ITU Post Operative Monitoring – Up to 4 hours

1. ITU Post Operative Monitoring – Up to 4 hours

2. Indication for Surgery • Haemothorax bleeding is usually self-limiting following drainage. However; • Drainage of more than 1500ml following initial intercostal catheter insertion or a sustained loss of more than 200mL per hour for more than 2 hrs are indicators for thoracotomy.

3. Transfer from Theatre • The nurse receiving the client from the OR needs the following information: • Medical diagnosis and surgical procedure done • Past medical history and allergies • Age, general condition • Airway status, current vital signs • Anaesthetic agents and medications given during surgery • Any pathology found and if so, have family members been informed • Amount of fluid and blood lost and administered • Any tubes, catheters • Any other pertinent information needed to care for the client

4. Transfer from Theatre • Patients are usually admitted to ICU for a number of reasons: • Post-operative ventilation and respiratory optimisation • Haemodynamic monitoring • Sedation and analgesia

5. Initial post operative assessment • airway potency / presence of artificial airways • effectiveness of respirations • mechanical ventilation / or supplemental oxygen • circulatory status • vital signs • wound condition including dressings and drains • fluid balance, including IV fluids, output from catheters and drains. • level of consciousness • pain

6. Nurses major responsibilities • Ensure patient airway • Maintain adequate circulation • Prevent and assist with the treatment of shock • Maintain proper position and function of drains, tubes and IV infusions; and monitor for potential complications

7. Postoperative Complications • Haemorrhage • Shock • Hypoxia • Aspiration

8. Haemodynamic Monitoring • Clinical haemodynamic assessment is informative and easy to perform. Simple and versatile clinical parameters include: • Blood pressure, pulse rate, respiratory rate, fluid balance, conscious level, capillary refill and peripheral cyanosis. The respiratory rate is the most sensitive indicator of underlying circulatory dysfunction.

9. Airways & Breathing • The airway should be examined to exclude any obstruction. Monitoring of breathing observing for bilateral chest movements and ventilation should considered effort (rate, depth, accessory muscle use) and efficacy (breath sounds using a stethoscope, signs of cyanosis, and oxygen saturation).

10. Fluid Balance Accurate measurement and monitoring of fluid balance over a 24-hour period, includes; • Correct administration, documentation and prescription of fluids and fluid types; being aware of electrolyte levels and the correct administration of replacement elements as prescribed. • Accurate measurement of urine output and fluid loss through drain sites and observation of wounds. • Observing vital signs for changes that may indicate internal haemorrhage.

11. Non-invasive blood pressure (NIBP) • Is usually measured with automated equipment. • Both systolic and diastolic arterial pressure can be accurately measured and mean pressure calculated from the two values. • Knowledge of the blood pressure does not give information about blood flow or tissue perfusion to other organ systems (e.g. kidney, gut, brain). It does, however, give important information about the level of circulatory

12. ECG • Used in the form of continuous monitoring on a screen by the bedside or a single 12-lead ECG. ECG is an essential part of cardiovascular assessment in the critically ill. Abnormalities of heart rhythm may cause or result from circulatory shock. Evidence of myocardial ischaemia, electrolyte imbalance, drug toxicity and other metabolic disturbances may also be detected.

13. Pulse Oximetry • Measurement of arterial oxygen saturation (SaO2) is important in the acutely ill. By measuring absorption of light oxygenated and deoxygenated haemoglobin may be differentiated allowing measurement of the oxygenated haemoglobin in arterial blood. Pulse rate and arterial haemoglobin oxygen saturation are continuously displayed.

14. Blood Gas Analysis • Blood gas analysis gives more information on respiratory function than pulse oximetry as it measures • PaCO2 (partial pressure of arterial carbon dioxide). • PaO2 (partial pressure of arterial oxygen). • SaO2 (saturation of haemoglobin by oxygen).

15. Blood Gas Analysis Four main groups of results that are routinely analysed on most samples are: • pH. • Respiratory function (oxygen, carbon dioxide, saturation). • Metabolic measures (bicarbonate, base excess). • Electrolytes and metabolites.

16. Invasive monitoring of central venous pressure (CVP) • CVP is the most common parameter to be monitored invasively. The CVP is usually measured in the superior vena cava. The purpose of measuring CVP is to obtain an estimate of the volume status (right-sided preload). However right-sided heart pressures do not always equate with left-sided pressures, especially in the critically ill. Therefore, the CVP may not provide a reliable index of left-ventricular preload, which is the main determinant of cardiac output.

17. Invasive monitoring of arterial pressure • Used when a continuous reading of blood pressure is required. This allows early recognition of haemodynamic changes, especially in an unstable patient, as well as enabling repeated blood sampling for analysis of arterial blood gases. Invasive monitoring of arterial pressure provides accurate and reliable data.

18. Monitoring of cardiac output • Measurement of cardiac output is recommended to ensure optimal fluid resuscitation and guide the choice of inotropic and vasoactive drugs. The measurement can be obtained with the pulmonary artery (Swan-Ganz) catheter (PAC). Information can be obtained about the preload, contractility and afterload.

19. Complications related to central venous cannulation • Line-related sepsis • Trauma to tricuspid and pulmonary valves • Arrhythmias • Perforation of cardiac chambers • Pulmonary artery rupture • Pulmonary infarction • Pulmonary embolism

20. Summary • Less than 10% of blunt thoracic trauma patients will require thoracotomy, the remainder requiring supportive care including chest decompression and drainage. • When faced with a critically ill patient you should first pay attention to airway, breathing, and circulation to attempt to correct any compromise. In an unstable patient, a diagnosis should be sought and definitive treatment started.   • Once the patient is stable, a frequently reviewed management plan will suffice.