post-operative management

Introduction

Risk factors:

• see perioperative risk assessment
• elderly at greater risk for postoperative complications

Management

• central nervous system
  • prevention of delirium more effective than treatment
    • environmental support
  • 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)
• 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
  • beta-2 adrenergic inhaler when airfow obstruction is present
• cardiac
  • 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
  • electrocardiogram (ECG)
    • generally abnormal
    • new Q waves
    • ST segment changes
    • conduction block
  • high cardiac risk
    • serial EGC for 1 week
    • markers of myocardial infarction (troponin-I) for 1 week
• hemorrhage:
  • laboratory evaluation
    • prothrombin time (PT) & aPTT
    • thrombin time
    • fibrinogen
    • platelet count
    • D-dimer
    • clot lysis time
  • most common cause is injury-related
  • cardiopulmonary bypass
    • qualitative platelet defects
    • fibrinolysis
  • liver transplantation
    • increased fibrinolysis due to
      • an increase plasminogen activator
      • a decrease in tissue plasminogen activator inhibitor
• thrombosis prophylaxis
  • pneumatic compression devices
  • 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
  • risk of venous thromboembolism may be elevated for 12 weeks after surgery in women
• 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)
• ileus
  • appropriate bowel regimen
    • minimize opioid use, adrequate hydration, bowel rest, electrolyte repletion, ambulation
  • opioid receptor antagonist alvimopan
  • chewing gum may be useful
• other
  • adequate nutritional intake (Ensure)
  • fluid & electrolyte balance
  • avoid unnecessary foley catheter
    • early removal of foley catheter
    • voiding trials
    • monitor urine output
  • appropriate environmental stimuli
  • elimination of unnecessary medication
  • avoid opiates in the immediate postoperative period
  • 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
• use lowest possible opiate dosing

More general terms

• management

Additional terms

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