Postoperative Management

From Anvita Health Wiki

Introduction

• Risk factors:
• see perioperative risk assessment
• elderly at greater risk for complications [2]

• 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*

• pulmonary:

• supplemental oxygen
• incentive spirometry
• early ambulation
• postural drainage
• optimize cough & secretion drainage
• 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)
• risk of venous thromboembolism may be elevated for 12 weeks after surgery in women [7]

• ileus

• appropriate bowel regimen
• opioid receptor antagonist ADL-8-2698 improves post- operative ileus [3]

• other

• adequate nutritional intake (Ensure)
• fluid & electrolyte balance
• avoid unnecessary foley catheter
• appropriate environmental stimuli
• elimination of unnecessary medication
• 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]

Additional Terms

• alvimopan (Entereg, ADL-8-2698)
• delirium (confusional state)
• perioperative risk assessment
• post-operative nausea & vomiting
• postoperative complications
• surgical staple(s)

References

1. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, American College of Physicians, Philadelphia 1998, 2006
2. Journal Watch 21(10):77, 2001 Polanczyc et al Ann Intern Med 134:637, 2001
3. Journal Watch 21(21):168, 2001 Taguchi et al, N Engl J Med 345:935, 2001
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. <PubMed> PMID: [1] <Internet> [2]
   - 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 <PubMed> PMID: [3] <Internet> [4]
   - 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 <PubMed> PMID: [5] <Internet> [6]
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 <PubMed> PMID: [7] <Internet> [8]
8. National Guideline Clearinghouse Prevention of deep vein thrombosis and pulmonary embolism ngc-guideline: [9]
   - Postoperative management in adults. A practical guide to postoperative care for clinical staff. ngc-guideline: [10]
   - Practice advisory for the perioperative management of patients with cardiac rhythm management devices: pacemakers and implantable cardioverter-defibrillators: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Cardiac Rhythm Management Devices. ngc-guideline: [11]
   - Practice guidelines for postanesthetic care: a report by the American Society of Anesthesiologists Task Force on Postanesthetic Care. ngc-guideline: [12]
   - American College of Chest Physicians guidelines for the prevention and management of postoperative atrial fibrillation after cardiac surgery. ngc-guideline: [13]
   - Best evidence statement (BESt). Guided imagery for pediatric post-operative pain. Cincinnati Children's Hospital Medical Center ngc-guideline: [14]

post-operative management