What is the recommended postoperative care regimen?

Postoperative Care Recommendations

For optimal postoperative recovery, implement a multimodal Enhanced Recovery After Surgery (ERAS) protocol that includes early mobilization within hours of surgery, opioid-sparing multimodal analgesia with scheduled acetaminophen and NSAIDs, early oral intake within 2-4 hours, removal of urinary catheters within 24 hours, and continuation of VTE prophylaxis. 1

Immediate Postoperative Monitoring

Vital Signs and Clinical Parameters:

• Monitor respiratory rate, heart rate, blood pressure, oxygen saturation, level of consciousness, and surgical site assessment for the first 24-48 hours 1, 2
• Maintain core temperature ≥36°C using active warming devices 1
• For emergency laparotomy patients, use validated preoperative risk scores to determine appropriate postoperative care location (ward vs. ICU) 1

Pain Management

Multimodal Opioid-Sparing Analgesia (First-Line):

• Administer scheduled acetaminophen (paracetamol) 1000 mg every 6 hours PLUS NSAIDs (ibuprofen 400 mg or naproxen) as the foundation of pain control 1, 2
• This combination provides superior analgesia with NNT of 1.5 compared to placebo, and NNT of 5.4 compared to ibuprofen alone 3
• Continue this regimen regularly, not as-needed, to maintain consistent analgesia 1

Regional Analgesia (Procedure-Specific):

• For open abdominal surgery: Mid-thoracic epidural (T7-10) continued for 48-72 hours postoperatively provides superior pain control compared to systemic opioids 1
• For minimally invasive surgery: Spinal analgesia, wound catheters, or transversus abdominis plane (TAP) blocks are alternatives to epidural 1
• Important caveat: In emergency laparotomy, assess for sepsis and coagulation abnormalities before placing epidural; manage epidural-induced hypotension with vasopressors rather than excessive fluid administration 1

Opioid Use (Last Resort Only):

• Reserve opioids for breakthrough pain uncontrolled by multimodal regimen 1, 2
• Use short-acting opioids in minimal doses 1
• Consider patient-controlled analgesia (PCA) if opioids are necessary 4

Early Mobilization

Mobilization Protocol:

• Begin mobilization 30 minutes on the day of surgery, then 6 hours per day thereafter 1, 2
• This aggressive early mobilization prevents venous thromboembolism, reduces pulmonary complications, and accelerates recovery 1
• For cesarean delivery, early mobilization is recommended despite lower quality evidence 1

Nutrition and Oral Intake

Early Feeding Protocol:

• Offer oral fluids as soon as patient is lucid after surgery 1, 2
• Advance to solid food within 2-4 hours postoperatively 1
• For cesarean delivery specifically, regular diet within 2 hours is supported by high-quality evidence showing improved maternal satisfaction, earlier ambulation, and reduced length of stay 1
• Discontinue intravenous fluids on postoperative day 1 once oral intake is established 1

Bowel Function:

• Chewing gum may accelerate return of bowel function in cesarean delivery, though may be redundant with early feeding protocols 1
• Avoid routine nasogastric tubes, which do not improve outcomes and delay recovery 1

Catheter Management

Urinary Catheter Removal:

• Remove Foley catheter within 24 hours for most procedures 1, 2
• For cesarean delivery, remove immediately after surgery if placed intraoperatively 1
• Early removal (within 24 hours) reduces urinary tract infections and facilitates mobilization 1
• Individualize timing only for patients at high risk of urinary retention 1

Venous Thromboembolism Prophylaxis

VTE Prevention Strategy:

• Continue combination prophylaxis: mechanical (compression stockings and/or intermittent pneumatic compression) PLUS pharmacological (low molecular weight heparin or unfractionated heparin) 1
• For emergency laparotomy patients (very high risk), both mechanical and pharmacological prophylaxis are mandatory 1
• Continue prophylaxis throughout hospital stay with daily reassessment 1
• For colorectal cancer patients, extend prophylaxis for 28 days post-discharge 1
• Exception: For cesarean delivery, routine heparin prophylaxis is not recommended (weak recommendation) 1

Postoperative Nausea and Vomiting (PONV)

PONV Management:

• Use multimodal antiemetic prophylaxis for patients with ≥2 risk factors 1
• Prevent intraoperative hypotension with fluid preloading and vasopressors (ephedrine or phenylephrine), which reduces PONV incidence 1
• Administer multiple antiemetic agents from different classes for high-risk patients 1

Respiratory Care (High-Risk Patients)

Pulmonary Complication Prevention:

• For emergency laparotomy patients with hypoxemia and low aspiration risk: Use continuous positive airway pressure (CPAP) or noninvasive positive pressure ventilation rather than standard oxygen therapy 1
• Implement respiratory physiotherapy including sputum clearance training, inspiratory muscle strengthening, and deep breathing exercises 1
• Assess suitability for extubation via multidisciplinary discussion, as reintubation carries 72-fold increased mortality risk 1

Glycemic Control

Blood Glucose Management:

• Maintain capillary blood glucose 7.7-10 mmol/L (approximately 140-180 mg/dL) using variable rate insulin infusion 1
• For cesarean delivery, tight glucose control is recommended (strong recommendation despite low evidence) 1
• Multiple ERAS interventions attenuate insulin resistance without hypoglycemia risk 1

Delirium Prevention (Elderly Patients)

Delirium Screening and Prevention:

• Screen all patients >65 years for delirium regularly postoperatively 1
• Implement non-pharmaceutical interventions: regular orientation, sleep hygiene, cognitive stimulation 1
• Minimize medication triggers including opioids and benzodiazepines 1

Drain and Tube Management

Surgical Drains:

• Avoid routine use of peritoneal drains after colonic anastomosis 1
• For pancreaticoduodenectomy, consider early drain removal at 72 hours if amylase content <5000 U/L 1

Discharge Planning

Discharge Criteria:

• Adequate pain control on oral medications 2
• Tolerating oral diet 1, 2
• Return of bowel function 2
• Independent mobilization 1, 2
• Provide standardized written discharge instructions 1

Red Flags Requiring Medical Attention:

• Fever >38°C (100.4°F) 2
• Increasing pain uncontrolled by prescribed medications 2
• Signs of wound infection (redness, swelling, warmth, purulent drainage) 2
• Heavy bleeding or foul-smelling discharge 2

Common Pitfalls to Avoid

• Do not administer excessive intravenous fluids for epidural-induced hypotension—confirm euvolemia first, then use vasopressors 1
• Do not use nitrous oxide anesthesia—increases PONV and delays bowel function 1
• Do not delay oral intake—traditional NPO rules are outdated and harmful 1
• Do not use routine preoperative sedatives—they delay recovery 1
• Do not prescribe excessive home-going opioids—most patients do well with scheduled NSAIDs and acetaminophen alone 1, 2