Postoperative Management in Adults

Scottish Intercollegiate Guidelines Network

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 0131 247 3664 OR ONLINE AT WWW.SIGN.AC.UK

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 1 899893 09 1
First published 2004

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

1

Introduction

1.1

THE NEED FOR GUIDANCE
Over the past five years, annual reports from the Scottish Audit of Surgical Mortality (SASM)
have highlighted problems in perioperative management of patients. These include failure to
predict or recognise clinical decline, failure to involve consultants at an early stage and failure to
appreciate the consequences of not acting promptly when decline is identified.1 SASM has
consistently highlighted variation in practice in postoperative care. Almost 2,000 patients die
following surgery in Scotland each year. In the vast majority, death is the inevitable consequence
of the disease process. However, it is likely that some 10,000 patients per year suffer major
complications after surgery and “best practice” guidelines might have an impact in this area.
As a consequence of these audits, SASM has called for the development of local and national
guidelines on the use of intensive care unit (ICU) and high dependency unit (HDU) resources
and in particular has suggested that the Scottish Intercollegiate Guidelines Network (SIGN) should
produce guidelines for postoperative management focusing on symptoms and signs of wellknown serious complications. The target audience for the guidelines would be nursing, allied
health care and trainee medical staff. It was suggested that a SIGN guideline could cover monitoring
of postoperative patients and the investigation and management of clinical deterioration in the
postoperative period.

1.2

DEVELOPING A CONSENSUS GUIDELINE
The evidence of variation in practice and the repeated calls for guidance in this area clearly
indicated the need for a guideline. SIGN however, has always developed evidence based guidelines,
and the lack of a strong evidence base of effective practice meant that postoperative management
would not be suitable for guideline development using standard SIGN methodology. Instead, it
was proposed to develop a guideline using consensus techniques. 2-6 Initial systematic searches
were used to identify any relevant evidence and this was critically appraised using standard SIGN
methodology. The evidence base was not extensive and was often confined to specific patient
groups. The evidence that was appraised was used, together with the clinical experience of the
guideline development group, to inform the formal consensus methods that were used to develop
recommendations. These are presented in the form of “consensus statements”. More details of
the methodology are given in section 9.

1.3

REMIT OF THE GUIDELINE
The remit of the guideline was determined by the guideline development group, who used
formal consensus techniques to prioritise their answers to the question “What treatment decisions
and evaluation criteria do you think are important in postoperative care?”
This guideline covers:
1. Early identification of at-risk patients
2. Monitoring in the postoperative period
3. Early recognition, investigation, and management of clinical deterioration
4. Identification of key physiological requirements in the postoperative period
5. Referral to expert care
6. Nutrition in the postoperative period.

1

POSTOPERATIVE MANAGEMENT IN ADULTS

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

ETHOS OF THE GUIDELINE

1.4.1

A TEAM APPROACH
In 1974 Professor P F Jones dedicated his book Emergency Abdominal Surgery8 to:
“The Night Watch - my registrar colleagues over the years in recognition of their hard won 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

FOCUSING ON POSTOPERATIVE MANAGEMENT
The guideline concentrates on the postoperative period and does not address concepts such as
optimisation or protective strategies instituted preoperatively. The development group recognises
that the postoperative period is only one part of the journey of care but, as reported by SASM,
this is perceived to be an area where the need for guidance is paramount.1
Much has been said about the “Golden Hour” after trauma when decisions taken can have a
significant effect on outcome. There may well be a “Platinum 24 Hours” after surgery when
patients are particularly vulnerable and where decision making has similar importance. This
guideline is designed to assist trainee staff in making decisions even if that decision is to call for
advice. The guideline development group recommends that surgical units develop protocols that
make it clear when it is time to call for advice.

1.5

STATEMENT OF INTENT
This guideline is not intended to be construed or to serve as a standard of care. Standards of 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 patient’s case notes at the time the relevant
decision is taken.

2

2 CLINICAL ASSESSMENT AND MONITORING

2

Clinical assessment and monitoring

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

DISCHARGE FROM POSTANAESTHETIC RECOVERY
The following criteria must be fulfilled before a patient can be discharged from the recovery
room:9
n

n
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 patient’s 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 (>36°C)
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 patient’s
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).

3

POSTOPERATIVE MANAGEMENT IN ADULTS

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

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

Level 1 - formerly ward
Appropriate for patients
n
n
n

at risk of their condition deteriorating
recently relocated from immediate postanaesthetic recovery
whose needs can be met on a surgical ward with additional advice and support from a critical
care team

Level 2 – formerly HDU
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

Level 3 - formerly ICU
Appropriate for patients
n
n
n

requiring advanced respiratory support alone
requiring basic respiratory support together with support of at least two organ systems
requiring complex support for multi-organ failure.

2.2

ASSESSMENT

2.2.1

THE FIRST POSTOPERATIVE ASSESSMENT – WHEN AND WHO?
The first postoperative assessment should take place immediately after surgery on return to the
ward. It provides a baseline against which the patient’s condition may subsequently be assessed
and identifies any problems that may have occurred on transfer from the operating department.
CS

A postoperative assessment should be carried out when the patient returns from theatre.

This assessment may be carried out by the doctor responsible in the first instance for patient care,
usually the House Officer. When the doctor is unavailable or the case is minor and 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

4

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

2 CLINICAL ASSESSMENT AND MONITORING

2.2.2

THE FIRST POSTOPERATIVE ASSESSMENT – HOW?
The first assessment reviews the intraoperative course, past medical history, medications and
allergies. The nurse responsible for the care of the patient should inform the doctor of any other
information concerning deterioration or incident during the patient’s transit from theatre.
CS

If the nurse responsible for the care of the patient becomes unavailable for 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 first postoperative assessment should determine:
n
intraoperative history and postoperative instructions
n
circulatory volume status
n
respiratory status
n
mental status.

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

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

Having assessed the patient, the doctor should legibly record the findings in the notes at 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.

5

POSTOPERATIVE MANAGEMENT IN ADULTS

Table 1: The first postoperative assessment
Checklist for the first postoperative assessment
Review intraoperative history and postoperative instructions
n
n
n
n
n
n

past medical history
medications
allergies
intraoperative complications
postoperative instructions
recommended treatment and prophylaxis.

Complete a respiratory status assessment
n
n
n
n
n
n
n

oxygen saturation
effort of breathing/use of accessory muscles
respiratory rate
trachea - central or not?
symmetry of respiration/expansion
breath sounds
percussion note.

Complete a circulatory volume status assessment
n
n
n
n
n
n
n
n
n
n

hands - warm or cool, pink or pale
capillary return – less than two seconds or not?
pulse rate
pulse volume
pulse rhythm
blood pressure (see section 3.3)
conjunctival pallor
jugular venous pressure (JVP, see below)
urine colour and rate of production (see section 5.6)
drainage from drains, wounds and nasogastric tubes.

