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CHAPTER 42: Postoperative Considerations

INTRODUCTION

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
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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		 2
1
0
Activity Steady gait, no dizziness, or meets preoperative level
Requires assistance
Unable to ambulate		 2
1
0
PONV Minimal, treated with oral medication
Moderate, treated with parenteral medication
Severe, continues despite treatment		 2
1
0
Pain Controlled with oral analgesics and acceptable to patient:
Yes
No
2
1
Surgical bleeding Minimal, no dressing change
Moderate, up to two dressing changes
Severe, more than three dressing changes		 2
1
0

Score ≥9 supports discharge.

BP = blood pressure; PONV = postoperative nausea and vomiting.

POSTOPERATIVE ORDERS

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
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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
Condition: stable
Allergies: NKDA		 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;
acute changes
Diet: Clear liquids, advance as tolerated
IV fluids: LR at 40 mL/hra; discontinue when tolerates 600 mL of oral fluids or POD#1

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