What are the post-operative orders for a patient who has undergone spinal anesthesia?

Post-Operative Orders Following Spinal Anesthesia

Patients who have undergone spinal anesthesia require structured monitoring with specific mobilization criteria, fluid management, analgesia planning, and discharge instructions that prioritize safety while avoiding unnecessary delays in recovery.

Immediate Post-Operative Monitoring

Vital Signs and Neurological Assessment

• Monitor vital signs at regular intervals including pulse oximetry, blood pressure, and heart rate, as hypotension occurs in approximately 33% of patients after spinal anesthesia 1
• Assess lower limb neurological function at regular intervals to detect any unexpected complications 2
• Maintain supplemental oxygen throughout the immediate recovery period, as this should always be provided during and after spinal anesthesia 2

Recovery Area Requirements

• First-stage recovery should occur in an appropriately equipped recovery area with trained staff until the patient is awake, protective reflexes have returned, and pain is controlled 2
• Patients with regional anesthesia alone may bypass first-stage recovery and be fast-tracked directly to second-stage recovery 2

Mobilization Criteria

Nursing staff must follow strict criteria before allowing ambulation after spinal anesthesia 2:

• Return of sensation to the perianal area (S4-5 dermatome) 2
• Plantar flexion of the foot at pre-operative levels of strength 2
• Return of proprioception in the big toe 2

These criteria must be met regardless of whether epidural analgesia was used, though any supplementary local anesthetic infiltration may affect timing 2.

Fluid Management

• Restrict intravenous fluids to no more than 500 ml to reduce the incidence of urinary retention 2
• Encourage oral fluid intake postoperatively to allow the patient's own body to correct fluid balance 2
• Mandatory oral intake is not necessary and may provoke nausea and vomiting, potentially delaying discharge 2

Urinary Catheter Management

• Routine transurethral bladder drainage for 1-2 days is recommended for most surgical procedures 2
• The bladder catheter can be removed regardless of epidural usage or duration 2
• Voiding is not always required before discharge, though identify patients at particular risk (those with prolonged bladder instrumentation or manipulation) 2

Analgesia Planning

Critical Timing Consideration

An analgesic plan is essential, as patients may experience significant pain when the spinal block wears off 2:

• Start oral analgesics before the local anesthesia begins to wear off 2
• Provide premedication with oral analgesics (unless contraindicated) in addition to postoperative oral analgesics 2
• Give written instructions regarding when to take analgesics and ensure regular dosing rather than as-needed administration 2

Opioid Considerations

• Avoid opioid analgesics as the sole adjunct due to increased risk of respiratory depression and postoperative confusion, particularly in elderly patients 2
• If intrathecal opioids were used, fentanyl is preferred over morphine or diamorphine, which carry greater risk of respiratory and cognitive depression 2

Discharge Instructions

Patient Education Requirements

All patients must receive both verbal and written instructions, preferably in the presence of their responsible escort 2:

• Information about post-dural puncture headache (PDPH) and what to do if it occurs, noting that risk is <1% with 25G pencil-point needles 2
• Warning signs of possible complications and where to seek help 2
• Alternative analgesics and pain management instructions 2

Activity Restrictions

• No alcohol consumption, operating machinery, or driving for 24 hours after spinal anesthesia 2
• Patients should not drive until pain or immobility from their operation allows them to control their car safely and perform an emergency stop 2
• Protect any limb with residual motor or sensory blockade if discharged home with ongoing block 2

Special Populations

Elderly Patients

• Mild postoperative confusion is common and usually insignificant, should not influence discharge if social circumstances permit 2
• Avoidance of hospitalization after minor surgery is preferred for elderly patients 2
• Lower doses of intrathecal bupivacaine (<10 mg) reduce associated hypotension in elderly patients 2

Day Surgery Patients

• Bed rest duration should be tailored to clinical circumstances 2
• Most patients can be discharged the same day after appropriate observation period 2
• Supervised ambulation should occur after meeting mobilization criteria 2

Common Pitfalls to Avoid

• Do not delay mobilization unnecessarily once neurological criteria are met, as this impairs recovery 2
• Do not mandate voiding before discharge in low-risk patients, as this delays discharge without benefit 2
• Do not forget to plan for analgesia transition, as inadequate planning leads to severe pain when block resolves 2
• Do not use sedation routinely or excessively, as it can mask important neurological signs 2, 3