Complete a mental status assessment
n

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

In addition to the physical assessment, record:
n
n

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

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

Appropriate lighting should be used in order to visualise the jugular venous pressure. The 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.

6

2 CLINICAL ASSESSMENT AND MONITORING

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

Patients at risk of deterioration require frequent assessment.

CS

Patients with the following risk factors for deterioration should be reassessed within two
hours of the first postoperative assessment:
n
ASA grade ³3
n
emergency or high risk surgery
n
operation out of hours.

TREATMENT AND PROPHYLAXIS
The following postoperative treatment and prophylaxis options should be discussed preoperatively
with the appropriate members of the clinical team:
n
n
n
n

n
n
n
n

adequate pain control
venous thromboembolism prophylaxis
antibiotic prophylaxis
continuation of current medications (these, and in particular cardiorespiratory treatments,
should be continued wherever possible)
substitution of current medication (eg diabetic control, steroid therapy)
prophylaxis for postoperative nausea and vomiting
ability of patients to take drugs by mouth
pressure area management.

Postoperatively, consider the need for:
n
n
n

physiotherapy
nutrition team consultation (see section 7.5.4)
oral hygiene.

CS

Local protocols should be established for:
n
drug treatment of pre-existing cardiovascular and respiratory disorders
n
treatment of postoperative nausea and vomiting.

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

7

POSTOPERATIVE MANAGEMENT IN ADULTS

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
patient’s 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

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

NB The monitoring of nutritional status and support is discussed in section 7.5.3.
2.4.2

ADDITIONAL MONITORING
Patients with, for example, pre-existing cardiorespiratory disease or who have had longer, 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

8

2 CLINICAL ASSESSMENT AND MONITORING

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

RULES AND TRIGGERS FOR MONITORING AND INTERVENTION
Patient monitoring is most useful when the doctor and nurse responsible for care agree:
n
n

specific criteria that should prompt a call to the doctor
specific time points (eg half hourly, hourly) for the reporting of trends, whether or not the
parameters being monitored fall within abnormal levels.

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.

DAILY CLINICAL ASSESSMENT
Successful management of patients in the postoperative period requires routine assessment until
discharge.
Repeated clinical assessment is key to early detection of deterioration but, depending on the
clinical condition of the patient, does not need to be as detailed as the initial assessment.
Surgical patients are usually seen once or twice a day on the ward round and their status must be
documented. Clear clinical notes must be kept and an entry made every time a patient is reviewed.
This assessment is the most complete opportunity to ensure that the patient is progressing in a
satisfactory manner. Each daily assessment is an opportunity to modify the monitoring regimen
so as best to provide data for clinical decision making.
CS

n
n

n

Postoperative monitoring should be continued on a daily basis
The monitoring regimen should be reviewed daily so as best to provide data for
clinical decision making
Any change in a monitoring regimen should prompt reassessment of the level of care.

9

POSTOPERATIVE MANAGEMENT IN ADULTS

2.6

THE ROLE OF SENIOR MEDICAL STAFF
Where junior doctors have difficulty managing a patient, or in admitting a patient to a special
care area, it is essential to discuss the patient with the responsible senior doctors. Training in
postoperative care may influence outcome.9
CS

n

n

n

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

3

Cardiovascular management

3.1

INTRODUCTION
In general, maintaining a patient’s 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

POSTOPERATIVE MANAGEMENT IN ADULTS

Table 3: Classification of Blood Pressure
Category

Systolic Pressure (mm Hg)

Diastolic Pressure (mm Hg)

Optimal
Normal
High Normal

<120
120-129
130-139

<80
80-84
85-89

Hypertension (mm Hg)
Stage 1
Stage 2
Stage 3
Stage 4

140-159
160-179
180-209
>210

90-99
100-109
110-119
>120

The American College of Cardiology/American Heart Association (ACC / AHA) guidelines18
recommend deferring surgery if the diastolic pressure is above 110 mm Hg and systolic is above
180 mm Hg.
Antihypertensive medication should be continued during the postoperative period for patients
with known and treated hypertension, as unplanned withdrawal of treatment can result in rebound
hypertension.
In practice, the decision to give antihypertensive drugs must be made for each patient, taking
into account their normal blood pressure, and their postoperative blood pressure.
For some patients, after major surgery, this may require a change from oral to parenteral
administration. The advice of the clinical pharmacist should be sought about equivalent dosages
or suitable alternatives to oral preparations.
Many patients on admission to hospital have elevated systolic pressure with normal diastolic
pressure. Once settled into the ward environment systolic pressure often falls to normal. Around
half of those aged over 60 years have isolated systolic hypertension.19 A linear relationship exists
between increasing admission systolic pressure and the risk of postoperative silent ischaemia. 20 A
clear association between admission arterial pressure and major perioperative cardiac complications
has not however been demonstrated.21,22
CS

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 patient’s 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

Further assessment is required for patients with:
n
heart rate below 50 beats per minute
n
heart rate above 100 beats per minute
n
blood pressure below 100 mm Hg systolic.

3 CARDIOVASCULAR MANAGEMENT

Table 4: Assessment of hypotension
Assessment of hypotension
Observe if:

3.3.2

Seek further advice if:

Awake or easily rousable

Drowsy or unrousable

Comfortable

Distressed

Normal preoperative BP

Hypertensive preoperatively

Warm

Cold

Well perfused (capillary refill <2 seconds)

Capillary refill >2 seconds

Heart rate 50-100bpm

Heart rate >100 or <50 bpm

Passing urine (>0.5 ml/kg/hr)

Oliguric (<0.5 ml/kg/hr)

No obvious bleeding

Signs of bleeding (drains, wounds, haematoma)

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

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.

C

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

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

2+

13

POSTOPERATIVE MANAGEMENT IN ADULTS

Factors affecting supply and demand of myocardial oxygen include:
n
n
n
n
n
n
n
n
n
n
n

release of pro-inflammatory mediators
hypercoagubility
diminished fibrinolytic activity
endothelial dysfunction
atherosclerotic plaque instability
fluctuating adrenergic activity
plasma catecholamine levels
body temperature
pulmonary dysfunction
fluid balance
pain.

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

ASSESSING THE RISK OF POSTOPERATIVE CARDIAC COMPLICATIONS
The ACC/AHA guidelines on perioperative cardiovascular evaluation for non-cardiac surgery
include a full discussion of preoperative assessment.18 In the perioperative period, the Revised
Cardiac Risk Index is a useful tool. It stratifies risk based on the presence of a number of clinical
factors, thus informing an appropriate patient management plan (see Tables 5 and 6).18,39
Table 5: Revised Cardiac Risk Index
Clinical factors
High risk surgery (see Table 6 for definitions)
History of ischaemic heart disease
History of congestive heart failure
History of cerebrovascular disease
Preoperative insulin treatment
Preoperative creatinine >180 micromol/l.
The rates of major cardiac complications postoperatively with 0,1,2,3 or more risk factors were
0.5%, 1.3%, 4% and 9% respectively.

