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INTENSIVE CARE UNIT
It is often difficult to know for certain whether a particular
patient needs to be nursed postoperatively in the intensive
care unit (ICU), if one exists in your hospital. The person
making the decision, whether surgeon or anaesthetist, has to
balance the risk of the patient dying from an avoidable cause
on the ordinary ward against the waste of expensive resources
if a patient is admitted to ICU for no good reason.
Intensive monitoring is generally required in the following
cases:
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Cranial
neurosurgery |
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Head
injuries with airway obstruction |
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Intubated
patients, including tracheostomy |
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After
surgery for major trauma |
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Abdominal
surgery for a condition neglected for more than 24 hours |
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Chest
drain in the first 24 hours |
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Ventilation
difficulties |
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Airway
difficulties, potential or established: e.g. post-thyroidectomy, removal
of a large goitre |
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Unstable
pulse or blood pressure, high or low |
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Anuria
or oliguria |
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Severe
pre-eclampsia or eclampsia |
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Surgical
sepsis |
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Complications
during anaesthesia or surgery, especially unexpected haemorrhage |
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Hypothermia |
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Hypoxia |
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Neonates,
after any surgery. |
Postoperative ventilation
Mechanical ventilation (IPPV) may be a planned part of postoperative management
for a major operation or decided on at the end of surgery because circumstances
demand it. IPPV should be continued postoperatively under the following circumstances:
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Respiratory
depression or oxygen saturation <80% |
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Deteriorating
general condition |
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Severely
distended abdomen |
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Severe
chest trauma |
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Head
injury or after intracranial surgery. |
Avoid giving long acting muscle relaxants to facilitate IPPV. If the patient
is “fighting” the
ventilator, ask why? Is he/she hypercarbic? In pain? Hypertensive? Treat
these needs first before giving a relaxant.
There
are non-surgical reasons for ventilation, including organophosphate
poisoning, snakebite, tetanus and some head injuries, but
probably only if the patient is breathing on admission.
Usually the decision to ventilate is quite easily made
from the above observations. But, if in doubt, ventilate.
With no ventilator, a patient in respiratory failure will
rapidly die of hypoxia and hypercarbia. Many people die purely
for lack of a short period of ventilation in the postoperative
period or after trauma.
Discharge from the ICU
The decision to discharge the patient from the ICU very
much depends on the quality of care to be found on the ward
to which the patient is being
transferred. The following conditions should be met before
discharging the patient from ICU:
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Conscious |
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Good
airway, extubated and stable for several hours after
extubation |
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Breathing
comfortably |
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Stable
blood pressure and urine output |
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Haemoglobin >6
g/dl or blood transfusion in progress |
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Minimal
nasogastric drainage and has bowel sounds, abdomen not distended |
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Afebrile |
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Looks
better, sitting up, not confused. |
Pressure
for beds to treat more urgent cases may mean that these guidelines
have to be modified. If a patient dies after discharge from
ICU, try to find
out why the death took place and to learn from it, especially
if it appears that the death was avoidable.
Try to put a system in place where patients discharged
from ICU are followed up for a week. Find out what happened
to them.
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