A C S0105 Postoperative Management Of The Hospitalized Patient

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  • 1. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 5 POSTOPERATIVE MANAGEMENT — 1 5 POSTOPERATIVE MANAGEMENT OF THE HOSPITALIZED PATIENT Deborah L. Marquardt, M.D., Roger P.Tatum, M.D., F.A.C.S., and Dana C. Lynge, M.D., F.A.C.S At the beginning of the modern era of surgery, operative proce- examination carried out, the procedure to be performed is decided dures commonly took place in an operating theater, performed by on. This decision then initiates a discussion of the complexity and plainclothes surgeons in aprons for audiences of students and potential complications associated with the procedure, as well as of other onlookers. Afterward, patients were typically cared for at the concerns and special needs related to any comorbid conditions home or in a hospital ward, with scarcely any monitoring and lit- that may be present. If, as is often the case, the surgeon requires tle to help them toward recovery besides their own strength and some assistance with planning the operation around the patient’s physiologic reserve. In the current era, surgery is a high-tech, other health problems, input from appropriate medical and surgi- rapid-paced field, with new knowledge and technological cal colleagues can be extremely helpful. Key factors to take into advances seemingly appearing around every corner. Many of these consideration include the potential complications related to the new discoveries have allowed surgeons to work more efficiently procedure and the urgency of their treatment; the level of monitor- and safely, and as a result, a number of operations have now ing the patient will require with respect to vital signs, neurologic become same-day procedures. In addition, some very complex examination, and telemetry; and the degree of care that will be nec- operations that were once thought to be impossible or to be asso- essary with respect to treatments, use of drains, and wound care. ciated with unacceptably high morbidity and mortality have now There are relatively few published references describing specific become feasible, thanks to advances in surgical technique, anes- criteria for the various disposition categories; however, most hospi- thesia, postoperative management, and critical care. The focus of tals and surgery centers will have developed their own policies spec- our discussion is on the postoperative considerations that have ifying a standard of care to be provided for each category. become essential for successful recovery from surgery. Each patient is unique, and each patient’s case deserves thought- SAME-DAY SURGERY ful attention; no two patients can be managed in exactly the same Same-day surgery is appropriate for patients who (1) have few or way. Nevertheless, there are certain basic categories of postopera- no comorbid medical conditions and (2) are undergoing a proce- tive care that apply to essentially all patients who undergo surgical dure that involves short-duration anesthesia or local anesthesia plus procedures. Many of these categories are discussed in greater detail sedation and that carries a low likelihood of urgent complications. elsewhere in ACS Surgery. Our objective in this chapter is to pro- Operations commonly performed on a same-day basis include vide a complete yet concise overview of each pertinent topic. inguinal or umbilical hernia repair, simple laparoscopic cholecys- tectomy, breast biopsy, and small subcutaneous procedures. The growth in the performance of minor and same-day proce- Disposition dures has led to the development of various types of short-stay The term disposition refers to the location and level of care and units or wards. The level of care provided by a short-stay ward is monitoring to which the patient is directed after the completion of generally equivalent to that provided by a regular nursing ward; the operative procedure. Although disposition is not often dis- however, the anticipated duration of care is substantially shorter, cussed as a topic in its own right, it is an essential consideration typically ranging from several hours to a maximum of 48 hours. that takes into account many important factors. It may be classi- Short-stay wards also undergo some modifications to facilitate the fied into four general categories, as follows: use of streamlined teaching protocols designed to prepare patients 1. Home or same-day surgery via the recovery room. for home care. Many hospitals now have short-stay units, as do 2. The intensive care unit, with or without a stay in the recovery some independent surgery centers. room. SURGICAL FLOOR 3. The surgical floor via the recovery room. 4. The telemetry ward via the recovery room. The vast majority of patients receive the postoperative care they require on the surgical floor (or regular nursing ward). Assessment The disposition category that is appropriate for a given patient of vital signs, control of pain, care of wounds, management of is determined by considering the following four factors: tubes and drains, and monitoring of intake and output are addressed every 2 to 8 hours (depending on the variable). Assign- 1. The patient’s preoperative clinical status (including both the ment of the patient to the regular nursing ward presupposes that condition being treated and any comorbid conditions), as indi- he or she is hemodynamically stable and does not need continu- cated by the history, the physical examination, and the input ous monitoring. of other medical practitioners. The telemetry ward is a variant of the regular nursing ward.The 2. The operative procedure to be performed. care provided in the telemetry ward is generally equivalent to that 3. The course and duration of the operative procedure. provided on other floor wards, except that patients undergo con- 4. The patient’s clinical status at the completion of the proce- tinuous cardiac monitoring. Patients commonly assigned to the dure, as managed with the help of anesthesia colleagues. telemetry ward after operation include (1) those with a known The initial phase of disposition planning begins preoperatively. medical history of arrhythmias that may necessitate intervention, After a full history has been obtained and a complete physical (2) those with intraoperative arrhythmias or other electrocardio-
  • 2. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 5 POSTOPERATIVE MANAGEMENT — 2 graphic (ECG) changes who are not believed to require ICU issue specific orders to ensure that this concern is appropriately monitoring but who do need this form of cardiac follow-up, and addressed. As a rule, surgical nurses are well acquainted with tube (3) those making the transition from the ICU to a regular ward maintenance; however, if thick secretions are expected, orders for who are hemodynamically stable but who require ongoing follow- routine flushing may be indicated. When the tube is no longer up of a cardiac issue. indicated, its removal may be ordered. INTENSIVE CARE UNIT URINARY CATHETERS When early postoperative complications may necessitate urgent Urinary catheters can serve a large variety of purposes. In the intervention and close observation is therefore essential, patients setting of bladder or genitourinary surgery, they are often should be admitted to the ICU for postoperative care. Postoper- employed to decompress the system so that it will heal more read- ative ICU admission may also be appropriate for patients who are ily. After general surgical procedures—and many other surgical clinically unstable after the procedure; these patients often require procedures as well—they are used to provide accurate measure- ongoing resuscitation, intravenous administration of vasoactive ments of volume output and thus, indirectly, to give some indica- agents, ventilatory support, or continuous telemetry monitoring tion of the patient’s overall volume and resuscitation status. for dysrrhythmias. In addition, admission to the ICU should be Furthermore, after many procedures, patients initially find it considered for patients in whom the complexity of drain manage- extremely difficult or impossible to mobilize for urination, and a ment, wound care, or even pain control may necessitate frequent urinary catheter may be quite helpful during this time. postoperative