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.

MEDICAL TREATMENT TO REDUCE PERIOPERATIVE CARDIAC RISK
Several studies have demonstrated that beta blockers are effective in reducing perioperative
ischaemia.40-43 Although caution has been expressed in the general use of prophylactic beta
blockade,44 reviews suggest that perioperative blockade reduces the incidence of both ischaemia
and MI in patients undergoing high risk surgery.45,46
CS

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

B

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

3.6

ARRHYTHMIAS AND CONDUCTION DEFECTS

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

POSTOPERATIVE MANAGEMENT IN ADULTS

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

GENERAL MANAGEMENT OF ARRHYTHMIAS
n

n
n

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.

MANAGEMENT OF SPECIFIC ARRHYTHMIAS
Atrial fibrillation (AF)
Chronic - maintain rate control, preferably using the drug treatment found to be effective preoperatively. Oral therapy may need to be converted to parenteral perioperatively.
New-onset - may be managed by DC cardioversion, pharmacological conversion to sinus rhythm
or rate control. Rate control is indicated where AF has been present for >48hrs, due to the
increasing risk of systemic embolus in the non-anticoagulated patient. New-onset AF has a high
rate of spontaneous conversion to sinus rhythm (about 50% at 24hrs).48
Pharmacological conversion
n

n

n

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

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.

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

16

3 CARDIOVASCULAR MANAGEMENT

Supraventricular tachycardia (SVT)
Adenosine (3-12 mg) and verapamil hydrochloride (5-10 mg) IV are equally effective in the
termination of regular narrow-complex paroxysmal supraventricular tachycardia. Adenosine has
the advantage of brief duration of action and less hypotension. It may be associated with a high
relapse rate in critically ill patients. Verapamil hydrochloride and beta blockers should not be
used concurrently.
Ventricular tachycardia (VT)
The occurrence of ventricular ectopic beats or non-sustained ventricular tachycardia does not
appear to have prognostic significance and, in the absence of signs or symptoms of myocardial
ischaemia, may not require aggressive monitoring or treatment. In haemodynamically unstable
patients, VT is most effectively treated by DC cardioversion. Inappropriate or ineffective drug
treatment may worsen the situation.
IV anti-arrhythmic drugs may be used in haemodynamically stable patients. The European
Resuscitation Council (ERC) guidelines51 recommend amiodarone hydrochloride or lidocaine
hydrochloride as the drugs of choice for monomorphic VT and magnesium sulphate (IV 8 mmol,
or 4 ml, 50% over 10-15 min)52 for polymorphic VT.
CS

Seek expert help early in the management of serious or potentially serious arrhythmias
and reconsider the level of care.

CS

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

CS

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

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.

Implanted Pacemakers and defibrillators
Patients with implanted pacemakers and defibrillators should have their device checked by a
cardiologist before and after surgical procedures.

3.8

PERIOPERATIVE MYOCARDIAL INFARCTION
Perioperative MI (PMI) carries a high risk of both short and long term morbidity. It is usually
silent in presentation with non-specific ECG changes.
Troponin I has been shown to be a sensitive and specific method for the diagnosis of PMI in
vascular and spinal surgery patients.54 Troponin T has been shown to be a marker for PMI in
patients with CAD or CAD risk factors undergoing non-cardiac surgery.55,56
Serial troponin measurements during the preoperative, intraoperative and postoperative periods
may identify myocardial injury, reflect the degree of injury and help in categorising subsequent
risk.
Patients who sustain perioperative MI should not receive thrombolytic agents. In all other respects
they should be managed as in any other setting, receiving aspirin 300 mg orally, but monitored
in a setting with immediate specialist input.

17

POSTOPERATIVE MANAGEMENT IN ADULTS

3.9

CS

Where perioperative MI is diagnosed or suspected early specialist medical advice should
be sought.

CS

Patients with high clinical risk of perioperative MI undergoing high or intermediate-risk
procedures should have:
n
ECG at baseline, immediately following surgery and daily for the two subsequent
days
n
cardiac troponin measurements 24 hours after surgery.

CS

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

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

Maintain normothermia in the postoperative period.

CS

Active warming is appropriate for patients who are hypothermic postoperatively.

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

n

n

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

examine patient thoroughly
assess IV fluid regimen and drugs
order ECG and chest X-ray
request specialist advice for assessment and possible echocardiogram
if patient in acute distress consider IV furosemide 40-80 mg.

Table 7: Features of cardiac failure
FEATURES OF LEFT HEART FAILURE include
lung crepitations
dyspnoea
pulmonary oedema on chest X-ray
gallop rhythm
FEATURES OF RIGHT HEART FAILURE include
peripheral oedema
raised JVP
hepatic enlargement and occasionally tenderness
PRECIPITATING FACTORS
acute myocardial infarction or ischaemia
arrhythmia (including loss of heart rate control in patients with established atrial fibrillation)
anaemia
fluid overload
pulmonary thromboembolism
drugs added, eg non-steroidal anti-inflammatory drugs
drugs omitted, eg diuretics
NB None of these signs are specific for cardiac failure and must be assessed in the
clinical context.

19

POSTOPERATIVE MANAGEMENT IN ADULTS

4

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

n

patients requiring IPPV may already have pulmonary complications
patients requiring prolonged preoperative stay may have other problems and may also have
an ASA >1
cognitive function may be impaired before operation or may develop as a result of the
intervention and be caused by pulmonary complications.

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

20

4 RESPIRATORY MANAGEMENT

4.3

REDUCING POSTOPERATIVE PULMONARY COMPLICATIONS

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+

POSTOPERATIVE FLUID BALANCE
Following surgery the capacity to excrete fluid is reduced. Fluid accumulation, particularly in the
lungs, may result in oedema. Cardiac and pulmonary complications and mortality after
pneumonectomy are more common if fluid balance is strongly positive 73 and this association
also appears to be relevant after non-thoracic surgery.74 Fluid balance following surgery must be
very carefully controlled to avoid excess fluid accumulation (see section 5).

4.3.3

OXYGEN THERAPY
Oxygen is often given to patients after surgery but good evidence supporting its routine use 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

POSTOPERATIVE MANAGEMENT IN ADULTS

4.4

MONITORING AND DIAGNOSIS

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

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

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.

Acute respiratory distress syndrome and acute lung injury:
n
n
n

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

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

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

The following indicate the possible development of respiratory complications:
n
Respiratory rate <10 or>25 breaths per minute
n
Pulse rate >100 beats per minute
n
Reduced conscious level.

