Competent postoperative management requires an understanding of the patient’s history, operative events, and fundamentals of the surgical stress response. Many problems after surgery can be avoided by the preoperative risk assessment and prevention strategies described in Chapter 39. However, complications can still develop despite ideal preparation, and vigilance for these adverse events can help ensure successful recovery for most patients.
POST-ANESTHESIA CARE UNIT
Patients who have received general or regional anesthesia or moderate sedation are typically transferred to a post-anesthesia care unit (PACU) after surgery for monitoring. Critically ill patients may bypass the PACU and instead recover in an intensive care unit. In either location, factors initially assessed are respiratory, cardiovascular, and neuromuscular function, temperature, pain, postoperative nausea and vomiting (PONV), mental status, fluid balance, urine output, wound drainage, and bleeding (Apfelbaum, 2013). Several scoring systems to guide discharge of the patient from the PACU are available, but none are universally recognized (Hawker, 2017). Table 42-1 presents one example (Aldrete, 1995; Marshall, 1999). Once an institution’s criteria are met, the patient is either discharged home or transferred to a ward bed.
TABLE 42-1Postanesthetic Discharge Scoring System |Favorite Table|Download (.pdf) TABLE 42-1 Postanesthetic Discharge Scoring System
|Criteria ||Score || |
|Vital signs ||BP, pulse within 20% of preoperative baseline |
BP, pulse within 20–40% of baseline
BP, pulse >40% of baseline
|Activity ||Steady gait, no dizziness, or meets preoperative level |
Unable to ambulate
|PONV ||Minimal, treated with oral medication |
Moderate, treated with parenteral medication
Severe, continues despite treatment
|Pain ||Controlled with oral analgesics and acceptable to patient: |
|Surgical bleeding ||Minimal, no dressing change |
Moderate, up to two dressing changes
Severe, more than three dressing changes
These written instructions address support of each organ system, while normal function is gradually reestablished. Although orders are customized for each woman, goals are common among all surgical patients and include fluid replacement, pain control, and resumption of daily activities. Table 42-2 offers a template for both inpatient and outpatient postoperative orders.
TABLE 42-2Typical Postoperative Orders |Favorite Table|Download (.pdf) TABLE 42-2 Typical Postoperative Orders
|Postoperative Orders (Inpatient) || |
|Admit to: PACU/assigned hospital floor/attending physician’s name |
Diagnosis: s/p what surgical procedure
|Vital signs: every 1 hr × 4; every 2 hr × 2; then every 4 hr |
Notify MD for: T >101°F; BP >160/110, <90/60;
P >130; RR >30, <10; UOP <120 mL/4 hr;
|Diet: Clear liquids, advance as tolerated |
|IV fluids: LR at 40 mL/hra; discontinue when tolerates 600 mL of oral fluids or POD#1 |
POD#0: Ambulate in room ...