monitoring that is not available on a regular nursing Their utility and importance notwithstanding, urinary ward. At present, there is no single set of accepted guidelines catheters are associated with the development of nosocomial uri- directing ICU admission. There are, however, published sources nary tract infections (UTIs). As many as 40% of all hospital infec- that can provide some guidance. For example, a 2003 article sup- tions are UTIs, and 80% to 90% of these UTIs are associated plied recommendations for the various services to be provided by with urinary catheters [see Complications, below]. Accordingly, differing levels of ICUs.1 Published recommendations of this sort when catheterization is no longer deemed necessary, prompt may be adopted or modified by individual hospitals and surgery removal is indicated. As a rule, orders specifically pertaining to centers as necessary. urinary catheter care are few, typically including gravity drainage, flushing to maintain patency (if warranted), and removal when appropriate. At times, irrigation is employed after urologic proce- Care Orders dures or for the management of certain infectious agents. Nurses and other ancillary personnel provide the bulk of the OXYGEN THERAPY care received by patients after a surgical procedure; accordingly, it is essential that they receive clear and ample instructions to guide Supplemental administration of oxygen is often necessary after their work. Such instructions generally take the form of specific a surgical procedure. Common indicators of a need for postoper- postoperative orders directed to each ancillary service. Services ative oxygen supplementation include shallow breathing and pain, for which such orders may be appropriate include nursing, respi- atelectasis, operative manipulation in the chest cavity, and postop- ratory therapy, physical therapy (PT), occupational therapy (OT), erative impairment of breathing mechanics. Because supplemen- and diet and nutrition. In what follows, we briefly outline some of tal oxygen is considered a medication, a physician’s order is the common tasks that require orders to be directed toward these required before it can be administered. In many cases, oxygen services. supplementation is ordered on an as-needed basis with the aim of enabling the patient to meet specific peripheral oxygen saturation NASOGASTRIC TUBES criteria. In other cases, it is ordered routinely in the setting of Nasogastric (NG) tubes are commonly placed after gastroin- known preoperative patient oxygen use. testinal operations, most frequently for drainage of gastric secre- An important factor to keep in mind is that oxygen supplemen- tions when an ileus is anticipated or offloading of the upper GI tation protocols may vary from one nursing unit to another. tract when a fresh anastomosis is located close by. Although NG Different units may place different limitations on the amount of tubes have often been placed routinely after abdominal surgery, the supplemental oxygen permitted, depending on their specific mon- current literature cites a number of reasons why routine use is itoring and safety guidelines. Another important factor is that inadvisable and selective use is preferable. For example, significant- patients with known obstructive pulmonary disease and carbon ly earlier return of bowel function, a trend toward less pulmonary dioxide retention are at increased risk for respiratory depression complications, and enhanced patient comfort and decreased nau- with hyperoxygenation; accordingly, particular care should be sea are reported when NG tubes are not routinely placed or when exercised in ordering supplemental oxygen for these patients. they are removed within 24 hours after operation.2 DRAINS When postoperative placement of an NG tube is considered appropriate, an order from a physician is required, along with Drains and tubes are placed in a wide variety of locations for a direction regarding the method of drainage. Sometimes, NG number of different purposes—in particular, drainage of purulent tubes are placed to low continuous suction; more often, however, materials, serum, or blood from body cavities. Several types are they are placed to low intermittent suction to eliminate the chance commonly used, including soft gravity drains (e.g., Penrose), of continuous suction against a visceral wall and to promote gen- closed suction drains (e.g., Hemovac, Jackson-Pratt, and Blake), eralized drainage. If large volumes of secretions are not expected, and sump drains, which draw air into one lumen and extract fluid continuous gravity may be used instead of suction. A key concern via a companion lumen. Traditionally, surgeons have often made with NG tubes is maintenance of the patency of both the main the decision to place a drain on the basis of their surgical training port and the sump port. Should either port become blocked, the and practice habits rather than of any firm evidence that drainage tube will be rendered ineffective. This concern should be dis- is warranted. Multiple randomized clinical trials have now cussed with the nursing staff. At times, it may be necessary to demonstrated that routine use of drains after elective operations—
  • 3. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 5 POSTOPERATIVE MANAGEMENT — 3 including appendectomies and colorectal, hepatic, thyroid, and closed primarily as a consequence of contamination or inability to parathyroid procedures—does not prevent anastomotic and other approximate the skin edges. Wet-to-dry dressings provide a moist complications (though it does reduce seroma formation). environment that promotes granulation and wound closure by Consequently, it is recommended that drains, like NG tubes, be secondary intention. Moreover, their removal and replacement employed selectively.3-5 Once a drain is in place, specific orders causes debridement of excess exudate or unhealthy superficial tis- must be issued for its maintenance.These include use of gravity or sue. Postoperative orders should specify the frequency of dressing suction (and the means by which suction is to be provided if changes, as well as the solution used to provide dampness. For ordered), management and measurement of output, stripping, most clean open incisions, twice-daily dressing changes using nor- and care around the drain exit site. mal saline solution represent the most common approach. If there Biliary tract drains include T tubes, cholecystostomy tubes, per- is excess wound exudate to be debrided, dressing changes may be cutaneous drains of the biliary tree, and nasobiliary drains. Daily performed more frequently. If there is particular concern about site maintenance, flushing, and output recording are performed by wound contamination or superficial colonization of organisms, the nursing staff. Most biliary tract drains are removed by the substitution of dilute Dakin solution for normal saline may be practitioner or other trained midlevel staff members. considered. T tubes are generally placed after operative exploration or repair A new era of wound management arrived in the late 1990s with of the common bile duct (CBD).The long phalanges are left with- the introduction of negative-pressure wound therapy (NPWT). In in the CBD, and the long portion of the tube is brought out to the NPWT, a vacuum-assisted wound closure device places the skin for drainage. The tube is left in place until the CBD is prop- wound under subatmospheric pressure conditions, thereby erly healing and there is evidence of adequate distal drainage (sig- encouraging blood flow, decreasing local wound edema and excess naled by a decrease in external drainage of bile). Before the T tube fluid (and consequently lowering bacterial counts and encourag- is removed, a cholangiogram is recommended to document distal ing wound granulation), and increasing wound contraction.10,11 patency and rule out retained gallstones or leakage.6 Since the first published animal studies, NPWT has been success- Cholecystostomy tubes are placed percutaneously—typically fully employed for a multitude of wound types, including complex under ultrasonographic guidance and with local anesthesia—to traumatic and surgical wounds, skin graft sites, and decubitus decompress the gallbladder. Generally, they are used either (1) wounds. Before vacuum-assisted closure is used, however, it