Level of care
Appropriate patients
0 – Ward
Those who have undergone minor surgical procedures
Those whose needs can be met through normal ward care
1 – Surgical Ward
Those who are at risk of their condition deteriorating
Those whose needs can be met on a surgical ward with advice and support from a critical care team available
2 – High Dependency Unit (HDU)
Those who require a monitored bed. Nurse:patient ratio in HDU is 1:2
Those who require support for failure of a single organ system, including the need for continuous positive airway pressure (CPAP)
3 – Intensive Therapy Unit (ITU)
Those who require complex support, e.g. advanced respiratory support or support for failure of more than one organ system
Those who require mechanical ventilation and advanced monitoring
Those who require one to one nursing
It may become necessary to move a patient to a different setting for a different level of care; ITU is considered the highest, while HDU is a step down. Care is provided by a multidisciplinary team (MDT) of ITU physicians and nurses, specialist physicians, dieticians and physiotherapists.
The patient’s notes should also include any surgical or anaesthetic complications that occurred, and specific instructions for any problems that may arise.
Care of the Critically Ill Surgical Patient
Critical illness is defined as injury overwhelming the physiologic reserve, to the point where life cannot be sustained without outside intervention; for example when asthma worsens, causing intubation and mechanical ventilation to become necessary. Physiological reserve may be compromised by age or prolonged illness.
The stress response to surgery causes physiological changes in patients. Figure 10.1 outlines the support methods provided in a critical care setting (HDU or ITU).
Fig. 10.1
Methods of support provided to critically ill patients in critical care settings. Cardiorespiratory support includes intubation, ventilatory and inotropic support, and a central line for monitoring central venous pressure. Fluid resuscitation is important. Ventilation strategies, including spontaneous breathing trials, allow faster weaning from mechanical ventilation
Post-operative Assessment and Monitoring [5]
A post-operative assessment should be carried out upon the patient’s return to the ward. This provides a baseline which subsequent assessments can be compared against during the recovery process.
This assessment should include:
A review of history and peri-operative instructions:
Past medical history, medication and allergies.
Intraoperative complications and post-operative treatment instructions.
Respiratory status: oxygen saturation, respiratory rate, breath sounds, percussion notes, and tracheal position.
Circulatory volume: hands (warm or cool), capillary refill, pulse rate/rhythm, blood pressure, jugular venous pressure (JVP), urine colour and rate of production, and drainage from the wound.
Mental state: assess patients’ consciousness and responsiveness using the AVPU scale (Alert – Responsive to Voice – Responsive to Pain – Unresponsive).
Any significant symptoms: chest pain, breathlessness
Post-operative pain
A monitoring regimen for the patient should be established including: temperature, pulse rate, blood pressure, respiratory rate, peripheral oxygen saturation, and urine output. Pain should also be assessed. Monitoring should be frequent in the initial period after surgery (e.g. every 15 min for the first hour), and then less frequently over time (e.g. every 30 min, dropping to once an hour after 2 h).
Certain patients, including those in higher levels of care, those who have undergone longer or more invasive procedures, or those with pre-existing cardiorespiratory disease, may require additional monitoring including: electrocardiogram (ECG), arterial blood pressure (ABP), central venous pressure (CVP), arterial blood gas (ABG), and haematology.
Post-operative monitoring assesses the patient’s physiological state, allowing decisions regarding analgesia, nutrition, fluid management and wound care to be made.
Post-operative Analgesia
Up to 75 % of surgical patients experience post-operative pain [1]. If uncontrolled, this can significantly affect recovery, increasing morbidity and mortality and decreasing quality of life. Post-operative management aims to minimise pain severity and duration.
Effects of Post-operative Pain
If unrelieved, post-operative pain can have a variety of effects (Table 10.2).
Table 10.2
The effects of uncontrolled post-operative pain by system
Effects of uncontrolled post-operative pain | |
|---|---|
Metabolic | Catabolism (increased cortisol, glucagon and catecholamines) |
Cardiovascular | Increased myocardial oxygen demand and coagulation |
Respiratory | Decreased functional residual capacity, sputum retention |
Gastrointestinal (GI)/Genitourinary (GU) | Vomiting, ileus, sodium and water retention |
Psychological | Anxiety and depression |
Unrelieved pain increases the likelihood of negative clinical outcomes, such as: deep vein thrombosis (DVT)/Pulmonary embolism (PE), coronary ischaemia/myocardial infarction (MI), poor wound healing, pneumonia, insomnia, and demoralisation.
There are also economic considerations – post-operative pain can extend the length of stay and increase chances of readmission [1].
