who are recovering normally and those in whom
there is cause for concern. The distinction between the two is often difficult and the guideline
emphasises early referral for senior or specialist advice where there is any doubt.
1.4.2
1.5
STATEMENT OF INTENT
This guideline is not intended to be construed or to serve as a standard of care. Standards of care
are determined on the basis of all clinical data available for an individual case and are subject to
change as scientific knowledge and technology advance and patterns of care evolve. Adherence
to guideline recommendations will not ensure a successful outcome in every case, nor should
they be construed as including all proper methods of care or excluding other acceptable methods
of care aimed at the same results. The ultimate judgement regarding a particular clinical procedure
or treatment plan must be made by the appropriate healthcare professional(s) in light of the
clinical data presented by the patient and the diagnostic and treatment options available. It is
advised however that significant departures from the national guideline or any local guidelines
derived from it should be fully documented in the patients case notes at the time the relevant
decision is taken.
2.1
INTRODUCTION
Optimal management of patients throughout the postoperative phase requires appropriate clinical
assessment and monitoring. In contrast with assessment of emergencies, which focuses on the
initial diagnosis and stabilisation after the patient has developed a complaint, postoperative care
requires pre-emptive management. Regular assessment, selective monitoring and timely
documentation are key to postoperative care.
This section of the guideline describes a model of care that establishes a minimum standard of
practice in postoperative patient care.
2.1.1
n
n
n
n
the patient is fully conscious, responding to voice or light touch, able to maintain a clear
airway and has a normal cough reflex
respiration and oxygen saturation are satisfactory (10-20 breaths per minute and SpO2>92%)
the cardiovascular system is stable with no unexplained cardiac irregularity or persistent
bleeding. The patients pulse and blood pressure should approximate to normal preoperative
values or should be at a level commensurate with the planned postoperative care
pain and emesis should be controlled and suitable analgesic and anti-emetic regimens should
be prescribed
temperature should be within acceptable limits (>36C)
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 responsible
for 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 patients
case notes:
n
any anaesthetic, surgical or intraoperative complications
n
any specific postoperative instruction concerning possible problems
n
any specific treatment or prophylaxis required (eg fluids, nutrition, antibiotics,
analgesia, anti-emetics, thromboprophylaxis).
2.1.2
LEVELS OF CARE
Postoperative care is provided in several different locations depending on the level of monitoring
or organ support that is required. At any time it may become appropriate to move a patient to a
setting in which a different level of care can be provided. The review of adult critical care
services10 recommends that the existing classification of ward, HDU and ICU, be replaced by a
classification of care that focuses on the level of care required by the patient, regardless of
location. The following definitions of care have been used throughout this guideline:
Level 0 - formerly ward
Appropriate for patients
n
n
requiring more detailed observation or intervention including support for a single failing
organ system
stepping down from a higher level of care
2.2
ASSESSMENT
2.2.1
A postoperative assessment should be carried out when the patient returns from theatre.
This assessment may be carried out by the doctor responsible in the first instance for patient care,
usually the House Officer. When the doctor is unavailable or the case is minor and straightforward
a trained nurse could complete this assessment. The doctor should attend later to assess the
patient in person. Any departure from accepted physiological parameters (see sections 3-6) requires
the attendance of the doctor as a matter of urgency.
CS
Doctors immediately responsible for patients should ensure that a contact/pager number
is available to the nursing staff on the ward.
2.2.2
If the nurse responsible for the care of the patient becomes unavailable for discussions
with other members of the care team, they should pass on all pertinent information to
another member of nursing staff who then assumes responsibility for that patient.
A structured care plan may aid the exchange of information between healthcare professionals.
Physical examination of the patient is different from the routine examination of patients
preoperatively. In the routine situation, the doctor has time to carry out a structured examination
which includes the variables described below. In the emergency setting, the standard airways,
breathing and circulation or ABC approach would be followed. The focus, in postoperative
assessment, is on circulatory volume status, respiratory function and level of consciousness.
Table 1 shows a checklist for the first postoperative assessment.
CS
The conscious level is often difficult to assess. The AVPU (Fully Alert, responsive to Verbal or
Pain, or Unresponsive) examination is a simple screening test and has been widely used in
emergency patient management. The abbreviated mental test (AMT), using 10 key questions, is
useful in acutely confused postoperative patients.11,12 The Glasgow Coma Scale (GCS) is rather
insensitive for confused patients, however, GCS 12 or less constitutes a medical emergency and
should be discussed with senior doctors prior to management at level 2 or 3 (see Annex 1 for
details of these scales).
Common causes of postoperative confusion include:
n
n
n
n
n
n
n
n
n
n
n
sepsis (eg infection of chest, urinary tract, wound, intravenous cannula site, or intra-abdominal
collection)
sedative drugs
hypoxaemia
hypercarbia
hypoglycaemia
acute neurological event
myocardial infarction
urinary retention
alcohol/drug withdrawal
hepatic encephalopathy
biochemical abnormality (eg urea, sodium, potassium, calcium, thyroid function,
liver function).
CS
Having assessed the patient, the doctor should legibly record the findings in the notes at the
same time. Any specific problems should be recorded and a management plan developed. The
interval after which the patient should be reassessed should also be chosen at this stage.
oxygen saturation
effort of breathing/use of accessory muscles
respiratory rate
trachea - central or not?
symmetry of respiration/expansion
breath sounds
percussion note.
Appropriate lighting should be used in order to visualise the jugular venous pressure. The height
of the JVP should specify the marker used; clavicle, sternal angle etc. 13
Proformas, which provide tick boxes to speed the recording of information after the postoperative
assessment, may be useful.
2.2.3
ADDITIONAL ASSESSMENTS
The initial postoperative assessment will determine how frequently reassessment of the patient is
required. 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) physical
status grade 3 (see Annex 2) has been shown to be an independent risk factor for postoperative
emergencies requiring intensive care team attendance. Thirty per cent of these emergencies occur
within the first six postoperative hours.14
2.3
CS
CS
Patients with the following risk factors for deterioration should be reassessed within two
hours of the first postoperative assessment:
n
ASA grade 3
n
emergency or high risk surgery
n
operation out of hours.
n
n
n
n
physiotherapy
nutrition team consultation (see section 7.5.4)
oral hygiene.
CS
In patients with persistent vomiting, exclude gastrointestinal obstruction before providing drug
treatment for vomiting.
2.4
MONITORING
2.4.1
ROUTINE MONITORING
Monitoring allows the collection of routine data so that trends may be established, assisting in
the detection of deterioration or improvement. This is vital for an objective assessment of a
patients response to treatment.
In general, the anaesthetist will recommend a monitoring regimen for the first few hours after
surgery, which would normally include:
n
n
n
n
n
n
n
temperature
pulse rate
blood pressure
respiratory rate
pain assessment (resting and moving)
urine output (postoperative voiding)
peripheral oxygen saturation.
Experienced nurses will usually institute an appropriate regimen after this initial period, depending
on 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 less
frequent 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 patient
and not all parameters will need to be measured at all time points. Excess data collection in well
patients 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 monitoring
regimen and appropriate level of care required for the next 24 hours in collaboration
with the nursing team.
CS
ADDITIONAL MONITORING
Patients with, for example, pre-existing cardiorespiratory disease or who have had longer, more
physiologically 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 level
of care.
Table 2: Suggested additional monitoring
Additional monitoring requirements dependent on clinical status
ECG
Hourly urine volumes
Arterial blood pressure
Central venous pressure
Arterial blood gases
Drainage from wounds
Haematology
Biochemistry
Continuous oxygen saturation and electrocardiography (ECG) may be carried out by automatic
equipment. Patients requiring advanced monitoring or frequent detailed assessments may be
more appropriately cared for in a level 2 setting.15
CS
CS
Patients requiring the frequent monitoring of multiple variables should be considered for
care at level 2 or above.
n
Any patient with circulatory disturbance should be catheterised and the urine output
measured hourly
n
Consider catheterisation in patients with no urine production after four hours.
Patients with complex needs often require enhanced levels of care. Invasive cardiovascular
monitoring, including the use of indwelling central venous or arterial cannulae, is usually restricted
to level 2 or level 3 care.
Patients who are initially admitted to the postoperative ward or to areas providing level 1 or 2
care may require a higher level of care thereafter. Patients who show cardiovascular instability or
respiratory difficulty should be considered very early in the postoperative course to be candidates
for level 2 or 3 care.
2.4.3
CS
2.5
Trends in the physiological data, rather than absolute numbers, should be reported to
assist in the detection of deteriorating patients before a severe physiological compromise
occurs.
n
n
2.6
10
The ultimate responsibility for patient care lies with the consultants providing surgical
and anaesthetic care
Junior doctors should assume only the responsibility appropriate to their training and
experience
Where a junior doctor feels that they may exceed their personal responsibilities or
capabilities, they have a duty of care to discuss the patient with a more senior doctor
in the same clinical team.
