Ward Management of Surgical Patients: Clinical Issues
Tips and suggestions for surgical management
Nasogastric tubes
These are often used to prevent postoperative gastric dilatation. Their efficacy is contentious in routine use. But if a postoperative patient is retching, nauseous and vomiting, please pass a nasogastric tube immediately. It will decompress the stomach and prevent aspiration of gastric contents and aspiration pneumonia. Do not use antiemetics to stop vomiting. Morphine rarely causes vomiting in patients having pain. It is the ileus and gastric dilatation which need to be relieved. A Nasogastric tube can be removed when after evaluation of both the quality and quantity of the aspirate matter. As a general rule, when the aspirate is clear or less than 500 ml over a 24 hour period and the patient does not complain of nausea etc., these can be safely removed. It is also important to check that the nasogastric tube in place is actually patent and working.
Intravenous Fluids
Intravenous fluid therapy is an integral part of the hospital management of most surgical patients. ‘Difficult Drips’are usually the result of hurried attempts at IV cannulation. When called for a difficult drip, a thorough search for the best vein with ‘all the time in the world’ usually pays off. Please change drips after 72 hours and keep them rotating to preserve veins. Flag the drip sets with dates. The average person requires 30-35 ml/kg IV fluid in 24 hours. This is increased in cases of elevated temperature, excessive gastrointestinal losses or dehydration. Routinely used fluid in our hospitals is general maintenance solution with 5% dextrose. Replacement solution is used to replenish excessive GI losses. It has more Na and K than GMS. Rehydration solution is 0.45% saline solution with 5% dextrose in it. It can be safely used in a dehydrated patient where the electrolyte status is not known. There is a specific way of writing intravenous fluids on the fluid management chart; please follow the same pattern. If a patient needs 2000 ml fluid in 24 hours, specify how it should be run. e.g.,
Maintenance solution: 1000 ml: 16h00
Rehydration solution: 1000 ml: 08h00
This is preferable to empirically writing one litre 12 hourly. Check for thrombophlebitis daily. This may be the cause of unexplained fever. It is treated with flucloxacillin 500 mg 6 hourly (if the patient has elevated temperature). Elevate the affected arm.
Fluid balance
Make sure the patient is passing adequate amounts of urine in the immediate postoperative period, and does not become hypovolemic. Aim for at least one ml of urine per kilogram body weight per hour. Do not use Lasix for postoperative low urine output. The patient may need additional fluids intravenously. There is no empirical level of haemoglobin to warrant blood transfusion. A patient with post-op Hb of 8.5g/dl may not need transfusion if no further bleeding is expected. Alternatively, a patient with a bleeding ulcer may need a transfusion at Hb 9g/dl. Always check with you registrar if not sure.
Foley’s Catheters and Drains
Foley’s catheters are commonly used to prevent urinary retention in the immediate postoperative period. At times these are also inserted to monitor urine output. Be aware of the disadvantages, namely the risk of infection and possible incontinence after the catheter is removed. Remove these catheters as soon as the patient is mobile, likely to pass urine by themselves and there is no need for strict monitoring of urine output.
Drains (usually a closed suction drain) are mostly used to drain a possible postoperative haematoma or to drain bowel contents in a controlled manner in the unlikely event of anastomotic dehiscence (a pencil drain). Their efficacy is debatable and the practice varies from surgeon to surgeon. Before ordering removal of a drain, always check with the surgeon who performed the operation. Always check the output from drains and if high, calculate it as fluid loss and replace with replacement solution with the patient’s daily fluid administration.
Nutrition
Periodic assessment of the nutritional status of the patient is an important part of daily ward rounds. Apart from clinical assessment (weight charts, muscle wasting, etc.), we use albumin estimation to monitor the nutritional status. This is not ideal but much more practical than other complicated methods. Supplemental nutrition in the form of enteral diets (e.g., ensure, build-up, vital, glucerna etc.) or total parenteral nutrition (if enteral feeding is not possible or not tolerated) is used in nutritionally depleted patients. Always seek a dietitian's help in this regard. Anticipate nutritional problems well in advance especially in patients who have not been able to eat for more than a week. They will often need some form of supplementation. In patients with acute pancreatitis with gastric atony, it may be better to insert a naso-jejunal tube for feeding than resorting to TPN. Check this with registrar or JC.
Analgesia
Ensure that the patient is receiving adequate analgesia postoperatively. Remember analgesia written on the prescription chart is not equal to analgesia received. Nursing staff may need to be reminded to start morphine infusion or to administer a bolus dose of morphine. Analgesia prescribed prn (if necessary) often is not administered at all. Always prescribe regular doses of analgesia.
Use antibiotics judiciously
Oral antibiotics are as good as intravenous antibiotics in most situations, but are much less expensive and less staff intensive. There should be a good reason to use antibiotics parenterally. Prophylactic antibiotics are crucial in reducing postoperative septic complications. Do no wait for the patient to go to theatre thinking these will be given with induction of anaesthesia. Prophylactic antibiotics are never used for more than 24 hours.
Respiratory Problems
Postoperative atelectasis is quite common after prolonged abdominal operations. It results in a raised temperature, tachypnoea, crackles in lung bases and mild to moderate respiratory distress. Suppress the urge to treat it with antibiotics but rather refer the patient to the physiotherapist for intensive chest physiotherapy. Use antibiotics only when there is clear evidence of pneumonia (persistently high temperature, raised white cell count, bronchial breathing, consolidation on CXR, yellow tracheal aspirate with organisms on Gram stain, etc.). Consult the antibiotics guidelines for therapy guidelines. Also think of venous thrombo-embolism in a patient with respiratory distress. DVT prophylaxis reduces the risk but does not prevent it completely.
Diabetes Mellitus
Proper management of diabetes is especially important as a combination of biliary sepsis and diabetes mellitus is a potentially dangerous situation. Ensure that blood sugar is well controlled in these patients. Most patients booked for an operation should be started on sliding scale. A simplified sliding scale is as follows, and can be modified according to the 4 hourly blood glucose results.
| Blood glucose (mmol/l) | Actrapid (units subcut.) |
| <5 | 10% dextrose water iv |
| 5.1-8.0 | nil |
| 8.1-10.0 | 2 |
| 10.1-12.0 | 4 |
| 12.1-14.0 | 5 |
| 14.1-16.0 | 6 |
| 16.1-18.0 | 8 |
| 18.1-20.0 | 10 |
| 20.1-22.0 | 12 |
| >22.1 | 14 |
| Call Doctor |
As soon as the patient’s condition is stable, commence his regular anti-diabetic medication and stop the sliding scale. Repeated blood sugar measurements should be continued.
The confused patient
Confusion is a frequent problem encountered in the wards. Suppress the urge to “sedate” a confused patient until the cause is identified and appropriately treated. Common causes in surgical and post-operative patients are: Hypotension (check Hb, BP, PR and urine output), Hypoglycaemia (finger prick glucose), Hypoxia (saturation with pulse oximeter and confirmed with arterial blood gas) hyponatraemia and sepsis. The confusion usually resolves with correction of the above problem.
Try to anticipate problems before they arise. If a patient looks as if he is deteriorating, rather investigate timeously before they “crash”. Remember a stitch in time saves nine (and lives)!
Adverse outcomes
Post- operative complications and deaths must be recorded in the clinical notes, in the eCCR summary, and communicated directly to the consultants in charge of the Unit. A regular M&M is a fundamental routine of each unit, and must be thoroughly documented.