Admitting Patients from the OR

by Andria RN · 6 comments

in ICU

Admitting surgical patients directly from the Operating Room (OR) can present some unique challenges.  The goal of this post is to educate you about anesthesia, the hand off, and help you prioritize your postoperative admission orders.

Why is the ICU getting an OR patient?

There are an infinite number of reasons a patient goes to the ICU after surgery.  Perhaps they need titration of an insulin drip, frequent doppler assessment for vascular status, or they have an open abdomen that has been packed, they’ve had a large amount of blood loss, an unexpected intraoperative complication, or any condition that warrants the need for ventilation, sedation, hemodynamic control, and close monitoring that cannot be done on a regular hospital floor.  Sometimes the nature of the procedure warrants the ICU bed; like open chest procedures, neuro procedures, or major traumas.  Sometimes the patient is simply being returned to their own ICU room.  You get the picture…

One of the most important things to keep in mind is that the surgical patient literally just completed surgery.  It may have been within 10 minutes depending on how close your ICU is to the OR.  It goes like this:  the surgeon finishes suturing or stapling the surgical site, a dressing is placed, anesthesia wakes up the patient (or leaves them intubated), they get transferred to an ICU bed, hooked up to the portable monitor, and they start moving toward you.

About Anesthesia

An Anesthesia Provider (CRNA, MD, MD Resident/Fellow) operates autonomously without official written orders, and they may be treating the patient en route to your waiting arms.  I’d guesstimate that 95% of the drugs used by anesthesia are quick on, quick off; so, it may seem like the provider is only temporarily fixing an issue (e.g. bumping up a blood pressure or giving a small bolus of sedation) and then leaving you with a mess when the med wears off.  In reality, the patient coming out of anesthesia is in a very labile state.  This is even the case for non-ICU patients (regular healthy-ish folks), that are recovered in the Postoperative Anesthesia Care Unit (PACU).  The PACU nurses often have 1-2 patients to monitor.  They look at vital signs, treat pain, investigate for any sign of a surgical complication, and they guide the patient out of the anesthesia fog/confusion that sometimes accompanies emergence.  I’ll come back to this later when I talk about why some patients have hypotension after surgery.

During the surgery, the patient commonly receives anesthesia via inhalation agents that enter and exit the body through the lungs.  The anesthetic agents (Sevoflurane, Isoflurane, and Desflurane) basically keep the patient “unconscious”- to put it in layman’s terms.  This is relevant to the RN in the ICU because the agent has not been administered since patient left the OR.  Every time the patient exhales they are exhaling some of the agent that is keeping them under.  The patient may be close to regaining consciousness even if they appear far from it.  Therefore, it’s important to find out what type of IV sedation is ordered for the intubated patient and try to set that up with fairly high priority so the patient doesn’t become irritated by the endotracheal tube.  Deep planes of anesthesia blunt the cough and gag reflex, so as the anesthesia wears off, the patient becomes aware of having a plastic tube in their trachea, which may lead to coughing, gagging and poor ventilation.

It is also important to find out if the patient is paralyzed; obviously, a paralyzed patient should never be without sedation.  In the OR, anesthesia often uses a nerve stimulator to determine the amount of receptors that are blocked by the paralytic.  Anesthesia may also reverse the paralytic, which means they give antagonizing drugs to reverse the block on the muscle receptors.  Paralytics like Rocuronium tend to wear off in 20-30 minutes, whereas Vecuronium may take longer.  This is all dose dependent so don’t be afraid to ask the anesthesia provider when the last dose of paralytic was administered and when they estimate it will wear off.

If anesthesia is using an ambu bag to ventilate the patient, connecting the patient to the ventilator is usually top priority- this means the ventilator should already be set up in the room.  If you know you are getting a patient from the OR, ask if the patient will be intubated.  If they are, you know for sure you are going to need some IV pumps and a ventilator.

 

After the ventilator has been connected, start to transfer the patient’s cables from the portable monitor to your monitor.  Anesthesia and the ICU RN are constantly observing the monitor so if you are unhooking from the portable, you want to quickly change over to the room monitor.  There is a pretty good running joke among ICU RN’s that anesthesia always brings a rat’s nest of lines.  The cables will be criss-crossed and messy.  This is something that ICU nurses hates because nurses are so particular and organized.  But, I promise- most anesthesia providers do not do this on purpose.  It is just the nature of the transfer process and there is often not time to straighten everything out when you are traveling down the hallway with a somewhat unstable patient.

I told you I was going to come back to the issue of hypotension after surgery.  Hypotension is pretty common under anesthesia because the inhalation agents used cause vasodilation and dose-dependent cardiac depression.  Also, the use of narcotics to treat surgical pain can cause hypotension.  So if a phenylephrine infusion was used to maintain adequate blood pressure during the procedure- it doesn’t necessarily mean that the patient will need it when they come out of surgery.  Give the patient some time to breathe off all the anesthetic gases and settle out.  Then you’ll have a better idea of the hemodynamic status.  This doesn’t mean you should leave hypotension left untreated…just that it might take awhile for the patient to stabilize.  Ask the anesthesia provider if they have anything to treat vital signs that are out of whack.  They usually carry meds with them, and this can buy you time while you prepare a vasopressor infusion.

Urine output is also altered by the anesthetic.  Anesthesia reduces the glomerular filtration rate (GFR) and less urine may be produced.  It usually returns back to baseline within a few hours, however, the patient may be “dry” and require a fluid bolus or the administration of blood and/or blood products.

The Hand Off/Report

Some hospitals have started using a “huddle” with a pre-formed script to give report in the ICU.  This means the surgical team, anesthesia, the attending ICU team, the RN, and respiratory are all present when report is given.  Some places aren’t as formal and the anesthesia provider gives a hand off to the ICU RN.  Usually the same type of information is passed on.

