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Postoperative care begins in the recovery room and continues throughout the recovery period. Critical concerns are airway clearance, pain control, mental status, and wound healing. Preventing urinary retention, constipation, deep venous thrombosis, and BP variability (high or low) is also important. For patients with diabetes, plasma glucose levels are closely monitored by finger-stick testing q 1 to 4 h until patients are awake and eating, as glycemic control improves outcome.
Airway:
Most patients are extubated before leaving the operating room and rapidly clear secretions from their airway. Patients should not leave the recovery room until they can clear and protect their airway (unless they are going to an ICU). After intubation, patients with normal lungs and trachea may have a mild cough for 24 h after extubation; for smokers and patients with a history of bronchitis, postextubation coughing lasts longer. Most patients who have been intubated, especially smokers and patients with a lung disorder, benefit from an incentive inspirometer.
Postoperative dyspnea may be caused by pain secondary to chest or abdominal incisions or by hypoxemia (see also Approach to the Critically Ill Patient: Oxygen Desaturation). Hypoxemia is usually secondary to pulmonary dysfunction; oversedation sometimes causes hypoxemia in which the sensation of dyspnea is masked by the sedation. Pulmonary dysfunction is often due to atelectasis; fluid overload and heart failure must be considered, especially in patients with a history of heart failure. Whether dyspnea is hypoxic or nonhypoxic must be determined by pulse oximetry and sometimes ABGs; chest x-ray can help differentiate fluid overload from atelectasis.
Hypoxic dyspnea is treated with oxygen; nonhypoxic dyspnea may be treated with anxiolytics or analgesics.
Pain:
Pain control may be necessary as soon as patients are conscious (see Pain: Treatment of Pain). Opioids are typically the 1st-line choice and can be given orally or parenterally. Often, oxycodone / acetaminophen 2 tablets po q 4 to 6 h or morphine 2 to 4 mg IV q 3 h is given as a starting dose, which is subsequently adjusted as needed. With less frequent dosing, breakthrough pain, which should be avoided, is possible. For more severe pain, IV patient-controlled, on-demand dosing is best (see Pain: Dosing and titration). If patients do not have a renal disorder or a history of GI bleeding, giving NSAIDs at regular intervals may reduce breakthrough pain, allowing the opioid dosage to be reduced.
Mental
status:
All patients are briefly confused when they come out of anesthesia. The elderly, especially those with dementia, are at risk of postoperative delirium, which can delay discharge and increase risk of death. Risk of delirium is high when anticholinergic drugs are used. They are sometimes used before or during surgery to decrease upper airway secretions, but they should be avoided whenever possible. Opioids, given postoperatively, may also cause delirium, as can high doses of H2 blockers. The mental status of elderly patients should be assessed frequently during the postoperative period. If delirium occurs, oxygenation should be assessed, and all nonessential drugs should be stopped. Patients should be mobilized as they are able, and any electrolyte or fluid imbalances should be corrected.
Wound care:
Wound care should be meticulous. The surgeon must individualize care of each wound. Typically, dry sterile bandages are used. The site should be checked twice/day, if possible, for signs of infection (eg, increasing pain, erythema, drainage). If they occur, wound drainage, systemic antibiotics, or both may be required. Topical antibiotics are usually not helpful. A drain tube, if present, must be monitored for quantity and quality of the fluid collected. Sutures, skin staples, and other closures are usually left in place 7 days to 3 wk, depending on the site and the patient. Face and neck wounds may be superficially healed in 3 days; wounds on the lower extremities may take weeks to heal to a similar degree.
Deep
venous thrombosis (DVT) prophylaxis:
Risk of DVT after surgery is small but significant. Surgery itself increases coagulability and often requires prolonged immobility, another risk factor for DVT (see Pulmonary Embolism (PE); see Peripheral Venous and Lymphatic Disorders). Prophylaxis for DVT usually begins in the operating room (see Table 5: Pulmonary Embolism (PE): Some Anticoagulation Options Other Than Heparin in Thromboembolic Disease ). Alternatively, heparin may be started shortly after surgery, when risk of bleeding has decreased. Patients should begin moving their limbs as soon as it is safe for them to do so.
Other issues:
Certain types of surgery require additional precautions. For example, hip surgery requires that patients be moved and positioned so that the hip does not dislocate. Any physician moving such patients for any reason, including auscultation of the lungs, must know the positioning protocol to avoid doing harm; often, a nurse is the best instructor.
Urinary retention and constipation are common after surgery. Causes include use of anticholinergic or opioid drugs, immobility, and decreased oral intake. Patients must be monitored for urinary retention. If patients have a distended bladder and are uncomfortable or if they have not urinated for 6 to 8 h after surgery, straight catheterization is typically necessary, although Credé's maneuver sometimes helps. Chronic retention is best treated by avoiding causative drugs and by having patients sit up as often as possible. Bethanechol 5 to 10 mg can be tried in patients unlikely to have any bladder obstruction and who have not had a laparotomy; doses can be repeated every hour up to a maximum of 50 mg/day. Sometimes a Foley catheter is needed, especially if patients have a history of retention or a large initial output after straight catheterization. Constipation is treated by avoiding causative drugs and, if patients have not had GI surgery, by giving stimulant laxatives (eg, bisacodyl , senna , cascara). Stool softeners (eg, docusate ) do not help.
Prolonged bed rest causes loss of muscle mass (sarcopenia) and strength in all patients. With complete bed rest, young adults lose about 1% of muscle mass/day, but the elderly lose up to 5%/day because growth hormone levels decrease with aging. Avoiding sarcopenia is essential to recovery. Thus, as soon as safety allows, patients should sit up in bed, transfer, stand, and exercise as much as is safe for their surgical and medical condition.
Last full review/revision November 2005
Content last modified November 2005
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