Prakash Shastri, Yogendra Pal Singh,

and Jigeeshu V. Divatia

A 45-year-old, previously healthy, female was admitted to the ICU in a state of shock. She had history of pain in the abdomen and vomiting. She had undergone vaginal hysterectomy and posterior floor repair under general anesthesia for prolapsed uterus a week back and apparently made complete recovery. After successful resuscitation, the surgeon was consulted who decided to perform an exploratory laparotomy.

Intensive care physicians are increasingly being involved in taking care of surgical patients perioperatively, due to acute physiological derangements which occurs during anesthesia and surgery and requirement for close monitoring. Principles of resuscitation and a coordinated care, essential ingredients for caring for any acutely ill patient, are equally applicable to perioperative patients.

Step 1: Assess the reason for perioperative admission to the ICU

•Perioperatively, the patient may be admitted to the ICU for the following reasons:

–Elective preoperative admission for monitoring and optimization of hemodynamics and respiratory status in high-risk cases.

–Elective postoperative admission for monitoring and organ support for highrisk and major surgeries

P. Shastri, M.D., F.R.C.A. (*)

Critical and Emergency Care, Sir Ganga Ram Hospital, New Delhi, India e-mail: prakashshastri@live.in

Y.P. Singh, M.D.

Critical Care, Max Superspeciality Hospita, New Delhi, India

J.V. Divatia, M.D., F.I.S.C.C.M.

Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai, India

•Airway monitoring in major oral, head, and neck surgery

•Flap monitoring in major plastic surgery

•Elective ventilation after prolonged surgery

–Emergent postoperative admission for unexpected intraoperative complications

•Intraoperative severe blood loss

•Hemodynamic instability due to arrhythmia and myocardial ischemia

•Intraoperative cardiac arrest

•Respiratory complications postextubation

•The approach in the form of initial resuscitation, monitoring, and intensity of investigation would be different in each of these situations.

Step 2: Obtain a complete and detailed handover from the anesthesia and surgical teams, take focused history, and perform physical examination

•Confirm the patient’s identification

•Type of surgery

•Duration of surgery

•Anesthesia chart and postoperative notes—airway problem during intubation

•Intraoperative complications, estimated blood loss, and transfusions of blood and blood products

•Postoperative instructions

•Surgical drains placement

•Fluids, antibiotics, analgesia, antiemetic prescription

•Epidural catheters or patient-controlled analgesia (PCA) pumps

•Review of the medical records of the patient

•Drug history—aspirin, other antiplatelet agents, oral anticoagulants, and oral hypoglycemics

Step 3: Identify immediate postoperative problems

•The following are the initial general concern in immediate postoperative period in the ICU:

•Postoperative pain

–Aggressive and appropriate pain relief is an essential component of any postoperative care and should be managed in consultation with the pain management team.

–Pain should be assessed objectively with a pain scale and analgesia is titrated according to the patient’s response (see Chap. 33).

–The following modalities of pain relief are usually available:

•Intermediate and long-acting opioid analgesics (morphine 2–4 mg) intravenously in aliquots or via PCA. During PCA, morphine is generally given without continuous infusion, and a common initial setting is 1 mg boluses on demand with a lock-out period of 10 min.

•Nonsteroidal opioid analgesic (e.g. diclofenac intravenously/intramuscularly/rectal suppository). These should be avoided in patients at risk of renal injury, including elderly patients, and in those who have suffered intraoperative hemodynamic compromise.

•Intravenous paracetamol.

•Intravenous tramadol.

•Intrathecal/epidural opioid and local anesthetic combinations (thoracic, abdominal, gynecological, and major orthopedic surgery).

•Intra-articular infiltration with opioid/local anesthetics (joint surgery).

•Nerve blocks.

•Persistent sedation

–Review the chart for perioperative anesthetic and sedative agents administered.

–Residual effect of anesthetic drugs is the most common cause, and treatment is expectant with close watch on airway. Rarely, reversal of opioids with naloxone is required.