INVESTIGATIONS
Specific and non-specific investigations are available and should be used as indicated clinically.
n

n

n

n

n

n

Pulse oximetry. It may be difficult to obtain a satisfactory signal if peripheral circulation is
poor. Patients receiving supplemental oxygen may have adequate oxygen saturation despite
hypoventilation and hypercapnia.
Arterial blood gas analysis (ABG). ABG is essential in the assessment of any patient with
suspected respiratory complications. ABG accurately defines the degree of respiratory failure
and differentiates between metabolic and respiratory acidosis.
Chest X-ray. Chest X-rays should be used to diagnose or exclude major collapse, pulmonary
embolism and pleural problems such as effusions, pneumothorax or haemothorax. Routine
X-rays are of limited value, even in patients who have had thoracic surgical procedures.83
Small areas of atelectasis are common but not necessarily significant. Diffuse pulmonary
infiltrates may be caused by conditions such as cardiac failure, infection and ARDS.
CT scan. Valuable in the accurate assessment of pulmonary masses, pulmonary embolism or
major pleural disease such as empyema. It has no place in the routine management of
postoperative pulmonary complications.
Bacteriology. Sputum culture is of value in planning appropriate antibiotic therapy. Specimens
taken by endobronchial suction may be used.
ECG. Significant respiratory compromise may relate to a primary cardiac event, and so all
patients who are investigated for pulmonary complications should also have an ECG.

CS

n

n

n

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.

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

TREATING RESPIRATORY INFECTION
Treatment should aim to maintain oxygenation, clear blocked airways, expand collapsed alveoli
and clear infection.

23

POSTOPERATIVE MANAGEMENT IN ADULTS

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

Nasal catheters (± foam)

Low flow system
Variable performance

2-4 litre/min

Hudson mask

Low flow system
Variable performance

4-8 litre/min

Venturi mask with venturi jet

High flow system
Fixed performance

24,28,35,40,60% oxygen

Venturi mask attached to
humidification system
Reservoir mask

High flow system
Fixed performance
High flow system
Fixed performance

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

TREATMENT OF RESPIRATORY FAILURE
Respiratory failure may be purely a ventilatory problem and in the postoperative period this may
be due to one of a variety of drugs. It is important to identify drug related problems as specific
antidotes are available.
Drugs
Many drugs depress ventilation. Specific antagonists are available for the commoner suppressant
drugs namely opioids, neuromuscular blocking agents and benzodiazepines. Specific respiratory
stimulants may also be appropriate. It is important to remember that antagonists usually have a
shorter action than agonists and dosage may have to be repeated. Antagonists such as naloxone
hydrochloride or flumazenil should be given carefully because acute reversal can cause acute
pain, withdrawal symptoms, or fits.
CS

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

CS

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

CS

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

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

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.

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

decreased lung volume
sputum retention
increased work of breathing
reduced exercise tolerance.

25

POSTOPERATIVE MANAGEMENT IN ADULTS

Following general anaesthetic, a patient’s 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

facilitate re-expansion of atelectasis
maintain adequate ventilation
assist with the removal of bronchial secretions
encourage early mobility
promote return to preoperative functional levels.

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

Increase lung volume

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

Reduce work of breathing

Rest and sleep
Positioning
Breathing control exercises
Breathing re-education
Mechanical aids/assisted ventilation

Adequate analgesia prior to physiotherapy will allow more patients to participate in treatment.
Local treatment protocols may be in place for specific patient groups.
4.6.2

REDUCING POSTOPERATIVE PULMONARY COMPLICATIONS
Postoperative pulmonary complications have been reduced from 60% to 19% with simple
supervised breathing exercises in patients undergoing upper abdominal surgery88 and major
abdominal surgery (from 27% to 6%, p<0.001), with the addition of resistance training in high
risk patients.89
Devices such as incentive spirometers have not been consistently shown to be better than standard
breathing exercises.90

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

Patients with sputum retention should be assessed by a physiotherapist.

CS

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

OUT OF HOURS SERVICES
Most hospitals also operate an out of hours respiratory physiotherapy service for emergencies,
with local guidelines giving details of service provision.91 Table 10 gives a guide to when out of
hours physiotherapy may be appropriate.
Table 10: When to use out of hours physiotherapy services
CRITERIA FOR EMERGENCY CALL-OUTS
The patient has a condition that is amenable to physiotherapy which has either:
n deteriorated
n or is likely to deteriorate without intervention before the daytime service resumes
PROBLEMS WHICH MAY BE HELPED BY PHYSIOTHERAPY
Secretion retention which is compromising ventilation
Acute lobar collapse
Acute aspiration
DO NOT CALL FOR
Respiratory compromise due to pain, until pain is controlled
Sputum retention due to dehydration, until patient is rehydrated
Bronchospasm
Pulmonary embolism
Reduced lung volume due to pleural effusion
Pulmonary oedema/fluid overload

27

POSTOPERATIVE MANAGEMENT IN ADULTS

5

Fluid, electrolyte and renal management

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

BASAL REQUIREMENTS IN THE POSTOPERATIVE PATIENT
CS

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

PRINCIPLES OF FLUID BALANCE
As in any patient, the standard principles of fluid balance in the postoperative patient are:
n
n
n
n

to correct any pre-existing deficit
to supply basal needs
to replace unusual losses (eg from the pre-existing surgical problem, surgical drains, pyrexia)
to use the oral route where possible; there is often an unnecessary delay in commencing oral
intake after surgery.

There is a longstanding conflict between ‘wet’ and ‘dry’ schools, particularly with regard 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

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

28

5 FLUID, ELECTROLYTE AND RENAL MANAGEMENT

5.2

CS

Invasive monitoring should be considered to assess fluid balance status, particularly in
high risk patients.

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

the surgical condition
medical problems complicating the surgical condition
pre-existing medical problems (eg renal, cardiac or hepatic disease)
medications such as diuretics
problems of limited homeostasis in older patients making them susceptible both to over- and
under-loading of fluids and electrolytes.

The following patients are particularly at risk:
n
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 patient’s fluid status
and electrolyte balance need to be estimated, taking into consideration:
n
n
n
n

5.4

unusual losses as the result of the surgical problem prior to assessment
continuing surgical-related losses
usual maintenance needs
vasodilating effects of epidural analgesia.

CS

Be aware that preoperative bowel preparation or prolonged preoperative fasting may
result in covert hypovolaemia, which may become evident only in the early postoperative
period.

CS

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

CS

Avoid excessive administration of fluids to hypotensive patients with epidural anaesthesia
who are well perfused. This can cause fluid overload which may only become manifest
when the epidural infusion is stopped.

DETECTION OF OVERT CLINICAL PROBLEMS
Patients should be monitored for problems such as:
n
n
n
n
n

hypotension
tachycardia
oliguria
signs of fluid overload (such as pulmonary oedema)
more subtle signs such as confusion or tachypnoea.