is when cholecystectomy cannot be performed, because concomi- necessary to consider whether and to what extent the wound is tant medical problems make anesthesia or the stress of operation contaminated, the proximity of the wound to viscera or vascular intolerable, or (2) when the presence of severe inflammation leads structures, and the potential ability of the patient to tolerate dress- the surgeon to conclude that dissection poses too high an opera- ing changes.Wounds that are grossly contaminated or contain sig- tive risk. Particularly in the latter setting, delayed elective cholecys- nificant amounts of nonviable tissue probably are not well suited tectomy may be appropriate; if so, the cholecystostomy tube may to an occlusive dressing system of this type, given that frequent be removed at the time of the operation. evaluation and possibly debridement may be needed to prevent Nasobiliary tubes are placed endoscopically in the course of bil- ongoing tissue infection and death. Furthermore, the suction iary endoscopy. They are used to decompress the CBD in some effect of the standard vacuum sponge may cause serious erosion of settings.They usually are placed to gravity and otherwise are man- internal viscera or exposed major blood vessels. Some silicone- aged in much the same way as NG tubes.7 impregnated nonadherent sponges are available that may be suit- able in this setting, but caution should be exercised in using them. WOUND CARE Finally, because of the adherence of the sponge and the occlusive The topic of wound care is a broad one. Here, we focus on ini- adhesive dressing, some patients may be unable to tolerate dress- tial postoperative dressing care, traditional wet-to-dry dressings, ing changes without sedation or anesthesia. and use of a vacuum-assisted closure device (e.g.,VAC Abdominal Dressing System; Kinetic Concepts, Inc., San Antonio, Texas). These and other components of wound care are discussed in more Nutrition detail elsewhere [see 1:7 Acute Wound Care and 3:3 Open Wound The patient’s nutritional status has a significant effect on post- Requiring Reconstruction]. operative morbidity and even mortality. After most operative pro- Initial wound management after an operative procedure gener- cedures that do not involve the alimentary tract or the abdomen ally entails placement of a sterile dressing to cover the incision.The and do not affect swallowing and airway protection, the usual traditional recommendation has been to keep this dressing in practice is to initiate the return to full patient-controlled oral nutri- place and dry for the first 48 hours after operation; because epithe- tion as soon as the patient is fully awake. In these surgical settings, lialization is known to take place within approximately this period, therefore, it is rarely necessary to discuss postoperative nutrition the assumption is that this measure will reduce the risk of wound approaches to any great extent. infection. Although most surgeons still follow this practice, espe- After procedures that do involve the alimentary tract or the cially in general surgical cases, supporting data from randomized abdomen, however, the situation is different. The traditional clinical studies are lacking. In addition, several small studies that practice has been to institute a nihil per os (NPO) policy, with evaluated early showering with closed surgical incisions found no or without nasogastric drainage, after all abdominal or alimen- increases in the rate of infection or dehiscence.8,9 It should be kept tary tract procedures until the return of bowel function, as evi- in mind, however, that these small studies looked primarily at soft denced by flatus or bowel movement, is confirmed. The routine tissue and other minor skin incisions that did not involve fascia. application of this practice has been challenged, however, espe- Thus, even though the traditional approach to initial dressing cially over the past 15 years. Data from prospective studies of management is not strongly supported, the data currently avail- high statistical power are lacking, but many smaller studies eval- able are insufficient to indicate that it should be changed. uating early return to enteral nutrition after alimentary tract Wet-to-dry dressings are used in a variety of settings. In a surgi- procedures have yielded evidence tending to favor more routine cal context, they are most often applied to a wound that cannot be use of enteral intake within 48 hours after such procedures.
  • 4. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 5 POSTOPERATIVE MANAGEMENT — 4 Issues related to postoperative nutritional support are discussed complication rates and shorter hospital stays. In contrast,TPN is further and in greater detail elsewhere [see 8:22 Nutritional known to be associated with altered immune function, an Support]. increased rate of infectious complications, and, in some studies, a higher incidence of anastomotic complications after GI NPO STATUS surgery. Moreover, there are as yet no data to indicate that acute In the setting of elective colorectal surgery, it is well-accepted utilization of TPN during short periods of starvation benefits practice to initiate a return to patient-controlled enteral-oral patients who are adequately nourished preoperatively.TPN may, feeding within 24 to 48 hours after operation; this practice yields however, be lifesaving in patients who are malnourished and who no increase in the incidence of postoperative complications (e.g., do not have functioning GI tracts (e.g., those with short gut syn- anastomotic leakage, wound and intra-abdominal infection, and drome, severe gut dysmotility or malabsorption, mesenteric vas- pneumonia) or the length of hospital stay and, according to some cular insufficiency, bowel obstruction, high-output enteric fistu- reports, may even decrease them.12 In the setting of upper GI las, or bowel ischemia).15 surgery (specifically, gastric resection, total gastrectomy, and CALORIC GOALS esophagectomy), the situation is less clear-cut. Traditional con- cerns—in particular, the need to avoid distention stress on gas- Once a route of nutritional support has been decided on, over- tric or gastrojejunal anastomoses after gastric resection, the more all goals for caloric and protein intake may be established on the tenuous nature of a esophagojejunostomy after total gastrecto- basis of the patient’s ideal body weight (IBW) and expected post- my, and the delayed gastric conduit emptying, aspiration risk, operative metabolic state. One approach is to rely on a general esti- and anastomotic stress seen after esophagectomy or resection— mate; a commonly used formula is 25 kcal/kg IBW. Another ap- have led to the current practice of instituting nasogastric proach is to calculate a basal energy requirement by using the Harris- drainage and placing the patient on NPO status postoperatively Benedict equation. This calculation is separate from the calcula- until evidence of the return of bowel function is apparent, as well tion of protein needs. A daily protein intake goal may be calculat- as, in some cases, investigating the anastomosis for possible leak- ed on the basis of the patient’s estimated level of physical stress. A age by means of contrast fluoroscopy. There are no clinical trial well-nourished unstressed person requires a protein intake of data to support this approach. In fact, many surgeons routinely approximately 1.0 g/kg IBW/day. A seriously ill patient under on- remove the NG tube within 24 hours after gastric resection and going severe physical stress, however, may require 2.0 g/kg IBW/day; early feeding without incurring increased complications. in some settings (e.g., extensive burns), a protein intake as high as However, there are also no clinical trial data indicating that the 3.0 g/kg IBW/day may be recommended. Once the patient’s needs current approach is potentially ineffective or harmful. specific needs have been calculated, the amount and type of nutri- Consequently, traditional management methods after upper GI ent solution to be provided enterally or via TPN is determined. If procedures still are often endorsed in the literature.13,14 the patient is on a full oral diet, a calorie count or recording of the percentage of items eaten at each meal or snack may be made by ENTERAL NUTRITION the nursing staff