Postoperative Care

Quality postoperative (postop) care is essential after every surgery and provides opportunities for residents and medical students to perform physical exams and build good judgment. Postop care begins immediately upon completion of the surgery and typically includes co-monitoring of the patient by anesthesia and surgical teams in a dedicated area (usually a postanesthesia care unit [PACU]). The emphasis of postop care is on restoring the patient’s physiological parameters to normal and early identification of postop complications.

In this section, we provide a general overview of the postoperative check and common postoperative complications organized by body system from head to toe to ensure a comprehensive evaluation and coincide with the order of mental checklists.

The topics in this rotation guide are organized as follows:

• The Postoperative Check

• Neurologic Complications

• Cardiovascular Complications

• Respiratory Complications

• Renal Complications

• Hematologic Complications

• Wound Complications

• Special Considerations

• Discharge from the Postoperative Setting

The Postoperative Check

The postop check is an essential aspect of postop care, especially following major procedures and in patients with planned admissions. The structure and specifics of postop checks can vary by department and service, but most guiding principles remain the same.

Guiding Principles of the Postop Check

• The postop check involves assessment of the patient’s general condition, including procedure-specific considerations, and typically occurs 4 to 6 hours after surgery.

• Start with an evaluation of the patient’s vital signs and general appearance; if possible, have a conversation with the patient to assess mental status and pain level.

  • An easy mistake is to let the patient sleep; doing so may result in missing important neurologic findings.

• Examine all wounds, dressings, and drains (see Wound Complications below).

  • Signs of hematoma, ongoing bleeding, wound breakdown, and drain malfunction should be escalated promptly.

• Create a mental checklist organized in a head-to-toe framework tailored to the patient and procedure specifics to ensure a comprehensive exam.

• Other key considerations include the following:

  • urine output

  • return of bowel function

  • ability to tolerate oral nutrition

• Noted abnormalities should guide further investigation.

Neurologic Complications

Pain Management

Pain control is an essential component of postop care. In addition to the benevolent reasons to control patients’ pain, uncontrolled pain can lead to decreased mobility, reduced respiratory effort, and changes in vital signs that obfuscate physiological status. Increasingly, multimodal pain control is emphasized to enhance management and reduce the negative effects of overutilizing a single agent. Because standard postop orders are not ideal for every patient, it is important to understand and adjust pain regimens as needed. See the Palliative Care rotation guide for an overview of pain management and helpful tables of pain management options.

Surgery-specific pain management considerations:

• Local anesthetics (e.g., lidocaine, bupivacaine, mepivacaine) are useful modalities in the perioperative period. The surgical team typically administers local anesthesia when closing the incision.

  • Pay attention to the amount of local anesthetic administered and possible systemic effects.

• The anesthesiology team sometimes administers regional anesthetic (including a block, epidural, or indwelling catheter) in the operating room (OR).

• Newer surgical protocols have demonstrated significant efficacy in controlling pain and enhancing the transition through the postop period. Enhanced Recovery After Surgery (ERAS) protocols have been designed for multiple surgical procedures to control pain, mobilize the patient, and promote early and safe discharge.

Neurologic Deficits

Stroke is one of the most severe complications in the intra or postop periods. Patients can experience a stroke for a variety of reasons, including embolism (e.g., from air, thrombi, or plaque) and hypoperfusion. In the postop period, patients are at risk of developing thrombus due to immobility and increased inflammation. As a result, patients frequently receive prophylactic anticoagulation during long procedures. Vascular surgeries, especially those involving the carotid artery, warrant particular attention to neurologic status in the postop period.

Surgery-specific treatment of stroke in postop patients:

• If a postop patient shows signs of stroke involving vascular structures that supply the brain (e.g., carotid endarterectomy), rapid mobilization to the OR and escalation through the surgical team should take place to try to reverse the problem surgically.

  • Notably, thrombolytic agents (e.g., tissue plasminogen activator [tPA]) are strongly contraindicated after surgical procedures.

• When evaluating focal deficits, focus on the pattern of deficits.

  • Mixed sensory and motor deficits in the perioperative setting can be due to patient positioning (e.g., ulnar nerve palsy from improperly placed elbow cushioning), and chronic deficits can persist.

• Global deficits may be due to neurologic injury, but troubleshooting is the first step.

