Introducing the postoperative care team

Additional support, expertise, and equipment for general postoperative inpatients

The 1992-3 and 1993-4 national confidential enquiries into perioperative deaths1 2 record the use of monitoring, the availability of facilities, and the experience of the doctors caring for patients. About two thirds of patients died three or more days after surgery, with most of the deaths taking place on a ward. A high percentage of those who died had had a cardiac or respiratory complication, renal failure, or infection, and some of these complications might have been preventable.

Preoperative preparation and a high standard of anaesthetic care are essential, as they affect postoperative events.3 4 By the end of surgery it may be too late to substantially alter outcome for some patients.5 On the other hand, aggressive postoperative optimisation of physiological values has been shown to decrease mortality and morbidity in selected groups of patients.6 7 The principle of proactive treatment to prevent complications could be widened to a larger group of postoperative patients.

In the postoperative period, vital organ function may be at risk because of inadequate perfusion and oxygen delivery. Breathing may be limited because of pain or oversedation, contributing to chest infection or episodes of hypoxaemia.8 Cardiac ischaemia may result from hypertension, tachycardia, or hypoxaemia.9 Deep vein thrombosis may be more likely with poor analgesia limiting early mobilisation and inadequate fluid replacement contributing to venous stasis. The incidence of wound infection and bowel anastomotic breakdown are likely to be related, in part, to postoperative factors. Many of these adverse events do not manifest for several days after surgery.

In high risk patients physiological values should be optimised before surgery, and it should be possible to lay down targets to be achieved in the postoperative period. These would certainly include an oxygen saturation of greater than 90%; the absence of episodes of significant depression of ST segment on electrocardiograms; adequate and appropriate cardiac output, renal output, and fluid replacement; excellent analgesia; and the absence of oversedation. Techniques exist for appropriate monitoring and management.

It is possible to imagine a ward where effective analgesia is available to all patients after surgery, and fluid management is guided by established critical care techniques. Pulmonary exercises may decrease the incidence of respiratory complications. Oxygen therapy is effective at preventing hypoxaemia10 and would be titrated against oxygen saturation as measured by pulse oximetry. Continuous electrocardiographic monitoring, with computer assisted processing to detect abnormalities, would provide early warning of dysrhythmias and ischaemia. Appropriate early nutrition would be encouraged and measures taken to minimise the risk of infection. Informed medical advice would be readily available to guide management. All of the above should be available on a routine surgical ward, but experience suggests that this is rarely the case.

The confidential enquiries rightly identify a “substantial shortfall in critical services,” and a high dependency unit should fulfil all of the functions described above. Although not as costly as an intensive care unit, the high dependency unit is none the less an expensive option that is unlikely to be available to most postoperative inpatients, particularly beyond the first few hours after surgery. Acute pain care teams have evolved to look after the analgesia needs of postoperative patients.11 It may be time to widen the concept to form a postoperative care team. Regular postoperative care rounds and a team of postoperative care nurses should be able to support nursing and medical staff on the surgical ward and provide additional expertise and equipment to assist in the care of most postoperative inpatients. The concept of early recognition and intervention may also be applicable to selected medical patients, such as those at risk of having a cardiac arrest.12

It remains to be proved whether a comprehensive system of continuing postoperative care would decrease morbidity and mortality, provide greater comfort and satisfaction, or allow patients to be safely discharged at an earlier time than is routine at present. If improvements in outcome after anaesthesia and surgery are to continue it may be necessary to take on the challenge of postoperative care.