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Postoperative Orders Sheets

Post operative management in the ICU for coronary and valve surgery

This postoperative management guide details the strategy for early ICU management following cronary bypass surgery or valve surgery. The key focus is a policy of reducing the transfusion of crystalloid or colloid solutions to compensate for a systemic inflammatory response syndrome (SIRS) that is a ubiquitous feature of major surgery combined with cardiopulmonary bypass. This is referred to as the - Tight and Dry - philosophy. In orther words, the treatment of a vasodilated state is vasoconstriction and not volume replacement. However it is a difficult transition for Intensivists to make, since they predominantly rely on their invasive pressure monitoring. Whereas, the operating team have the benefit of continuous echocardiography assessment and do pay relatively little regard to the invasive pressure monitoring parameters.

The key issue relates the the preload pressures of the central venous pressures (CVP) and pulmonary diastolic pressure (PADP) being reduced as a results of a vasodilated state. This leads the intensive care staff to believe that the patient is underfilled and then to transfuse large volumes of fluid. This also leads to haemodilution, an exacerbation of coagulopathy and hypothermia.

So, the CVP and PADP are only accurately reflective of volume status when the systemic vascular resistance (SVR) is within the normal range. Therefore, the vasodilated state must be corrected FIRST with vasoconstrictors; after which, if the filling pressures are low, then volume shoud be administered.

See the full Postoperative Orders Sheet. | Download the PDF and print.

Post Operative Oders Sheet for High Thoracic Epidural Analgesia (HTEA) following cardiac and thoracic surgery

This postoperative management guide details the use of a high thoracic epidural (T2/3) for postoperative pain relief following cardiac thoracic surgery.

It is important to realise that this is quite different to the classical midthoracic epidural traditionally used in thoracic surgery. This is because the traditional midthoracic site blocked all of the sympathetic output for the body resulting in profound vasodilation. The higher placement for the high thoracic epidural site results in approximately 50% of the sympathetic output being affected by this block and therefore the degree of vasodilatation significantly reduced.

Overall this block provides excellent analgesia and is very simple to use. If the patient is pain-free with minimal sensory or motor loss affecting the inner border of the forearms and hands (T1), then the dose is optimal. If the patient is in pain, an additional dose is required. Given the long half life of the local anaesthetic agents, it is usually necessary to give the patient bolus as well as resetting the infusion rate. Similarly reducing the dose frequently requires interruption of the infusion for about half an hour before commencing at a lower infusion rate to allow for more rapid equilibrate should.

The purpose of the epidural is to provide optimal pain relief. It should never be adjusted for reasons other than pain relief or the lack of pain relief. Specifically, it should never be adjusted to try and alter blood pressure.

See the full Postoperative Orders Sheet | Downloadthe PDF and print.