Post-Operative Care

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 operation.

 

Enhance Recovery

Enhance recovery aims to get patients independent, mobile and out of hospital as soon as possible. This leads to better outcomes for the patient.

The principles of enhanced recovery are:

  • Good preparation for surgery (e.g. health diet and exercise)
  • Minimally invasive surgery (keyhole or local anaesthetic where possible)
  • Adequate analgesia
  • Good nutritional support around surgery
  • Returning to oral diet and fluid intake
  • Early mobilisation
  • Avoiding drains and NG tubes where possible, early catheter removal
  • Early discharge

 

Analgesia

Adequate analgesia in the post-operative period is important to encourage the patient to:

  • Mobilise
  • 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). 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 s ibuprofen, naproxen and diclofenac may be inappropriate or contraindicated in patients with:

  • Asthma
  • 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 at the start of a contraction 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 the 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. Avoid other 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:

  • Female
  • History of motion sickness or previous PONV
  • Non-smoker
  • 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 it from occurring. Common options for prophylaxis given at the end of the operation:

  • Ondansetron (5HT3 receptor antagonist) – avoid in patients at risk of prolonged QT interval
  • Dexamethasone (corticosteroid) – cautious in diabetics and immunocompromised patients
  • Droperidol (dopamine (D2) receptor antagonist) – avoid in patients with Parkinson’s disease

 

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

 

Guidelines also refer to the P6 acupuncture point on the inner wrist. There is evidence that pressure to this area can reduce nausea.

 

Tubes

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 and is more common in male patients.

 

Nutritional Support

Good nutrition is important for health wound healing and overall recovery from surgery. A dietician may be involved.

Wherever possible patients should get their nutrition through their gastrointestinal tract. Having nutrition via the gastrointestinal tract is called enteral feeding. This could be by:

  • Mouth
  • NG tube
  • Percutaneous endoscopic gastrostomy (PEG) – a tube from the surface of the abdomen to the stomach

 

Total parenteral nutrition 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 is it not possible to use the gastrointestinal tract for nutrition. It is prescribed under the guidance of a dietician.

 

Post-Operative Complications

Patients are monitored for a long list of complications that can occur in the post-operative period:

  • Anaemia
  • Atelectasis is where a portion of the lung collapses due to under-ventilation
  • Infections (e.g. chest, urinary tract or wound site)
  • Wound dehiscence (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

 

Anaemia

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.

 

Last updated March 2021
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