Most of the recommendations are given as consensus statements (CS), which are statements developed from structured discussion, informed by any existing evidence and the development group's clinical experience, and validated using a formal scoring system.
For evidence-based recommendations, the strength of recommendation grading (A-D) and level of evidence (1++-4) are defined at the end of the "Major Recommendations" field.
Clinical Assessment and Monitoring
CS: Anaesthetic and surgical staff should record the following items in the patient's case notes:
- Any anaesthetic, surgical, or intraoperative complications
- Any specific postoperative instruction concerning possible problems
- Any specific treatment or prophylaxis required (e.g., fluids, nutrition, antibiotics, analgesia, anti-emetics, thromboprophylaxis)
Assessment
CS: A postoperative assessment should be carried out when the patient returns from theatre.
CS: Doctors immediately responsible for patients should ensure that a contact/pager number is available to the nursing staff on the ward.
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.
CS: The first postoperative assessment should determine:
- Intraoperative history and postoperative instructions
- Circulatory volume status
- Respiratory status
- Mental status
CS: If an acute confusional state is present, exclude treatable causes by appropriate history, physical examination, and investigations.
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:
- American Society of Anesthesiologists (ASA) grade >3
- Emergency or high risk surgery
- Operation out of hours
Treatment and Prophylaxis
CS: Local protocols should be established for:
- Drug treatment of pre-existing cardiovascular and respiratory disorders
- Treatment of postoperative nausea and vomiting
Monitoring
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, from original guideline document.)
CS: Patients requiring the frequent monitoring of multiple variables should be considered for care at level 2 or above.
CS: Any patient with circulatory disturbance should be catheterised and the urine output measured hourly
CS: Consider catheterisation in patients with no urine production after four hours.
CS: 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
CS: Postoperative monitoring should be continued on a daily basis
CS: The monitoring regimen should be reviewed daily so as best to provide data for clinical decision making
CS: Any change in a monitoring regimen should prompt reassessment of the level of care.
The Role of Senior Medical Staff
CS: The ultimate responsibility for patient care lies with the consultants providing surgical and anaesthetic care
CS: Junior doctors should assume only the responsibility appropriate to their training and experience
CS: 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.
Cardiovascular Management
Blood Pressure
CS: Postoperative blood pressure should always be reviewed with reference to the preoperative and intraoperative assessments.
CS: Further assessment is required for patients with:
- Heart rate below 50 beats per minute
- Heart rate above 100 beats per minute
- Blood pressure below 100 mm Hg systolic
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 intravenous (IV) nitrates may be used safely and effectively in postoperative hypertension.
Myocardial Ischaemia
CS: 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
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.
Arrhythmias and Conduction Defects
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: Direct current (DC) shock should be considered as a first treatment option where there is haemodynamic deterioration as a result of a tachyarrhythmia.
Conduction Defects
CS: Seek expert help early when perioperative conduction defects result in bradycardia unresponsive to atropine.
Perioperative Myocardial Infarction
CS: Where perioperative myocardial infarction (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:
- Electrocardiogram (ECG) at baseline, immediately following surgery, and daily for the two subsequent days
- 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.
Hypothermia
CS: Maintain normothermia in the postoperative period.
CS: Active warming is appropriate for patients who are hypothermic postoperatively.
Oxygenation
CS: Patients with coronary artery disease, or major risk factors for coronary artery disease, should receive oxygen continuously until mobile.
CS: Oxygen saturation should be maintained above 92%.
Respiratory Management
Reducing Postoperative Pulmonary Complications
CS: Oxygen therapy should be used in those patients at high risk of postoperative complications, or who are hypoxaemic following surgery (oxygen saturation measured by a pulse oximeter [SpO2] <92%).
Monitoring and Diagnosis
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:
- Respiratory rate <10 or >25 breaths per minute
- Pulse rate >100 beats per minute
- Reduced conscious level
CS: Patients in whom there is a suspicion of postoperative pulmonary complications should have an arterial blood gas analysis, a sputum culture, and ECG.
CS: Chest x-ray should be performed on suspicion of major collapse, effusions, pneumothorax, or haemothorax.
CS: Other investigations should be used only if there are specific indications.
Treatment
CS: 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 arterial oxygen partial pressure (PaO2) >8.0 kPa is an indication to consider assisted ventilation.
CS: 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.
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 central nervous system (CNS) depression not responsive to specific antagonists is an indication for specialist anaesthetic or critical care referral.
CS: 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
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.
Fluid, Electrolyte, and Renal Management
CS: The basal requirements for young adults are approximately 30 mL/kg/day of water, 1.0 to 1.4 mmol/kg/day of sodium, and 0.7 to 0.9 mmol/kg/day of potassium.
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.
Prophylaxis
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
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.
Management of Volume Depletion and Overload
CS: 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.
CS: Volume overload should be avoided.
Oliguria
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.
Sodium
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.
CS: 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
CS: 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.
CS: Hyperkalaemia is a medical emergency and senior help should be obtained.
Acid/Base Balance
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.
Management of Sepsis
Prophylaxis
CS: Prophylactic antibiotics should be administered to appropriate groups of patients to reduce the risk of developing postoperative sepsis.
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.
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
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.
Management
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 to 7 days. It is important to appreciate that fungi and atypical organisms can contribute to sepsis syndrome, and to take cultures and prescribe appropriately.
CS: Surgical intervention in the form of debridement or drainage of infected, devitalised tissue should be undertaken as soon as possible following haemodynamic stabilisation.
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.
Postoperative Nutrition
Avoiding Routine Nasogastric Intubation
CS: Oral intake should be commenced as soon as possible after surgery.
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.
CS: Anti-emetics should be used as required in order to promote an early return of oral intake.
Nutritional Support for Malnourished Patients
CS: Malnourished patients with benign disease requiring surgery should receive postoperative nutritional support by the appropriate route.
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.
Artificial Nutritional Support
CS: Nutritional replacement should be discussed with a dietitian and tailored to the patient's requirements.
CS: Enteral nutrition is the preferred method of postoperative nutritional support and should be used if possible.
CS: For patients with ongoing postoperative complications, enteral nutrition should be used whenever possible, combined with parenteral nutrition where necessary, to meet nutritional needs.
Artificial Nutritional Techniques
CS: 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.
CS: Parenteral nutrition should be provided through a dedicated intravenous catheter.
CS: Nutritional and metabolic status should be assessed regularly and the nutritional prescription modified as necessary.
CS: Quality of nutritional support is enhanced by the use of dedicated nutrition teams.
Definitions:
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 randomised controlled trials (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+.
Levels of Evidence
1++: High quality meta-analyses, systematic reviews of randomized clinical trials, or randomized clinical trials with a very low risk of bias
1+: Well-conducted meta-analyses, systematic reviews, or randomized clinical trials with a low risk of bias
1-: Meta-analyses, systematic reviews, or randomized clinical trials with a high risk of bias
2++: High quality systematic reviews of case control or cohort or 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 (e.g. case reports, case series)
4: Expert opinion