  • Postop effects of sedation or narcotic medication often are the culprits for altered mental status. However, more-serious causes (including hypercarbia, hypoxia, and hypotension) should be ruled out.

Markers to escalate patient care:

• lethargy or significantly altered mental status

• Glasgow coma scale (GCS) <8

• new focal neurologic deficits

Cardiovascular Complications

Hypotension

Hypotension is a common postop abnormality and can be due to a number of factors or a mixture of factors.

• Mild hypotension is any significant deviation below the patient’s normal blood pressure range.

• Severe hypotension typically refers to a mean arterial pressure (MAP) <65 mm Hg.

To avoid the pulmonary complications of volume overload, anesthesiologists are often conservative with fluid administration in the OR, which can result in the need to catch up on volume in the postop period.

• Mild hypotension may necessitate a small bolus of intravenous (IV) fluid in addition to any standing IV fluids the patient may be receiving.

• Maintenance fluids are often necessary to achieve volume goals until patients are able to tolerate oral hydration.

• Noninvasive cardiac output (CO) monitoring and volume status evaluation can assist in guiding volume resuscitation.

Caveats in the evaluation of hypotension in postsurgical patients:

• Hypotension is not an absolute metric.

  • Although a MAP of 65 mm Hg is often targeted as a minimum, this goal may be unrelated to the actual optimal physiology of the patient.

  • Preop records can assist in guiding the target MAP; some patients (e.g., elderly women) have a baseline MAP below 65 mm Hg, and reactionary resuscitation to an overly high target may be harmful.

  • Conversely, a patient may have untreated or refractory hypertension at baseline (e.g., 170/120 at home) and titration to a MAP goal of 65 mm Hg can cause relative ischemia.

Hypertension

Causes of postop hypertension include untreated baseline hypertension, cessation of blood pressure medication, and uncontrolled pain. Transient hypertension is better tolerated in the postoperative setting than chronic hypertension in the outpatient setting. Although exceptions exist (e.g., postaneurysm repair), transient hypertension in the absence of end-organ damage is typically not harmful. However, aggressive treatment of hypertension in the postop patient can cause absolute or relative hypotension, which can cause harm.

Treatment of hypertension in postop patients:

• Antihypertensive medications include:

  • beta-blockers

  • calcium-channel blockers

  • antihypertensive drip medications (e.g., nicardipine and esmolol) for rapid titration of blood pressure in critical settings due to relatively short half-life

• Short-acting antihypertensives commonly used in the postop setting include:

  • labetalol

  • hydralazine

  • nicardipine (Cardene)

  • esmolol

• Once the patient is close to discharge, home antihypertensives should be resumed and monitored for overmedication.

• Better pain control is often the optimal treatment in postsurgical patients with hypertension, tachycardia, and higher reported pain levels, and usually results in normalization of blood pressure and heart rate.

Tachycardia

Postop tachycardia and hypotension have many similar etiologies, including hypovolemia and PE. Poor pain control and tachyarrhythmias can also cause tachycardia.

• When tachycardia is a physiological response to increased cardiac output (e.g., in the setting of hypovolemia), primary treatment of the heart rate is unlikely to provide significant benefit.

• The cause of tachycardia should be investigated and treated appropriately.

• Beta-blockers are the mainstay of treatment for tachycardia in most postop patients, although a variety of other medications can be used.

Arrhythmia

Arrhythmias are not uncommon in postop patients and warrant prompt response, especially when associated with unstable vital changes (e.g., atrial fibrillation [AF] with hypotension). AF is common in postop patients, often due to large fluid shifts.

• Paradoxically, volume overload causing AF and subsequent hypotension may improve with diuretics.

Markers to escalate patient care:

• new-onset chest pain, pressure, or tightness with features concerning for acute coronary syndrome

• hypotension requiring significant fluid bolus or pressor administration

• new onset of arrhythmia or unstable arrhythmia

• hypertension with signs of end-organ damage

Respiratory Complications

Respiratory complications are some of the most common challenges in the postop period.

Causes of respiratory problems include large fluid shifts, prolonged mechanical ventilation, and oversedation, especially in elderly patients and patients with preexisting respiratory pathology.

Assessment of postoperative respiratory problems:

• Decreased respiratory rate or effort can be due to postanesthetic effects or narcotic administration.