3 CARDIOVASCULAR MANAGEMENT
Cardiovascular management
3.1
INTRODUCTION
In general, maintaining a patients heart rate and blood pressure within normal limits will result
in a satisfactory outcome. However, there are no clinical studies to indicate what is normal with
respect to heart rate and blood pressure for individual patients in the postoperative period.
Surgery is associated with a stress response that persists postoperatively.16 Anaesthesia modifies
the stress response, which can be further modified by the use of techniques such as regional
anaesthesia or use of high dose opioids. During anaesthesia heart rate and blood pressure are
maintained within appropriate limits at the discretion of the anaesthetist. On emergence from
anaesthesia this damping down of the stress response is lost and heart rate and blood pressure
rise in the postoperative period.
3.2
HEART RATE
Most patients will tolerate a postoperative heart rate of between 50 and 100 beats per minute. A
heart 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 the
blood pressure is well maintained, the simplest strategy is to observe the patient closely over the
next few hours.
In some patients a slow heart rate can reduce blood pressure as a result of reduced cardiac output
(cardiac output = heart rate x stroke volume).
Correcting the slow heart rate with a vagolytic agent (eg intravenous glycopyrronium bromide
0.2-0.4 mg or atropine sulphate 0.3- 0.6 mg) should restore the blood pressure and allow time
for the cause of the low blood pressure and heart rate to be deduced. If the blood pressure does
not respond to the increase in heart rate then other possible causes should be considered, such as
blood loss (see Table 4).
3.2.2
TACHYCARDIA
Heart rates over 100 beats per minute may be well tolerated by fit patients but may indicate a
clinical problem. Sustained tachycardia is particularly dangerous for patients who have documented
ischaemic heart disease or risk factors for ischaemic heart disease as myocardial oxygen supply
cannot be increased (see section 3.4).
Tachycardia associated with high blood pressure may simply be the consequence of pain and
anxiety and appropriate analgesia may be all that is required. If elevated rates and pressure are
maintained despite good analgesia, senior advice should be sought.
In hypovolaemic patients tachycardia may precede development of hypotension. Hypotension
indicates severe hypovolaemia caused by fluid deficit and in the context of recovery from surgery,
acute blood loss should be excluded. Assessment of fluid balance is mandatory at this stage (see
section 5).
3.3
BLOOD PRESSURE
The Sixth Joint National Committee on Detection, Evaluation and Treatment of High Blood
Pressure gives a classification of blood pressure.17 Note that this is a general classification and is
not specific to patients undergoing surgery (see Table 3).
11
Optimal
Normal
High Normal
<120
120-129
130-139
<80
80-84
85-89
140-159
160-179
180-209
>210
90-99
100-109
110-119
>120
3.3.1
Postoperative blood pressure should always be reviewed with reference to the preoperative
and intraoperative assessments.
HYPOTENSION
Hypotension is defined as either a systolic blood pressure of less than 100 mm Hg or as a fall of
at least 25% from the patients normal pressure.
Hypotension is relatively common postoperatively and may be drug induced (eg residual effects
of anaesthesia, epidural or opioids) or may represent fluid deficit. Table 4 lists broad categories
for the assessment of hypotension.
Hypotension should not be allowed to persist unless the clinician is absolutely sure that no
important pathological process is taking place. If in doubt senior advice should be sought.
CS
12
3 CARDIOVASCULAR MANAGEMENT
3.3.2
Drowsy or unrousable
Comfortable
Distressed
Normal preoperative BP
Hypertensive preoperatively
Warm
Cold
No obvious bleeding
HYPERTENSION
Hypertension is common in the postoperative period as a result of a number of factors including
the stress response, pain, anxiety and failure to continue medication perioperatively.
Postoperative hypertension is associated with bleeding, cerebral events and myocardial ischaemia
especially if the heart rate is also elevated.
Treatment of Hypertension
Beta blockers and intravenous (IV) nitrates are effective for the control of postoperative
hypertension.23,24
3.4
CS
If patients are hypertensive, ensure that they are receiving adequate analgesia. If
hypertension persists seek specialist medical advice and review the level of care.
CS
Beta blockers and IV nitrates may be used safely and effectively in postoperative
hypertension.
2+
MYOCARDIAL ISCHAEMIA
Patients with ischaemic heart disease or risk factors for ischaemic heart disease represent a
special 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 myocardial
oxygen supply to match an increased myocardial oxygen demand. An estimated 30% of patients
undergoing 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
2+
13
It used to be considered that the peak incidence for perioperative myocardial infarction was the
third postoperative day. Recent studies using biochemical markers and serial ECGs suggest that
infarction occurs earlier, either on the day of surgery or during the first postoperative day. 35
2+
Most infarctions are non-Q wave in nature suggesting the cause is prolonged ischaemia rather
than rupture of an atheromatous plaque. However, one small study in patients who died following
perioperative 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 less
than 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 undergoing
major 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) in
patients with postoperative infarction or unstable angina.25,38 For patients who leave hospital
alive, event free survival decreases from 93% to 78% when compared with patients with no
episodes of myocardial ischaemia.38
All patients who suffer adverse cardiac events should be referred for assessment by cardiologists
and consideration of cardiac risk reducing strategies for the longer term.
3.4.2
14
2+
3 CARDIOVASCULAR MANAGEMENT
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 elderly
Aortic and other major vascular surgery
Peripheral vascular surgery
Anticipated prolonged surgical procedures associated with large fluid shifts and/or blood loss
INTERMEDIATE RISK PROCEDURES reported cardiac risk generally <5%
Carotid endarterectomy
Head and neck surgery
Intraperitoneal and intrathoracic surgery
Orthopaedic surgery
Prostate surgery
LOW RISK PROCEDURES reported cardiac risk generally<1%
Endoscopic procedures
Superficial procedures
Cataract surgery
Breast surgery
Patient and procedure-associated risk factors should be taken into account preoperatively when
planning any surgical procedure. Clinicians caring for patients postoperatively need to appreciate
the level of risk and any clinical factors which may influence that risk.
CS
3.5
Clinicians caring for patients postoperatively must be aware of clinical factors which
increase risk to the patient and how these interact with the risks imposed by the surgical
procedure.
3.6
3.6.1
SUPRAVENTRICULAR ARRHYTHMIAS
2++
Supraventricular arrhythmias (SVAs) have been reported to occur in 7.6% of patients undergoing
major non-cardiac surgery25 and in 10.2% of surgical ICU patients.26 They occur most commonly
in the elderly, those with previous cardiorespiratory disease and those undergoing thoracic, vascular
or 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 regarded
as a marker for increased morbidity.
15
3.6.2
VENTRICULAR ARRHYTHMIAS
Ventricular arrhythmias occur most commonly in patients with preoperative arrhythmias, smokers
and those with a history of heart failure. Non-sustained ventricular arrhythmias do not appear to
have prognostic significance and, when occurring without other signs or symptoms of myocardial
ischaemia or infarction, may not require aggressive monitoring or treatment during the perioperative
period.47
3.6.3
n
n
3.6.4
identify and correct underlying factors such as hypoxia, hypovolaemia, electrolyte imbalance
and sepsis (see sections 4, 5 and 6)
seek expert advice for patients showing cardiovascular instability and review level of care
seek expert advice where the diagnosis or management of an arrhythmia is in doubt as DC
cardioversion is the first option where tachyarrhythmia results in haemodynamic deterioration
A 12 lead ECG should be obtained before and after DC shock or pharmacological cardioversion
and a rhythm strip obtained during drug intervention if possible
Multiple or inappropriate drug therapy can be dangerous.
amiodarone hydrochloride is well tolerated in ill patients and may be the drug of choice. The
standard IV regimen is 300 mg over 1 hour followed by an infusion of 900 mg over the next
24 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 regimen
should only be considered following expert advice.
class 1c drugs such as flecainide acetate and propafenone hydrochloride have potentially
serious adverse effects and should be avoided, particularly in patients with cardiac disease.
IV magnesium sulphate has been reported to be superior to conventional-dose amiodarone
hydrochloride in surgical and non-surgical ICU patients and can be considered as an alternative
to amiodarone in the critically ill patient.50 The dosing regimen is 8 mmol (2g) intravenously
over 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
n
n
verapamil hydrochloride and diltiazem hydrochloride can effectively control heart rate in
patients presenting with fast AF
beta blockade with IV esmolol hydrochloride can effectively control heart rate in patients
presenting with fast AF
verapamil hydrochloride and beta blockers should not be used together because of the risk of
severe hypotension and asystole
IV digoxin has a relatively slow onset of action and is less effective than other agents
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.
16
3 CARDIOVASCULAR MANAGEMENT
Seek expert help early in the management of serious or potentially serious arrhythmias
and reconsider the level of care.
CS
CS
Helpful algorithms for the management of acute tachyarrhythmias and bradyarrhythmias can be
found 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 in
the nonsurgical context, as stated in the ACC/AHA guidelines53 for implantation of pacemakers
and antiarrhythmia devices.
CS
Seek expert help early when perioperative conduction defects result in bradycardia
unresponsive to atropine.
