35 General Principles of Postoperative Intensive Care Unit Care Michael J. Hockstein | Laura S. Johnson CHAPTER OUTLINE POSTOPERATIVE EVALUATION Management of Agitation and Delirium RECOVERY FROM ANESTHESIA Management of Blood Glucose level Postoperative Resuscitation POSTOPERATIVE NUTRITION Awakening from Anesthesia Timing and Route Postoperative Extubation Feeding Considerations in General BEST PRACTICES Surgery Patients Prevention of Venous Thromboembolism and WOUND HEALING AND CARE Deep Venous Thrombosis Physiology and Biology of Wound Healing Stress Ulcer Prophylaxis Epithelialization and Wound Care Preventing Nosocomial Pneumonia Optimizing Wound Healing Regionalization within a health care structure allows for volume resuscitation, or administration of vasoactive medi- more efficient control and use of limited resources. The cations, make ICU care unavoidable. Monitoring of level of intensive care unit (ICU) contains specially trained staff and consciousness, airway, bleeding, pulses, rhythm, acidosis, a variety of support devices, such as mechanical ventilators, urine output, and global perfusion also is facilitated by ICU intra-aortic balloon pumps, ventricular assist devices, and admission. Identifying patients who may need postoperative dialysis machines, which in most cases cannot be used else- ICU care can be difficult. Although there are scoring systems where. Optimally, the location of a patient is determined by to assess risk and fatality (APACHE, SAPS, MPM, SOFA), it matching the patient’s needs with a location’s resources and is difficult to apply these predictions to specific disease states expertise. or individual patients. Some prediction models utilize physi- Generally, the surgical ICU is where experience, staffing, ologic data for patients after admission to the ICU and have skills, and technology converge to provide services that not been validated as preadmission screening tools.7,8 Physi- cannot be provided anywhere else within the hospital. cians may predict mortality risk even better than scoring Highly skilled nurses, often greater in number than the systems.9 In practice, most physicians do not use these tools patients themselves, work intimately with intensivists and to determine postoperative ICU admission. Admission cri- ancillary staff in an environment designed to stabilize, diag- teria based on priority, diagnosis, and objective parameter nose, and simultaneously treat the most acutely ill patients. models have been published by the Task Force of the Ameri- ICU management by intensivists allows for improved staff can College of Critical Care Medicine and the Society of and family satisfaction, reduced complication rates, lower Critical Care Medicine.10 costs, shorter length of stay, improved processes of care, and a morbidity and mortality risk advantage.1-4 ICU systems focused on an environment of safety and compliance with POSTOPERATIVE EVALUATION evidence-based standards promote improvement in many outcome metrics.5 Safe and efficient patient throughput Obtaining a comprehensive medical and surgical history is allows for greater institutional procedural volume, which, a fundamental step in understanding a patient in the surgi- when paired with surgeon procedural volume, has been cal ICU. The medical record, traditionally written but now shown to be associated with reduced mortality risk.6 more commonly electronic, should contain all of the ele- Classic postoperative indications for ICU admission ments necessary to assemble the story up until the time of include advanced age or prolonged duration of the opera- ICU admission, although deciphering a chart, particularly tion, both criteria without specifically defined thresholds. when it is long, requires time, patience, and detective skills. Other factors, such as the need for mechanical ventilation, Data gathering usually begins by word of mouth from the 594 CHAPTER 35 — GENERAL PRINCIPLES OF POSTOPERATIVE INTENSIVE CARE UNIT CARE 595 providers delivering the patient. Effective “hand-off” is intravenous fluid rates are 80 to 125 mL/hour, but can be essential to maintain the continuity of care and to ascertain substantially higher in the presence of ongoing intravascu- important operative events that may have escaped docu- lar volume loss. Isotonic fluids are the most appropriate mentation. It is in fact a standard expected by The Joint maintenance fluids. It is useful to inquire about the last time Commission.11 Certain questions are common to virtually all the patient received narcotics, benzodiazepines, or paralyt- admissions: ics and if reversal agents were given. Finally, any intra- operative laboratory values, particularly ones that require 1. How old is the patient? immediate attention, should be reviewed. 