and used to estimate the patient’s intake, with Enteral nutrition may be delivered via several routes. Most nutritional supplementation provided as needed.16 patients who have undergone an operation are able to take in an Patients who require assistance with nutritional intake should adequate amount of calories orally.When they are unable to do so, be monitored to determine whether the interventions being car- whether because of altered mental status, impaired pulmonary func- ried out are having the desired effect. The most common method tion, or some other condition, the use of enteral feeding tubes may of monitoring patients’ nutritional status with nutritional supple- be indicated. In the acute setting, nasogastric and nasojejunal feed- mentation is to measure the serum albumin and prealbumin ing tubes are the types most commonly employed to deliver enter- (transthyretin) concentrations. Albumin has a half life of approxi- al solutions into the GI tract. Either type is appropriate for this pur- mately 14 to 20 days and thus serves as a marker of longer-term pose; the two types are equivalent overall as regards their ability to nutritional status. A value lower than 2.2 g/dl is generally consid- provide adequate nutrition, and there are no significant differences ered to represent severe malnutrition, but even somewhat higher in outcome or complications. In cases where prolonged inability to values (< 3.0 g/dl) have been associated with poorer outcomes take in adequate calories orally is expected, the use of an indwelling after elective surgery. Although the serum albumin concentration feeding tube, such as a gastrostomy or jejunostomy tube, may be is a commonly used marker, it is not always a reliable one. Because indicated. These tubes must be placed either at the time of opera- of albumin’s relatively long half-life, the serum concentration does tion or subsequently via surgical or percutaneous means, and there not reflect the patient’s more recent nutritional status. In addition, is some potential for complications.The specific indications for the the measured concentration can change quickly in response to the use of such tubes are patient derived; they are not routinely associ- infusion of exogenous albumin or to the development of dehydra- ated with the performance of specific procedures. tion, sepsis, and liver disease despite adequate nutrition. Pre- albumin is a separate serum protein that has a half-life of approx- TOTAL PARENTERAL NUTRITION imately 24 to 48 hours and thus can serve as a marker of current Total parenteral nutrition (TPN) is a surrogate form of nutri- and more recent nutritional status. Like the albumin concentra- tion in which dextrose, amino acids, and lipids are delivered via tion, the prealbumin concentration can be affected by liver and a central venous catheter. It is a reliable method, in that it deliv- renal disease. Overall, however, it is more immediately reliable in ers nutrients and calories regardless of whether the patient’s gut following the effects of nutritional intervention. is functioning or not. Nevertheless, multiple studies over the past 20 years have shown that when the patient has a functioning intestinal tract, enteral feeding is clearly preferable to TPN. Fluid Management Although the specific mechanisms are not fully understood, Intravenous fluids may be classified into two main categories: enteral nutrition is known to foster gut mucosal integrity, to sup- resuscitation and maintenance. Supplemental fluids constitute a port overall immune function, and to be associated with lower third category.
  • 5. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 5 POSTOPERATIVE MANAGEMENT — 5 RESUSCITATION FLUIDS citation, with colloid an acceptable substitute when its secondary Resuscitation fluids maintain tissue perfusion in the setting of effects are desired in specific situations.17,18 hypovolemia by restoring lost volume to the intravascular space. MAINTENANCE FLUIDS They may be further classified into two subcategories: crystalloids and colloids. Maintenance fluids provide required daily amounts of free water and electrolytes (e.g., sodium, potassium, and chloride) in Crystalloids order to balanced expected daily losses and maintain homeostasis. Crystalloid solutions are water-based solutions to which elec- A basic rule of thumb used by many practitioners to calculate the trolytes (and, sometimes, organic molecules such as dextrose) infusion rate for maintenance I.V. fluids is the so-called 4, 2, 1 have been added. The crystalloid solutions used for resuscitation rule: are generally isotonic to blood plasma and include such common • 4 ml/kg/hr for the first 10 kg of body weight; examples as 0.9% sodium chloride, lactated Ringer solution, and • 2 ml/kg/hr for the next 10 kg of body weight; and Plasma-Lyte (Baxter Healthcare, Round Lake, Illinois). The • 1 ml/kg/hr for every 1 kg of body weight above 20 kg. choice to use one solution over another is usually inconsequential, but there are a few notable exceptions. For example, in the setting Generally accepted maintenance requirements include 30 to 35 of renal dysfunction, there is a risk of hyperkalemia when potassi- ml/kg/day for free water, 1.5 mEq/kg/day for chloride, 1 um-containing solutions such as lactated Ringer solution and mEq/kg/day for sodium, and 1 mEq/kg/day for potassium. In the Plasma-Lyte are used. As another example, the administration of setting of starvation or poor oral intake, dextrose 5% is often large volumes of 0.9% sodium chloride, which has a pH of 5.0 added to maintenance fluids to inhibit muscle breakdown. In reg- and a chloride content of 154 mmol/L, can lead to hyperchlore- ular practice, however, these specific values are not commonly mic metabolic acidosis. Regardless of which crystalloid solution is used: more often, a rough estimate is made of expected daily fluid used, large volumes may have to be infused to achieve a significant requirements, and solutions are ordered in accordance with this increase in the circulating intravascular volume. Only one third to estimate. Although this practice is unlikely to cause noticeable one quarter (250 to 330 ml/L) of the fluid administered stays in harm in the majority of postoperative patients, there are situations the intravascular space; the rest migrates by osmosis into the inter- where inaccurate calculations can lead to dehydration and volume stitial tissues, producing edema and potential impairment of tissue overload. Three studies from the early 2000s evaluated patients perfusion (the latter is a theoretical consequence whose existence undergoing elective colorectal surgery with the aim of determin- has not yet been directly demonstrated).17 ing whether providing higher volumes of fluid perioperatively had an impact on outcome.19-21 In all three, the data supported the use Colloids of smaller fluid volumes perioperatively, which was shown to Colloid solutions are composed of microscopic particles dis- result in earlier return of gut function after operation, shorter hos- persed in a second substance in such a way that they are sus- pital stays, and overall decreases in cardiopulmonary and tissue- pended and do not separate out by normal filtration. Colloids healing complications. are derived from three main forms of semisynthetic molecules: SUPPLEMENTAL FLUIDS gelatins, dextrans, and hytroxyethyl starches. All of the common- ly used synthetic colloids are dissolved in crystalloid solution. Supplemental fluids are given to replace any ongoing fluid loss Nonsynthetic colloids also exist, including human albumin solu- beyond what is expected to occur via insensible loss and excretion tions, fresh frozen plasma, plasma-protein fraction, and in urine and stool.They are most commonly required by patients immunoglobulin solutions. Compared with crystalloid solu- with prolonged NG tube output, enterocutaneous fistulas, diar- tions, colloid solutions increase the circulating intravascular vol- rhea, high-output ileostomies, or large open wounds associated ume to a much greater degree per unit of volume infused. In this with excessive insensible fluid loss. In each case, the amount of respect, the various colloids may be thought of as a single group; fluid lost daily should be calculated, and replacement fluid should however, in practice, they are most often given