3.8
17
3.9
CS
CS
CS
CS
Thrombolysis is not indicated in the management of perioperative MI, but all other
aspects are as for MI in any other setting.
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 is
deemed safe postoperatively. The SIGN guideline on Antithrombotic Therapy suggests that
surgeons intending to perform surgery or invasive procedures in patients receiving anticoagulant
therapy 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 takes
about 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-impaired
thermoregulation, cold operating environments, open body cavities and the administration of
unwarmed IV fluid.
Without active methods to retain or provide heat approximately half of all patients undergoing
surgery develop a core temperature of less than 36oC and in one third of patients the temperature
drops below 35oC.
In a prospective randomised controlled trial forced air warming, used both intraoperatively and
postoperatively, maintained a core temperature significantly higher than non-heated controls
(36.7 +/- 0.1oC versus 35.3 +/- 0.1oC, p = 0.0001).58
The maintenance of normothermia using a forced air warming technique intraoperatively and
postoperatively is also associated with fewer cardiac events (eg cardiac arrest, myocardial infarction
and/or unstable angina or ischaemia occurring in the first 24 hours postoperatively) in elderly
patients undergoing abdominal, vascular and thoracic surgery.58
3.11
CS
CS
OXYGENATION
Patients with coronary artery disease are at risk from ischaemia in the first few postoperative
days.
The effect of anaesthesia and analgesia on respiratory function predisposes patients to hypoxia
postoperatively. The potential for hypoxia may remain for up to five days postoperatively, 59 and
is increased at night.
18
3 CARDIOVASCULAR MANAGEMENT
For most patients there is no consistent evidence regarding the relationship between hypoxia and
ischaemic events postoperatively. In high risk patients undergoing vascular surgery, new ischaemic
changes have been shown to be associated with a fall in oxygen saturation.60 Myocardial ischaemia
has been shown to be more likely when episodes of hypoxia are prolonged beyond five minutes
and are severe (SpO2<85%).61
See sections 4.3.3 and 4.5.2 for further information.
CS
3.12
Patients with coronary artery disease, or major risk factors for coronary artery disease,
should receive oxygen continuously until mobile.
Oxygen saturation should be maintained above 92%.
CARDIAC FAILURE
Even patients with stable cardiac failure may not tolerate anaemia, tachycardia or intravascular
volume shifts. Features of cardiac failure are shown in Table 7. Patients on drug treatment for
established cardiac failure should have their medication continued throughout the perioperative
period where possible. It may be necessary to use an IV loop diuretic where oral intake is not
possible.
If cardiac failure is suspected in the postoperative period:
n
n
n
n
n
19
Respiratory management
4.1
INTRODUCTION
Pulmonary complications are an important and common cause of postoperative morbidity and
mortality and are particularly common after major abdominal and thoracic surgery. Reported
incidence varies from about 20-75%,62-64 perhaps because of inconsistent diagnostic criteria. If
patients at risk can be recognised, it may be possible to modify some risk factors before elective
surgery to reduce the rate of these complications. Early recognition of developing respiratory
complications with appropriate interventions may improve outcome. Failure to recognise pulmonary
complications may result in rapid deterioration leading to death.
Treatment must be based on an accurate assessment of the patient. In some cases no specific
treatment is required but in others rapid and aggressive treatment is required to prevent death.
4.2
RISK FACTORS
A number of risk factors for postoperative pulmonary complications have been identified: 65-70
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
n
duration of anaesthesia66
nasogastric intubation66,67
type of surgery65
functional status65
ASA >2 68,69
age >59 68,70
body mass index >25 kg/m2 68 or BMI >27 kg/m2 70
weight loss65
smoking history within last eight weeks65,70
upper abdominal incisions68,70
chronic bronchitis65,68
presence of cancer68
stroke65
increased blood urea65
transfusion65
emergency surgery65
smoking, alcohol, and long term steroid use65
intermittent positive pressure ventilation (IPPV) >1 day67
impaired cognitive function65,70
preoperative stay >4 days.65
The evidence supporting some of these risk factors is tenuous and may be circumstantial:
n
n
Other risk factors for which there is no specific evidence include oesophageal problems such as
pharyngeal pouch, hiatus hernia, achalasia and intestinal obstruction.
20
4 RESPIRATORY MANAGEMENT
4.3
4.3.1
ANALGESIA
Compared with systemic opioids, neuroaxial blockade after surgery can reduce pulmonary
complications; epidural opioids (RR 0.53 95% CI 0.2-1.33), epidural local anaesthetics (RR
0.58 95%CI 0.42-0.80), and intercostal nerve blocks (RR 0.47 95% CI 0.12-1.22).71
A large multicentre comparison of high risk patients having abdominal surgery found that analgesia
with epidural after surgery did not improve survival (5.1% vs 4.3%) or major morbidity.72 Only
one of eight categories of morbid end points in individual systems (respiratory failure) occurred
less frequently in patients managed with epidural techniques (23% vs 30%, p=0.02). In this
study, the term respiratory failure is a pooled end point covering need for prolonged intubation
or reintubation, or a PaO2 50 mm Hg or a PaCO2 50 mm Hg on room air. These criteria may
not all be clinically relevant.
4.3.2
1+
4.3.3
OXYGEN THERAPY
Oxygen is often given to patients after surgery but good evidence supporting its routine use is
scarce. The theoretical concern that nitrous oxide excretion may cause postoperative hypoxia has
not been substantiated.75 One study has shown that increasing FiO2 after operation reduces the
incidence of wound infection.76 Hypoxaemia is common after surgery and is caused by impaired
gas exchange and impaired ventilatory control. Episodes of minor hypoxaemia after surgery are
common but are of doubtful significance. Routine use of oxygen in fit patients after uncomplicated
surgery, 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 postoperative
morbidity.78 The threshold for adverse effects of hypoxaemia in individual patients however, is
unknown 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 prolonged
monitoring and oxygen therapy:
n
n
n
n
obese patients
patients who have undergone thoracic or upper abdominal surgery
patients with acute and chronic pulmonary disease
patients receiving sedative drugs and opiates.
In some patients oxygen delivery to the tissues may be impaired despite a normal PaO2. This
includes patients with:
n
n
n
n
n
n
n
hypovolaemia
hypotension
myocardial ischaemia
cerebral ischaemia
anaemia
increased oxygen consumption (eg pyrexia)
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%).
21
4.4
4.4.1
INTRODUCTION
The widely accepted methods of monitoring patients have not generally been subject to evidence
based assessment. An RCT of 20,802 patients found no difference in the incidence of postoperative
complications between those routinely monitored with pulse oximetry and those not routinely
monitored. Monitored patients had significantly more episodes of hypoxaemia identified and
had fewer episodes of ECG detected myocardial ischaemia. 79,80 No other trials of routine monitoring
were identified.81
4.4.2
DIAGNOSTIC CRITERIA
The generally accepted diagnostic criteria for respiratory failure, pulmonary infections, acute
respiratory distress syndrome (ARDS) and acute lung injury are as follows:
Respiratory failure
n
n
Type 1 PaO2 < 8kPa (60 mm Hg), PaCO2 <6.6kPa (50 mm Hg)
Type 2 PaO2 < 8kPa (60 mm Hg), PaCO2 >6.6kPa (50 mm Hg).
Atelectasis
n
Respiratory infection
Any two of the following on two or more days:
n
n
n
n
Pyrexia >38oC
Positive sputum culture
Positive clinical findings
Abnormal chest X-ray Atelectasis/infiltrates.
n
n
4.4.3
Acute onset
Bilateral infiltrates on chest radiography
Pulmonary artery capillary wedge pressure (PACWP) 18 mm Hg or the absence of clinical
evidence of left heart failure
Acute lung injury is considered to be present if PaO 2 (kPa) / FiO2 is 40
ARDS is considered to be present if PaO2 (kPa) / FiO2 is 26.
OBSERVATION
Simple measures are most appropriate in view of the absence of evidence of efficacy of more
sophisticated measures.82
The following indicate the possible development of respiratory complications:
n
n
n
22
1+
4 RESPIRATORY MANAGEMENT
Clinical assessment of the chest should be performed. Adventitial sounds on breathing are common
and need not indicate significant disease but major abnormalities such as gross pulmonary collapse
and pleural effusions are easily detectable.
4.4.4
CS
Respiratory rate, pulse rate and conscious level should be monitored routinely to identify
postoperative respiratory complications.
CS
INVESTIGATIONS
Specific and non-specific investigations are available and should be used as indicated clinically.
n
CS
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 most
cases no specific treatment is required beyond normal mobilisation and breathing exercises.
Hypoxia requires oxygen therapy as described in section 4.5.2. Very occasionally where
physiotherapy fails to effectively treat extensive lobar or pulmonary collapse, therapeutic
bronchoscopy and bronchial suction may be necessary as the collapsed lung contains no air with
which to cough out the mucus plugs.
