ABC of postoperative intensive care for maxillofacial oncology patients
A
Nasoendotracheal tube – manage as normal ET tube
Tracheostomy –refer to NTSP emergency algorithm
(www.tracheostomy.org.uk)
Seek senior help immediately as potentially difficult airway
Extubation to be managed by consultant only
B
Aim pO2 ≥ 10 (8 if COPD), normocapnia; PEEP 5–10; TV 6ml/kg
C
Aim MAP 65–80 and lactate <2 mmol/l
Clinically assess fluid status and obtain LiDCO readings
Step 1
250ml Hartmann’s boluses as guided by LiDCO; avoid flap oedema
If administered 1L seek senior advice +/- inform MaxFax
Step 2
Low-dose noradrenaline (1st line) or dopamine (2nd line) AFTER filling
If NA > 0.2 mcg/kg per min, seek senior advice +/- inform MaxFax
Do NOT reduce sedation to counteract hypotension
Aim Hb8–10 and Hct30% – transfuse if indicated
Control hypertension (SBP>180) firstly by increasing sedation and optimising analgesia. Then use amlodipine (max 10mg daily) +/-labetalol infusion 0.5–2mg/min.
Hourly flap observations (colour, cap refill, Doppler, swelling)
Call MaxFax any time if concerns about flap (SHO bleep 7510; with low threshold for calling MaxFax consultant for advice)
D
Sedation to keep head strictly neutral for 12 hours from admission to ITU
Do not allow head movement by reducing sedation to counteract low BP
Avoid coughing and straining
E
Nurse head up 300°; no neck tapes; normothermia
Aim urine output > 0.5ml/kg/h
Ensure BP cuff is not on same limb as donor site
Keep wide bore NG tube on drainage and aspirate prior to extubation; remove wide bore post-extubation and recheck fine bore NG position for feeding
Pain control – prescribe regular and prn analgesia +/- PCA
If epidural catheter in bone graft: give15–20ml of 0.25% Bupivacaine TDS (max 2mg/kg daily). Pain is generally not a big issue, in severe pain consider complications, e.g. bleeding
Monitor for bleeding – flap site, drains and donor site. Drains should have minimal output and be removed as directed by surgeons when output <30ml/day. If drainage bottles are filling up rapidly, seek help immediately as airway may become compromised
Delirium – early use of haloperidol, clonidine, chlordiazepoxide and Pabrinex
Abbreviations used: ET, endotracheal; Hb, haemoglobin; Hct, haematocrit; LiDCO, lithium dilution cardiac output; MAP, mean arterial blood pressure; NG, nasogastric; PCA, patient-controlled analgesia; PEEP, positive end-expiratory pressure; SBP, systolic blood pressure; TDS, three times daily; TV, tidal volume.