–If effect remains prolonged, other causes such as hypothermia, hypercarbia, hypoglycemia, and hyponatremia should be looked for.

–Residual neuromuscular blockade is another important cause of hypoventilation and “delayed recovery.” It can be diagnosed using a peripheral nerve stimulator.

•Nausea and vomiting

–Postoperative nausea and vomiting is a troublesome complication of general anesthesia.

–Manage with reducing doses of opioids, changing to alternative analgesics.

–Give ondansetron 4–8 mg intravenously.

•Altered mental state

–Occasionally, abnormal behavioral response during recovery from anesthesia is encountered and is usually due to medication effect and is rarely due to hypoxia, acidosis, or hypotension.

–Reassurance, avoidance of hypnotics, and correcting underlying physiological derangements usually suffice.

•Hypothermia and shivering

–This results from combined effects of inhalation of dry gases during anesthesia, convective and evaporative losses during surgery, infusion of cold intravenous fluid and blood products, medication effect, and use of muscle relaxants.

–These may be detrimental to the cardiorespiratory system especially in patients with low cardiorespiratory reserve.

–This may also lead to tissue ischemia with delayed wound healing, increased incidence of surgical site infection, organ hypoperfusion due to vasoconstriction, and a tendency to bleed. Patients with coronary artery disease and those with vascular anastomoses and skin grafts are particularly vulnerable.

–Patients with core temperature below 35°C on arrival to the ICU should be actively rewarmed with warm air blankets, warm intravenous fluid, and adequate covering. All hypothermic patients should receive supplemental oxygen.

Step 4: Identify and correct fluid imbalance

•Conventional fluid intake–output charts may not reflect fluid balance in postoperative patients.

glucocorticoids in patients with reactive airway disease.

•Postoperatively, high-risk patients are prone to develop respiratory failure due following reasons:

–Atelectasis

–Aspiration

–Splinting of diaphragm due to pain and hypoventilation

–Tracheobronchitis and pneumonia

–Noncardiogenic pulmonary edema—due to aspiration, blood transfusion, fat emboli

•The following measures should be taken postoperatively to avoid respiratory complications:

–Early ambulation and assisted coughing

–Adequate hydration and humidification of inspired air and oxygen

–Intermittent positive-pressure breathing exercises

–Noninvasive ventilation specially in patients with chronic obstructive pulmonary disease with hypercarbia

–Optimizing use of analgesics, epidural analgesia, and avoiding excessive sedation

–Minimizing the use of the nasogastric tube

–Early identification and treatment of sepsis and shock

–Early stabilization by external fixators of long bone fractures using a damage control philosophy, with formal internal fixation undertaken later, after the acute inflammatory response has ebbed

Step 7: Provide other general measures

•Transporting patients perioperatively safely, with adequate monitoring, appropriate handover, and documentation checklist, should be performed judiciously (see Chap. 83).

•Early identification of ongoing hemorrhage by inspecting volume and type of drain, hemodynamic instability, falling hematocrit and correcting volume deficit, hypothermia, acidosis, coagulopathy, and thrombocytopenia.

•Identify the site of bleeding and prepare the patient for re-exploration if necessary in consultation with the surgical team.

•Use blood and blood products judiciously. In a hemodynamically stable patient, without active bleeding or active coronary artery disease, keep the hemoglobin level at 8 g/dL (see Chap. 61).

•Early identification of sepsis and use of antibiotics judiciously. Institutional protocol should be followed as per established guidelines for perioperative antibiotic prophylaxis (see Chap. 49).

•Perioperatively, surgical patients are in a hypercoagulable state and at increased risk for venous thromboembolic manifestations. Institutional protocols should be followed as per established guidelines for deep venous thrombosis prophylaxis. Mechanical methods (pneumatic compression or graduated compression stockings) should be used in patients who have undergone intracranial, spinal, or ocular surgery and in those at high risk of bleeding.