29

POSTOPERATIVE MANAGEMENT IN ADULTS

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

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

MANAGEMENT OF VOLUME DEPLETION AND OVERLOAD

5.5.1

VOLUME DEPLETION
Volume depletion can lead to poor tissue perfusion and this can result in both morbidity and
mortality.
The specific consequences are:
n
n
n
n

anastomotic breakdown
cerebral damage
renal failure
multiple organ failure.

Table 11: Volume depletion
Possible causes of volume depletion
n
n

n
n

unrecognised or uncorrected preoperative hypovolaemia (including effects of fasting)
inadequate intra- or postoperative replacement, bearing in mind:
n
third space losses (fluid sequestration in the gut or peritoneal cavity, oedema)
n
drain losses
n
fistulae
n
polyuric renal failure
n
hyperventilation
n
pyrexia
n
nasogastric aspirate
haemorrhage
inappropriate use of diuretics.

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 FLUID, ELECTROLYTE AND RENAL MANAGEMENT

Table 12: Volume overload
Possible causes of volume overload
Excessive fluid administration due to:
n
overestimation of loss (drain or third space losses)
n
failure to recognise deteriorating renal function
n
failure to recognise deteriorating cardiac function.
CS

5.6

Volume overload should be avoided.

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

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

CS

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

CS

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

CS

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

31

POSTOPERATIVE MANAGEMENT IN ADULTS

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

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

CS

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

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

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.

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).

5 FLUID, ELECTROLYTE AND RENAL MANAGEMENT

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

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

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

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

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 Hartmann’s
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

POSTOPERATIVE MANAGEMENT IN ADULTS

6

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

RISK FACTORS FOR INFECTION
Several studies have identified a series of risk factors for postoperative infection, outlined in
Table 14. Minimising the risk of infection in such patients is logical and should be an integral
part of their care pathway.
Table 14: Risk factors for postoperative infection
complicated surgery, eg total gastrectomy > than other gastroduodenal procedures94
prolonged operation time94-96
blood transfusions94,95
hypothermia
increasing age95,97
presence of remote infection96,98 or faecal contamination98
male sex98
poor physical status of patient,98 malnutrition, immunocompromise, severe underlying disease
emergency surgery95
use of invasive procedures (urinary catheter, chest tubes, nasogastric tube passage)95
prolonged intravascular cannulation
prolonged postoperative stay96
patients receiving chemotherapy or radiotherapy, immunosuppressants, steroids
severe trauma or burns
There is little evidence to demonstrate how these factors influence or predict outcome.

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

Prophylactic antibiotics should be administered to appropriate groups of patients to reduce
the risk of developing postoperative sepsis.

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.

Other aspects of hand care and protection:
Glove use
n
n
n

n

n
n

gloves should be used as an adjunct to, not a substitute for, handwashing
gloves should be used for hand-contaminating activities
gloves should be removed and hands washed when hand-contaminating activity is completed,
when the integrity of the gloves is in doubt, and between patients
gloves may need to be changed during the care of a single patient, for example when moving
from one procedure to another
disposable gloves should be used only once and should not be washed for reuse
gloves made of other materials should be available for personnel with sensitivity to usual
glove material (such as latex), and for use in patients with a similar sensitivity.

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

35

POSTOPERATIVE MANAGEMENT IN ADULTS

6.4

CS

Gloves should be used for hand-contaminating activities.

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

n

n

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

Early identification and appropriate treatment of sepsis improves outcome.

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

ANTIMICROBIAL THERAPY IN SEPSIS
Antimicrobial therapy is the cornerstone of management of patients with sepsis. Results from
analysis of microbial specimens, and any proposed changed in antibiotic therapy may need to be
reviewed with the consultant microbiologist. There are few comparative studies on the efficacy
and safety of different antimicrobial regimens in non-neutropenic or postoperative patients.
Treatment guidelines for patients with sepsis have been based on the results of large, multicentre
studies conducted in neutropenic cancer patients.108 Retrospective studies have shown that early
administration of appropriate, broad spectrum109 antibiotics reduces mortality.110

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

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

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

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

Abdominal sepsis, if localised, can be managed initially with antibiotics or percutaneous drainage,
but generally the primary source of sepsis must be treated surgically (eg anastomotic leakage).
Meticulous attention to peritoneal toilet with copious lavage is essential. The role of 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

POSTOPERATIVE MANAGEMENT IN ADULTS

6.5.3

CS

Percutaneous drainage following radiological identification should be considered for
well defined collections.

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

7

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

AVOIDING ROUTINE NASOGASTRIC INTUBATION
To promote a return to normal dietary intake, the presence of a nasogastric (NG) tube should be
avoided. Evidence from several randomised trials 115 and a meta-analysis 116 indicates that
avoiding routine nasogastric decompression after abdominal surgery significantly reduces the
incidence of fever, atelectasis and pneumonia.

7.2.1

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

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++

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

PROVISION AND ACCESS TO APPETISING FOOD
Studies in hospital patients have shown that up to 20% of meals are missed while patients attend
or are fasted for investigative or therapeutic interventions, whilst 40% of the content of meals
delivered to the patient is discarded.119 The provision of appetising hospital food and access to
sufficient nursing staff to help patients who have difficulty in eating is a key issue in helping
patients return to a normal food intake.

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.

NUTRITIONAL STATUS AND POSTOPERATIVE NAUSEA AND VOMITING
The control of postoperative nausea and vomiting is essential if patients are to resume normal
oral fluid and dietary intake. The regular use of anti-emetics is advised.
CS

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

39

POSTOPERATIVE MANAGEMENT IN ADULTS

7.2.4

PREVENTION OF POSTOPERATIVE ILEUS
The effect of early enteral feeding on ileus is controversial. No data were identified from randomised
clinical trials on the effect of laxatives on postoperative paralytic ileus.

7.2.5

USE OF ORAL SUPPLEMENTS
Patients who are malnourished either at the time of, or shortly following, major abdominal or
vascular surgery have a more rapid recovery of nutritional status, physical function and quality of
life, if given nutritional advice and prescribed routine oral supplements in the immediate
postoperative period and following two months.120

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

MULTIMODAL RECOVERY PROGRAMMES
Use of early oral or artificial enteral nutrition at a time when gastrointestinal function has not
returned to a suitable level can be associated with abdominal distension, vomiting and respiratory
embarrassment.123

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+

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

7.3.1

MALNUTRITION AND SURGICAL RISK; SCREENING TOOLS
Patients who are malnourished are at increased risk of postoperative complications.126,127 A variety
of strategies have been suggested for screening patients for malnutrition in the community, but it
is not clear whether their implementation reduces morbidity or mortality.