4.5.2
23
Oxygen therapy
Oxygen can be delivered by a large number of different devices. 100% oxygen can only be
supplied by endotracheal intubation and positive pressure ventilation. The highest inspired
concentration that can be supplied by external devices is about 70% with a mask and reservoir
bag. A 60% ventimask can reliably supply sufficient oxygen for most patients with respiratory
insufficiency.84 A selection of fixed performance devices (ie providing a fixed FiO2) are available,
allowing delivery of an FiO2 appropriate to individual patients.
Hudson masks and nasal catheters with a foam collar allow better PaO2 than nasal catheters, but
there is no difference in oxygen saturation between the three devices.85 Hudson masks, when
used with low flow oxygen, may result in hypercapnia due to inadequate ventilation. Nasal
catheters are better tolerated and therefore compliance is better.86
In a normally hydrated patient humidification of oxygen is not necessary unless the patient is
intubated with an endotracheal tube or has a tracheostomy.
Patients with type 2 respiratory failure due to chronic obstructive pulmonary disease (COPD)
have chronic CO2 retention and are dependent on hypoxic drive. They should be given whatever
FiO2 is necessary to return their SpO2 to its usual level.
Table 8: Equipment used for oxygen delivery
Type of mask
Characteristics of system
Rate or concentration
of oxygen delivery
2-4 litre/min
Hudson mask
4-8 litre/min
24,28,35,40,60% oxygen
28,35,40,60% oxygen
CS
70% oxygen
Oxygen should be given to patients with hypoxaemia using a device that is best tolerated
to achieve the necessary SpO2. In normally hydrated patients humidification is unnecessary.
Failure to maintain an SpO2 >90% or PaO2 >8.0 kPa is an indication to consider assisted
ventilation.
Antibiotics
Patients fulfilling the diagnostic criteria for respiratory infection (see section 4.4.2) should be
treated with appropriate antibiotics, based on local protocols and represcribed later on the basis
of the results from sputum culture.87 Any patient in whom aspiration may be suspected should
receive additional cover for anaerobic organisms. Continued monitoring of sputum bacteriology
is necessary as treatment failure is associated with development of drug resistance and change in
bacteria.87
CS
24
Patients with evidence of respiratory infection should receive antibiotics based initially
on local protocols and modified later on the basis of the results from sputum culture. If
aspiration of intestinal contents is suspected additional cover for anaerobic organisms
should be given.
4 RESPIRATORY MANAGEMENT
4.5.3
Opioid overdose should be treated with oxygen, airway maintenance, ventilatory support
if necessary, and immediate anaesthetic or critical care specialist advice.
CS
CS
Assisted ventilation
In patients who develop respiratory failure assistance with breathing may be necessary. Assisted
ventilation is required when a patient develops hypercapnia and occasionally for severe hypoxaemia
(see section 4.4.2. for definitions).
Accepted criteria for ventilation are:
In a patient receiving FiO2 of 0.6:
n
n
n
PaCO2 >6.6kPa
PaO2 < 8.0kPa
Respiratory rate >25 breaths/min.
CS
4.6
ROLE OF PHYSIOTHERAPY
Physiotherapy is widely used before and after surgery. As this is an under-researched area, limited
high quality evidence is available. In addition, the evidence that was identified addresses techniques
that tend not to be used in current practice. Further research regarding the role of postoperative
physiotherapy would be beneficial.
Although evidence for its efficacy is variable, physiotherapy may be useful in patients with:
n
n
n
n
25
Following general anaesthetic, a patients functional residual capacity may be lowered, particularly
following upper abdominal or thoracic surgery. Reduction in lung volume reduces lung compliance,
increases airway resistance and may lead to atelectasis.
The aims of postoperative physiotherapy are to:
n
n
n
n
n
A combination of these approaches may help to maintain respiratory function and prevent early
postoperative respiratory complications. Other treatment techniques are available for patients
with more complex needs. There should be a multidisciplinary approach to the promotion of
optimal positioning and early mobilisation.
4.6.1
TREATMENT OPTIONS
Table 9: Summary of common physiotherapy treatments
Effect required
Treatments available
Positioning
Thoracic expansion exercises
Controlled mobilisation
Active exercise programme
Mechanical aids, eg incentive spirometer,
intermittent positive pressure breathing (IPPB)
Clear secretions
Systemic hydration/humidification
Airway clearance techniques
Thoracic expansion exercises
Mobilisation
Manual techniques
Mechanical aids
Suction
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
26
4 RESPIRATORY MANAGEMENT
Retention of sputum is common and assistance with breathing and positioning helps expectoration.
Additional use of humidification in patients with very viscid secretions may help expectoration.
Patients with evidence of collapse or decreased lung volume on X-ray, and those who have had
recent abdominal surgery may also benefit from physiotherapy.
Postoperative pain, particularly in upper abdominal or chest surgery, may cause difficulty with
deep breathing and coughing. Both are essential in the treatment of respiratory infections, making
appropriate positioning of the patient important. Patients often find the sitting position helpful
for breathing. This is also a more comfortable position in patients with respiratory distress.
4.6.3
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
CS
Patients with collapse or decreased lung volume or who have undergone recent thoracic
or abdominal surgery should be considered for physiotherapy.
27
5.1
INTRODUCTION
There is surprisingly little primary research on this important topic. There are studies based on
specialist populations, including those in ICU, and on preoperative optimisation. Many of these
studies are small and have methodological flaws. The guideline development group did not feel
that the results of trials in different populations could be used as evidence to guide management
of the postoperative patients covered by this guideline.
Acute renal failure can be defined in terms of creatinine clearance or a rise in serum creatinine
from the baseline value. Creatinine clearance is seldom measured in postoperative patients and
decisions are generally made on the basis of serum creatinine. Patients may have serum creatinine
within the normal laboratory range and still have significant impairment of function. This is
particularly the case in patients who are debilitated or elderly.
The SIGN guideline on perioperative blood transfusion for elective surgery provides guidance on
the use of packed cells in the postoperative period.92
5.1.1
The basal requirements for young adults are approximately 30 ml/kg/day of water, 1.01.4 mmol/kg/day of sodium and 0.7-0.9 mmol/kg/day of potassium.
Given that fat is relatively metabolically inert and that the percentage of fat relative to lean mass
tends to increase with age, the standard calculations above are particularly likely to overestimate
the basal needs of the obese, the elderly and women.
5.1.2
There is a longstanding conflict between wet and dry schools, particularly with regard to
prevention of complications and correction of pre-existing deficits. The wet school offers evidence
that 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-related
changes in endocrine function, many patients do better with restriction of water and sodium
intake. The advocates of both approaches often include them as part of a package of perioperative
care.
This guideline is concerned with postoperative care and not with these overall strategies. The
evidence base for fluid management in the postoperative setting is poor, but it is important to
avoid hypovolaemia in the early postoperative phase.
5.1.3
28
5.2
CS
CS
Elderly patients should be observed closely as they are more likely to have overt or covert
cardiac, respiratory or renal disease and to have less reserve. Clinical signs may be less
reliable in these patients.
RISK FACTORS
Risk factors for postoperative fluid or electrolyte disturbance could relate to:
n
n
n
n
n
5.3
the elderly
those with pre-existing cardiovascular disease
those with pre-existing cerebrovascular disease
those with pre-existing renal disease
those who have suffered perioperative myocardial ischaemia or infarction
those who have suffered large perioperative fluid losses.
PROPHYLAXIS
The ideal way of tackling problems with fluid and electrolyte balance is to avoid them in the first
place. Appropriate monitoring strategies are discussed in section 2.4. The patients fluid status
and electrolyte balance need to be estimated, taking into consideration:
n
n
n
n
5.4
CS
CS
Assess hypotensive patients with epidurals to exclude fluid deficit. It should not be assumed
that the hypotension is due to the epidural.
CS
hypotension
tachycardia
oliguria
signs of fluid overload (such as pulmonary oedema)
more subtle signs such as confusion or tachypnoea.
29
Accurate assessment of fluid and electrolyte status can be difficult and the treatment of a
particular patient must be individualised and reviewed frequently in the light of the
response to treatment.
5.5
5.5.1
VOLUME DEPLETION
Volume depletion can lead to poor tissue perfusion and this can result in both morbidity and
mortality.
The specific consequences are:
n
n
n
n
anastomotic breakdown
cerebral damage
renal failure
multiple organ failure.
n
n
CS
5.5.2
Volume depletion should be avoided as this can lead to poor perfusion and problems
such as anastomotic breakdown, cerebral damage, renal failure and multiple organ failure.
VOLUME OVERLOAD
Volume overload can lead to pulmonary and tissue oedema. Pulmonary oedema can be
immediately life threatening. Tissue oedema can lead to poor tissue perfusion, failure to absorb
enteral feed, and failure to eat.
30
5.6
OLIGURIA
Oliguria is defined as urine volume of less than 0.5 ml/kg/hr for two consecutive hours. The
appropriate response depends on the cause and whether it is associated with impaired renal
function.
