INTRODUCTION
The modern surgeon is involved with the management of a patient from preoperative evaluation, through the conduct of the operation into the postoperative care period and often into generating a long-term plan. As the operating surgeon, he/she is best situated to apply evidence-based scientific knowledge and a deep understanding of potential complications to that patient’s care. The recovery from major surgery can be divided into three phases:
An immediate, or postanesthetic phase
An intermediate phase, encompassing the hospitalization period
A convalescent phase
During the first two phases, care is principally directed at maintenance of homeostasis, treatment of pain, and prevention and early detection of complications. The convalescent phase is a transition period from the time of hospital discharge to full recovery. The trend toward earlier postoperative discharge after major surgery has shifted the venue of this period.
THE IMMEDIATE POSTOPERATIVE PERIOD
The primary causes of early complications and death following major surgery are acute pulmonary, cardiovascular, and fluid derangements. The postanesthesia care unit (PACU) is staffed by specially trained personnel and provided with equipment for early detection and treatment of these problems. All patients should be monitored in this specialized unit initially following major procedures unless they are transported directly to an intensive care unit. While en route from the operating room to the PACU, the patient should be accompanied by a physician and other qualified attendants. In the PACU, the anesthesiology service generally exercises primary responsibility for cardiopulmonary function. The surgeon is responsible for the operative site and all other aspects of the care not directly related to the effects of anesthesia. The patient can be discharged from the recovery room when cardiovascular, pulmonary, and neurologic functions have returned to baseline, which usually occurs 1-3 hours following operation. Patients who require continuing ventilatory or circulatory support or who have other conditions that require frequent monitoring are transferred to an intensive care unit. In this setting, nursing personnel specially trained in the management of respiratory and cardiovascular emergencies are available, and the staff-to-patient ratio is higher than it is on the wards. Monitoring equipment is available to enable early detection of cardiorespiratory derangements.
Detailed treatment orders are necessary to direct postoperative care. The transfer of the patient from OR to PACU requires reiteration of any patient care orders. Unusual or particularly important orders should also be communicated to the nursing team orally. The nursing team must also be advised of the nature of the operation and the patient’s condition. Errors in postoperative orders, including medication errors and omission of important orders, are diminished by electronic order entry systems that can contain postoperative order sets. Careful review of order sets is still warranted, as individual patients require specialized attention. Postoperative orders should cover the following.
Blood pressure, pulse, and respiration should be recorded frequently until stable and then regularly until the patient is discharged from the recovery room. The frequency of vital sign measurements thereafter depends upon the nature of the operation and the course in the PACU. When an arterial catheter is in place, blood pressure and pulse should be monitored continuously. Continuous electrocardiographic monitoring is indicated for most patients in the PACU. Any major changes in vital signs should be communicated to the anesthesiologist and attending surgeon immediately.
Central venous pressure should be recorded periodically in the early postoperative period if the operation has entailed large blood losses or fluid shifts, and invasive monitoring is available. A Swan-Ganz catheter for measurement of pulmonary artery wedge pressure is indicated under these conditions if the patient has compromised cardiac or respiratory function.
The anesthetic record includes all fluid administered as well as blood loss and urine output during the operation. This record should be continued in the postoperative period and should also include fluid losses from drains and stomas. This aids in assessing hydration and helps to guide intravenous fluid replacement. A bladder catheter can be placed for frequent measurement of urine output. In the absence of a bladder catheter, the surgeon should be notified if the patient is unable to void within 6-8 hours after operation to determine whether intermittent catheterization may be warranted.
Depending on the nature of the operation and the patient’s preexisting conditions, other types of monitoring may be necessary. Examples include measurement of intracranial pressure and level of consciousness following cranial surgery and monitoring of distal pulses following vascular surgery or in patients with casts, evaluating for expanding hematoma in patients after thyroid surgery et cetera.
Most patients who remain in the hospital beyond the immediate postoperative period require an evaluation by a physician or adjunct during the 4-6 hours following surgery. This evaluation should include a review of the patient’s overall subjective status, any objective alterations during that time period, an assessment of whether the postoperative orders are appropriate and adequate and if the patient has developed any signs or symptoms indicative of a complication related to their particular procedure or the anesthesia and medications administered since that time. A thorough understanding of the patient’s history and surgical course will help in anticipating, preventing, and identifying any complications. Any worrisome findings should be directly and quickly communicated to the attending surgeon, who is in the best position to determine if an intervention is warranted.
In the early postoperative period, the patient may remain mechanically ventilated or be treated with supplemental oxygen by mask or nasal prongs, preferably with humidification. These orders should be specified. For intubated patients, tracheal suctioning or other forms of respiratory therapy must be specified as required. Patients who are not intubated should be instructed on how to cough and do deep breathing exercises frequently to prevent atelectasis.
