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1062 PART 10: The Surgical Patient

translocation, decreased length of stay, and decreased rates of infec-
TABLE 112-1 Association of Surgical Technologists Malignant Hyperthermia 12,13
Treatment Guidelines 9 tion when compared to delayed initiation of feedings. In addition,
patients who cannot assume normal nutritional requirements by
• Immediate discontinuation of anesthesia and the paralytic succinylcholine. If the surgery oral feeding alone may need additional enteral nutritional support.
is for a life-threatening condition or cannot be immediately stopped, then continue with Trauma patients with blunt or penetrating abdominal injuries show
use of different anesthetic agent and machine. reduced infection rates when fed enterally, and in burn patients,
• Consider immediate contact of Malignant Hyperthermia Association of the United States studies demonstrate that nutrition should be started immediately.
(MHAUS) or delayed contact if assistance is needed at (800)644-9737. Even delaying 18 hours results in a higher rate of parenteral nutrition
• Hyperventilate with 1.0 fraction of inspired oxygen at high flow rate to treat requirement. 14
hypercapnia, metabolic acidosis, and increased oxygen consumption. Even when critically ill, most postoperative patients who have under-
• Dantrolene at a dose of 2.5 mg/kg IV immediately and every 5 min until symptoms gone a laparotomy have return of bowel function in the first few days.
subside. Gastroparesis can occur and will delay gastric emptying. Clinical signs
• Change ventilator tubing and soda lime canister. Newer research indicates this may not of gastroparesis include abdominal distention, 500 mL/day of nasogastric
be necessary with aggressive oxygen delivery. tube output, or residual volumes greater than 300 mL in the stomach after
• Administer sodium bicarbonate, 1-2 mEq/kg IV, for the metabolic acidosis from feedings. Theoretically, one method to combat this would be to initiate
increased lactate. postpyloric feeding, but postpyloric feeding has not been shown to
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• Apply ice packs to the groin, axillary region, and sides of the neck. decrease ICU length of stay, mortality rate, or pneumonia rate when com-
• In some instances, ice lavage of the stomach and rectum can be performed, but be pared with gastric feeding. Prokinetic agents, such as metoclopramide
cautious not to induce hypothermia. Cooling measures should be stopped when the core and erythromycin, can be used with some positive results. 16
body temperature reaches 38°C. While most critically ill patients tolerate gastric feedings well, the
• Administer mannitol at 0.25 g/kg IV and/or furosemide at 1 mg/kg IV, up to four doses Eastern Association for the Surgery of Trauma (EAST) outlines which
of each, in order to promote and maintain urinary flow to help reduce the amount of trauma patients warrant postpyloric feedings including patients with
myoglobin in the kidneys. It is recommended to maintain urinary output of at least severe traumatic brain injury who did not tolerate gastric feedings in the
2 mL/kg/h to help reduce the incidence of renal failure. first 48 hours of trauma and patients with abdominal trauma who have
• If cardiac arrhythmias develop, the use of procainamide, 200 mg IV, may be helpful. undergone laparotomy. It is critical that trauma patients are adequately
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• Monitor potassium closely because hyperkalemia can develop rapidly from destruction resuscitated or else they may develop intestinal necrosis in the face of
of muscle cells. Treat hyperkalemia with dextrose, 50 g IV, and regular insulin, 10 U IV, direct small bowel feeding.
as well as sodium bicarbonate, as previously mentioned. In cases of acute pancreatitis, the degree of inflammation plays a role
• Insert a Foley catheter, if not already in place, to monitor urinary output. in route of nutrition. In mild pancreatitis, enteral nutrition (feeding via
• Monitor potassium, sodium chloride, calcium, phosphate, and magnesium levels every a tube into the stomach or small intestine) will not be needed unless oral
10 min until symptoms subside. (taking food by mouth) feeding cannot be tolerated after 5 to 7 days. In
• Check arterial blood gases every 5 to 10 min to monitor oxygenation and acidosis. patients with severe acute pancreatitis, early enteral feeding should be
• Insert arterial and central lines if not already present. Dantrolene should be administered used. This route has been shown to have reduced infection, need for
via a central line. Monitor end-tidal carbon dioxide levels through a ventilator. surgery, and length of stay compared with parenteral nutrition. Gastric
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Data from Guideline statement for malignant hyperthermia in the perioperative environment: http://www. feedings can be used in most patients with acute pancreatitis. 19
ast.org/uploadedFiles/Main_Site/Content/About_Us/Guideline_Malignant_Hyperthermia.pdf. Parenteral nutrition has not been shown to reduce morbidity or mor-
tality and it is associated with increased risk of catheter- and noncatheter-
related infections. 20,21 A recent study by Casaer and colleagues found
that those patients where parenteral nutrition was initiated at day 8 or
after had a faster overall recovery time and fewer overall complications.
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must be reconstituted at bedside. In an average 70-kg patient, thirty-six If bowel function or injury will not allow enteral nutrition or if enteral
20-mg vials will be needed for stabilization. After the patient is stabi- nutrition is not expected within 7 days, then parental nutrition should
lized, dantrolene is administered at 1 mg/kg every 6 to 8 hours for 1 to be given. It is generally recommended that if patients fail to reach at
3 days to prevent recurrence during which time patients should remain least 50% of their goal enteral rate by day 7, parenteral nutrition should
in the ICU for monitoring. Comprehensive treatment guidelines for MH be started, but the combination of parenteral and enteral nutrition
according to the Association of Surgical Technologists are included in has only demonstrated benefit in malnourished patients. Parental
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Table 112-1. 1,9 nutrition is frequently used in patients with an enterocutaneous fistula
where enteral nutrition can worsen fistula healing by increased out-
GENERAL POSTOPERATIVE AND TRAUMA CARE put. In general, these patients should have complete bowel rest and
AND SURGICAL EMERGENCIES parenteral nutrition with 1.5 to 2 times the normal nonprotein calorie
■
complement.
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A complete overview of nutrition in the critically ill patient is discussed ■ SURGICAL DRAINS, CEREBROSPINAL FLUID DRAINS,
NUTRITION IN THE SURGICAL AND TRAUMA PATIENT
elsewhere. Postoperative patients have increased nutritional needs AND CHEST TUBES
because of wound healing, changes in bowel motility, swallowing, and The monitoring and management of drains in the postoperative patient
support of surgical anastomoses. In most postoperative patients who is an important task that is frequently overlooked or not given the atten-
are relatively well nourished, enteral or parenteral support may not tion that it deserves. The surgical team should be queried during the
be needed unless it is anticipated that oral nutrition cannot be started handoff communication with the critical care team regarding the loca-
within 7 days after surgery. In critically ill patients whose metabolic tion, type, and purpose of each drain that is in place. Many abdominal
demands are increased, nutritional support may be needed earlier. surgeries can involve numerous drains in various locations. Sometimes a
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Patients in whom the duration of illness is expected to be 7 or more days pictorial representation on the patient chart can help simplify the task of
should be considered for early nutritional support. Examples of patients monitoring drain output. Increased or decreased drain output or change
include those with severe intra-abdominal sepsis, pancreatitis, major in the fluid of the drain can represent significant clinical findings and
trauma, or burns. an understanding of the types and locations of the drains is essential to
In general, enteral access is the preferred route of administration. diagnosing these. For instance, a change in drain content to presence of
It has been associated with reduced gut mucosal atrophy, bacterial bile, debris, or stool suggests a leak or anastomotic breakdown. A list
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