Oliguria should not be regarded as a diagnosis but as a sign requiring explanation. It is not
appropriate to artificially increase the urine output in a hypovolaemic patient using diuretics.
These should be reserved for patients who are fluid overloaded. Dopamine has been widely used
in the past in the hope of preventing acute renal failure, but the overwhelming evidence from
studies in critically ill patients is that it is not beneficial.
Oliguria associated with normal pre-existing renal function, cardiovascular stability and an alert
patient is unlikely to require intervention unless it persists for four hours or more. If associated
with other symptoms or signs suggestive of fluid depletion it should be treated initially with a
fluid challenge. Careful monitoring is required in patients with poor cardiac function.
Colloid is preferred as the effect is more readily apparent, but crystalloid, such as normal saline,
can also be used. In a normal adult, 250 ml colloid should be given over 30 minutes. It is
essential to assess the response in terms of haemodynamics and subsequent urine output. If there
is no improvement, this may be repeated once. If this does not produce improvement then
consideration should be given to the measurement of central venous pressure. Smaller volumes
may be appropriate in the frail elderly and those with cardiovascular disease.
CS
Oliguria is defined as urine volume of less than 0.5 ml/kg/hr for two consecutive hours.
The appropriate response depends on the cause and whether there is pre-existing renal
impairment.
CS
Oliguria in an alert patient, that is associated with normal pre-existing renal function
and cardiovascular stability, is unlikely to require intervention unless it persists for four
hours or more.
CS
CS
CS
Diuretics should not be used to treat oliguria and should be reserved for fluid overload.
CS
31
5.7
SODIUM
5.7.1
HYPONATRAEMIA
Hyponatraemia does not by itself indicate saline deficiency and is most commonly due to excess
water. Antidiuretic hormone (ADH) secretion is increased after surgery and if excess water is
given (as 5% dextrose) then hyponatraemia may be induced. If hyponatraemia is associated with
volume depletion then there must be a degree of sodium deficiency. The estimation of the degree
of volume excess or volume depletion requires clinical assessment in addition to biochemical
estimates. Very low levels of serum sodium (110-120 mmol/L or less) can produce symptoms
such as stupor, coma or fits and constitute a medical emergency. Over-vigorous correction of
severe hyponatraemia is also dangerous. Patients with hyponatraemia should be managed by
medical staff with appropriate experience.
5.7.2
CS
CS
HYPERNATRAEMIA
In patients with hypernatraemia, clinical assessment of the patient may add little to the
biochemical assessment, as water depletion initially leads to volume losses from the intracellular rather than the extracellular space. The signs and symptoms of water depletion tend to be
non- specific, particularly where the sensation of thirst is impaired by the surgical or medical
situation.
CS
5.8
POTASSIUM
Potassium levels in the blood are not a good indicator of total body potassium. However, abnormal
blood levels, and in particular hyperkalaemia may precipitate cardiac arrest, and an ECG is an
important adjunct when deciding the potential ill effects of potassium abnormalities in an
individual postoperative patient.
Protocols for the emergency treatment of potassium abnormalities are described in standard
emergency medicine texts. Most hospitals will also have local protocols which should be referred
to. It is important to correct hypoxia and institute ECG monitoring.
5.8.1
HYPOKALAEMIA
Chronic hypokalaemia indicates a significant deficit in total body potassium, which may be
several hundred millimoles. The clinical effects of hypokalaemia include skeletal muscle weakness,
ileus, and cardiac arrhythmias. It can also potentiate the adverse effects of digoxin.
Acute hypokalaemia can result from shift of potassium into cells due to, for example, alkalosis,
insulin or beta adrenergic stimulation (including nebulised beta agonists).
True potassium deficiency in postoperative patients may result from:
n
n
n
n
32
inadequate replacement
renal losses
endocrine abnormalities
upper and lower GI losses (the actual loss of potassium from the upper GI tract is small, but
the loss of chloride causes alkalosis which promotes the movement of potassium into cells
and increases renal excretion).
Not only does alkalosis cause hypokalaemia, but hypokalaemia can cause alkalosis.
Treatment of hypokalaemia should first focus on removing avoidable causes. Unless there is true
potassium deficiency, it is seldom necessary to replace potassium at a rate of greater than 10-20
mmol/hr. Faster administration usually requires a central line and careful monitoring and should
by undertaken in an environment which provides level 2 care. Concentrated solutions of potassium
are intensely irritant to peripheral veins and can cause tissue necrosis if they extravasate.
When correcting severe or persistent hypokalaemia, also ensure that magnesium is not deficient.
Magnesium deficiency leads to increased renal loss of potassium.
CS
5.8.2
HYPERKALAEMIA
Emergency treatment of hyperkalaemia may include IV calcium chloride, which must be titrated
slowly, IV calcium gluconate, nebulised beta agonists (such as salbutamol) or IV 50 ml 50%
dextrose with 10 units of shortacting insulin.
CS
5.9
ACID/BASE BALANCE
Acute acid/base problems in the postoperative period are commonly due to respiratory/ventilation
problems (see section 4). Metabolic acidosis is usually due to poor tissue perfusion but can also
be due to renal failure, or rarely, can be caused by excessive administration of 0.9% saline which
has a high chloride concentration.93 If large volumes of crystalloid are required then Hartmanns
solution is preferable. A total venous bicarbonate of less than 20 mmol/L or a base deficit of
greater 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 by
excessive administration of saline. A total venous bicarbonate of less than 20 mmol/L or
a base deficit of greater than 4 mmol/L may indicate cause for concern, particularly if the
trend is towards progressive acidosis. Expert opinion should be sought.
33
Management of sepsis
6.1
INTRODUCTION
Sepsis is the systemic inflammatory response to infection and represents a progressive response
to infection leading to a generalised inflammatory reaction in organs remote from the initial
insult and eventually to end-organ dysfunction and/or failure (see Table 13 for list of definitions).
The development of systemic sepsis in a postoperative patient marks a serious decline in their
condition. If associated with shock or organ dysfunction (sepsis syndrome) mortality is between
20 and 40%. Clearly identifying patients at risk and taking appropriate prophylactic measures is
vital. Once a patient has developed sepsis syndrome however, the principles of early identification,
immediate resuscitation, moving the patient up to the appropriate level of care (level 2 or 3),
identifying the primary source, use of early and appropriate antibiotics and undertaking appropriate
surgical drainage are the mainstays of treatment.
Table 13: Definitions of sepsis
Systemic inflammatory response syndrome: SIRS
The response is defined by the presence of two or more of the following:
0
0
n temperature >38 C or <36 C
n heart rate >90 beats/min
n respiratory rate >20 breaths/min or PaCO <4.3kPa
2
3
3
n white cell count >12,000 cells/mm , <4,000 cells/mm , 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, lactic
acidosis, oliguria or an acute alteration in mental state.
6.2
34
6 MANAGEMENT OF SEPIS
6.3
PROPHYLAXIS
6.3.1
ANTIBIOTIC PROPHYLAXIS
Antibiotic prophylaxis in surgery has previously been reviewed by SIGN (for recommendations
see SIGN guideline on Antibiotic Prophylaxis in Surgery).99
CS
6.3.2
HAND WASHING
Hand washing is widely recognised as an important but underused measure to prevent nosocomial
infections.100 Guidelines exist for handwashing techniques.101 The following statements are based
on 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 with
alcohol based handrubs (if hands are not visibly soiled):
a) before and after patient contact
b) 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-containing
soaps or detergents or by use of alcohol based antiseptic handrubs, is recommended in the
following instances:
a) before the performance of invasive procedures such as surgery or the placement of
intravascular catheters, indwelling urinary catheters, or other invasive devices
b) when persistent antimicrobial activity on the hands is desired
c) 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 performed
before and after patient contact.
CS
Strict hand antisepsis must be achieved before the performance of invasive procedures
such as surgery or the placement of intravascular catheters, indwelling urinary catheters,
or other invasive devices.
n
n
35
6.4
CS
CS
Gloves made from a range of materials should be available for personnel with sensitivity
to standard glove material, and for use in patients with a similar sensitivity.
EARLY IDENTIFICATION
Early identification and management of sepsis is vital as the prompt administration of appropriate
empirical antimicrobial therapy reduces by half the frequency with which shock develops in
patients 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 require
a 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 in
Table 15 has been adapted from Matot et al.103
Table 15: Clinical signs of sepsis
Fever/hypothermia
Unexplained tachycardia
Unexplained tachypnoea
Signs of peripheral vasodilation
Unexplained hypotension/shock
Changes in mental state
Leucocytosis/neutropenia
Unexplained alteration in renal or liver function
Thrombocytopenia/ disseminated intravascular coagulation
Metabolic acidosis
6.4.2
IDENTIFICATION OF SEPSIS
Early identification of systemic sepsis involves:
n
36
focused clinical examination, for both a primary site of infection and the systemic sequelae
of sepsis
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 fluid
should be obtained from the suspected wound infection. Examination of chest, examination
of urine. Microscopy and/or dipstix testing for nitrites may give an early indication of infection,
before formal sensitivities from culture are available
examination for systemic sequelae; include measurement of temperature, respiratory rate,
heart rate, blood pressure and laboratory investigation of neutrophil count 104
severity of sepsis may be assessed by looking for organ dysfunction which may be reflected by
altered platelet count, coagulation screen, renal function, liver function and C-reactive protein.