The postoperative orders should describe any required special positioning of the patient. Unless doing so is contraindicated, the patient should be turned from side to side every 30 minutes until conscious and then hourly for the first 8-12 hours to minimize atelectasis. Early ambulation is encouraged to reduce venous stasis; the upright position helps to increase diaphragmatic excursion. Venous stasis may also be minimized by intermittent compression of the calf by pneumatic stockings. Safety considerations are paramount, including special alerts to fall risk (such as using red socks and bed rails), one-on-one monitoring, and assistance with all transfers. Support under the knees and heels can help reduce back pain and tension from immobility during surgery.
Patients at risk for emesis and pulmonary aspiration should have nothing by mouth until some gastrointestinal function has returned (usually within 4 days). Most patients can tolerate liquids by mouth shortly after return to full consciousness.
Orders for postoperative intravenous fluids should be based on maintenance needs, operative losses, and the replacement of gastrointestinal losses from drains, fistulas, or stomas.
Drain care instructions should be included in the postoperative orders. Details such as type and pressure of suction, irrigation fluid and frequency, skin exit site care and support during ambulation or showering should be specified. The surgeon should examine drains frequently, since the character or quantity of drain output may herald the development of postoperative complications such as bleeding or fistulas. Careful positioning and reinforcement of anchors can prevent the dreaded early loss of key placement of nasogastric tubes, chest tubes, and drains.
Orders should be written for antibiotics, analgesics, gastric acid suppression, deep vein thrombosis prophylaxis, and sedatives. If appropriate, preoperative medications should be reinstituted. Medication reconciliation is important, as interactions are possible and potentially harmful. Route of administration of medications and medication substitution should be discussed with the pharmacy when necessary. Careful attention should be paid to replacement of corticosteroids in patients at risk, since postoperative adrenal insufficiency may be life threatening, but over-supplementation can affect wound healing. Other medications such as antipyretics, laxatives, and stool softeners should be used selectively as indicated. Prophylaxis for postoperative nausea and vomiting can be useful; the type and route of medication remains controversial and should be tailored to the patient.
Postoperative laboratory and radiographic examinations should be used to detect specific abnormalities in high-risk groups. The routine use of daily chest radiographs, blood counts, electrolytes, and renal or liver function panels is not useful. Identification and treatment of hyperglycemia should be instituted in patients who require management.
THE INTERMEDIATE POSTOPERATIVE PERIOD
The intermediate phase begins with complete recovery from anesthesia and lasts for the rest of the hospital stay. During this time, the patient recovers most basic functions and becomes self-sufficient and ready to continue convalescence at home. Transfer from the PACU/SICU to a less monitored setting usually occurs at the start of this period. Communication within the care team is important during this transition; this team can include surgeons, nurses, nutritionists, social workers and case managers, respiratory, physical and occupational therapists, residents and consulting physicians. Isolation and specialized management of patients colonized or infected with drug-resistant organisms or highly contagious infectious agents continues from the OR through stay in the PACU and then with appropriate barrier devices and room determination throughout the hospital stay.
Within hours after a wound is closed, the wound space fills with an inflammatory exudate. Epidermal cells at the edges of the wound begin to divide and migrate across the wound surface. By 48 hours after closure, deeper structures are completely sealed off from the external environment. Sterile dressings applied in the operating room provide protection during this period.
Removal of the dressing and handling of the wound during the first 24 hours should be done with aseptic technique. Medical personnel should wash their hands before and after caring for any surgical wound. Gloves should always be used when there is contact with open wounds or fresh wounds.
Dressings over closed wounds should be removed by the third or fourth postoperative day. If the wound is dry, dressings need not be reapplied; this simplifies periodic inspection. Dressings should be removed earlier if they are wet or placed in a contaminated setting, because soaked dressings increase bacterial contamination of the wound. Dressings should also be removed if the patient has new manifestations of infection (such as fever or increasing wound pain). The wound should then be inspected and the adjacent area gently compressed. Any drainage from the wound should be examined by culture and Gram-stained smear.
Vacuum dressings should usually be replaced within 24-72 hours. Pain management around the time of dressing change is important to consider, as proper prophylaxis can make the procedure less difficult for both the patient and the surgical team.
Generally, skin sutures or skin staples may be removed by the fifth postoperative day and replaced by tapes. Sutures should be left in longer (eg, for 2 weeks) for incisions that cross creases (eg, groin, popliteal area), for incisions closed under tension, for some incisions in the extremities (eg, the hand), and for incisions of any kind in debilitated patients. Sutures should be removed if suture tracts show signs of infection. If the incision is healing normally, the patient may be allowed to shower or bathe by the seventh postoperative day (and often sooner, depending on the incision).