Information that may be reported: patient name, age, allergies, medical history, type of IV access, ventilator settings in the OR, lab and ABG values, whether or not the patient was an easy or challenging intubation, antibiotic dosing, last dose of narcotic, last dose of paralytic, and the I’s and O’s (In’s and Out’s) e.g. crystalloid fluid and colloid fluid administered, blood products administered, urine collected, estimated blood loss (EBL), gastric fluids, etc.  And to reiterate what I mentioned earlier- if anesthesia tells you the patient was reversed, this means drugs were given to antagonize the paralytic- so you can assume the patient is no longer paralyzed.

report

 

Ask the anesthesia provider what medications, if any, were given en route to the ICU.  If they were administering small boluses of phenylephrine (to boost blood pressure) on the way to you, then shortly after they leave you are going to see the blood pressure decrease and the heart rate increase (because phenylephrine causes reflex bradycardia).  If they gave sedation like Propof0l, you know you have about 5-10 minutes before the patient starts to arouse.  Some providers also use Esmolol, which is a very short acting beta blocker.  If they gave that to decrease HR/BP, within a few minutes your heart rate and blood pressure will start to climb again.

When the surgical team and anesthesia are present, feel free to ask what their biggest concerns are.  For example, if the patient underwent a long facial procedure or neck dissection- there is a potential for airway swelling and respiratory distress.  Perhaps the patient lost a large amount of blood volume and has coagulation issues and they want you to be on edge for hemodynamic compromise.  Perhaps the team is worried about postoperative pain control.  You will not be laughed at for asking this question and it can give you some very helpful information.  Another great question to pose is if there is a plan for the patient.  Some neuro patients remain intubated until they are awake enough to assess neurological and respiratory status.  Again, not a dumb question.  Part of patient advocacy is helping develop a clear plan to improve the situation!

Don’t be afraid to speak up!  You are a valuable part of the team and pretending like you KNOW what is going on when you are unsure will only hurt you in the long run!

Post-op Admission Orders

Getting a new admit always seems to be a lot of work.  But prioritizing the most critical orders should help you stabilize the patient enough to where you can go about the rest of your tasks and hopefully find the time to chart before the end of shift.  ABCD is a great pnemonic to use.  If Airway and Breathing are under control, which they should be before anesthesia leaves, your life is much easier.  If the patient is intubated, one of the first orders you should carry out is sedation and/or pain control.  Next, are there Circulation concerns?  If the patient has low blood pressure, see if there are orders for a vasopressor drip, fluid bolus, or call the staff to get an order.  On to D for Drainage.  Perhaps the patient has a wound vac, a bulb, a chest tube, etc that you need to be checking frequently.  A large amount of bright red blood early after the procedure might alert you that there is still uncontrolled bleeding.  Feel free to ask the surgical team during report how much blood loss they expect or when to notify them.  Also, check your antibiotic schedule, you definitely don’t want to miss any doses for these types of patients who are higher risk for infections.

Some patients have special needs, like doppler monitoring for vascular patients or patients that have undergone breast reconstruction with a flap.

After you sort through the initial orders and let the patient stabilize, many of the patients settle out and become just as familiar as our other ICU patients.

**Side note, certain procedures require the patient be in steep trendelenberg or in the prone position (on their stomach).  If the patient has been in surgery for many hours, it is not uncommon to see facial swelling.  For example, a patient that has undergone a long spinal operation has been laying prone for several hours under anesthesia.  The anesthesia provider often tries to limit fluid administration but sometimes gravity causes the fluid to pool under the patient’s eyes and in the face.   Also, any time you have facial swelling, be concerned for airway swelling.  If these kinds of patients pull out their own endotracheal tube, their airway may close because that tube may have been the only thing keeping it open.  This is not an ideal situation so do everything you can to ensure that tube does not come out before it’s safe.  Over time, the body will naturally reabsorb the extra fluid and the patient will return to baseline.

 

Questions, concerns, comments?  Stories about your own surgical admits?  We’d love to hear them!

 

  • http://www.CollegeAtlas.org/ CollegeAtlas.org

    Andrea,
    I’d like to get in touch with you regarding a nursing guide we just created that might be helpful to your readers. Do you have an email address where I can email you?
    Thanks!
    rachel @CollegeAtlas.org

  • http://www.oldfoolrn.blogspot.com Old Fool

    Hi Andrea,
    This is one of the best summaries of OR to ICU transfers I have read. Back in my time before the myriad of various ICUs, we used to keep unstable patients in the recovery room overnight. If you have any interest in what was state of the art 40+ years ago, p lease see my blog. I’m at oldfoolrn.blogspot.com. I really enjoyed reading your blog.

  • Lisa

    Hi, this is probably not the right forum to ask this question but if you could direct me to the right place I would be grateful : I am developing communication apps to be used in ICU between patients and nurses and I would appreciate if I could run some of my ideas through an ICU nurse who knows more than I do as to the communication needs of both the nurses and the patients. I have come across a few papers that give me some idea but I believe the expertise that nurses have would be really helpful in ensuring the app’s usefulness. Is there an online place where I can contact ICU nurses for to discuss? or are there resources that can give me more recent and ideas about the practical issues? or if there are nurse meet-ups I can probably visit them to see if anyone is interested in further discussion? I realize they are busy but any kind of help would be appreciated. I really appreciate it. thanks, Lisa

  • AndriaCRNA

    You can try allnurses.com, ICU section. Best of luck!

  • Lisa

    Thanks

  • Annie

    You can also try r/nursing on Reddit

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