selectively on the be given in a quantity determined by this measurement (either as basis of secondary characteristics other than their volume- a whole or in part) and by the patient’s overall intravascular vol- increasing action, such as effect on hemostasis, risk of allergic ume status. The particular solution to be used depends on the reaction, and cost. characteristics of the fluid loss. The components and volume of the fluids produced in the GI tract are different at different sites Crystalloids versus Colloids [see Table 1]. The debate over whether crystalloids or colloids are superior for resuscitation has been going on for at least 30 years. Although multiple randomized, controlled trials have compared the two Pain Control types of solutions in a variety of settings, including sepsis, trauma, The topic of postoperative pain control covers a broad spec- burns, and surgery, the evidence accumulated to date has not trum of possible interventions that serve a wide range of purpos- established that one is clearly better than the other in terms of es.The most obvious purpose is simply to relieve the suffering and overall outcome. Supporters of crystalloid resuscitation cite the stress associated with postoperative pain. Another is to improve risk of altered hemostasis, the increased likelihood of drug inter- the patient’s overall postoperative status. Bringing the patient clos- actions and allergic reactions, the potential for volume overload, er to the baseline sensory state by reducing pain allows him or her and the relatively high cost as factors arguing against the use of to engage in activities that promote healing and prevent complica- colloids. Supporters of colloid resuscitation cite the large volume tions, including mobilization to help prevent deep vein thrombo- of crystalloid needed to produce significant volume effects, the sis (DVT) and deep breathing and coughing to help prevent pneu- subsequent tissue edema, and for the potential for impaired tissue monia. Common methods of pain relief include intravenous infu- perfusion and oxygenation as factors arguing against the use of sion of narcotics, epidural analgesia using local anesthetics with or crystalloids. Current recommendations favor crystalloid for resus- without narcotics, oral administration of narcotics, and the use of
  • 6. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 5 POSTOPERATIVE MANAGEMENT — 6 Table 1—Electrolyte Content and Rate of Production of Fluids Secreted in the Gastrointestinal Tract Electrolyte Concentration (mEq/L) Rate of Source of Production Secretion Na+ K+ Cl– HCO3– H+ (ml/day) Salivary glands 50 20 40 30 100–1,000 Stomach Basal 100 10 140 30 1,000 Stimulated 30 10 140 100 4,000 Bile 140 5 100 60 500–1,000 Pancreas 140 5 75 100 1,000 Duodenum 140 5 80 100–2,000 Ileum 140 5 70 50 100–2,000 Colon 60 70 15 30 nonnarcotic oral medications such as nonsteroidal anti-inflamma- ORAL ADMINISTRATION OF NARCOTICS tory drugs (NSAIDs) and acetaminophen (see below).These and Oral administration of narcotics is one of the oldest methods of other issues related to postoperative pain control are discussed in providing postoperative pain relief. Numerous different narcotic greater detail elsewhere [see 1:6 Postoperative Pain]. agents are now available for use in this setting. When deciding I.V. NARCOTIC ANALGESIA which narcotic to prescribe, however, physicians typically do not select freely from the entire available range; rather, they tend to Intravenous narcotics may be administered either by the med- choose from a small subset of agents that they know well and are ical staff or, if patient-controlled analgesia (PCA) is feasible, by the comfortable with. A key point to keep in mind is that in some for- patient. In most cases, with the exception of brief hospital stays (< mulations, narcotics are combined with other compounds (e.g., 48 hours) and ICU settings where the patient may not be alert acetaminophen or aspirin), and these added medications can have enough to manage a patient-controlled system, PCA is now gen- side effects of their own if taken in excessively high doses. Such erally considered preferable to as-needed nurse-administered I.V. formulations may require more careful titration than narcotics narcotic analgesia. Numerous studies and reviews have shown that alone would. Another key point is that many narcotics are available PCA is safe and is no more likely to cause side effects (e.g., overse- in both short-acting and long-acting versions. In patients who are dation, overdose, itching, and nausea) than nurse-administered experiencing substantial postoperative pain, a combination of I.V. narcotic analgesia is. In addition, the use of PCA improves long-acting agents and short-acting agents may yield more sus- patients’ subjective perceptions of the efficacy of pain relief and the tained and predictable pain relief than either type alone would. timeliness of drug administration.22 Finally, for patients who have a history of chronic pain condi- tions and who regularly used pain medications preoperatively, the EPIDURAL ANALGESIA assistance of an acute pain service management team may be Epidural analgesia usually makes use of a local anesthetic (e.g., invaluable in treating pain postoperatively. bupivicaine), with or without the addition of a narcotic (e.g., fen- tanyl). The anesthetic solution is instilled into the epidural space, NSAIDS AND ACETAMINOPHEN bathing the nerve roots in a given region and thereby providing NSAIDs are available both by prescription and over the counter. pain relief. Until the past decade or so, epidural analgesia was con- They not only provide effective analgesia for pain from minor pro- sidered a more dangerous method of pain relief and was not rou- cedures but also may be a powerful adjunct to narcotics in more tinely employed outside the ICU. With time and further observa- acute hospital settings. Their major disadvantages, which in some tion has come the recognition that epidural analgesia is safe and contexts are substantial enough to limit their use, include their effective for postoperative pain control in a routine floor setting if propensity to cause gastric irritation and ulceration; their antiplatelet managed by the proper supporting team of physicians. effects, which increase the tendency toward bleeding; and their There has been some debate regarding whether epidural anal- potential nephrotoxic effects in some formulations.When employed gesia leads to earlier return of bowel function after GI surgery or in settings where these disadvantages are not considered to pose a reduces the incidence of pulmonary complications; at present, this high risk, NSAIDs can be a useful addition to narcotics, both by debate remains unresolved. There is clear evidence, however, that providing further pain relief and by reducing the required narcotic patients subjectively experience less pain with epidural analgesia, doses (and thus the incidence of narcotic-related side effects). both at rest and in the course of activities such as mobilization and Like the NSAIDs, acetaminophen provides minor pain relief coughing. Moreover, in patients who have sustained traumatic rib and is an antipyretic, but unlike the NSAIDs, it has no anti- fractures, early use of epidural analgesia in place of I.V. narcotic inflammatory effect. Acetaminophen also is often added to narcot- analgesia has been shown to reduce the incidence of associated ic regimens or formulations to reduce the need for narcotics. Its pneumonia and shorten the time for which mechanical ventilation greatest potential side effect is hepatic toxicity with excessive use. is required.23 Epidural analgesia does have certain drawbacks, Accordingly, the dosage should be less than 2 g/day in patients including an increased incidence of orthostatic episodes and a with normal hepatic function and even lower in those with need for more frequent adjustments of the medication dosage. impaired hepatic function. It is particularly important to keep Nevertheless, it can be highly effective and can be a reasonable these dose limits in mind when narcotic-acetaminophen combina- option when judged appropriate by the anesthesiologist and tions are prescribed on an as-needed basis; in this situation, safe agreed to by the patient.24,25 dosage limits may well be exceeded if sufficient care is not taken.