7.3.2

2+

MALNUTRITION IN BENIGN DISEASE
There is no evidence that malnourished patients with benign disease and requiring surgery (eg
Crohn’s disease) benefit from prolonged preoperative artificial nutritional support. Such patients
are best treated by surgical correction of their pathology followed by intensive nutritional support
in the postoperative period.
CS

7.3.3

Malnourished patients with benign disease requiring surgery should receive postoperative
nutritional support by the appropriate route.

MALNUTRITION IN MALIGNANT DISEASE
There is some evidence to suggest that severely malnourished patients with cancer benefit from
perioperative total parenteral nutrition (TPN).128 This benefit does not pertain to cancer patients
with mild or moderate malnutrition, where a meta-analysis has shown that perioperative TPN
has no benefits in terms of mortality.129
Upper GI cancer patients are often given postoperative enteral feeding either via a jejunostomy or
fine-bore nasoenteral feeding tube. This allows maintenance of nutritional status should the
patient develop a postoperative complication that retards normal progression towards oral nutrition
(eg an anastomotic leak).

40

1+

7 POSTOPERATIVE NUTRITION

A meta-analysis has demonstrated that enteral nutritional support supplemented with
immunomodulatory nutrients results in a significant reduction in the risk of developing infectious
complications but has no effect on mortality.130 The cost effectiveness of such a strategy has not
been clearly established. Immunonutrition may be given preoperatively as well as
postoperatively.131

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+

ARTIFICIAL NUTRITIONAL SUPPORT
Generally, if oral nutrition is not re-established within five to seven days postoperatively, enteral
or parenteral feeding should be considered.

7.4.1

ASSESSMENT OF NUTRITIONAL REQUIREMENTS
Energy and protein requirements depend on body composition, clinical status and mobility. An
estimation of requirements is 30 kcal/kg/day and 1.0 g protein/kg/day for the average patient.
Few patients require more than 2,200 kcal/day. Additional calories are unlikely to be used
effectively and may constitute a metabolic stress.
Daily biochemical monitoring must be undertaken when initially refeeding the chronically severely
malnourished patient because of the dangers of hypokalaemia and hypophosphataemia. Nutritional
requirements should be determined in consultation with a dietitian.
CS

7.4.2

Nutritional replacement should be discussed with a dietitian and tailored to the patient’s
requirements.

ENTERAL OR PARENTERAL NUTRITION?
Postoperative nutritional support has potentially serious complications. Enteral nutrition uses
the physiological route of nutrient intake, is cheaper and is generally safer, and should be the
preferred method of nutritional support, in the presence of a functioning gastrointestinal tract.
CS

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

POSTOPERATIVE MANAGEMENT IN ADULTS

7.5

ARTIFICIAL NUTRITIONAL TECHNIQUES

7.5.1

ENTERAL NUTRITION
Nasogastric feeding
The most appropriate route of enteral tube feeding for patients who require short term support (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

Parenteral nutrition should be provided through a dedicated intravenous catheter.

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

42

7 POSTOPERATIVE NUTRITION

Table 16: Monitoring nutritional support requirements
Status

Markers

Biochemistry

Electrolytes, urea, blood glucose, urinalysis, liver
function tests (twice weekly)
Fluid charts, weight
Weight, nitrogen balance (once weekly)
Nursing records, food and fluid charts

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

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

43

POSTOPERATIVE MANAGEMENT IN ADULTS

8

Information for discussion with patients
and carers

8.1

EXAMPLE INFORMATION SHEET FOR DISCUSSION WITH PATIENTS
WHO WILL BE LOOKING AFTER YOU?
During your stay in hospital you will be cared for by a team of healthcare professionals,
including, doctors, nurses, physiotherapists, pharmacists and occupational therapists.
Decisions on your care will be made on a team basis with input from all members
under the supervision of the consultants who are responsible for your care.
The main aim of the team caring for you is to ensure that your recovery from surgery
is uneventful and completed in the shortest time possible.
Before your operation you will be carefully assessed and this may reveal other
conditions requiring treatment. If so you may be started on new treatments which
may have to be continued after the operation.
WHAT HAPPENS AFTER YOUR OPERATION?
Immediately after the operation your recovery from the anaesthetic and surgery will
be assessed by measuring your blood pressure, pulse rate, breathing rate, temperature
and the amount of oxygen in your blood. If you have had major surgery or have
other conditions such as heart disease you may require additional tests.
When your condition is stable you will be transferred from the recovery area to a
ward, high dependency unit or intensive care unit depending on the type of care
you require. If you are taken to an intensive care unit or high dependency unit at
first, then as your condition improves and you require less intensive observation, you
may then be cared for in a normal ward.
In the early phase of your recovery from your operation you may need to be very
carefully monitored, especially if you have undergone major surgery. You may find
that you are assessed quite frequently, and although you may find this disruptive, it
is necessary to monitor your progress. The observations will be no more frequent
than necessary to ensure your well being. The monitoring is vital to detect any changes
so that remedial actions may be taken at an early stage.
You may need oxygen treatment, usually from a mask or a tube in your nose, after
your operation. If you have chest or heart problems, this may be needed for several
days. In some cases, a tube (catheter) in your bladder will be used to measure how
much urine is being produced, which helps show how well the kidneys are working.
Your care can also involve treatment to prevent blood clots (deep vein thrombosis),
infections, and nausea.
COPING WITH PAIN
Many patients are concerned about having pain following surgery and your team
of carers will have a plan of how this will be controlled. It is important that you tell
them if you have pain as they wish to make your recovery as pain free as possible.
MOVING AND EATING AFTER YOUR OPERATION
Following your operation you will be encouraged to become as mobile as possible
as this helps to prevent complications such as blood clots or chest infection and
speeds recovery. You may receive instruction from the physiotherapist to help you
with your breathing. You will also be encouraged to eat and drink as soon as it is
feasible as maintaining your level of nutrition is an important aspect of recovery.

44

9 DEVELOPMENT OF THE GUIDELINE

9

Development of the guideline

9.1

INTRODUCTION
This guideline was supported by a grant from the Chief Scientist’s 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 SIGN’s standard evidence based methodology are contained in SIGN 50: A
guideline developer’s handbook available at www.sign.ac.uk

9.2

THE DEVELOPMENT GROUP
Dr Harry McFarlane (Co-chair)
Mr Robert C Smith (Co-chair)
Ms Sarah Armstrong
Mr Ian Currie
Dr Gordon Drummond
Professor Kenneth Fearon
Miss Mary Glasgow
Dr Graham Hilditch
Mr Roland Ingram
Dr Simon Mackenzie
Ms Morag Naysmith
Dr David O’Neill
Mr Christopher Rodger
Professor D Gwyn Seymour
Miss Gail Thomson

