Contents

Search

post-operative management

Risk factors: 1) see perioperative risk assessment 2) elderly at greater risk for postoperative complications [2] Management: 1) central nervous system a) prevention of delirium more effective than treatment - environmental support b) adequate pain management - 1 g of acetaminophen every 6 hours (4 g/day) - titrate opiates to level of pain* - long-term opiate use (< 90 days) uncommon in the elderly after major surgery (3%, 8% for open thoracic procedures) [8] 2) pulmonary: - supplemental oxygen - incentive spirometry - early ambulation - postural drainage, chest physiotherapy - optimize cough & secretion drainage - elevate head of bed (30 degrees) for suspected sleep apnea [1] - beta-2 adrenergic inhaler when airfow obstruction is present 3) cardiac a) post-operative MI - peak incidence is 24-48 hours - angina pectoris in 50% - heart failure, hypotension, supraventricular tachycardia are presenting signs of post-op MI b) electrocardiogram (ECG) - generally abnormal - new Q waves - ST segment changes - conduction block c) high cardiac risk - serial EGC for 1 week - markers of myocardial infarction (troponin-I) for 1 week 4) hemorrhage: a) laboratory evaluation - prothrombin time (PT) & aPTT - thrombin time - fibrinogen - platelet count - D-dimer - clot lysis time b) most common cause is injury-related c) cardiopulmonary bypass - qualitative platelet defects - fibrinolysis d) liver transplantation - increased fibrinolysis due to - an increase plasminogen activator - a decrease in tissue plasminogen activator inhibitor 5) thrombosis prophylaxis - pneumatic compression devices [10] - enoxaparin 30 mg SC BID - heparin 5000 U SC BID - generally continued for 4 weeks postoperatively (major surgery, orthopedic knee or hip) - low to moderate risk non-orthopedic surgical patients do not benefit from venous thromboembolism chemoprophylaxis [11] - risk of venous thromboembolism may be elevated for 12 weeks after surgery in women [7] 6) endocrine - diabetes mellitus type 2 - a basal level of long-acting insulin with as needed short-acting insulin is the preferred method of glycemic control in the acute care setting - a target for serum glucose < 180 mg/dL (expert opinion) [1] 7) ileus - appropriate bowel regimen - minimize opioid use, adrequate hydration, bowel rest, electrolyte repletion, ambulation [1] - opioid receptor antagonist alvimopan [3] - chewing gum may be useful [1] 8) other - adequate nutritional intake (Ensure) - fluid & electrolyte balance - avoid unnecessary foley catheter - early removal of foley catheter - voiding trials - monitor urine output [1] - appropriate environmental stimuli - elimination of unnecessary medication - avoid opiates in the immediate postoperative period [9] - early ambulation - surgical staples generally removed in 21 days * Considerations in the elderly: - titrate postoperative opiates similarly in younger & older patients, using weight & subjective pain to guide dosing [5] - use lowest possible opiate dosing [9]

Related

perioperative risk assessment postoperative complication postoperative pain surgical staple(s)

General

management

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2012, 2015, 2018, 2022.
  2. Journal Watch 21(10):77, 2001 Polanczyc et al Ann Intern Med 134:637, 2001
  3. Journal Watch 21(21):168, 2001 Taguchi A, Sharma N, Saleem RM, et al, Selective postoperative inhibition of gastrointestinal opioid receptors. N Engl J Med. 2001 Sep 27;345(13):935-40. PMID: 11575284 Free Article
  4. Winawer et al, Medical Clinics of North America 85, 2001
  5. Journal Watch 22(5):37, 2002 Aubrun F et al, Anesthesiology 96:17, 2002
  6. Qaseem A, Snow V, Fitterman N, Hornbake ER, Lawrence VA, Smetana GW, Weiss K, Owens DK, Aronson M, Barry P, Casey DE Jr, Cross JT Jr, Fitterman N, Sherif KD, Weiss KB; Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardio- thoracic surgery: a guideline from the American College of Physicians. Ann Intern Med. 2006 Apr 18;144(8):575-80. PMID: 16618955 http://www.annals.org/content/144/8/575.full - Smetana GW et al, Perioperative pulmonary risk stratification for noncardithoracic surgery: Systematic review for the American College of Physicians. Ann Intern Med 2006; 144:581 PMID: 16618956 http://www.annals.org/content/144/8/581.full - Lawrence VA et al, Stategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: Systematic review for the American College of Physicians Ann Intern Med 2006; 144:596 PMID: 16618957 http://www.annals.org/content/144/8/596.full
  7. Sweetland S et al Duration and magnitude of the postoperative risk of venous thromboembolism in middle aged women: prospective cohort study. BMJ 2009;339:b4583 PMID: 19959589 http://www.bmj.com/cgi/content/full/339/dec03_1/b4583
  8. Clarke H et al Rates and risk factors for prolonged opioid use after major surgery: population based cohort study. BMJ 2014;348:g1251 PMID: 24519537 http://www.bmj.com/content/348/bmj.g1251
  9. American Urological Association Fifteen Things Physicians and Patients Should Question Released February 21, 2013 (1-5), June 11, 2015 (6-10), May 13, 2017 (11-15); sources for #5 revised May 9, 2016 http://www.choosingwisely.org/societies/american-urological-association/
  10. Lobastov K et al. Intermittent pneumatic compression in addition to standard prophylaxis of postoperative venous thromboembolism in extremely high-risk patients (IPC SUPER): A randomized controlled trial. Ann Surg 2021 Jul 1; 274:6 PMID: 33201130 https://journals.lww.com/annalsofsurgery/Abstract/2021/07000/Intermittent_Pneumatic_Compression_in_Addition_to.16.aspx
  11. Sutzko DC et al. Low to moderate risk non-orthopedic surgical patients do not benefit from VTE chemoprophylaxis. Ann Surg 2022 Dec; 276:e691. PMID: 33214487 https://journals.lww.com/annalsofsurgery/Abstract/2022/12000/Low_to_Moderate_Risk_Non_orthopedic_Surgical.27.aspx