  • 7. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 5 POSTOPERATIVE MANAGEMENT — 7 Glycemic Control involving laparotomy—especially bowel resections—where intra- Over the last decade, blood glucose control in the postoperative abdominal abscess is a possible complication). period has become a topic of great interest. Many studies, begin- ning with that of Van den Berghe and associates in 2001,26 have PNEUMONIA found that strict glucose control reduces morbidity and mortality Respiratory infections in the postoperative period are generally in critically ill surgical ICU patients. Although most of the data considered nosocomial pneumonias and, as such, are potentially currently available are derived from ICU patients rather than from serious complications [see 8:16 Nosocomial Infection].The estimat- the surgical population as a whole, the principle of tight glycemic ed incidence of postoperative pneumonia varies significantly, with control has been generalized to apply to most postoperative many estimates tending to run high. A 2001 study of more than patients. 160,000 patients undergoing major noncardiac surgery provided The target glucose range has been the subject of debate, with what may be a reasonable overall figure, finding the incidence of most institutions using a range of 80 to 140 mg/dl. The ability to postoperative pneumonia to be approximately 1.5%.29 In the achieve this target range and the means of achieving it vary 2,466 patients with pneumonia, the 30-day mortality was 21%. according to the level of nursing care that is provided. Options Thoracic procedures, upper abdominal procedures, abdominal include continuous I.V. insulin infusion and combinations of sub- aortic aneurysm repair, peripheral vascular procedures, and neu- cutaneous injections that utilize various long- and short-acting rosurgical procedures were all identified as placing patients at sig- insulin formulations. Episodes of hypoglycemia are an ever-pre- nificantly increased risk for pneumonia. Patient-specific risk fac- sent risk with tight glucose control; accordingly, the use of stan- tors included age greater than 60 years, recent alcohol use, depen- dard dosage regimens and careful monitoring are recommended dent functional status, long-term steroid use, and a 10% weight to reduce the risk of such episodes. loss in the 6 months preceding the operation.29 The debate over the specifics of glycemic control notwithstand- The diagnosis of postoperative pneumonia is based on the ing, it is generally well accepted that this issue should be addressed usual combination of index of suspicion, findings from the histo- in all patients who have undergone major operative procedures, ry and physical examination (e.g., fever, shortness of breath, regardless of whether they carry a preoperative diagnosis of dia- hypoxia, productive cough, and rales on lung auscultation), imag- betes mellitus.26,27 ing, and laboratory evaluation [see 8:17 Postoperative and Ventilator- Associated Pneumonia]. Appropriate workup, directed by the clini- cal findings, typically starts with chest x-rays (preferably in both Postoperative Complications posteroanterior and lateral views, if possible) and sputum cul- There are numerous complications that may arise in the post- tures, sometimes accompanied by CT scanning of the chest and, operative period. Many of these are specific to particular operative possibly, bronchoscopy with bronchoalveolar lavage (which may procedures and hence are best discussed in connection with those be useful in directing antibiotic therapy when sputum cultures are procedures. Many others, however, may develop after virtually any nondiagnostic). Empirical broad-spectrum antibiotic therapy is operation and thus warrant a general discussion in this chapter typically initiated before the causative organism is identified; this (see below). Prompt discovery and treatment of these latter com- practice has been shown to reduce mortality. Piperacillin-tazobac- plications relies heavily on a sufficiently high index of suspicion. tam, which is effective against Pseudomonas aeruginosa, is com- monly used for this purpose; however, when Gram’s staining of POSTOPERATIVE FEVER the sputum identifies gram-positive cocci, vancomycin or linezol- Postoperative temperature elevations are quite common, occur- id may be used initially instead.30 Once the causative organism is ring in nearly one third of patients after surgery. Only a relatively identified, specific antibiotic therapy directed at that organism is small number of these are actually caused by infection. Fevers that indicated, as in treatment of other infectious processes. Drainage are caused by infections (e.g., pneumonias, wound infections, or of parapneumonic effusions may also be necessary, and this mea- urinary tract infections) tend to reach higher temperatures (> sure may be helpful in diagnosing or preventing the development 38.5°C), usually are associated with moderate elevation of the of empyema. white blood cell (WBC) count 3 or more days after operation, and typically extend over consecutive days. Noninfectious causes of SURGICAL SITE INFECTION postoperative fevers include components of the inflammatory Surgical site infection (SSI) is one of the most common post- response to surgical intervention, reabsorption of hematomas, and operative complications and may occur after virtually any type of (possibly) atelectasis.28 procedure [see 1:1 Prevention of Postoperative Infection]. Rates of Beyond checking the WBC count, a shotgun approach to the infection vary widely (from less than 1% to approximately 20%), workup of postoperative fever probably is not warranted. A depending on the procedure performed, the classification of the focused approach based on well-directed questioning and a care- operative wound (clean, clean-contaminated, contaminated, or ful physical examination is more likely to obtain the highest diag- dirty), and a host of patient-related and situation-specific fac- nostic yield. Coughing, sputum production, and respiratory effort tors. The majority of SSIs, regardless of site, are caused by skin- should be noted, and the lungs should be auscultated for rales. All based flora, most commonly gram-positive cocci (e.g., staphylo- incisions should be inspected for erythema and drainage, and cur- cocci). Gram-negative infections are also commonly seen after rent and recent I.V. sites should be checked for evidence of celluli- GI procedures, and anaerobes may be present after pharyngoe- tis. If a central line has been placed, particularly if it has been in sophageal procedures.31 With SSI, as with other postoperative place for several days, the possibility of a line infection should be infectious complications, prompt recognition of the signs and considered. Patients who have undergone prolonged nasogastric symptoms is the key to successful management. Hence, regular intubation may have sinusitis, which is most readily diagnosed examination of the wound, particularly in the setting of postop- through computed tomography of the sinuses. Further workup for erative fever, is critical. Erythema and induration (indicative of fever may include, as indicated, chest x-ray, sputum cultures, uri- cellulitis) are obvious signs of SSI, as is active drainage of pus nalysis, blood cultures, or CT of the abdomen (after procedures from the wound. A more subtle sign is pain that is greater than