CS
CS
Urine and blood cultures should be obtained whenever there is reason to suspect systemic
sepsis.
CS
If clinical signs are unclear, appropriate radiological investigations should be used for
the diagnosis of intra-abdominal infection.
6 MANAGEMENT OF SEPIS
6.4.3
DIAGNOSTIC PROCEDURES
No evidence was identified to inform timing of blood culture in relation to clinical signs. Expert
opinion suggests that blood cultures should be taken as soon as possible following onset of
fever.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 been
compared.106 ,107 The accuracy of ultrasound ranges from 75-96% while CT correctly diagnoses
71-100%. CT and ultrasonography may be complementary.
6.5
MANAGEMENT
Once a patient has been identified to be septic, further diagnosis and treatment usually occur in
parallel. Immediate care demands assessment of airways, breathing and circulation (the ABCs).
The patient will often be hypovolaemic and hypoxaemic and the presence of these changes
demands at least the administration of oxygen and establishment of intravenous access with
volume expansion using either colloid or crystalloid. Patients with sepsis syndrome need careful
monitoring and, in general, require level 2 care. Once a patient has been examined fully and
initial diagnostic tests undertaken, antibiotics should be given as early as possible and are generally
prescribed on a best guess basis for the clinical scenario.
6.5.1
6.5.2
CS
If the cause of sepsis is unknown, treatment should be with broad spectrum antibiotics,
guided by local protocols.
CS
The results from microbiological specimens should be reviewed regularly and antibiotics
changed as necessary.
CS
SURGERY
Surgical approaches to the treatment of infection have evolved through principal and tradition
and few have been evaluated by randomised controlled trials. Localised collections of pus generally
need either operative or percutaneous drainage and dead tissue should be excised.
Severe pulmonary sepsis may require bronchoscopy and toilet of the bronchial tree. Early
intervention in necrotising soft tissue infection has been shown to reduce mortality compared to
historical controls in some case series.111
CS
Abdominal sepsis, if localised, can be managed initially with antibiotics or percutaneous drainage,
but generally the primary source of sepsis must be treated surgically (eg anastomotic leakage).
Meticulous attention to peritoneal toilet with copious lavage is essential. The role of planned
second-look laparotomy is still not clear. There are no randomised controlled trials comparing
percutaneous and operative drainage techniques. Case series show that percutaneous drainage is
as effective as conventional surgery for the drainage of intra-abdominal collections.112,113
37
6.5.3
CS
CS
Patients with multiple collections or with failure of percutaneous drainage should have
open surgery.
OTHER INTERVENTIONS
Obstruction of the biliary or urinary system must be relieved usually by endoscopic or percutaneous
radiological means. Major sepsis associated with an infected prosthesis most commonly demands
removal of the latter. It is essential to remain vigilant about the possibility of catheter-related
sepsis, particularly in patients receiving level 2 or 3 care.
Short term, high concentration oxygen after surgery reduces wound infection.75
38
7 POSTOPERATIVE NUTRITION
Postoperative nutrition
7.1
INTRODUCTION
For normally nourished patients, the primary objective of postoperative care is restoration of
normal GI function to allow adequate food intake and rapid recovery. Malnourished patients are
at increased risk of postoperative complications and mortality, yet artificial nutritional support
can be associated with major complications.114
This section discusses a number of key issues that should be addressed if restoration of oral food
intake is to be achieved quickly and safely.
7.2
7.2.1
1+
For patients with an anastomosis in the upper GI tract, ingestion of solid food may have to be
delayed 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) solid
food can be commenced without adverse effect on the first postoperative day.118 Patients may find
liquid supplements easier to take in the first instance.
1-
CS
7.2.2
1++
7.2.3
CS
Patients should not be fasted for any longer than necessary, either for investigations or
surgery.
CS
Hospitals should provide appetising food and assist patients to eat, if this is needed.
39
7.2.4
7.2.5
1+
The evidence supporting the short term routine use of oral supplements in patients who are not
malnourished is not clear.121,122
7.2.6
7.3
1-
Multimodal enhanced recovery programmes (with a focus on pain control, early mobilisation
and promotion of gastrointestinal function) are associated with an early return of oral nutrition in
the postoperative period.124 ,125 Patient care pathways should be designed to take account of a
multimodal approach.
2+
7.3.1
7.3.2
2+
7.3.3
Malnourished patients with benign disease requiring surgery should receive postoperative
nutritional support by the appropriate route.
40
1+
7 POSTOPERATIVE NUTRITION
7.4
CS
Mild or moderately malnourished cancer patients should proceed with surgery and only
receive artificial nutritional support if specifically indicated.
CS
All malnourished cancer patients should be considered for nutritional advice and oral
supplements in the postoperative period and for a period following discharge.
1+
7.4.1
7.4.2
Nutritional replacement should be discussed with a dietitian and tailored to the patients
requirements.
Enteral nutrition is the preferred method of postoperative nutritional support and should
be used if possible.
Patients with partial gut failure and who are catabolic, eg with necrotising pancreatitis or ongoing
intra-abdominal sepsis, may benefit from artificial nutritional support in the postoperative period.
In the presence of partial gut function either combined TPN/EN, or if possible, full enteral
feeding, is the method of choice.
CS
For patients with ongoing postoperative complications enteral nutrition should be used
whenever possible, combined with parenteral nutrition where necessary, to meet nutritional
needs.
41
7.5
7.5.1
ENTERAL NUTRITION
Nasogastric feeding
The most appropriate route of enteral tube feeding for patients who require short term support (eg
less 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 or
blockage. 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 following
major upper gastrointestinal surgery. The jejunostomy is sited at the time of surgery and can be
used for feeding within 12 hours of surgery.
Administration
Most surgical patients can tolerate a standard whole protein feed (1 kcal/ml). A peptide or
elemental formula can be considered in patients with significant malabsorption. Patients are
generally started with 30-50 ml/hour, increasing within 24-48 hours until prescribed targets are
reached. If supplementation of an inadequate oral intake is required, then overnight feeding for
8-12 hours may be sufficient and allows the patient to be mobile during the day. A pump should
be used to control the rate of feed delivery, avoiding the abdominal cramps and bloating associated
with bolus feeding.
CS
7.5.2
Enteral nutrition should be provided by the simplest technique possible. The feeding
should be given in such a way as to interfere minimally with the normal stimuli to
eating.
PARENTERAL NUTRITION
Peripheral intravenous feeding (eg via a cannula) should only be used in the short term. Central
venous feeding, via either a peripherally inserted catheter (PIC line) or a catheter in a central
vein, is the preferred route. A dedicated central venous feeding line minimises infective
complications. However in suitable circumstances a triple lumen central line inserted under
aseptic conditions and with a dedicated port for total parenteral nutrition can be used. Following
insertion of a dedicated central or jugular line, a chest X-ray must be taken to exclude a
pneumothorax and confirm the position of the catheter tip at or near the junction of the superior
vena cava with the right atrium.
Mixtures of nutrients are usually combined in a single bag. Many pharmacies now use three or
four standard regimens. The solutions contain fixed amounts of energy and nitrogen, and typically
provide 1,800-2,400 kcals (50% glucose, 50% lipid) and 10-14 g nitrogen. The amount of
electrolytes, vitamins and trace elements can be varied. In general, standard regimens are simpler,
safer and cheaper than those prepared individually.
CS
7.5.3
42
7 POSTOPERATIVE NUTRITION
Markers
Biochemistry
Fluid balance
Nutritional status
Nutritional intake
CS
7.5.4
Nutritional and metabolic status should be assessed regularly and the nutritional
prescription modified as necessary.
NUTRITION TEAMS
A coordinated multidisciplinary team approach to nutritional support can reduce the incidence
of feeding complications and improve the overall quality of care.
CS
43
8.1
44
9.1
INTRODUCTION
This guideline was supported by a grant from the Chief Scientists Office which aimed to assess
the feasibility of applying formal consensus techniques to SIGN guideline development. Although
intended to be fully developed by consensus techniques, the guideline is in fact a hybrid of
consensus and evidence based methodology. This situation arose when it became clear that
several of the clinical issues which were chosen for inclusion in this guideline were supported by
a robust evidence base and these were fed through the standard SIGN development process as
described in section 9.3. Following the systematic review of evidence, formal consensus was
then applied to statements developed by specialist subgroups of the development group as described
in section 9.4.
