Post-Operative Assessment for Surgeries
All post-operative patients require systematic monitoring of eight core parameters during emergence and recovery: airway patency/respiratory rate/oxygen saturation, pulse/blood pressure with ECG availability, neuromuscular function (if relevant), mental status, temperature, pain, nausea/vomiting, and hydration status. 1
Core Vital Sign Monitoring
Respiratory Assessment
- Monitor airway patency, respiratory rate, and oxygen saturation (SpO2) periodically throughout emergence and recovery 1
- Particular attention must be given to oxygenation and ventilation, as postoperative pulmonary complications are among the highest risk events 1
- Patients undergoing emergency or prolonged abdominal surgery face significantly elevated risk (OR 4.21-4.47) for reintubation and pulmonary complications 1
Cardiovascular Monitoring
- Routine monitoring of pulse and blood pressure must be performed during emergence and recovery 1
- Electrocardiographic monitors should be immediately available (though not necessarily continuous for all patients) 1
- These parameters detect cardiovascular complications and reduce adverse outcomes 1
Neuromuscular Function
- Assessment of neuromuscular function should be performed for patients who received nondepolarizing neuromuscular blocking agents or have medical conditions associated with neuromuscular dysfunction 1
- Physical examination is primary; neuromuscular blockade monitoring may be used when indicated 1
- This assessment identifies potential complications and reduces adverse outcomes 1
Neurological and Metabolic Parameters
Mental Status
- Periodic assessment of mental status should be done during emergence and recovery 1
- Several scoring systems are available for standardized assessment 1
- This detects complications and reduces adverse outcomes despite limited direct evidence 1
Temperature
- Patient temperature assessment should be done during emergence and recovery 1
- Temperature monitoring detects complications and reduces adverse outcomes 1
Pain Assessment
- Pain should be periodically assessed during emergence and recovery 1
- Routine pain monitoring detects complications and reduces adverse outcomes 1
- Multimodal opioid-sparing analgesia using combinations of paracetamol and NSAIDs should be implemented, with opioids as last resort 2
Gastrointestinal and Fluid Management
Nausea and Vomiting
- Periodic assessment of nausea and vomiting should be performed routinely during emergence and recovery 1
- Both detection and prophylactic treatment reduce complications 1
Hydration Status
- Postoperative hydration status should be assessed and managed accordingly 1
- Procedures involving significant blood or fluid loss require additional fluid management 1
Urine Output
- Assessment of urine output should be performed for selected patients during emergence and recovery 1
- Not routine for all patients, but indicated for those at risk or undergoing major procedures 1
Early Warning Systems and Escalation
Standardized Monitoring Protocols
- Key parameters to measure include respiratory rate, heart rate, blood pressure, oxygen saturation, level of consciousness, and surgical site assessment 1
- Use of standardized early warning scores (NEWS, MEWS) in conjunction with escalation protocols helps identify at-risk patients and promote rescue 1
- Early warning systems have demonstrated benefit in high-income countries and should be adapted to local resources 1
Failure to Rescue Prevention
- Timely recognition and appropriate intervention for complications reduces mortality through prevention of "failure to rescue" 1
- Failure to rescue rates vary from <1% to >40% despite similar complication rates, suggesting many lives can be saved through early identification 1
- Institutional-specific guidelines for postoperative monitoring, evaluation, and escalation of care should be developed 1
Monitoring Frequency and Duration
Traditional Pattern
- Vital sign collection typically follows hourly monitoring for the first 4 hours, then reduces to every 4 hours across the 12-24 hour period 3
- However, subtle changes in vital signs often occur 8-12 hours before acute events, and intermittent monitoring misses these critical periods 4
Enhanced Surveillance
- Continuous monitoring may be beneficial for high-risk patients, though challenges include artifacts and alarm fatigue 4
- The duration of monitoring interventions depends on the patient's clinical status 1
Special Considerations for High-Risk Patients
Emergency Surgery Patients
- A multidisciplinary discussion at the end of surgery should assess suitability for endotracheal extubation, as risk of postoperative pulmonary complications and reintubation is high 1
- Consider an "end of surgery" bundle including risk scoring, arterial blood gas assessment, P/F ratio evaluation, fluid review, and temperature documentation 1
Early Mobilization and Feeding
- Early oral feeding should be facilitated, with fluids as soon as the patient is lucid and solids after 4 hours 2
- Promote early mobilization with 30 minutes on the day of surgery and 6 hours/day thereafter 2
- Urinary catheters should be removed within 24 hours for most patients 2
Common Pitfalls to Avoid
- Incomplete vital sign documentation: No patient records should lack any of the seven core MEWS parameters, yet this occurs frequently 5
- Failure to respond to abnormal vital signs: Studies show 61-93% of abnormal vital signs triggering escalation algorithms receive no documented response 5
- Inadequate monitoring frequency: Intermittent checks miss prolonged periods of subtle physiological changes 6, 4
- Poor communication during transitions: Ensure comprehensive handover between recovery and ward settings 2
Quality Improvement
Regular audits of compliance to guidelines and reporting of outcomes is essential 1