Consultant Anaesthetist, Aberdeen Royal Infirmary
Consultant in General Surgery,
Falkirk and District Royal Infirmary
Associate Director of Nursing,
Forth Valley NHS Acute Hospital, Falkirk
Clinical Lecturer in Surgery, Royal Infirmary of Edinburgh
Consultant Anaesthetist, Royal Infirmary of Edinburgh
Professor of Surgical Oncology,
Royal Infirmary of Edinburgh
Clinical Nurse Educator, Aberdeen Royal Infirmary
Specialist Registrar in Anaesthesia,
Glasgow Western Infirmary
Consultant Orthopaedic Surgeon, Glasgow Royal Infirmary
Consultant Anaesthetist, Royal Infirmary of Edinburgh
Principal Pharmacist, Western General Hospital, Edinburgh
Consultant Physician, Crosshouse Hospital, Kilmarnock
Research Fellow, Department of Coloproctology,
Glasgow Royal Infirmary
Professor of Medicine (Care of the Elderly),
University of Aberdeen
Senior 1 Physiotherapist, Royal Infirmary of Edinburgh

SIGN FACILITATORS
Miss Gemma Healy
Dr Moray Nairn
Dr Safia Qureshi

Assistant Information Officer, SIGN
Programme Manager, SIGN
Programme Director, SIGN

ACKNOWLEDGEMENTS
Dr Joris Berwaerts
Mr Ross Carter
Mrs Jane McCready

9.3

Medicines Control Agency, London
Consultant General Surgeon, Glasgow Royal Infirmary
Senior Staff Nurse, Victoria Infirmary, Glasgow

SYSTEMATIC LITERATURE REVIEW
The evidence base for this guideline was synthesised in accordance with SIGN methodology. A
systematic review of the literature was conducted using an explicit search strategy devised by a
SIGN Information Officer in collaboration with members of the development group. Internet
searches were conducted on the websites of the US National Guidelines Clearinghouse, the
45

POSTOPERATIVE MANAGEMENT IN ADULTS

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 panel’s collective opinion on the
suitability of each consensus statement.
The appropriateness score for an individual statement is the median of the panel’s ratings. The
panel is considered to be:
n

n

n
n
n

in agreement over the appropriateness of a statement when no more than 3 of the
individual members’ ratings are outside a 3-point region that includes the median rating
disagreement occurs when 1 or more ratings is in the 1-3 region, and 1 or more in
the 7-9 region
clearly appropriate statements will have a median of 7-9 without disagreement
clearly inappropriate statements will have a median of 1-3 without disagreement
equivocal statements - with a median of 4-6, or where there is disagreement on a
proper rating

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

9.5

CONSULTATION AND PEER REVIEW

9.5.1

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

46

9 DEVELOPMENT OF THE GUIDELINE

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

Nutrition Nurse Specialist, Aberdeen Royal Infirmary
Final year medical student, University of Aberdeen
Specialist Registrar in Obstetrics and Gynaecology,
Aberdeen Maternity Hospital
Consultant Physician, Victoria Hospital, Kirkcaldy
Consultant Anaesthetist, Ninewells Hospital, Dundee
Consultant in Anaesthesia and Intensive Care,
Glasgow Royal Infirmary
Specialist Registrar in Anaesthesia,
Falkirk and District Royal Infirmary
Consultant Radiologist, Stirling Royal Infirmary
SHOIII / Research fellow,
Lister Department of Surgery, Glasgow
Final Year Medical Student, University of Aberdeen
Practice Development Nurse,
Grampian University Hospitals
Charge Nurse, Aberdeen Royal Infirmary
Practice Development Nurse, Stirling Royal Infirmary
Consultant in Anaesthesia,
Southern General Hospital, Glasgow
Clinical Ward Manager, High Dependency Unit,
Stirling Royal Infirmary
Final Year Medical Student, University of Aberdeen
Consultant in General Surgery, Aberdeen Royal Infirmary
Lecturer, School of Nursing and Midwifery,
Robert Gordon University, Aberdeen
Surgical Co-ordinator, Surgical Unit,
Falkirk and District Royal Infirmary
Consultant Anaesthetist, Ninewells Hospital, Dundee
Specialist Registrar in Orthopaedics,
Glasgow Royal Infirmary
Portex Professor of Anaesthesia and Critical Care,
Institute of Child Health, London
Consultant in Anaesthesia, Royal Infirmary of Edinburgh
Final Year Medical Student, University of Aberdeen
Consultant Radiologist,
Borders General Hospital, Roxburghshire
Surgical Specialist Registrar, Victoria Infirmary, Glasgow
Lay Representative, Glendevon
Consultant in Anaesthesia, Royal Infirmary of Edinburgh
Clinical Specialist in Respiratory Physiotherapy,
Aberdeen Royal Infirmary
Professor and Honorary Consultant of Anaesthesia and
Intensive Care, Aberdeen Royal Infirmary
Charge Nurse, Intensive Care Area,
Falkirk and District Royal Infirmary
Professor of Anaesthesia, University Department of
Anaesthesia, Ninewells Hospital and
Medical School, Dundee
Clinical Lecturer, Clinical and Surgical Sciences,
University of Edinburgh

47

POSTOPERATIVE MANAGEMENT IN ADULTS

Abbreviations

48

ABC

Airways, breathing, circulation

ABG

Arterial blood gases

ACC/AHA

American College of Cardiology/American Heart Association

ADH

Antidiuretic hormone

AF

Atrial fibrillation

ALI

Acute lung injury

ARDS

Acute respiratory distress syndrome

ASA

American Society of Anesthesiologists

AVPU

Alert, verbal, painful, unresponsive

BMI

Body mass index

CAD

Coronary artery disease

CHF

Chronic heart failure

CI

Confidence intervals

COPD

Chronic obstructive pulmonary disease

CS

Consensus statement

CT

Computed tomography

ECG

Electrocardiogram

FiO2

Fractional concentration of oxygen in inspired gas

GCS

Glasgow coma score

GI

Gastrointestinal

GTN

Glyceryl trinitrate

HDU

High dependency unit

ICD

Implantable cardioverter defibrillators

ICU

Intensive care unit

INR

International normalised ratio (of the prothrombin time)

IPPB

Intermittent positive pressure breathing

IPPV

Intermittent positive pressure ventilation

JVP

Jugular venous pressure

LBBB

Left bundle branch block

LVH

Left ventricular hypertrophy

MI

Myocardial infarction

NG

Nasogastric

NSAID

Non-steroidal anti-inflammatory drug

OR

Odds ratio

PaCO2

Arterial carbon dioxide partial pressure (measured from a blood gas sample)

PaO2

Arterial oxygen partial pressure (measured from a blood gas sample)

PAWCP

Pulmonary artery wedge capillary pressure

RCT

Randomised controlled trial

RR

Relative risk

SASM

Scottish Audit of Surgical Mortality

SIGN

Scottish Intercollegiate Guidelines Network

SIRS

Systemic inflammatory response syndrome

SpO2

Oxygen saturation measured by a pulse oximeter

SaO2

Oxygen saturation from a blood gas sample

SVA

Supraventricular arrhythmia

SVT

Supraventricular tachycardia

TPN

Total parenteral nutrition

VT

Ventricular tachycardia

ANNEXES

Annex 1
Assessing Conscious Level
THE AVPU SCALE
A - Alert

The patient is alert, awake, responsive to voice and oriented to person,
time, and place.