Further details about SIGNs standard evidence based methodology are contained in SIGN 50: A
guideline developers handbook available at www.sign.ac.uk
9.2
SIGN FACILITATORS
Miss Gemma Healy
Dr Moray Nairn
Dr Safia Qureshi
ACKNOWLEDGEMENTS
Dr Joris Berwaerts
Mr Ross Carter
Mrs Jane McCready
9.3
Canadian Practice Guidelines Infobase, the Australian National Health and Medical Research
Council, the New Zealand Guidelines programme, and the UK Health Technology Assessment
programme. Searches were also conducted on the search engines Citeline, Medical World Search,
Echidna, Medisearch and Google, and all suitable links followed up. Database searches were
conducted from 1993-2001 on the Cochrane Library, Medline, Embase and CINAHL. The Medline
version of the main search strategies is available on the SIGN website, in the section covering
supplementary guideline material. The main searches were supplemented by literature identified
by individual members of the development group. All selected papers were appraised using
standard methodological checklists before conclusions were considered as evidence.
9.4
CONSENSUS TECHNIQUES
Nominal group technique (NGT)132 was used to identify 125 items important to the management
of postoperative patients. Two further rounds of NGT reduced this list to 14 items which related
to clinical assessment and monitoring, or cardiovascular; respiratory; fluid, electrolyte and renal
or sepsis management. The items were used to develop a set of key questions, and used to
develop 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 that
could not be answered using published evidence. For each of these questions a consensus
statement was prepared. The group reviewed the consensus statements and summaries of appraised
evidence 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 both
their interpretations of the literature review and their clinical experience.
An appropriateness score was calculated, which reflected the panels collective opinion on the
suitability of each consensus statement.
The appropriateness score for an individual statement is the median of the panels ratings. The
panel is considered to be:
n
n
n
n
Only clearly appropriate consensus statements, with a median score of 7-9, are used as consensus
statements in this guideline.
9.5
9.5.1
46
9.5.2
SPECIALIST REVIEWERS
The guideline was reviewed in draft form by a panel of independent expert referees. SIGN is very
grateful to the following experts:
Ms Dorothy Barber
Miss Shirley Brennan
Dr Martin Cameron
Professor Ian Campbell
Dr Matthew Checketts
Dr Malcolm Daniel
Dr Pamela Doherty
Dr Dugald Glen
Dr Paul Glen
Miss Susie Goodwin
Mrs Kate Gordon Smith
Mr John Graham
Mrs Fiona Grant
Dr Heather Hosie
Mrs Sandra Jamard
Mr Richard James
Mr Ronald Kennan
Ms Caroline MacDonald
Mrs Heather Macgowan
Dr Fergus Miller
Mr Aslam Mohammed
Professor Michael Mythen
Dr Alastair Nimmo
Mr James Parris
Dr John Reid
Mr Chris Shearer
Mr Walter Simpson
Dr David Swann
Miss Gillian Thain
Professor Nigel Webster
Miss Senga Welsh
Professor Tony Wildsmith
Dr John Wilson
47
Abbreviations
48
ABC
ABG
ACC/AHA
ADH
Antidiuretic hormone
AF
Atrial fibrillation
ALI
ARDS
ASA
AVPU
BMI
CAD
CHF
CI
Confidence intervals
COPD
CS
Consensus statement
CT
Computed tomography
ECG
Electrocardiogram
FiO2
GCS
GI
Gastrointestinal
GTN
Glyceryl trinitrate
HDU
ICD
ICU
INR
IPPB
IPPV
JVP
LBBB
LVH
MI
Myocardial infarction
NG
Nasogastric
NSAID
OR
Odds ratio
PaCO2
Arterial carbon dioxide partial pressure (measured from a blood gas sample)
PaO2
PAWCP
RCT
RR
Relative risk
SASM
SIGN
SIRS
SpO2
SaO2
SVA
Supraventricular arrhythmia
SVT
Supraventricular tachycardia
TPN
VT
Ventricular tachycardia
ANNEXES
Annex 1
Assessing Conscious Level
THE AVPU SCALE
A - Alert
V - Verbal
The patient responds to voice, but is not fully oriented to person, time,
or place.
P Painful
The patient does not respond to voice, but does respond to a painful
stimulus, eg pinching the skin.
U - Unresponsive
Scale
Responses
Score
Notation
Eye opening
Spontaneous
To speech
To pain
None
4
3
2
1
Verbal response
Orientated
Confused conversation
Words (inappropriate)
Sounds (incomprehensible)
None
5
4
3
2
1
Obey commands
Localise pain
Flexion - Normal
- Abnormal
Extend
None
6
5
4
3
2
1
3/15 - 15/15
49
Annex 2
American Society of Anesthesiologists Physical Status
Classification System
50
ASA 1
ASA 2
ASA 3
ASA 4
ASA 5
ASA 6
A declared brain-dead patient whose organs are being removed for donor purposes
ANNEXES
Annex 3
Example of a Postoperative Monitoring Chart
This is an example chart only. These parameters will not be suitable for all patients and should be adjusted
in line with local protocols.
DATE
Name
Hosp. Number
DOB
Weight
Consultant
TIME
40
39.5
39
38.5
38
37.5
37
36.5
36
35.5
35
210
200
190
180
170
160
150
140
130
120
110
100
90
80
70
60
50
TEMPERATURE
BLOOD
PRESSURE
ADMISSION
BP
Plus 30%
Less 30%
Example
CVP
170
160
150
140
130
120
110
100
90
80
70
60
50
40
30
20
HEART RATE
SaO2
FiO2 (l/min or %)
40
35
30
25
20
15
10
5
0
RESP. RATE
URINE
>0.5mls/kg
Volume
<0.5mls/kg
NEUROLOGICAL
AWAKE
STATE
VERBAL
PAIN
UNRESP
Pain score
BM
DR CALLED
51
References
26
27
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
52
Scottish Audit of Surgical Mortality. [cited 7 Jan 2004]. Available from url:
http://www.sasm.org.uk
Fink A, Kosecoff J, Chassin M, Brook RH Consensus methods: characteristics
and guidelines for use. Am J Pub Health 1984;74(9) 979-83.
Merrick NJ, Fink A, Park RE, Brook RH, Kosecoff J, Chassin MR, et al. Derivation
of clinical indications for carotoid endarterectomy by an expert panel. Am J
Pub Health 1987;77(2):187-90.
Wietlisbach V, Vader JP, Porchet F, Costanza MC, Burnand B. Statistical
approaches in the development of clinical practice guidelines from expert
panels: the case of laminectomy in sciatica patients. Med Care
1999;37(8):785-97.
Lomas J, Anderson G, Enkin M, Vayda E, Roberts R, MacKinnon B. The role
of evidence in the consensus process. Results from a Canadian consensus
exercise. JAMA 1988;259(20):3001-5.
Roche N, Durieux P. Clinical practice guidelines from methodological to
practical issues. Intensive Care Med 1994; 20(8): 593-601.
The Management of Postoperative Pain Working Group. VHA/DoD clinical
practice guideline for the management of postoperative pain. Washington
(DC): Department of Defense; 2002. [cited 7 Jan 2004]. Available from url:
http://www.oqp.med.va.gov/cpg/PAIN/PAIN_base.htm
Jones PF. Emergency abdominal surgery: in infancy, childhood and adult life.
Oxford: Blackwell Scientific; 1974.
The Association of Anaesthetists of Great Britain and Ireland. Immediate
postanaesthetic recovery. London: The Association; 2002. [cited 8 Jan 2004].
Available from url: http://www.aagbi.org/pdf/Postanaes2002.pdf
Department of Health. Comprehensive critical care: a review of adult critical
care services. London: The Department; 2000. [cited 8 Jan 2004]. Available
from url: http://www.doh.gov.uk/pdfs/criticalcare.pdf
Hodkinson HM. Evaluation of a mental test score for assessment of mental
impairment in the elderly. Age Ageing 1972;1(4):233-8.
Ni Chonchubhair A, Valacio R, Kelly J, OKeefe S. Use of the abbreviated
mental test to detect postoperative delirium in elderly people. Br J Anaesth
1995;75(4):481-2.
Cook DJ, Simel DL. The rational clinical examination. Does this patient have
abnormal central venous pressure? JAMA 1996;275:630-634.
Lee A, Lum ME, ORegan WJ, Hillman KM. Early postoperative emergencies
requiring an intensive care team intervention. The role of ASA physical status
and after-hours surgery. Anaesthesia 1998;53(6):529-35.
Rheineck-Leyssius AT, Kalkman CJ, Trouwborst A. Influence of motivation of
care providers on the incidence of postoperative hypoxaemia in the recovery
room. Br J Anaesth. 1996;77(4):453-7.
Desborough JP. The stress response to trauma and surgery. Br J Anaesth
2000;85:109-17.
The sixth report of the Joint National Committee on prevention, detection,
evaluation, and treatment of high blood pressure. Arch Intern Med
1997;157(21):2413-46.
Eagle KA, Berger PB, Calkins H, Chaitman BR, Ewy GA, Fleischmann KE, et al.
ACC/AHA guideline update for perioperative cardiovascular evaluation for
noncardiac surgery. A Report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines (Committee to Update
the 1996 Guidelines on Perioperative Cardiovascular Evaluation for
Noncardiac Surgery). Bethesda (MD): American College of Cardiology; 2002.
