Postoperative Care

Most intubated patients are extubated before leaving the operating room and soon become able to clear secretions from their airway. Patients should not leave the recovery room until they can clear and protect their airway (unless they are going to an intensive care unit [ICU]). After intubation, patients with normal lungs and trachea may have a mild cough for 24 hours after extubation; for patients who smoke and those with a history of bronchitis, postextubation coughing lasts longer. Most patients who have been intubated, especially patients who smoke and patients with a lung disorder, benefit from an incentive inspirometer.

Postoperative dyspnea may be caused by pain secondary to chest or abdominal incisions (nonhypoxic dyspnea) or by hypoxemia (hypoxic dyspnea—see also Oxygen Desaturation). Hypoxemia secondary to pulmonary dysfunction is usually accompanied by dyspnea, tachypnea, or both; however, oversedation may cause hypoxemia but can blunt dyspnea, tachypnea, or both. Thus, sedated patients should be monitored with pulse oximetry or capnometry. Hypoxic dyspnea may result from atelectasis or, especially in patients with a history of heart failure or chronic kidney disease, fluid overload. Whether dyspnea is hypoxic or nonhypoxic must be determined by pulse oximetry and sometimes arterial blood gas; chest x-ray can help differentiate fluid overload from atelectasis.

Hypoxic dyspnea is treated with oxygen. Nonhypoxic dyspnea may be treated with anxiolytics or analgesics.

Fluid management and hemodynamic monitoring are crucial aspects of perioperative care that influence patient outcomes after surgery. Adequate fluid balance is essential to maintain tissue perfusion, oxygen delivery, and organ function. The latest guidelines emphasize individualized fluid therapy based on patient characteristics, surgical factors, and hemodynamic monitoring. The goal is to achieve euvolemia and avoid hypovolemia and fluid overload. The Society of Thoracic Surgeons (STS) and the European Society of Anaesthesiology (ESA) guidelines recommend minimally invasive techniques for hemodynamic monitoring, such as pulse contour analysis (eg, arterial waveform analysis) and transesophageal echocardiography (TEE) (1, 2). Use of dynamic parameters is also recommended, such as stroke volume variation (SVV) and pulse pressure variation (PPV). These parameters can help identify fluid responsiveness and guide fluid administration, reducing the risk of complications such as acute kidney injury and respiratory complications.

Risk of DVT after surgery is small, but because consequences can be severe and risk is still higher than that in the general population, prophylaxis is often warranted. Surgery itself increases coagulability and often requires prolonged immobility, which is another risk factor for DVT (see Pulmonary Embolism and Deep Venous Thrombosis). Prophylaxis for DVT usually begins in the operating room or earlier (see table Risk of Deep Venous Thrombosis and Pulmonary Embolism in Surgical Patients3). Patients should ambulate or undergo physical therapy to facilitate mobilization as soon as it is safe to do so.

Pain control may be necessary as soon as patients are conscious. Multimodal pain management is typically used, including opioid and nonopioid analgesics. Opioids, which should be used for the shortest duration and at the lowest dose, are typically given orally for moderate pain. For severe pain, IV patient-controlled, on-demand dosing is sometimes used (see Dosing and Titration). If patients do not have a renal disorder or a history of gastrointestinal bleeding, giving nonsteroidal anti-inflammatory drugs (NSAIDs) at regular intervals may reduce breakthrough pain, allowing the opioid dosage to be reduced.

To address the increased prevalence of opioid use disorder, consensus guidelines for postoperative opioid use have been provided by medical organizations in the United States and an international medical panel.

All patients are briefly confused when they come out of anesthesia. Opioids, given postoperatively, may also contribute to delirium, as can anticholinergic medications and high doses of H2 blockers.

Older adults, especially those with dementia, are at risk of postoperative delirium, which can delay discharge and increase risk of death. Anticholinergic medications are sometimes used before or during surgery to decrease upper airway secretions, but they should be avoided whenever possible. The mental status of older adults should be assessed frequently during the postoperative period. If delirium occurs, oxygenation should be assessed, and all nonessential medications should be stopped.

Patients should be mobilized as they are able, and any electrolyte or fluid imbalances should be corrected.

