Taking a safe theatre-to-ICU handover, the first 30 minutes after arrival, and a systematic approach to the common early post-operative problems: hypoxaemia, hypotension, oliguria, hypothermia, pain, PONV, delirium and myocardial injury after non-cardiac surgery (MINS).
At the bedside
Timed steps- 1
Hands-off, eyes-on handover
ArrivalConnect monitors and ventilator first, then stop everything for a structured handover with anaesthetist and surgeon present: patient and procedure, airway grade/difficulty, intra-operative events, blood loss, fluids/blood products, urine output, drugs given (antibiotic time, last opioid, reversal, vasopressors), lines/drains, and the explicit plan (BP target, analgesia, VTE, feeding, drains, when to call the surgeon).
- 2
ABCDE assessment
0–15 minAirway and breathing (SpO₂, RR, ETCO₂ if ventilated, chest expansion, residual neuromuscular block — TOF ratio <0.9 means incomplete reversal); circulation (MAP, HR, CRT, lactate, drains, wound); disability (pain score, sedation, pupils, glucose); exposure (temperature, pressure areas, limb perfusion).
- 3
Baseline investigations
0–30 minABG with lactate, Hb, electrolytes (K⁺, Mg²⁺, Ca²⁺), glucose, coagulation if bleeding risk, ECG; chest X-ray if central line, ETT, chest/abdominal procedure or hypoxaemia.
- 4
Screen for myocardial injury (MINS)
Day 0–2In patients at risk (known cardiovascular disease, risk factors, age ≥65): troponin before and at 24 and 48 h after major surgery. Most MINS is silent — a rise needs ECG, review of haemodynamics/anaemia and cardiology input.
- 5
Keep warm
OngoingMeasure core temperature on arrival and hourly; if <36 °C use forced-air warming until ≥36.5 °C; warm IV fluids and blood above 500 mL.
- 6
Analgesia and PONV
OngoingMultimodal analgesia (regular paracetamol, regional/epidural where placed, opioid-sparing adjuncts), pain score with every observation. PONV: assess Apfel risk factors (female, non-smoker, history of PONV/motion sickness, post-operative opioids); give 2 prophylactic agents for 1–2 risk factors and treat breakthrough with a different class.
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Prevent the predictable
DailyVTE prophylaxis once haemostasis is secure; early mobilisation and feeding; delirium screening (CAM-ICU); glucose control; stop unnecessary lines and catheters; restart chronic medications appropriately (beta-blockers, statins).
Multimodal analgesia backbone
Paracetamol (acetaminophen)
- Dose
- 1 g every 6 h (max 4 g/day); 15 mg/kg if <50 kg
- Worked example
- 70 kg: 1 g IV 6-hourly; 45 kg frail patient: 650 mg 6-hourly (max 3 g/day).
PONV prophylaxis/treatment
Ondansetron
- Dose
- 4 mg at end of surgery or for treatment
- Worked example
- 70 kg: 4 mg IV (2 mL of 2 mg/mL) slowly.
Post-operative vasodilatory hypotension after volume optimisation
Noradrenaline (norepinephrine)
- Dose
- 0.05–0.5 mcg/kg/min
- Range
- 0.05–0.5 mcg/kg/min
- Preparation
- 4 mg in 50 mL = 80 mcg/mL
- Worked example
- 70 kg at 0.1 mcg/kg/min = 7 mcg/min = 5.25 mL/h
Early post-operative problems — causes and first actions
| Problem | Common causes | First actions |
|---|---|---|
| Hypoxaemia | Atelectasis, residual block, opioids, aspiration, pulmonary oedema, pneumothorax, PE | Sit up, O₂/HFNC/CPAP, check TOF and reverse, CXR, ABG, POCUS |
| Hypotension | Hypovolaemia/bleeding, epidural sympathectomy, sepsis, MI, arrhythmia, anaphylaxis, tamponade | Fluid challenge, check drains/Hb, ECG, echo, vasopressor if vasodilated |
| Hypertension | Pain, hypercapnia, urinary retention, withdrawal of chronic antihypertensives | Treat cause first; then IV antihypertensive per target |
| Oliguria (<0.5 mL/kg/h) | Hypovolaemia, low MAP, blocked catheter, abdominal compartment, nephrotoxins | Flush catheter, assess volume and MAP, bladder pressure, stop nephrotoxins |
| Hypothermia (<36 °C) | Exposure, cold fluids, anaesthesia | Forced-air warming, warm fluids |
| PONV | Opioids, volatile anaesthesia, female, non-smoker | Antiemetic from a different class from prophylaxis |
| Delirium | Age, frailty, pain, drugs (benzodiazepines, anticholinergics), sepsis, hypoxia | CAM-ICU, treat cause, non-drug measures, review drug chart |
| Troponin rise (MINS) | Supply–demand mismatch, type 1 MI, PE, sepsis | ECG, Hb, haemodynamics, cardiology; aspirin/statin per cardiology |
Calculators for this topic
Mean arterial pressure
(SBP + 2 × DBP) ÷ 3 (estimate; use the arterial line value when available).
Infusion rate from mcg/kg/min
Pump rate in mL/h for drugs dosed in mcg/kg/min (noradrenaline, adrenaline, dobutamine, milrinone, nitroglycerin by weight).
NEWS2
National Early Warning Score 2 (SpO₂ scale 1).
References
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Post-operative hypotension
Step 1 of ~4
Systematic approach in the first 24 h after surgery.
Check monitoring (transducer level), ABCDE, drains, wound, abdomen, ECG
Based on Halvorsen S, Mehilli J, Cassese S, et al. Educational use; follow local protocol.
Pathophysiology
Surgery triggers a stress response (catecholamines, cortisol, cytokines), hypercoagulability and fluid shifts. Anaesthetic drugs, opioids and residual neuromuscular block depress ventilation and airway reflexes; atelectasis develops in most patients after general anaesthesia. Supply–demand myocardial ischaemia (tachycardia, hypotension, anaemia) explains most MINS.
Evidence
- ESC 2022 non-cardiac surgery guideline: pre-operative risk assessment, peri-operative continuation of beta-blockers/statins in those already taking them, and recommendation to measure hs-troponin before and 24/48 h after intermediate/high-risk surgery in patients with cardiovascular disease, risk factors or age ≥65.
- VISION (2017): 21,842 patients; hs-troponin T thresholds associated with 30-day mortality; MINS mostly asymptomatic (>90% without ischaemic symptoms).
- Fourth Consensus Guidelines on PONV (2020): risk-based multimodal prophylaxis; avoid using the same drug class for rescue.
- NICE CG65: measure temperature, keep ≥36 °C, forced-air warming.
Controversies
- Routine troponin screening: improves detection, but the best treatment of MINS is uncertain (MANAGE trial suggested benefit of dabigatran).
- Liberal vs restrictive peri-operative fluids (RELIEF: restrictive associated with more AKI).
- Target BP after surgery — individualised (e.g. within 10–20% of baseline) vs fixed MAP 65.
🇮🇳 India notes
- Many Indian patients arrive in ICU from theatres in other blocks without the anaesthetist; insist on a phone/face-to-face handover and a written anaesthesia chart.
- Forced-air warming devices may be limited; warmed fluids, blankets and room temperature control still help.
- hs-troponin may not be available everywhere; conventional troponin trends plus ECG are acceptable.
- Post-operative delirium is under-recognised in Indian wards; routine CAM-ICU screening is low cost.
References
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