By: 7 May 2015
ABC of postoperative intensive care for maxfax oncology patients

ABC of postoperative intensive care for maxillofacial oncology patients

Nasoendotracheal tube – manage as normal ET tube
Tracheostomy –refer to NTSP emergency algorithm
Seek senior help immediately as potentially difficult airway
Extubation to be managed by consultant only

Aim pO2 ≥ 10 (8 if COPD), normocapnia; PEEP 5–10; TV 6ml/kg

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)

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

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.