Page 1541 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

1060 PART 10: The Surgical Patient

therapy exceeding this amount is beneficial. Patients on chronic CHAPTER Principles of Postoperative
steroid therapy undergoing minor surgery should have their regular
steroid dose on the morning of surgery and no additional doses if sur- Critical Care
gery is uncomplicated. Candidates for major surgery should receive no 112
more than physiologic doses of glucocorticoid. A regime might consist Jonathan Simmons
of 25 mg hydrocortisone intravenously on induction of anesthesia, and Laura A. Adam
100 to 150 mg per day over the following 24 to 72 hours. If a patient
presenting for surgery is already receiving a maintenance steroid dose
greater than the estimated requirement, additional steroid coverage is KEY POINTS
not necessary. 90,91
Clinical and biochemical preoperative assessment of patients on • The initial sign that a malignant hyperthermia crisis is developing is
chronic steroid therapy is invaluable in the identification of patients a rise in end-tidal CO levels. The treatment of choice is dantrolene.
2
at risk for adrenal insufficiency in the perioperative period. Published • Twitch monitors should be utilized to ensure that neuromuscular
recommendations for supplemental steroid coverage should be followed blockade has been adequately reversed as physical examination is
by dosing to physiologic levels. not generally adequate. Residual neuromuscular blockade is an
important cause of postoperative respiratory failure.
• Unfractionated heparin for DVT prophylaxis offers no benefit for
trauma patients. Low-molecular-weight heparin should be used
KEY REFERENCES unless contraindicated.
• Bonow RO, Carabello BA, Chatterjee K, et al. 2008 focused • Patients with systolic anterior motion (SAM) of the mitral valve
update incorporated into the ACC/AHA 2006 guidelines for the or significant ventricular hypertrophy should undergo fluid resus-
management of patients with valvular heart disease: a report of citation as the mainstay of post-cardiac surgery management as
the American College of Cardiology/American Heart Association inotropes may cause severe obstructive cardiogenic shock.
Task Force on Practice Guidelines (Writing Committee to • Cardiac tamponade, massive hemothorax, and right heart failure
revise the 1998 guidelines for the management of patients with are significant causes of morbidity and mortality in cardiac
valvular heart disease). J Am Coll Cardiol. September 23, 2008; surgery. Their presentations can be similar and distinguishing
52(13):e1-e142. between the different causes is imperative to ensure that proper
• Celli BR, Rodriguez KS, Snider GL. A controlled trial of intermit- medical and/or surgical treatment is performed.
tent positive pressure breathing exercises in preventing pulmo- • Inhaled pulmonary vasodilators are important adjuncts in the
nary complications after abdominal surgery. Am Rev Respir Dis. treatment of acute right heart failure in the postoperative period
1984;130:12. as they do not have the systemic effects of hypotension and hypox-
• Devereaux PJ, Yang H, Yusuf S, et al. Effects of extended-release emia seen with intravenous agents.
metoprolol succinate in patients undergoing non-cardiac surgery • β-Blockers and amiodarone are the main agents used for periop-
(POISE trial): a randomised controlled trial. Lancet. May 31, erative prevention of atrial fibrillation in cardiac surgery patients.
2008;371(9627):1839-1847. • Augmentation of mean arterial pressure, maintenance of cardiac
• Epstein SK, Faling J, Daly BDT, et al. Predicting complications output, and monitoring and drainage of cerebrospinal fluid with a
after pulmonary resection. Chest. 1993;104:694. lumbar drain are important adjunctive therapies to reduce rates of
• Fleisher LA, Beckman JA, Brown KA, et al. 2009 ACCF/AHA paralysis following aortic surgery.
focused update on perioperative beta blockade incorporated into • Cardiac herniation following pneumonectomy and pericardial
the ACC/AHA 2007 guidelines on perioperative cardiovascular patch breakdown is characterized by acute obstructive shock,
evaluation and care for noncardiac surgery. J Am Coll Cardiol. jugular venous distention, and discoloration of the upper torso.
November 24, 2009;54(22):e13-e118. The mortality rate is 50%; therefore, immediate recognition and
• Ford GT, Whitelaw WA, Rosenal TW, et al. Diaphragm function surgical treatment are imperative.
after upper abdominal surgery in humans. Am Rev Respir Dis. • Bilateral recurrent laryngeal nerve injury leads to acute, emergent
1983;127:431. respiratory failure requiring intubation, followed by tracheostomy.
• Frazee RC, Roberts JW, Okeson GC, et al. Open versus laparo-
scopic cholecystectomy: a comparison of postoperative pulmo-
nary function. Ann Surg. 1991;213:651. OVERVIEW OF POSTOPERATIVE CRITICAL CARE
• McFalls EO, Ward HB, Moritz TE, et al. Coronary-artery revas-
cularization before elective major vascular surgery. N Engl J Med. The principles of postoperative management for general care and post-
December 30, 2004;351(27):2795-2804. operative emergencies are often discussed only in depth in large surgical
• Milbrandt EB, Deppen S, Harrison PL, et al. Costs associated with texts or specialized surgical service texts. Any critical care provider who
cares for general surgical, cardiothoracic, neurosurgical, and trauma
delirium in mechanically ventilated patients. Crit Care Med. April patients should have a basic understanding of routine postoperative
2004;32(4):955-962. care, including understanding of surgical drains, chest tubes, and wound
• Van den Bergh G, Wouters P, Weekers F, et al. Intensive care. As with all aspects of patient care, communication with nursing,
insulin therapy in the critically ill patient. N Engl J Med. ancillary personnel, and other health care providers is essential to appro-
2001;345:1359. priate recognition and care for the emergencies. Communication with
the anesthesia and surgical teams bringing the patient to the ICU should
occur to ensure that the critical care provider understands what surgical
procedure occurred, what events are expected, and what potential com-
REFERENCES plications to watch for. The critical care unit should furthermore have
appropriate equipment to assist in recognition and, when appropriate,
Complete references available online at www.mhprofessional.com/hall treatment of these emergencies. Much of the critical care management of

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