Drains are used either to prevent or to treat an unwanted accumulation of fluid such as pus, blood, or serum. Drains are also used to evacuate air from the pleural cavity so that the lungs can re-expand. When used prophylactically, drains are usually placed in a sterile location. Strict precautions must be taken to prevent bacteria from entering the body through the drainage tract in these situations. The external portion of the drain must be handled with aseptic technique, and the drain must be removed as soon as it is no longer useful. When drains have been placed in an infected area, there is a smaller risk of retrograde infection of the peritoneal cavity, since the infected area is usually walled off. Drains should usually be brought out through a separate incision, because drains through the operative wound increase the risk of wound infection. Closed drains connected to suction devices (Jackson-Pratt or Blake drains are two examples) are preferable to open drains (such as Penrose) that predispose to wound contamination. The quantity and quality of drainage should be recorded and contamination minimized. When drains are no longer needed, they may be withdrawn entirely at one time if there has been little or no drainage or may be progressively withdrawn over a period of a few days.
Sump drains (such as Davol drains) have an airflow system that keeps the lumen of the drain open when fluid is not passing through it, and they must be attached to a continuous suction device. Sump drains are especially useful when the amount of drainage is large or when drainage is likely to plug other kinds of drains. Some sump drains have an extra lumen through which saline solution can be infused to aid in keeping the tube clear. After infection has been controlled and the discharge is no longer purulent, the large-bore catheter may be progressively replaced with smaller catheters as the cavity closes.
Drains that have clot or thick material within them or that have lost their drainage capacity can be stripped or flushed to restore function; this should be performed only under the supervision and approval of the attending surgeon as doing so could disrupt the operative bed in some circumstances.
The changes in pulmonary function observed following anesthesia and surgery are principally the result of decreased vital capacity, functional residual capacity (FRC), and pulmonary edema. Vital capacity decreases to about 40% of the preoperative level within 1-4 hours after major intra-abdominal surgery. It remains at this level for 12-14 hours, slowly increases to 60%-70% of the preoperative value by 7 days, and returns to the baseline level during the ensuing week. FRC is affected to a lesser extent. Immediately after surgery, FRC is near the preoperative level, but by 24 hours postoperatively, it has decreased to about 70% of the preoperative level. It remains depressed for several days and then gradually returns to its preoperative value by the tenth day. These changes are accentuated in patients who are obese, who smoke heavily, or who have preexisting lung disease. Elderly patients are particularly vulnerable because they have decreased compliance, increased closing volume, increased residual volume, and increased dead space, all of which enhance the risk of postoperative atelectasis. In addition, reduced forced expiratory volume in 1 second (FEV1) impairs the aged patient’s ability to clear secretions and increases the chance of infection postoperatively.
The postoperative decrease in FRC is caused by a breathing pattern consisting of shallow tidal breaths without periodic maximal inflation. Normal human respiration includes inspiration to total lung capacity several times each hour. If these maximal inflations are eliminated, alveolar collapse begins to occur within a few hours, and atelectasis with transpulmonary shunting is evident shortly thereafter. Pain is thought to be one of the main causes of shallow breathing postoperatively. Complete abolition of pain, however, does not completely restore pulmonary function. Neural reflexes, abdominal distention, obesity, and other factors that limit diaphragmatic excursion appear to be as important.
The principal means of minimizing atelectasis is deep inspiration and cough. Using an incentive spirometer can facilitate periodic hyperinflation. This is particularly useful in patients with a higher risk of pulmonary complications (eg, elderly, debilitated, or markedly obese patients). Early mobilization, encouragement to take deep breaths (especially when standing), and good coaching by the nursing staff suffice for most patients.
Postoperative pulmonary edema is caused by high hydrostatic pressures (due to left ventricular failure, fluid overload, decreased oncotic pressure, etc), increased capillary permeability, or both. Edema of the lung parenchyma narrows small bronchi and increases resistance in the pulmonary vasculature. In addition, pulmonary edema may increase the risk of pulmonary infection. Adequate management of fluids postoperatively and early treatment of cardiac failure are important preventive measures.
Systemic sepsis increases capillary permeability and can lead to pulmonary edema. In the absence of deranged cardiac function or fluid overload, the development of pulmonary edema postoperatively should be regarded as evidence of sepsis. Signs and symptoms of pulmonary complications include fever, tachypnea, tachycardia, and an alteration in mental status. Development of atrial fibrillation or an abnormal cardiac rhythm can often precede identification of pulmonary complications.
Patients who smoked tobacco up until the time of surgery should be considered at higher risk for postoperative pulmonary complications. Symptoms of withdrawal from nicotine can be managed with a nicotine patch or gum.
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