2. What are the highlights of the medical/surgical history? When time permits, attention should be directed back to 3. Was the operation elective or emergent? the medical record. The clinician should scan the history 4. What operation was performed, and what are the details and physical examination, progress notes, and consultations of the surgery? to develop a cohesive story line of events that led up to the 5. Are there any drains? operation. Did the illness have an impact on nutrition or 6. What are the current ventilator settings if the patient is functional state? How are other comorbid conditions or past intubated? operations related to the current presentation? The past 7. What medications is the patient receiving currently? medical history and the medication list should be scruti- 8. Where are the vascular access points? Were they placed nized; the two are complementary. Inclusion of a disease in under sterile conditions? the past medical history and absence of an expected medica- 9. What was the intubation and anesthetic course like? tion warrants further investigation (and vice versa). The 10. What were the complications, if any? medication list should be scanned in particular for anti- seizure medications, bronchodilators, antihypertensives, Age, comorbid conditions, and emergency operations all antiarrhythmics, anticoagulants, diuretics, steroids, thyroid affect mortality risk. The details of the operation are key, replacement, and insulin. It must be decided which medica- often aided by diagrams in the chart. Resections, diversions, tions must be continued in the immediate postoperative anastomoses, transplantations, use of prosthetic materials, period and which can be temporarily delayed. If antibiotics and other surgical findings are some of the details that were administered preoperatively, the clinician should iden- should be obtained. In addition, the type and location of tify what they were and how long had they been given and each drain must be accounted for. Only by knowing where for what indication. In general, if administered preopera- a drain is placed can a care provider know how to interpret tively, bronchodilators, steroids, and insulin are resumed the quantity and quality of the effluent. Each drain or wire postoperatively. Long-acting antihypertensives should be must be labeled correctly. Also, the completion of wound avoided in the early postoperative period, and short-acting closure must be ascertained (skin and fascia closed?). intravenous agents should be used to control hypertension. Finally, if the operation was incomplete or intentionally Diuretics should be avoided in the immediate postoperative staged, the health care provider needs to inquire about period unless directed by invasive monitoring or required intentions and timing of return to the operating room. because of some other medical necessity. The use of early The significance of the anesthesia record should not be postoperative beta blockade in patients with coronary artery minimized. The details about trends in gas exchange, blood disease is encouraged if the overall hemodynamic perfor- pressure, urine output, medications, and summary fluid mance allows. Most other medications can be safely delayed balance should be reviewed. Always identify if the intubation until the postoperative patient has shown satisfactory cardio- was easy or difficult. Reviewing the ventilator settings that pulmonary performance and stability. were used in the operating room sheds some light on any Postoperative laboratory, imaging, and electrocardio- possible gas exchange difficulties and provides a first oppor- gram studies should be selected on a case-by-case basis. tunity to make corrections. Tidal volumes in the operating Patients who have been moved from operating room table room are often much larger than those used in the ICU. to bed and then transported for any distance are at risk for Identification of current medications and the purpose of displacement of tubes and catheters. The admission chest each help to formulate short-term therapeutic strategies. radiograph allows for the evaluation of intravascular cathe- Assessing the adequacy of intraoperative resuscitation ter and endotracheal, nasogastric, and thoracostomy tube begins with a review of the quantifiable gains and losses. positions in addition to visualization of the pleural, medias- Resuscitation fluids, blood products, urine output, cavity tinal, and parenchymal structures. Measurements of blood fluid, and blood losses should all be reviewed. Evaporative counts and chemistries are usually routine, but may be and extravascular (third space) losses may be more difficult deemed unnecessary if preoperative or intraoperative values to accurately quantitate. Major surgical procedures such as were unremarkable