• Pain from surgical sites may cause patients to take short, shallow breaths (splint) or modified breaths, resulting in failure to ventilate, oxygenate, or clear secretions.

• Incentive respirometer is an easy-to-use tool that helps patients maintain lung capacity and clear secretions, and it provides a measurement of respiratory function.

• Ambulation as early as feasible is imperative in protecting and improving respiratory function.

• Nasal cannula is often inappropriately administered to postop patients because the number (peripheral oxygen saturation [SpO₂]) on the monitor may disguise inadequate respiratory function, specifically poor ventilation leading to occult hypercarbia.

• Use of carbon dioxide monitors with respiratory support devices can provide reassurance that the patient is ventilating appropriately.

• Autonomic oxygen-dependent ventilation may be utilized in patients with chronic obstructive pulmonary disease (COPD) as they become conditioned to chronic hypercarbia; therefore, elevating a patient’s SpO₂ above the target of 89%-92% may actually induce respiratory depression.

• If a patient’s respiratory function on room air appears to be insufficient, escalation of respiratory support is likely warranted. However, improved SpO₂ with oxygen administration may disguise ventilatory insufficiency.

Markers to escalate patient care:

• new-onset hypoxia or hypercarbia

• respiratory failure necessitating increase in support or mechanical ventilation

Renal Complications

Urine Output

Urine output is an excellent way to measure a patient’s volume status.

• A target rate of 0.5-1 cc/kg/hr is an acceptable goal for most patients.

  • Because elderly patients typically make less urine at baseline, oliguria as an isolated finding does not necessarily warrant additional fluid administration, especially because this population is particularly susceptible to the negative effects of volume overload.

• A Foley catheter is often placed in patients undergoing large or lengthy surgeries or who have baseline medical comorbidities. In such cases, the catheter helps measure the quantity and quality of urine in the postop setting.

  • In the absence of a Foley catheter, urine collection for volume measurement in the postop period is useful in patients who will be admitted.

  • In patients undergoing outpatient surgery, voiding is often necessary prior to discharge.

• In patients with an enlarged prostate or baseline urinary retention, home medications are usually continued through the day of surgery.

• The effects of anesthesia can cause urinary retention.

Urine Quality

Urine in the patient with normal renal function should be clear-to-light-yellow in color. Red coloration can indicate myoglobinuria or hematuria.

• A small amount of blood from insertion of a Foley catheter can be normal in patients due to minor urethral trauma.

• Large volumes of blood, especially when clots are present, warrant further investigation, especially following abdominal surgery, in case inadvertent injury to the kidneys, ureters, or bladder was missed.

IV Fluids and Resuscitation

Understanding the patient’s volume status is imperative to guide fluid administration. Fluid management and resuscitation are discussed in detail in the Critical Care rotation guide and in the section on Fluids and Electrolytes in this rotation guide.

Special considerations for fluid management in postop patients:

• Conservative fluid administration is particularly advisable in some circumstances. Therefore, a team conversation about goals of resuscitation is appropriate in nonroutine patient populations, including but not limited to the following patient groups:

  • elderly patients

  • thoracic surgery patients

  • patients with decreased or absent baseline urine output

• The choice of resuscitative fluid is also important.

  • Isotonic fluids (e.g., normal saline or lactated Ringer solution) should usually be administered when the goal is to increase the patient’s intravascular volume. Most surgical services prefer using lactated Ringer because it has a more balanced effect on pH and includes other ions (e.g., calcium and potassium).

• The rate and type of fluids should be adjusted in patients who are adequately resuscitated but still require IV fluid administration (e.g., patients with no food or drink [NPO] orders).

  • Hourly maintenance fluid administration uses the 4/2/1 rule (i.e., an hourly rate of 4 cc/kg for the first 10 kg, 2 cc/kg for the second 10 kg, and 1 cc/kg thereafter; this rule can be abbreviated to 1 cc/kg + 40 cc in adults).

  • A healthy, recent preop weight is usually the best for determining the rate of fluid administration. However, morbidly obese patients, for instance, often require less than their unadjusted maintenance rate.

• Hypotonic solutions (usually half normal saline [½ NS]) are used for maintenance fluid administration in typical adult patients. Glucose (D5) can be added for modest caloric supplementation, and potassium chloride (KCL) can be added to replenish naturally lost potassium.

