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CHAPTER 115: Principles of Postoperative Critical Care

Mark Nunnally; Greta Piper

KEY POINTS

KEY POINTS

  • Perioperative ICU management is nuanced and requires special consideration of the surgical patient. The physiology of the surgical patient and the response to organ dysfunction is informed by the insult of the surgery itself.

  • Surgical ICU admission may be expected or unplanned. Planned admissions may be required for short-term ventilator support, hemodynamic monitoring, or neurovascular or flap monitoring. Unplanned admissions result when surgical procedures deviate from expected and/or a patient’s physiology becomes unpredictable or unstable.

  • Enhanced recovery after surgery (ERAS) protocols, validated in colorectal and other surgical specialties, provide an expected pathway, but deviation from the algorithm must be recognized early.

  • Hospital course in the surgical ICU can be divided into: acute management in the first 24 hours (assessment and resuscitation); subacute management (24-72 hours) (define the patient’s expected pathway and focus on reversing organ injury); chronic phase (prevention and management of secondary complications [e.g., hospital acquired infections]).

  • Surgical ICU requires a collaborative, multidisciplinary approach that includes input from the surgical team, the ICU team, critical care nursing, consultants, and other teams including physical therapy, pharmacy, social work, case management, and speech therapy.

ACUTE MANAGEMENT (FIRST 24 HOURS)

Acute management of an ICU patient focuses on assessment, anesthesia recovery, and resuscitation. Enhanced recovery after surgery (ERAS) protocols, validated in colorectal and other surgical specialties,1,2 provide an expected pathway, but deviation from the algorithm must be recognized early. The initial intake assessment of a postoperative patient includes a signout directly from the surgical and anesthesia teams with critical nursing and providers present. There are many tools described to structure a signout, but teams should be aware of practical considerations, such as emphasizing important data and facilitating a conversation. (Tables 115-1 and 115-2).

TABLE 115-1Some Members of a Surgical ICU Service: Their Credentials, Roles, and Responsibilities. Other Essential Members of the Team May Include Nutritionists and Physical and Occupational Therapists.
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TABLE 115-1 Some Members of a Surgical ICU Service: Their Credentials, Roles, and Responsibilities. Other Essential Members of the Team May Include Nutritionists and Physical and Occupational Therapists.

Clinician

Role

Procedures

Documentation

Intensivist

Service management, resource allocation, direct diagnostics and therapeutics, and triage

Can do most common procedures, usually supervises their completion

Daily assessment of patient

Primary Surgeon

Service management, postoperative management, and sometimes triage

May have variable involvement in ICU procedures, but surgery-specific expertise

Daily assessment of patient, which may be deferred to the intensivist team

Pharmacist

Advisory expertise on pharmacotherapeutics, able to adjust medications and dosing. Approval and oversight of specific medications.

Drug administration procedures only

Variable: active with medication lists, but may document key pharmacokinetic information and clinical recommendations

Respiratory therapist

Advisory in respiratory support, provide respiratory therapies and equipment

May draw blood gasses and perform endotracheal intubation, bag mask ventilation

Ventilator settings, therapies, equipment checks

Critical care fellow

Support intensivist roles under ...

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