What are the key components of post-operative care?

Key Components of Post-Operative Care

Effective post-operative care should be delivered through an Enhanced Recovery After Surgery (ERAS) pathway that focuses on pain management, early mobilization, and prevention of complications to optimize patient outcomes.

Pain Management

• Multimodal analgesia should be the cornerstone of post-operative pain management to minimize opioid use and associated side effects 1, 2
• Paracetamol (acetaminophen) should be considered first-line therapy for all post-operative patients due to its safety profile 1
• NSAIDs should be used with caution, especially in elderly patients and after bariatric surgery, due to increased risk of gastrointestinal complications; when used, they should be administered at the lowest effective dose for the shortest duration with proton pump inhibitor protection 1, 3
• Opioids should be reserved for moderate to severe pain and administered cautiously, particularly in patients with poor renal or respiratory function or cognitive impairment 1
• Regional anesthesia techniques (epidural, spinal, nerve blocks) should be utilized when appropriate based on the surgical procedure 1
• Patient-controlled analgesia (PCA) is an optimal solution for many patients requiring opioid analgesia 1

Early Mobilization

• Early mobilization should begin within 24 hours of surgery to prevent pulmonary complications, thromboembolism, insulin resistance, and muscle weakness 1
• Mobilization should be incentivized and structured, with clear goals for patients 1, 4
• The benefits of early mobilization are particularly important for elderly patients with pre-existing sarcopenia and patients with sepsis who are at increased risk of muscle catabolism 1

Fluid and Nutrition Management

• Intravenous fluids should be discontinued at the latest during day 1 post-operatively, with patients encouraged to drink when fully recovered 1
• Early oral intake should be promoted, with solid food introduced as soon as possible (within 2 hours for cesarean delivery) 1, 4
• Enteral nutrition should be prioritized over parenteral nutrition, particularly in elderly patients 1
• Balanced crystalloids (e.g., Ringer's lactate) should be used instead of 0.9% saline to avoid salt and fluid overload 1
• Oliguria should not automatically trigger fluid therapy as it is a normal physiological response during surgery and anesthesia 1

Respiratory Care

• Supplemental oxygen should be administered post-operatively to maintain oxygen saturation >95% 1
• Incentive spirometry, chest physiotherapy, and early mobilization should be implemented to prevent pulmonary complications 1
• Continuous positive airway pressure (CPAP) may be beneficial in certain contexts 1
• Patients with asthma may benefit from postoperative albuterol therapy 1

Wound Care

• For patients receiving a dressing over the surgical incision, it should remain in place for at least 48 hours 4
• Regular wound assessment should be performed to detect early signs of surgical site infection 5
• Appropriate cleansing and dressing changes should follow institutional protocols 5

Prevention of Complications

Thromboembolism Prophylaxis

• Mechanical thromboprophylaxis should be provided until the patient is fully mobile 4
• Chemoprophylaxis should be reserved for patients with additional risk factors 4

Prevention of Delirium

• Regular delirium screening should be performed, especially in elderly patients 1
• Drugs that precipitate delirium should be avoided, including benzodiazepines, antihistamines, atropine, sedative hypnotics, and corticosteroids 1
• Non-pharmacologic interventions should be implemented, including return of hearing aids and promoting family presence 1

Temperature Management

• Hypothermia should be avoided at all costs in the postoperative setting 1
• Ice packs should not be used directly on the skin 1
• Warm blankets or higher room temperatures should be used to prevent hypothermia 1

Postoperative Monitoring and Destination

• Risk assessment should be performed towards the end of surgery to determine the appropriate level of postoperative care (ward vs. critical care) 1
• Basic monitoring should be continued upon return to the ward, with Modified Early Warning Scores and Critical Care Outreach teams available 1
• Patients with a predicted perioperative mortality >10% should be admitted to a level 2 or 3 critical care facility 1

Discharge Planning

• For low-risk patients, hospital discharge may occur as early as 24-28 hours if close outpatient follow-up is available 4
• Discharge counseling should include guidance on pain management, physical activity resumption, and follow-up care 1, 4
• Patients should be provided with a record of their preoperative condition and postoperative status for future healthcare providers 1

Special Considerations for Elderly Patients

• Age-adjusted and renal function-adjusted doses of postoperative analgesia should be prescribed 1
• Promotion of patient-oriented rehabilitation should be part of care pathways for older patients 1
• Re-enablement (return to pre-operative functional level) should be a priority, extending beyond remobilization or rehabilitation 1