  • D5 ½ NS with 20 mEq KCL is a standard hypotonic solution in postop patients who require maintenance fluids beyond the early hours of the postop period.

• Once patients are able to tolerate PO nutrition and hydration, fluids should typically be discontinued.

Markers to escalate patient care:

• no urine output or unresponsive to fluid challenge

• new blood in urine

Hematologic Complications

Anticoagulation

Surgical patients are susceptible to developing deep-vein thromboses (DVTs) during hospitalization due to reduced mobility and a hyperinflammatory state. As a result, prophylactic anticoagulation is common in postop care.

• Prophylactic anticoagulation is often continued through the postop period.

  • In patients with a history of cancer or recent trauma, unfractionated heparin (enoxaparin) is preferred over subcutaneous heparin as an anticoagulant.

  • In patients with chronic or acute renal dysfunction, enoxaparin is contraindicated, and heparin should be used instead.

• Mechanical DVT prophylaxis (e.g., sequential compression devices on the legs) also decreases DVT risk.

• Early and frequent ambulation, as tolerated, is important for reducing DVT risk and enhancing rehabilitation.

Markers to escalate patient care:

• concerns for a PE

• active bleeding from a surgical site

Wound Complications

Dressings

Most patients leave the OR with some form of dressing on the operative site, and a variety of wound dressings are utilized in surgical care. A provider caring for the postop patient requires a good understanding of the function of drains, especially chest tubes, and dressings (e.g., external, wet-to-wet, wet-to-dry, wound vacuum-assisted closure [VAC]).

Principles of wound dressings:

• Number and type: Note the number and type of wounds and dressings, especially in trauma patients who may have numerous wounds with varied dressings applied.

• Dressing management: Note the attending surgeon’s preferences for dressing management among the multitude of viable choices.

  • Pay attention to the quality and quantity of drainage, and consider expected or tolerated amounts (e.g., a small amount of bleeding is acceptable for many open wounds, but any active bleeding in a neck wound may be cause for concern).

• External bandages: External dressings are often used for wounds closed by primary intent (sewing or stapling the wound closed) to keep the wound dry from drainage and protect it from the external unsterile environment.

  • External dressings can typically be left on the wound for the first 2 days following surgery unless they become soaked through or compromised.

• Secondary closure: Wounds closed by secondary intent are initially left unclosed and packed with gauze saturated with saline or an antiseptic solution.

  • Secondary closure is common for wounds with a high likelihood of infection. An open wound and frequent dressing changes allow for a clean, draining environment.

  • Wet-to-dry dressings, in which the inner layer of the dressing is saturated, and the outer layers are dry, are often used to allow for a wicking process without entirely drying out the underlying tissues.

  • Dressings are typically changed at least once daily, and the wound should be monitored for signs of infection or necrosis of the wound bed and breakdown of the underlying tissue integrity.

• Wound VAC: A wound vacuum-assisted closure (VAC) is a popular dressing choice that can take the place of packed or external dressings. The negative pressure helps keep a sterile, clean environment and assist granulation tissue development. Wound VACs uniquely provide the functions of both dressings and drains.

  • A seal leak is a common problem with wound VACs. As a rule, identifying the channel through which air is entering is better than adding more wound VAC-sealing plastic. Passing a stethoscope over the field to listen for an occult leak can help.

Drains

A variety of drains are used in the postop period. A provider caring for the postop patient should be familiar with patient-specific expectations of drain management and the quality and quantity of drainage.

• Bulb drains: Bulb drains (e.g., Jackson-Pratt wound drain) are among the most common drains used in surgery.

  • These drains have a variety of internal drain configurations but typically drain to an external, clear bulb to allow for the drainage of a variety of potential fluid collections (e.g., oozing blood, pancreatic fluid).

  • Bulb drains may be kept off suction and physically lower than the wound to allow passive drainage (gravity drainage) or depressed while the emptying port is left open and then closed, allowing for modest suction from the bulb’s negative pressure (suction drainage).

• Penrose drains: To prevent buildup of fluid, these drains are used to facilitate drainage through open wounds. Penrose drains are often fixed into the wound to prevent premature closure that would trap fluid and lead to infection.

• Chest tubes: The chest tube is one of the most important drains to understand how to manage. Chest tubes include large, straight tubes (e.g., diameter of 28-36 French catheter scale) and pigtail catheters (e.g., 14 French).