[cited 8 Jan 2003]. Available from url: http://www.acc.org/clinical/guidelines/
perio/clean/perio_index.htm
Wilkinson IB, Webb Christison DJ, Cockroft JR. Isolated systolic hypertension:
a radical rethink. Its a risk factor that needs treatment, especially in the over
50s. BMJ 2000;320(7251):1685.
Howell SJ, Hemming AE, Allman KG, Glover L, Sear JW, Foex P. Predictors of
postoperative myocardial ischaemia. The role of intercurrent arterial
hypertension and other cardiovascular risk factors. Anaesthesia
1997;52(2):107-11.
Howell SJ, Sear YM, Yates D, Goldacre M, Sear JW, Foex P. Risk factors for
cardiovascular death after elective surgery under general anaesthesia. Br J
Anaesth 1998;80(1):14-9.
Howell SJ, Sear YM, Yates D, Goldacre M, Sear JW, Foex P. Hypertension,
admission blood pressure and perioperative cardiovascular risk. Anaesthesia
1996;51(11):1000-4.
Dimich I, Lingham R, Gabrielson G, Singh PP, Kaplan JA. Comparative
hemodynamic effects of labetalol and hydralazine in the treatment of
postoperative hypertension. J Clin Anesth 1989;1(3):201-6.
Chen TL, Sun WZ, Cheng YJ, Lee TS, Lin SY, Lin CJ. Comparison of
antihypertensive effects of nicardipine with nitroglycerin for perioperative
hypertension. Acta Anaesthesiol Sin 1995;33(4):199-204.
Mangano DT, Browner WS, Hollenberg M, London MJ, Tubau JF, Tateo IM.
Association of perioperative myocardial ischemia with cardiac morbidity and
mortality in men undergoing noncardiac surgery. The Study of Perioperative
Ischemia Research Group. N Engl J Med 1990;323(26):1781-8.
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
Mangano DT, Hollenberg M, Fegert G, Meyer ML, London MJ, Tubau JF, et
al. Perioperative myocardial ischemia in patients undergoing noncardiac
surgery-I: incidence and severity during the 4 day perioperative period. The
Study of Perioperative Ischemia (SPI) Research Group. J Am Coll Cardiol
1991;17(4):843-50.
Mangano DT, Wong MG, London MJ, Tubau JF, Rapp JA. Perioperative
myocardial ischemia in patients undergoing noncardiac surgery-II: Incidence
and severity during the 1st week after surgery. The Study of Perioperative
Ischemia (SPI) Research Group. J Am Coll Cardiol 1991;17(4):851-7.
Raby KE, Barry J, Creager MA, Cook F, Weisberg MC, Goldman L. Detection
and significance of intraoperative and postoperative myocardial ischaemia in
peripheral vascular surgery. JAMA 1992;268(2):222-7.
Pasternack PF, Grossi EA, Baumann FG, Riles TS, Lamparello PJ, Giangola G,
et al. Silent myocardial ischaemia monitoring predicts late as well as
perioperative cardiac events in patients undergoing vascular surgery. J Vasc
Surg 1992;16(2):171-80.
Hollenberg M, Mangano DT, Browner WS, London MJ, Tubau JF, Tateo IM.
Predictors of postoperative myocardial ischaemia in patients undergoing
noncardiac surgery. JAMA 1992;268(2):205-9.
Landesberg G, Luria MH, Cotev S, Eidelman LA, Anner H, Mosseri M, et al.
Importance of long duration post operative ST segment depression in cardiac
morbidity after vascular surgery. Lancet 1993;341(8847):715-9.
Berlatzky Y, Landesberg G, Anner H, Luria MH, Eidelman LA, Mosseri M.
Prolonged postoperative myocardial ischaemia and infarction in vascular
surgery performed under regional anaesthesia. Eur J Vasc Surg
1994;8(4):413-8.
Landesberg G, Mosseri M, Zahger D, Wolf Y, Perouansky M, Anner H, et al.
Myocardial infarction after vascular surgery: the role of prolonged stressinduced, ST depression-type ischemia. J Am Coll Cardiol
2001:37(7);1839-45.
Warltier DC, Pagel PS, Kersten JR. Approaches to the prevention of
perioperative myocardial ischaemia. Anaesthesiology 2000;92(1):253-9.
Badner NH, Knill RL, Brown JE, Novick TV, Gelb AW. Myocardial infarction
after noncardiac surgery. Anaesthesiology 1998;88(3):572-8.
Dawood MM, Gutpa DK, Southern J, Walia A, Atkinson JB, Eagle KA.
Pathology of fatal perioperative myocardial infarction: implications regarding
pathophysiology and prevention. Int J Cardiol 1996;57(1):37-44.
Mangano DT, Goldman L. Preoperative assessment of patients with known or
suspected coronary disease. N Engl J Med 1995;333(26):1750-6.
Mangano DT, Browner WS, Hollenberg M, Li J, Tateo IM. Long-term cardiac
prognosis following noncardiac surgery. The Study of Perioperative Ischemia
Research Group. JAMA 1992;268(2):233-9.
Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF,
et al. Derivation and prospective validation of a simple index for prediction of
cardiac risk of major noncardiac surgery. Circulation 1999;100(10):1043-9.
Mangano DT, Layug EL, Wallace A, Tateo I. Effect of atenolol on mortality and
cardiovascular morbidity after noncardiac surgery. Multicenter Study of
Perioperative Ischemia Research Group. N Engl J Med
1996;335(23):1713-20.
Poldermans D, Boersma E, Bax JJ, Thomson IR, Paelinck B, van de Ven LL, et
al. Bisoprolol reduces cardiac death and myocardial infarction in high-risk
patients as long as 2 years after successful major vascular surgery. Eur Heart J
2001;22(15):1353-8.
Poldermans D, Boersma E, Bax JJ, Thomson IR, van de Ven LL, Blankensteijn
JD, et al. The effect of bisoprolol on perioperative mortality and myocardial
infarction in high-risk patients undergoing vascular surgery. Dutch
Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography
Study Group. N Engl J Med 1999;341(24):1789-94.
Wallace A, Layug B, Tateo I, Li J, Hollenberg M, Browner W, et al. Prophylactic
atenolol reduces postoperative myocardial ischemia. McSPI Research Group.
Anaesthesiology 1998;88(1):7-17.
Howell SJ, Sear JW, Foex P. Peri-operative beta-blockade: a useful treatment
that should be greeted with cautious enthusiasm. Br J Anaesth
2001;86(2):161-4.
Auerbach AD, Goldman L. beta-Blockers and reduction of cardiac events in
noncardiac surgery: scientific review. JAMA 2002;287(11):1435-44.
Stevens RD, Burri H, Tramer MR. Pharmacologic myocardial protection in
patients undergoing noncardiac surgery: a quantitative systematic review.
Anesth Analg 2003;97(3):623-33.
OKelly B, Browner WS, Massie B, Tubau J, Ngo L, Mangano DT. Ventricular
arrhythmias in patients undergoing noncardiac surgery. The Study of
Perioperative Ischemia Research Group. JAMA 1992;268(2):217-21.
Slavik RS, Tisdale JE, Borzak S. Pharmacological conversion of atrial fibrillation:
a systematic review of available evidence. Prog Cardiovasc Dis
2001:44(2):121-52.
Cotter G, Blatt A, Kaluski E, Metzkor-Cotter E, Koren M, Litinski I, et al.
Conversion of recent onset paroxysmal atrial fibrillation to normal sinus rhythm:
the effect of no treatment and high-dose amiodarone. A randomized, placebocontrolled study. Eur Heart J 1999:20(24):1833-42.
Moran JL, Gallagher J, Peake SL, Cunningham DN, Salagaras M, Leppard P.
Parenteral magnesium sulfate versus amiodarone in the therapy of atrial
tachyarrhythmias: a prospective, randomized study. Crit Care Med.
1995;23(11):1816-24.
REFERENCES
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
53
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
54
SEPSIS
RESPIRATORY MANAGEMENT
Patients in whom there is a suspicion of postoperative pulmonary
complications should have an arterial blood gas analysis, a sputum
culture and ECG.
Warm
Normal preoperative BP
Comfortable
Observe if:
Cold
Hypertensive preoperatively
Distressed
Drowsy or unrousable
NUTRITION
CARDIOVASCULAR MANAGEMENT
ASSESSMENT OF HYPOTENSION
No obvious bleeding
If abnormal determine:
Conjunctival pallor
Blood pressure
Percussion note
Breath sounds
Symmetry of respiration/expansion
Respiratory rate
Oxygen saturation
Postoperative instructions
Intraoperative complications
Allergies
Medications
MONITORING
POSTOPERATIVE MANAGEMENT IN ADULTS: A PRACTICAL GUIDE TO POSTOPERATIVE CARE FOR CLINICAL STAFF
PRINCIPLES OF POSTOPERATIVE
MANAGEMENT
77