Immediately after the operation, the patient will go to the recovery room to be monitored closely whilst they regain consciousness. Once they are conscious and stable, they can return to the ward. Patients may be transferred to HDU or ICU depending on their condition and the monitoring requirements post-operatively.
Enhanced recovery aims to get patients back to their pre-operative condition as quickly as possible, by encouraging independence, early mobility and appropriate diet. There are increased nutritional requirements after the physiological stress of surgery, so sufficient calories are very important. The aim is to discharge as soon as possible. This leads to better outcomes for the patient.
The principles of enhanced recovery are:
- Good preparation for surgery (e.g., healthy diet and exercise)
- Minimally invasive surgery (keyhole or local anaesthetic where possible)
- Adequate analgesia
- Good nutritional support around surgery
- Early return to oral diet and fluid intake
- Early mobilisation
- Avoiding drains and NG tubes where possible, early catheter removal
- Early discharge
Adequate analgesia in the post-operative period is important to encourage the patient to:
- Ventilate their lungs fully (reducing the risk of chest infections and atelectasis)
- Have an adequate oral intake
Analgesia is usually started in theatre by the anaesthetist, with regular paracetamol, NSAIDs and opiates if required (e.g., regular modified-release oxycodone with immediate-release oxycodone as required for breakthrough pain). The surgeon may put local anaesthetic into the wound to help with the initial pain after the procedure. Analgesia should be reduced and stopped as symptoms improve. There is more detail on analgesia in the anaesthetics section.
Non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen, naproxen and diclofenac may be inappropriate or contraindicated in patients with:
- Renal impairment
- Heart disease
- Stomach ulcers
Patient Controlled Analgesia
Patient-controlled analgesia (PCA) involves an intravenous infusion of a strong opiate (e.g., morphine, oxycodone or fentanyl) attached to a patient-controlled pump. This involves the patient pressing a button as pain starts to develop, for example during a contraction in labour, to administer a bolus of this short-acting opiate medication. The button will stop responding for a set time after administering a bolus to prevent over-use. Only the patient should press the button (not a nurse or doctor).
Patient-controlled analgesia requires careful monitoring. There needs to be input from an anaesthetist, and facilities in place if adverse events occur. This includes access to naloxone for respiratory depression, antiemetics for nausea, and atropine for bradycardia. The anaesthetist may prescribe background opiates (e.g., patches) in addition to a PCA, but avoid other “as required” opiates whilst a PCA is in use. The machine is locked to prevent tampering.
Post-Operative Nausea and Vomiting
Nausea and vomiting are common in the 24 hours after an operation and is called post-operative nausea and vomiting (PONV). There are many causes, including the surgical procedure, anaesthetic, pain and opiates.
Risk factors for post-operative nausea and vomiting are:
- History of motion sickness or previous PONV
- Use of postoperative opiates
- Younger age
- Use of volatile anaesthetics
Prophylactic antiemetics are often given at the end of the procedure by the anaesthetist to prevent PONV from occurring. Common options for prophylaxis given at the end of the operation are:
- Ondansetron (5HT3 receptor antagonist) – avoided in patients at risk of prolonged QT interval
- Dexamethasone (corticosteroid) – used with caution in diabetic or immunocompromised patients
- Cyclizine (histamine (H1) receptor antagonist) – caution with heart failure and elderly patient
Examples of “rescue” antiemetics used in the post-operative period if nausea or vomiting occur are:
- Ondansetron (5HT3 receptor antagonist) – avoid in patients at risk of prolonged QT interval
- Prochlorperazine (dopamine (D2) receptor antagonist) – avoid in patients with Parkinson’s disease
- Cyclizine (histamine (H1) receptor antagonist) – caution with heart failure and elderly patients
Some local guidelines also refer to the P6 acupuncture point on the inner wrist. There is evidence that pressure to this area can reduce nausea.
Post-operative patients may have a catheter, drains or nasogastric tube, and these will be monitored and removed when appropriate.
- Drains are usually removed once they are draining minimal or no blood or fluid
- Nasogastric tubes are removed when they are no longer required for intake or drainage of gas or fluid
- Catheters are removed when the patient can mobilise to the toilet
Removal of a catheter is called a trial without catheter (TWOC). It is called this as there is a risk the patient will find it difficult to pass urine normally and go into urinary retention, and the catheter may need to be reinserted for a period before removal can be tried again. This is quite common, more so in male patients.
Good nutrition is important for healthy wound healing and overall recovery from surgery. A dietician may be involved.
Where possible, patients should get their nutrition via their gastrointestinal tract. Having nutrition via the gastrointestinal tract is called enteral feeding. This could be by:
- NG tube
- Percutaneous endoscopic gastrostomy (PEG) – a tube from the surface of the abdomen to the stomach
Total parenteral nutrition (TPN) involves meeting the full ongoing nutritional requirements of the patient using an intravenous infusion of a solution of carbohydrates, fats, proteins, vitamins and minerals. This is used where it is not possible to use the gastrointestinal tract for nutrition. It is prescribed under the guidance of a dietician. TPN is very irritant to veins and can cause thrombophlebitis, so is normally given through a central line rather than a peripheral cannula.
Patients are monitored for a long list of complications that can occur in the post-operative period:
- Atelectasis is where a portion of the lung collapses due to under-ventilation
- Infections (e.g., chest, urinary tract or wound site)
- Wound dehiscence is where there is separation of the surgical wound, particularly after abdominal surgery
- Ileus is where peristalsis in the bowel is reduced (typically after abdominal surgery)
- Haemorrhage with bleeding into a drain, inside the body creating a haematoma or from the wound
- Deep vein thrombosis and pulmonary embolism
- Shock due to hypovolaemia (blood loss), sepsis or heart failure
- Arrhythmias (e.g., atrial fibrillation)
- Acute coronary syndrome (myocardial infarction) and cerebrovascular accident (stroke)
- Acute kidney injury
- Urinary retention requiring catheterisation
- Delirium refers to fluctuating confusion and is more common in elderly and frail patients
A post-op full blood count is used to measure the haemoglobin.
Treatment of anaemia is based on individual factors and preferences alongside local guidelines. As a rough guide (local policies will vary):
- Hb under 100 g/l – start oral iron (e.g., ferrous sulphate 200mg three times daily for three months)
- Hb under 70-80 g/l – blood transfusion in addition to oral iron
Patients with symptoms of anaemia or underlying cardiovascular or respiratory disease may need a transfusion with higher haemoglobin levels.
It is worth noting that Jehovah’s Witnesses may refuse blood transfusions. They often have a written advanced directive to state that even in an emergency scenario where they lose capacity, blood transfusions are prohibited. Provided they have capacity and are making an informed decision, they have the right to autonomy. Measures are taken before surgery to optimise any anaemia, and careful steps are taken during surgery to minimise blood loss.
Last updated May 2021