  • Improper management of chest tubes can lead to the development of a pneumothorax, which can be lethal. Evaluation and treatment paradigms of pneumothorax are described in the Pulmonology rotation guide.

  • Chest tubes are typically connected to a box that utilizes a water seal to allow one-way drainage of fluid and evacuation of air. This evacuation can be assisted by connecting the box to negative suction.

  • Most often, the suction should be turned to the maximum allowed. The level of suction carried through the system is controlled by a dial or switch on the box. If adequate suction is achieved, an indicator (usually an orange tab) should appear on the box.

  • Possible points of failure in the chest tube system include:

    • The chest tube may be clogged, kinked, or stuck in a lung fissure.

    • The dressing around the tube must be sufficiently airtight to allow the system to function.

    • The connection of the chest tube to the hose coming from the box and the connection of that hose to the box should be properly secured.

    • The suction settings of the box and the wall should be checked.

Markers to escalate patient care:

• dislodged drain

• active bleeding into drain or dressing

• failure/malfunction of chest tube apparatus that cannot be corrected

Special Considerations

Ostomy Complications

Details of ostomy management are beyond the scope of this rotation guide. However, the following early postop signs after ostomy surgery are important to be aware of:

• A slightly darkened appearance of ostomy or bowel tissue may be attributed to the small degree of injury or venous congestion associated with a new ostomy and should normalize in a few days.

• Significant blue, purple, or black discoloration should be cause for concern and may indicate that the blood supply is severely compromised.

• The ostomy may slowly output mucous or watery discharge but is not expected to make stool in the initial postop period.

Neck Surgery Complications

Patients with a variety of neck surgeries (e.g., carotid endarterectomies, thyroidectomies, and parathyroidectomies) require postop surgical care. A pulsatile or expanding neck hematoma are hallmark emergency signs.

• Left untreated, the hematoma pressure can compromise the patient’s airway and constitute a surgical emergency. A blade or suture removal kit is often left at the patient’s bedside to use to reopen the wound in an emergency.

• If facing active respiratory compromise, the neck should be opened without delay (i.e., don’t wait to go to the OR). A small developing hematoma without signs of impending respiratory compromise likely warrants return to the OR.

• Active bleeding from the wound should also be treated as an underlying hematoma.

Vascular Surgery Complications

Vascular surgeries contain unique risks and alarm signs that require specific postop care directions. Any vascular structure accessed can become impinged or occluded and release thrombi to distal structures.

• Pay attention to perfusion distal of the surgical site. This may be simple, as in a femoral procedure, where assessment of distal perfusion is easily verified with physical examination, including inspection and palpation of distal pulses (i.e., dorsalis pedis or posterior tibial).

• Doppler or ultrasound may be useful, especially in patients with weak pulses.

• Vascular cases in the abdomen and neck are more complicated and can be associated with occult compromises in blood flow.

• Extremity vascular cases are at high risk for compartment syndrome (pressure within the muscles builds to dangerous levels). Alarm symptoms include tense swelling, neurovascular deficits, and extreme pain.

• Abdominal and neurologic exams are important to include in these cases, as needed. These are also instances where it is wise to use the same practitioner in serial exams, as they have a better baseline in order to note subtle changes. Compromise of any blood flow in the postop period typically warrants emergent takeback to the OR.

Markers to escalate:

• dark or retracted ostomy

• signs of neck hematoma or respiratory compromise after a neck surgery

• signs of arterial embolism

• signs of compartment syndrome

Respect for Patient Modesty

Respect for patient modesty in the postop setting is an important and often forgotten aspect of patient care. Patients in the PACU are often closely grouped with various degrees of screening by curtains or shades. Due to the effects of anesthesia, it is not uncommon for patients to partially disrobe. It is important to respect a patient’s modesty and take care to only expose necessary areas.

Discharge from the Postoperative Setting

Conditions for ambulatory discharge: As outpatient procedures continue to increase in frequency, more patients are being discharged home directly from the PACU. To be discharged safely, patients must be able to resume a significant degree of baseline function. With some exceptions (e.g., the patient is on oxygen at home), most patients must meet the following conditions before they are cleared for discharge:

• ambulate

• urinate

• pass flatus or stool

• adequately intake oral nutrition and hydration

• manage pain with oral pain medication

• oxygenate without supplemental oxygen