  • 8. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 5 POSTOPERATIVE MANAGEMENT — 8 CARDIAC COMPLICATIONS expected, especially when the pain seems to be increasing sever- al days after operation. Cardiac dysrhythmias may occur after a wide variety of surgical In most cases, it is necessary to open and drain the wound procedures; as one might imagine, they are most common after (which is easily done at the bedside or in the clinic in most cases) cardiac operations. Predisposing factors and possible causes are and allow it to heal via secondary intention. Generally, wet-to-dry numerous and various, including underlying cardiac disease, peri- dressing changes with saline are employed; however, larger operative systemic stress, electrolyte and acid-base imbalances, wounds may benefit from NPWT [see Care Orders,Wound Care, hypoxemia, and hypercarbia.Thus, controlling such conditions to above]. Success with NPWT has been widely reported, and this the extent possible both preoperatively and postoperatively is an technique has been used to treat such difficult wounds as exposed important part of preventing and managing postoperative cardiac vascular grafts and sternotomy infections.32,33 The use of antibi- dysrhythmias. Treatment generally involves first achieving hemo- otics depends on the presence and degree of cellulitis. The initial dynamic stability and then converting the rhythm back to sinus if choice of an agent should be guided by the likelihood that partic- possible. ular organisms will be present, which is estimated on the basis of Supraventricular tachycardias (SVTs) are the dysrhythmias the site of the operation and the type of procedure being per- most commonly seen in the postoperative period, occurring after formed. Whenever possible, any purulent material in the SSI approximately 4% of noncardiac major operations. Atrial fibrilla- should be cultured; this step may permit more targeted antimicro- tion and atrial flutter account for the majority of SVTs.38 bial therapy. Ventricular rate control may be achieved pharmacologically by infusing diltiazem. Digoxin has long been used for this purpose, DEEP VEIN THROMBOSIS AND PULMONARY EMBOLISM but it is less effective in acute settings than diltiazem is. Amioda- In the absence of appropriate prophylaxis, the incidence of rone, which is used to treat ventricular dysrhythmias [see 8:2 Acute DVT may be as high as 30% in abdominal and thoracic surgery Cardiac Dysrhythmia], may also be used to restore sinus rhythm post- patients, and that of fatal pulmonary embolism (PE) may be as operatively in some cases, especially after cardiac procedures.39 When high as 0.9%. Thus, prophylaxis against thromboembolism is pharmacologic rate control is not possible, particularly in hypoten- clearly of high importance in the postoperative care of many sive patients, cardioversion is indicated. patients [see 6:6 Venous Thromboembolism]. Major risk factors for Approximately one third of patients who undergo noncardiac DVT and PE in this setting include the operation itself, physical surgery in the United States have some degree of coronary artery immobility, advanced age, the presence of a malignancy, obesity, disease and thus are at increased risk for perioperative MI. The and a history of smoking.34 incidence of coronary artery disease is even higher in certain sub- DVT should be suspected postoperatively whenever a patient com- populations, such as patients who undergo major vascular proce- plains of lower-extremity pain or one leg is noticeably more swollen dures.40,41 In the perioperative setting, however, the pathophysiol- than the other. The gold standard for diagnosis remains a venous ogy of coronary ischemia is different from that in nonsurgical set- duplex examination, which has a sensitivity of 97% for detecting DVT tings, where plaque rupture is the most common cause of MI. of the femoral and popliteal veins.35 In most cases, treatment involves Approximately 50% of all MIs occurring in surgical patients are starting a heparin infusion (typically without a loading bolus in the caused by increased myocardial oxygen demand in the face of postoperative setting), targeting a partial thromboplastin time inadequate supply resulting from factors such as fluid shifts, phys- (PTT) that is double to triple the normal PTT (i.e., approximate- iologic stress, hypotension, and the effects of anesthesia. The ly 60 to 80 seconds), and then switching to warfarin therapy when majority of cardiac ischemic events occur in the first 4 days of the the patient is stable and able to tolerate oral medications. postoperative period.41 PE should be suspected whenever a postoperative patient expe- Perioperative beta blockade for patients at risk for MI is now riences a decrease in oxygen saturation or shortness of breath; this routine. Multiple trials and meta-analyses have demonstrated that decrease may be accompanied by chest pain, tachycardia, and this practice yields significant risk reductions in terms of both car- diaphoresis, all of which may also be seen in the setting of myocar- diac morbidity and mortality42,43 and that these risk reductions are dial infarction (MI).When PE is suspected, it may be appropriate achieved regardless of the type of surgery being performed. Although to start heparin therapy even before the diagnosis has been con- there has been some variation in the protocols used by these trials firmed, depending on the degree of suspicion and the relative risk and the results reported, there is general agreement that beta anticoagulation may pose to the patient. Currently, the principal blockade should be initiated preoperatively, delivered at the time means of diagnosing acute PE is spiral CT. This modality has rel- of surgery, and continued postoperatively for up to 1 week.42 atively wide availability, can be performed fairly rapidly, and has a Diagnosis of postoperative MI is complicated by the fact that as sensitivity of 53% to 100% and a specificity of 81% to 100%. In many as 95% of patients who experience this complication may not addition, it is readily usable in most critically ill patients, including present with classic symptoms (e.g., chest pain). Identification of those undergoing mechanical ventilation (though the amount of MI may be further hindered by the ECG changes brought on by I.V. contrast material it requires may limit its use in patients with the stress of the perioperative period (including dysrhythmias). renal insufficiency). Greater diagnostic yield may be obtained by Ultimately, the most useful signal of an ischemic cardiac event in combining spiral CT with a lower-extremity venous duplex exam- the postoperative period is a rise in the levels of cardiac enzymes, ination.36 For most patients with postoperative PE, anticoagula- particularly troponin-I. Accordingly, cardiac enzyme activity should tion is administered in the form of heparin. Low-molecular-weight be assessed whenever there is a high index of suspicion for MI or a heparins (LMWHs) are also generally safe and effective; however, patient is considered to be at significant perioperative risk for MI.40 because their effect cannot be turned off in the same way as that Treatment of postoperative MI focuses on correcting any fac- of I.V. unfractionated heparin, they may be less useful in the peri- tors contributing to or exacerbating the situation that led to the od after operation.37 In patients with massive PE, surgical embo- event (e.g., hypovolemia or hypotension). Typically, although lectomy or suction-catheter embolectomy may be considered, as antiplatelet agents (e.g., aspirin) are sometimes given, thrombolyt- conditions warrant. Thrombolytic therapy is generally contraindi- ic therapy is avoided because of concerns about postoperative cated in the postoperative setting. bleeding. Acute percutaneous coronary intervention is also associ-