Urinary retention and constipation are common after surgery. Causes include

• Anticholinergics

• Opioids

• Immobility

• Decreased oral intake

Urine output must be monitored. Straight catheterization is typically necessary for patients who have a distended bladder and are uncomfortable or who have not urinated for 6 to 8 hours after surgery. After surgery, many patients have an indwelling bladder catheter in place until they can ambulate. However, an indwelling catheter should be removed as soon as possible to decrease the risk of infection.

Chronic urinary retention is best treated by avoiding causative medications and by having patients sit up as often as possible.

Constipation

The surgeon must individualize care of each wound, but the sterile dressing placed in the operating room is generally left intact for 24 to 48 hours unless signs of infection (eg, increasing pain, erythema, drainage) develop. After the operative dressing is removed, the site should be checked twice daily for signs of infection. If they occur, wound exploration and drainage of abscesses, systemic antibiotics, or both may be required. Topical antibiotics are usually not helpful.

Sutures, skin staples, and other closures are usually left in place 7 days or longer depending on the site and the patient. Face and neck wounds may be superficially healed in 3 days; wounds on the lower extremities may take weeks to heal to a similar degree.

A drain tube, if present, must be monitored for quantity and quality of the fluid collected. However, drain tubes should be removed as soon as possible, because they can serve as a nidus for infection and may not manifest signs of adverse effects such as bleeding or anastomotic leak.

A common cause of postoperative fever is an inflammatory or hypermetabolic response to an operation. Other causes include pneumonia, urinary tract infection (UTI), wound infection, and venous thromboembolism (deep venous thrombosis [DVT] or pulmonary embolism [PE]). Additional possibilities are drug-induced fever and infections affecting implantable devices and drains. Common causes of fever during the days or weeks after surgery include the so-called "six Ws":

• Wound infections

• Water (eg, UTIs)

• Wind (eg, atelectasis, pneumonia)

• Walking (eg, DVTs)

• Wonder drugs (eg, drug-induced fever)

• Widgets (eg, implantable devices, drains)

Optimal postoperative care (eg, early ambulation and removal of bladder catheters, meticulous wound and drain care) can decrease risk of thromboembolism, UTI, and wound infection. Incentive spirometry and periodic coughing can help decrease risk of pneumonia and should be encouraged up to 10 times once every hour.

Patients should be encouraged to sit up in bed, transfer to a chair, stand, and exercise as much as and as soon as is safe for their surgical and medical condition. Physical therapy or more extensive rehabilitation may be required for some patients, depending on the procedure and their preoperative performance status.

Loss of muscle mass (sarcopenia) and strength occur in all patients who require prolonged bed rest. With complete bed rest, young adults lose about 1% of muscle mass/day, but older adults lose up to 5%/day because growth hormone levels decrease with age. Avoiding sarcopenia is essential to recovery. Nutritional deficiencies may also contribute to sarcopenia. Thus, nutritional intake of patients on complete bed rest should be optimized. Oral intake should be encouraged, and tube feeding or, rarely, parenteral feeding may be necessary.

Before discharge from the hospital or other surgery facility, patients should be free of severe pain and should be able to think clearly, breathe normally, drink, walk, and urinate.

If sedatives (eg, opioids, benzodiazepines) were used during an outpatient procedure, patients should not leave the hospital unaccompanied. Even after anesthetic effects have apparently worn off and patients feel fine, they are likely to be weak and have subtle residual effects that make driving inadvisable. Many patients require opioids for pain. Older adults may be temporarily disoriented because of the combined effects of anesthesia and surgical stress and may develop urinary retention caused by immobility and anticholinergic drug effects.

1. 1. Society of Thoracic Surgeons Blood Conservation Guideline Task Force, Ferraris VA, Brown JR, et al. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg. 2011;91(3):944-982. doi:10.1016/j.athoracsur.2010.11.078

2. 2. Navarro LH, Bloomstone JA, Auler JO Jr, et al: Perioperative fluid therapy: a statement from the international Fluid Optimization Group. Perioper Med (Lond). 2015;4:3. Published 2015 Apr 10. doi:10.1186/s13741-015-0014-z

3. 3. Garcia DA, Baglin TP, Weitz JI, Samama MM: Parenteral anticoagulants: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines [published correction appears in Chest 141(5):1369, 2012. Dosage error in article text] [published correction appears in Chest 144(2):721, 2013. Dosage error in article text]. Chest 141(2 Suppl):e24S-e43S, 2012. doi:10.1378/chest.11-2291