Postoperative management in adults

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1 Scottish Intercollegiate Guidelines Net work 77 Postoperative management in adults A practical guide to postoperative care for 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 COPIES OF ALL SIGN GUIDELINES ARE AVAILABLE BY CALLING OR ONLINE AT

2 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 significant 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 reflect 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 + Scottish Intercollegiate Guidelines Network ISBN First published 2004 SIGN consents to the pho to cop y ing of this guideline for the purpose of implementation in NHSScotland Scottish Intercollegiate Guidelines Network Royal College of Physicians 9 Queen Street, Edinburgh EH2 1JQ SIGN IS FUNDED BY NHS QUALITY IMPROVEMENT SCOTLAND

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53 DATE Postoperative Monitoring Chart Name Hosp. Number DOB Weight Consultant TIME TEMPERATURE BLOOD 190 PRESSURE ADMISSION 160 BP Plus 30% Less 30% CVP HEART RATE SaO2 FiO2 (l/min or %) Example RESP. RATE URINE Volume NEUROLOGICAL STATE >0.5mls/kg <0.5mls/kg AWAKE VERBAL PAIN UNRESP Pain score BM DR CALLED

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57 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. Chest X-ray should be performed on suspicion of major collapse, effusions, pneumothorax or haemothorax. Other investigations should be used only if there are specific indications. Oxygen should be given to patients with hypoxaemia using a device that is best tolerated to achieve the necessary SpO 2. In normally hydrated patients humidification is unnecessary. Failure to maintain an SpO 2 >90% or PaO 2 >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 timely as hypoxia or hypercapnia may lead rapidly to cardiorespiratory arrest. Diagnosis of respiratory infection Any two of the following on two or more days: Pyrexia >38 0 C Positive sputum culture Positive clinical findings Abnormal chest X-ray Atelectasis/infiltrates CARDIOVASCULAR MANAGEMENT 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 bpm 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) CARDIOVASCULAR MANAGEMENT (Contd.) Postoperative blood pressure should always be reviewed with reference to the preoperative and intraoperative assessments Further assessment is required for patients with: heart rate < 50 and > 100 bpm blood pressure <100 mm Hg systolic. Patients on regular antihypertensive medication should normally be maintained on this medication perioperatively. If the patient becomes hypotensive then it may be appropriate to discontinue some drugs. Beta blockers and IV nitrates may 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 arrhythmias. Be aware of clinical factors which increase risk to the patient and how these interact with the risks imposed by the surgical procedure. Seek expert help early in the management of serious or potentially serious arrhythmias. Reconsider the level of care. Search for the underlying causes of any supraventricular arrhythmias, eg hypoxia, hypovolaemia, electrolyte abnormality, sepsis or drug toxicity. Where perioperative MI is diagnosed or suspected early specialist medical advice should be sought. Maintain normothermia in the postoperative period. FLUID, ELECTROLYTE & RENAL MANAGEMENT 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. 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. Diuretics should not be used to treat oliguria and should be reserved for fluid overload. Hyponatraemia is more commonly due to excess water than sodium deficiency assess volume status. Hypernatraemia most commonly indicates a total body deficiency of water and is an indication for prompt assessment and intervention, especially when levels exceed 155 mmol/l. Hypokalaemia can delay postoperative recovery - magnesium supplementation may also be required. Hyperkalaemia is a medical emergency obtain senior help. Metabolic acidosis is usually due to poor tissue perfusion but can also be caused by excessive administration of saline. SEPSIS Hand washing with soap and water or with alcoholic cleansing agents should be performed before and after patient contact. Early identification and appropriate treatment of sepsis improves outcome. Urine and blood cultures should be obtained whenever there is reason to suspect systemic sepsis. If the cause of sepsis is unknown, treat with broad spectrum antibiotics, guided by local protocols. Results from microbiological specimens should be reviewed regularly and antibiotics changed as necessary. A course of antimicrobial treatment should generally be limited to 5-7 days. Fungi and atypical organisms can contribute to sepsis syndrome, so take cultures and prescribe appropriately. Systemic inflammatory response syndrome (SIRS) is defined as the presence of 2 or more of the following: temperature >38 0 C or <36 0 C heart rate >90 bpm respiratory rate >20 breaths/min or PaCO 2 <4.3kPa white cell count >12,000 cells/mm 3, <4,000 cells/mm 3 or >10% immature forms. When SIRS is present an infective cause should be sought first. NUTRITION Oral intake should be commenced as soon as possible after surgery. Nutritional replacement 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 metabolic status should be assessed regularly and the nutritional prescription modified as necessary. Given the lack of a strong evidence base of effective practice for postoperative management this guideline has been developed using a combination of evidenced based and consensus techniques. Initial systematic searches identified any relevant evidence. The critically appraised evidence, together with the clinical experience of the guideline development group, informed the formal consensus methods that were used to develop recommendations. These are presented in the form of consensus statements.

58 Any change in a monitoring regimen should prompt reassessment of the level of care. 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. Following specialist surgery it may be necessary to assess additional factors. Pain and adequacy of pain control The monitoring regimen should be reviewed daily so as best to provide data for clinical decision making. Any significant symptoms eg chest pain, breathlessness Postoperative monitoring should be continued on a daily basis. operation out of hours emergency or high risk surgery 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. ASA grade 3 Patients with the following risk factors for deterioration should be reassessed within two hours of the first postoperative assessment: Patients requiring the frequent monitoring of multiple variables should be considered for care at level 2 or above. GCS, oxygen saturation and blood glucose Patients at risk of deterioration require frequent assessment. if confusion is present (AMT) MONITORING If abnormal determine: A postoperative assessment should be carried out when the patient returns from theatre. Patient conscious and normally responsive? (AVPU; Alert, Verbal, Painful, Unresponsive) THE FIRST POSTOPERATIVE ASSESSMENT Drainage from drains, wounds & NG tubes Urine colour and rate of production any specific treatment or prophylaxis required (eg fluids, nutrition, antibiotics, analgesia, anti-emetics, thromboprophylaxis). Jugular venous pressure Conjunctival pallor any specific postoperative instruction concerning possible problems Blood pressure Pulse rate, volume and rhythm any anaesthetic, surgical or intraoperative complications Capillary return <2s or not? Anaesthetic and surgical staff should record the following items in the patient s case notes: Hands - warm or cool, pink or pale? Percussion note DISCHARGE FROM THEATRE AND POSTANAESTHETIC RECOVERY Breath sounds Symmetry of respiration/expansion Trachea central or not? Only accept responsibility appropriate to your training and experience. If in doubt ASK FOR HELP Respiratory rate Effort of breathing/use of accessory muscles Oxygen saturation clinical assessment and monitoring respiratory management cardiovascular management fluid, electrolyte and renal management control of sepsis nutrition Recommended treatment & prophylaxis Postoperative instructions Intraoperative complications Allergies Optimal postoperative care requires: Medications Past medical history PRINCIPLES OF POSTOPERATIVE MANAGEMENT SAMPLE MONITORING REGIMEN FOR FIRST FEW POSTOPERATIVE HOURS CHECKLIST FOR FIRST POSTOPERATIVE ASSESSMENT 77 POSTOPERATIVE MANAGEMENT IN ADULTS: A PRACTICAL GUIDE TO POSTOPERATIVE CARE FOR CLINICAL STAFF

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