  • 9. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 1 BASIC SURGICAL AND PERIOPERATIVE CONSIDERATIONS 5 POSTOPERATIVE MANAGEMENT — 9 ated with an increased risk of bleeding, but it has nonetheless been Over the past two decades, critical pathways, which are orga- used successfully in the perioperative setting and is recommended nized plans that outline the sequence of patient care and dis- by some physicians.44 Beta blockade is often advocated as a means charge, have been increasingly used in managing postoperative of treating postoperative MI, though it is probably more effective care after a variety of procedures from all disciplines. They have when used both preoperatively and perioperatively as a means of been shown to reduce hospital stays and maintain safety in preventing MI.40 patients undergoing common procedures (e.g., colectomy), patients undergoing complex procedures (e.g., esophagectomy),47 and patients with high comorbidity.48 Individual pathways are typ- Discharge ically specific to a hospital or health care system; thus, the dis- Planning for discharge from the hospital is clearly an essential charge criteria are those agreed on by the providers involved in the part of perioperative care. In the best of circumstances, discharge care of eligible patients at that particular institution. Critical path- planning starts before admission for elective surgery and is dis- ways can be helpful not only by standardizing care and improving cussed with the patient and family as part of preoperative patient the relative appropriateness of postoperative discharge but also, in education. Starting the process early enables the provider to esti- many cases, by decreasing the overall length of postoperative hos- mate the patient’s probable needs at the end of acute hospitaliza- pitalization.46 In a 2003 study of 27 postoperative critical path- tion and thus to make preliminary arrangements as needed. For ways used at the Johns Hopkins Hospital, the authors found that example, if it appears likely that the patient will have to stay in a seven (27%) of the pathways were associated with significant (5% skilled nursing or extended care facility or will require prolonged to 45%) decreases in length of stay.49 physical therapy and rehabilitation, these matters can be Regardless of whether critical pathways are implemented, if dis- addressed to the mutual satisfaction of both patient and physician charge planning is not addressed preoperatively, addressing it as in advance of hospital discharge. In this way, delays in discharge early as possible in the postoperative period is extremely valuable and unnecessary days of acute hospitalization can be avoided, at not only for ensuring an appropriate length of stay but also for least in some instances. maintaining the satisfaction and comfort of both patient and fam- Criteria for discharge or transfer from acute hospital care vary ily. Specific issues should be addressed at this point as needed, widely, depending on the procedure, the provider, and the patient; including the home resources and support available to the patient, rarely are they codified. For example, in a 2005 survey of 16 sur- wound care, ostomy care, management of feeding tubes and geons performing open colorectal resections within one hospital, drains, I.V. antibiotic therapy, and physical rehabilitation.Thus, as only two factors—absence of complications and reported postop- soon as it appears that a patient is on track either for discharge erative bowel movement—were considered criteria for early dis- home or for transfer to a rehabilitation or skilled nursing facility, a charge by most (but not all) of the surgeons.45 There was wide dis- discussion with the appropriate social work or discharge planning agreement on all other criteria, including postoperative mobility personnel should be scheduled. Physical therapy and occupation- and the ability to tolerate a general diet. Given such variation in al therapy (PT/OT) evaluations early in the postoperative course discharge criteria for even one category of procedure, it is clear can also be of great assistance in determining a patient’s needs that a discussion of specific criteria for each type of surgery is well upon discharge, and such evaluations are essential for any patient beyond the scope of this chapter. It is worth pointing out, howev- who may need a stay in an inpatient rehabilitation facility.Typically, er, that the various discharge criteria now in use, despite their dif- it requires at least 1 day to set up services such as home health care ferences, have a common basis—namely, the idea that at dis- and outpatient physical therapy, and it may take this long or longer charge, the patient should ideally be able to manage basic self-care to obtain a bed at an appropriate rehabilitation or skilled nursing activities (e.g., feeding, wound care, and mobility) without facility. Consequently, the earlier these plans are made, the better. advanced assistance and that the likelihood of readmission should For many surgical patients, formal discharge planning and PT/OT be minimized to the extent possible. Identification, investigation, evaluations are not actually necessary. Brief discussions with the and control of factors such as nausea, pain, fever, deconditioning, patient, the family, or the nursing staff caring for the patient will and fatigue are important in determining whether a patient is at assist in determining which surgical patients are most likely to risk for a return to the hospital in the postoperative period.46 benefit from this approach. References 1. 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Crit JPEN J Parenter Enteral Nutr 27:355, 2003 29. Arozullah AM, Khuri SF, Henderson WG, et al: Care Med 32:S126, 2004 17. Grocott MPW, Hamilton MA: Resuscitation flu- Development and validation of a multifactorial risk 41. Grayburn PA, Hillis DL: Cardiac events in patients ids. Vox Sanguinis 82:1, 2002 index for predicting postoperative pneumonia after undergoing noncardiac surgery: shifting the para- major noncardiac surgery. Ann Intern Med digm from noninvasive risk stratification to thera- 18. Roberts I, Alderson P, Bunn F, et al: Colloids ver- 135:847, 2001 py. Ann Intern Med 138:506, 2003 sus crystalloids for fluid resuscitation in critically ill patients (review). Cochrane Database Syst Rev 30. Mehta RM, Niederman MS: Nosocomial pneu- 42. Schouten O, Shaw LJ, Boersma E, et al: A meta- (3):1, 2006 monia. Curr Opin Infect Dis 15:387, 2002 analysis of safety and effectiveness of perioperative 19. Tambyraja AL, Sengupta F, MacGregor AB, et al: 31. 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Kiran RP, Delaney CP, Senagore AJ, et al: analgesia improves outcome after multiple rib frac- Screening for deep vein thrombosis and pul- Outcomes and prediction of hospital readmission monary embolism in outpatients with suspected tures. Surgery 136:426, 2004 after intestinal surgery. J Am Coll Surg 198:877, DVT or PE by the sequential use of clinical score: 24. Mann C, Pouzeratte Y, Boccara B, et al: a sensitive quantitative D-dimer test and noninva- 2004 Comparison of intravenous or epidural patient- sive diagnostic tools. Semin Vasc Med 5:351, 2005 47. Cerfolio RJ, Bryant AS, Bass C, et al: Fast tracking controlled analgesia in the elderly after major after Ivor-Lewis esophagogastrectomy. Chest 36. Cook D, Douketis J, Crowther MA, et al:The diag- abdominal surgery. Anesthesiology 92:433, 2000 126:1187, 2004 nosis of deep vein thrombosis and pulmonary 25. Flisburg P, Rudin A, Linner R, et al: Pain relief and embolism in medical-surgical intensive care unit 48. Delaney CP, Fazio VW, Senagore AJ, et al: ‘Fast safety after major surgery: a prospective study of patients. J Crit Care 20:314, 2005 track’ postoperative management protocol for epidural and intravenous analgesia in 2696 patients with high co-morbidity undergoing com- 37. Piazza G, Goldhaber SZ: Acute pulmonary patients. Acta Anaesthesiol Scand 47:457, 2003 plex abdominal and pelvic colorectal surgery. Br J embolism: part II: treatment and prophylaxis. 26. Van den Berghe G, Wouters P, Weekers F, et al: Circulation 114:42, 2006 Surg 88:1533, 2001 Intensive insulin therapy in critically ill patients. N 38. Heintz KM, Hollenberg SM: Perioperative cardiac 49. Dy SM, Garg PP, Nyberg D, et al: Are critical Engl J Med 345:1345, 2001 issues: postoperative arrhythmias. Surg Clin North pathways effective for reducing postoperative 27. Hammer L, Dessertaine G, Timsit JF, et al: Am 85:1103, 2005 length of stay? Med Care 41:637, 200