The WHO analgesic ladder is reversed for surgical patients. Opioid analgesics, such as morphine, are usually administered as first line treatment intravenously or into the epidural space. These can have side effects, including nausea (an anti-emetic may be administered), urinary retention and respiratory depression. Supplementing opioids with other analgesics, such as non-steroidal anti-inflammatory drugs (NSAIDs), has been associated with reduced risk of opioid side effects.
A common management method for post-operative pain is patient-controlled analgesia (PCA), where a programmed dose of opioid is given ‘on demand’ – it is administered intravenously via a pump when the patient pushes a button. This is also used in labour pain and palliative care, and usually results in high patient satisfaction.
Pain Scoring
Post-operative pain can be scored using a variety of methods.
Qualitatively: verbal rating score (none/mild/moderate/severe).
Quantitatively: numerical rating scale (0 -no pain, 10 -worst pain imaginable).
Visual analogue scale: pain indicated on line (no pain to worst pain imaginable), which is good for children.
Fluid Management
In addition to providing the normal daily fluid requirements of the patient, fluid management is used to administer drugs, correct fluid and electrolyte imbalances and for fluid resuscitation.
Normally, fluid production (metabolic processes) and intake (food and liquids) balance the fluid lost from urine, stool, lungs and the skin. If losses exceed intake, patients become dehydrated; if intake is greater, they experience fluid overload.
Symptoms of dehydration: thirst, fatigue, impaired concentration, dry skin, cool peripheries, and reduced urine output.
Symptoms of fluid overload: shortness of breath, ankle swelling, and fatigue.
Assessing fluid balance: fluid balance should be assessed by examination. The basic procedure is outlined below.
General inspection: IV fluids, consciousness level (Glasgow Coma Scale)
Hands: peripheral perfusion, capillary refill, pulse, skin turgor, blood pressure
Face: sunken eyes, dry mucous membranes
Neck: jugular venous pulse, central venous pulse
Chest: pulmonary oedema, extra heart sounds
Abdomen: ascites
Legs: peripheral oedema
Daily weight
The fluid challenge: fluid balance can be assessed by a fluid challenge, where 250 mL of the colloid gelofusin is given over 15 min.
If blood pressure increases and returns to normal, the patient is euvolaemic (normal blood volume).
If blood pressure does not increase, the patient is hypovolaemic (decreased blood volume) and fluid resuscitation is necessary.
If blood pressure increases, the patient is hypervolaemic (increased blood volume).
Prescribing IV fluids: there are two main types of IV fluid that can be prescribed to correct fluid balance –
Crystalloids (solutions of water-soluble molecules) include 0.9 % saline, dextrose saline and Hartmann’s solution (contains electrolytes such as sodium, chloride, potassium, and lactate).
Colloids (insoluble particles in suspension) may be natural (blood and albumin) or synthetic (gelofusin or haemacell).
Nutrition
Malnutrition in surgical patients is associated with poor outcomes and longer hospital stays. It impairs protein dependent functions in the body, leading to complications such as infection, poor wound healing and wound dehiscence (modern Latin dehiscentem, to gape).
Patients with weight loss of >10 % of their body weight are considered to be severely malnourished. Nutritional support for post-operative patients can be provided in three ways: oral, enteral and parenteral.
Oral support: the rise of enhanced recovery after surgery (ERAS) programmes mean that more and more patients are provided with oral support after undergoing surgery, instead of enteral or parenteral. Oral support can be polymeric (whole or undigested proteins), elemental (individual amino acids that require little digestion) or disease specific, for example in patients with liver failure, branched chain amino acids and Vitamin K are provided.
Enteral support: administering nutrition directly into the GI tract. This is usually done via a nasogastric tube. Risks include malposition of the tube and aspiration of food into the respiratory tract.
Parenteral support: providing nutrition intravenously. Both macronutrients such as amino acids, lipids and glucose, and micronutrients such as electrolytes and vitamins can be administered using this method.
Wound Healing
Types of incision closure: surgical incisions can be closed in two main ways.
Primary intention – the edges of the wound are brought together and the wound is closed with sutures, staples, adhesives or tape. Epithelialisation occurs within 24–48 h.
Secondary intention – the wound is left open and allowed to granulate.
The stages of wound healing: there are four main stages of wound healing.
Get Clinical Tree app for offline access
- 1.
Haemostasis – occurs immediately and Von Willebrand factor is secreted. Platelets then adhere to the damaged endothelium and aggregate, forming a platelet plug. Fibrin is added to this platelet plug, reinforcing it.
- 2.
Inflammation: there are two phases.
Early phase (24–48 h) – the complement cascade is activated, and granulocytes produce free radicals and antibacterial proteases. Epithelial cell migration and proliferation then begins.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