V - Verbal

The patient responds to voice, but is not fully oriented to person, time,
or place.

P – Painful

The patient does not respond to voice, but does respond to a painful
stimulus, eg pinching the skin.

U - Unresponsive

The patient is unresponsive to both verbal and painful stimuli.

THE ABBREVIATED MENTAL TEST
Correct answers to each question score one point
Age
Time to nearest hour
An address, eg 42 West Street, to be repeated at the end of the test
Month
Year
Name of place
Date of birth
Year first world war started
Name of present monarch
Count backwards from 20 to 1
TOTAL SCORE
Scores: 8-10 normal; 7 probably abnormal; <6 abnormal
THE GLASGOW COMA SCALE AND SCORE
Feature

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

Best motor response

Obey commands
Localise pain
Flexion - Normal
- Abnormal
Extend
None

6
5
4
3
2
1

TOTAL COMA ‘SCORE’

3/15 - 15/15

49

POSTOPERATIVE MANAGEMENT IN ADULTS

Annex 2
American Society of Anesthesiologists Physical Status
Classification System

50

ASA 1

A normal healthy patient

ASA 2

A patient with mild systemic disease

ASA 3

A patient with severe systemic disease

ASA 4

A patient with severe systemic disease that is a constant threat to life

ASA 5

A moribund patient who is not expected to survive without the operation

ASA 6

A declared brain-dead patient whose organs are being removed for donor purposes

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.

Postoperative Monitoring Chart

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

POSTOPERATIVE MANAGEMENT IN ADULTS

References

26

1

27

2
3
4

5
6
7

8
9
10
11
12
13
14
15
16
17
18

19
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technique: a research tool for general practice? Fam Pract 1993:10(1):76-81.

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

SEPSIS

Postoperative blood pressure should always be reviewed with
reference to the preoperative and intraoperative assessments

Early identification and appropriate treatment of sepsis improves
outcome.

CARDIOVASCULAR MANAGEMENT (Contd.)

Further assessment is required for patients with:

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.

Well perfused (capillary
refill <2 seconds)

Warm

Normal preoperative BP

Comfortable

Awake or easily rousable

Observe if:

Heart rate >100 or <50 bpm

Capillary refill > 2 seconds

Cold

Hypertensive preoperatively

Distressed

Drowsy or unrousable

Seek further advice if:

Beta blockers and IV nitrates may be used safely and effectively in
postoperative hypertension.

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.

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.

Results from microbiological specimens should be reviewed
regularly and antibiotics changed as necessary.

If the cause of sepsis is unknown, treat with broad spectrum
antibiotics, guided by local protocols.

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.

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”.

Nutritional and metabolic status should be assessed regularly and
the nutritional prescription modified as necessary.

Enteral nutrition is the preferred method of postoperative
nutritional support and should be used if possible.

Nutritional replacement should be discussed with a dietitian and
tailored to the patient's requirements.

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

NUTRITION

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

Systemic inflammatory response syndrome (SIRS) is defined as the
presence of 2 or more of the following:
§ temperature >380C or <360C
§ heart rate >90 bpm
§ respiratory rate >20 breaths/min or PaCO2 <4.3kPa
§ white cell count >12,000 cells/mm3 , <4,000 cells/mm3 or
>10% immature forms.

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

Urine and blood cultures should be obtained whenever there is
reason to suspect systemic sepsis.

§
§

Heart rate 50-100 bpm

Oliguric (<0.5 ml/kg/hr)

heart rate < 50 and > 100 bpm
blood pressure <100 mm Hg systolic.

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 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.
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 >380C
§ Positive sputum culture
§ Positive clinical findings
§ Abnormal chest X-ray – Atelectasis/infiltrates

CARDIOVASCULAR MANAGEMENT

Passing urine (>0.5 ml/kg/hr)

ASSESSMENT OF HYPOTENSION

No obvious bleeding

Signs of bleeding (drains,
wounds, haematoma)

Metabolic acidosis is usually due to poor tissue perfusion but can
also be caused by excessive administration of saline.

§
§
§

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

Pain and adequacy of pain control

Any significant symptoms eg chest pain,
breathlessness

§ GCS, oxygen saturation and
blood glucose

§ if confusion is present (AMT)

If abnormal determine:

Patient conscious and normally responsive ?
(AVPU; Alert, Verbal, Painful, Unresponsive)

Drainage from drains, wounds & NG tubes

Urine colour and rate of production

Jugular venous pressure

Conjunctival pallor

Blood pressure

Pulse rate, volume and rhythm

Capillary return <2s or not?

Hands - warm or cool, pink or pale?

Percussion note

Breath sounds

Symmetry of respiration/expansion

Trachea central or not?

Respiratory rate

Effort of breathing/use of accessory muscles

Oxygen saturation

Recommended treatment & prophylaxis

Postoperative instructions

Intraoperative complications

Allergies

Medications

Past medical history

CHECKLIST FOR FIRST
POSTOPERATIVE ASSESSMENT

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

The monitoring regimen should be reviewed daily so as best to
provide data for clinical decision making.

Postoperative monitoring should be continued on a daily basis.

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.

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

MONITORING

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SAMPLE MONITORING REGIMEN FOR FIRST
FEW POSTOPERATIVE HOURS

POSTOPERATIVE MANAGEMENT IN ADULTS: A PRACTICAL GUIDE TO POSTOPERATIVE CARE FOR CLINICAL STAFF

PRINCIPLES OF POSTOPERATIVE
MANAGEMENT

clinical assessment and monitoring
respiratory management
cardiovascular management
fluid, electrolyte and renal management
control of sepsis
nutrition

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.

Patients with the following risk factors for deterioration
should be reassessed within two hours of the first
postoperative assessment:
§ ASA grade ≥ 3
§ emergency or high risk surgery
§ operation out of hours

Patients at risk of deterioration require frequent assessment.

A postoperative assessment should be carried out when the
patient returns from theatre.

THE FIRST POSTOPERATIVE ASSESSMENT

any anaesthetic, surgical or intraoperative complications
any specific postoperative instruction concerning
possible problems
any specific treatment or prophylaxis required
(eg fluids, nutrition, antibiotics, analgesia, anti-emetics,
thromboprophylaxis).

Anaesthetic and surgical staff should record the following
items in the patient’s case notes:

DISCHARGE FROM THEATRE
AND POSTANAESTHETIC RECOVERY

Only accept responsibility appropriate to your training and
experience. If in doubt ASK FOR HELP

§
§
§
§
§
§

Optimal postoperative care requires:

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