What are the post-operative care guidelines in the immediate post-operative period?

Immediate Post-Operative Care Guidelines

In the immediate post-operative period, patients should receive systematic pain assessment, multimodal analgesia including NSAIDs with morphine when not contraindicated, regular vital sign monitoring with enhanced surveillance for high-risk patients, and early identification of potential complications through appropriate screening tools. 1

Pain Assessment and Management

Pain Assessment

• Use validated pain assessment tools appropriate for the patient population:
  • Adults: Numerical Rating Scale (0-10) or Visual Analog Scale
  • Children ≥5 years: Self-assessment with face scale 1
  • Children <7 years: FLACC scale (Face, Legs, Activity, Cry, Consolability) 1
  • Non-communicating patients: Modified FLACC scale for children, ALGOPLUS scale for elderly 1
• Screen for neuropathic pain using DN4 scale to identify early neuropathic pain that requires specific treatment 1

Pain Management

• First-line therapy: Combine non-selective NSAIDs or COX-2 inhibitors with morphine if no contraindications exist 1
  • This combination provides superior pain relief and reduces morphine consumption compared to other analgesic combinations
  • Contraindications to NSAIDs: Renal hypoperfusion, creatinine clearance <50 mL/min 1
  • Avoid COX-2 inhibitors in patients with history of atherothrombosis 1
  • Limit NS-NSAIDs to <7 days in patients with atherothrombosis 1
• Consider regional analgesia techniques when appropriate:
  • Wound catheters, abdominal wall blocks, thoracic epidural, TAP blocks 2
  • Evaluate carefully for sepsis and coagulation abnormalities before neuraxial techniques 2

Vital Signs Monitoring

Standard Monitoring

• Monitor vital signs according to institutional protocols with frequency based on patient risk factors
• Include pulse oximetry for respiratory monitoring, especially in high-risk patients 1
• Maintain mean arterial pressure 60-65 mmHg and cardiac index ≥2.2 L/min/m² 2

Enhanced Monitoring for High-Risk Patients

• Implement more frequent clinical and/or non-invasive monitoring (plethysmography, capnography) for patients at high risk of respiratory depression 1:
  • Age >70 years
  • Opioid-naïve patients
  • BMI >35 (morbid obesity)
  • Respiratory disease
  • Obstructive sleep apnea (OSA)
  • Liver or kidney failure
  • Patients receiving CNS depressants (benzodiazepines, barbiturates, antidepressants)
  • Patients with history of substance abuse
  • Neurological/neuromuscular disorders
  • Patients receiving perimedullary analgesia

Respiratory Management

Oxygenation

• Provide supplemental oxygen in head-elevated or semi-sitting position 1
• For patients with OSA on home CPAP, ensure they use their equipment immediately post-op 1
• Maintain low threshold for non-invasive positive pressure ventilation with signs of respiratory distress 1, 2
• Consider CPAP or non-invasive ventilation for patients with hypoxemia 2

Respiratory Therapy

• Implement respiratory physiotherapy including sputum clearance, inspiratory muscle training, and deep breathing exercises 2

Fluid and Electrolyte Management

• Use balanced crystalloids rather than 0.9% normal saline for resuscitation and maintenance 2
• Implement goal-directed fluid therapy using standardized algorithms to guide administration of fluids, vasopressors, and inotropes 1
• Monitor and correct electrolyte disturbances throughout the perioperative period 2

Delirium Prevention and Management

Screening

• Implement systematic delirium screening at least once per nursing shift using validated tools 1:
  • Confusion Assessment Method for ICU
  • ICU Delirium Screening Checklist
• Pay particular attention to patients >65 years of age 2

Management

• Use non-pharmacological interventions first:
  • Regular orientation
  • Sleep hygiene approaches
  • Cognitive stimulation
  • Minimize medications that can trigger delirium 2

Thromboprophylaxis

• Assess VTE risk with validated tool on admission and throughout hospital stay 2
• Provide combined pharmacological and mechanical prophylaxis for high-risk patients 1, 2
• Use mechanical prophylaxis alone if pharmacological prophylaxis is contraindicated 2
• Reassess VTE risk daily 2

Temperature Management

• Prevent hypothermia using:
  • Forced-air warming blankets
  • Increased ambient room temperature
  • Warming of irrigation and intravenous fluids 1
• Target normothermia (>36°C) within 2-5 hours of ICU admission 1

Glucose Management

• Monitor glucose levels closely
• Maintain glucose in range of 7.7-10 mmol/L (139-180 mg/dL) 2
• Use variable rate insulin infusion for glucose control when needed 2

Catheter and Tube Management

• Evaluate urinary catheter use daily and remove as early as possible 2
• Assess need for nasogastric tube individually based on risk of gastric stasis and aspiration 2
• Ensure chest tube patency after cardiac surgery using active chest-tube clearance methods rather than stripping or milking 1

Early Nutrition

• Initiate clear liquid diet several hours after surgery when appropriate 1
• Consider early tube feeding within 24 hours for patients who cannot start oral nutrition or when oral intake will be inadequate 2

Common Pitfalls to Avoid

1. Relying solely on normal vital sign values: Normal values may be present in both survivors and non-survivors of critical illness 3
2. Routine collection of vital signs without clinical context: Collecting vital signs based on tradition rather than clinical need may not help detect complications 4
3. Inadequate pain management: Untreated pain increases stress response and can lead to chronic post-surgical pain
4. Overlooking high-risk patients: Failure to identify patients at risk for respiratory depression can lead to preventable adverse events
5. Chest tube stripping: This practice is ineffective and potentially harmful for maintaining chest tube patency 1
6. Delayed recognition of delirium: Early detection and intervention are essential to determine underlying causes and initiate appropriate treatment 1

By following these evidence-based guidelines for immediate post-operative care, clinicians can optimize patient outcomes, reduce complications, and improve the quality of recovery after surgery.