Postoperative Care

After any procedure performed in the operating room, all patients must undergo close observation at least in the recovery room. After larger procedures and for patients who require hospitalization, observation must continue on the surgical ward. The primary intent of this practice is the early detection of postoperative complications. The entire medical team must be vigilant and aware of the patient’s history, the procedure performed, and risk factors for potential complications. Some of the most important things to attend to include monitoring vital signs (which may indicate severe complications such as bleeding), wound and drain care, postoperative pain control, nausea and vomiting, pulmonary hygiene to prevent atelectasis, deep vein thrombosis prophylaxis, and fluid management.

Last update:

Table of Contents

Share this concept:

Share on facebook
Share on twitter
Share on linkedin
Share on reddit
Share on email
Share on whatsapp

Recovery Room

The recovery room is reserved for patients in the immediate postoperative period who have received general anesthesia. Observation usually lasts 6 hours (until they are conscious and their vital signs are stable).

Monitoring airway, breathing, and circulation (the ABCs) and vital signs

  • Monitoring of the ABCs is the priority.
  • The patient may initially remain intubated, even in the recovery room.
  • Following extubation, patients should receive supplemental oxygen and should be encouraged to take frequent deep breaths.
  • Assess the patient’s vital signs:
    • ↑ Temperature: consider atelectasis, infection  
    • ↑ Pulse rate (PR): consider hemorrhage, pulmonary embolism (PE), MI, infection, or pain (most common) 
    • ↓ BP: consider hemorrhage, cardiac dysfunction, infection
    • ↑ RR: consider pulmonary embolism, atelectasis, infection   
    • ↓ Oxygen saturation: consider PE, MI, airway obstruction, atelectasis
    • ↓ Level of consciousness: consider stroke, cerebral hemorrhage, or lingering anesthetic effects
  • Major complications:
    • Airway obstruction
    • MI
    • Hemorrhage 
    • Respiratory failure
    • Acute kidney injury
Timeline of postoperative complications

Timeline of postoperative complications
DVT: deep vein thrombosis

Image by Lecturio. License: CC BY-NC-SA 4.0

Other activities in the recovery room

  • The patient’s symptoms (e.g., dyspnea) and concerns (e.g., pain or nausea) should be addressed.
  • Evaluate symptoms that could be caused by complications:
    • Chest pain → ECG to assess for possible MI
    • Uncontrolled pain → evaluate for internal surgical bleeding
  • Serial physical examinations are performed with a focus on ruling out complications:
    • Heart and lung exam
    • Surgical wound exam
  • Based on the procedure performed, the patient’s risks, and the patient’s current status, the surgeon will determine the disposition of the case, which may be:
    • Discharge to home, for healthy patients undergoing minor and/or minimally invasive procedures without worrisome signs/symptoms in recovery
    • Transfer the patient to the inpatient ward for continued, routine postoperative care
    • Transfer the patient to the ICU for more complex care

Surgical Ward

The patient is moved to the surgical ward for continued observation.

Basics of routine surgical care on the ward

All patients should be physically evaluated by a member of the surgical team at least once daily (if not more often).

  • Monitor vital signs, urinary output, and mental status.
  • Monitor the state and output of drains and tubes (e.g., Foley catheter, nasogastric tube, chest tube).
  • Manage fluids.
  • Check the surgical site for signs of dehiscence, infection, or bleeding.
  • Help control common postoperative symptoms:
    • Pain
    • Nausea and vomiting
  • Prophylaxis against:
    • Atelectasis
    • Deep vein thrombosis (DVT)
  • For patients at risk of internal bleeding and/or metabolic issues, order and follow up on basic lab work:
    • CBC (typically within the first 24 hours after surgery); consider transfusion based on Hb levels and blood loss during surgery
    • Consider a basic metabolic panel (BMP).
    • Labs unique to the patient and/or procedure
  • Work toward discharge:
    • Ambulation
    • Tolerating nutrition
    • Normal voiding and appropriate bowel activity
    • Symptoms controlled without IV or IM medications

Drains

  • Drains should be checked and emptied regularly:
    • Lost fluid should be replaced with a fluid of similar characteristics.
    • Continuous blood loss through a drain should be investigated. 
    • Remove as soon as clinically appropriate in order to minimize complication risks.
  • Urinary catheter: for most procedures, typically removed once the patient can ambulate

Wound care

Wound infections can affect either the superficial or the deep incisional spaces. Pressure sores may also develop in immobile patients.

  • Wounds should be examined daily for signs of infection: redness, swelling, drainage
  • Wounds should be covered with a dry dressing, which should be removed when clinically appropriate, often within 48 hours.
  • Superficial infections involve only the skin and subcutaneous tissue near the incision and can present with:
    • Cellulitis
    • Purulent drainage
    • Superficial abscess
  • Deep infections may involve the peritoneal or organ spaces and present with:
    • Pain
    • Fever
    • Ileus (in GI surgery)
  • Signs of infection should be managed: 
    • Wound swab for Gram staining and culture
    • Antibiotics if clinical infection is apparent on physical exam
    • +/– surgical debridement
  • Pressure sores
    • A result of friction/persistent pressure over soft tissue affecting pressure points (e.g., sacrum)
    • Risk factors:
      • Immobility
      • Malnutrition
      • Poor peripheral circulation 
      • Diabetes mellitus 
      • Edema
    • Prevention:
      • Early mobilization
      • Adequate nutrition 
      • Regular turning by staff, if immobile 
      • Air filter mattress for high-risk patients 
  • Risk factors for impaired wound healing:
    • Obesity
    • Smoking
    • Diabetes mellitus
    • Peripheral vascular disease

Fluid replacement and oral intake

  • Fluid input (fluid intake) and output (sensible and insensible losses) should be balanced.
    • Fluid input sources:
      • Exogenous sources: oral and IV fluid
      • Endogenous sources: water produced by metabolism
    • Fluid output sources:
      • Sensible losses: urine and drains
      • Insensible losses: respiration, feces, sweat
    • Extra losses, such as increased insensible losses due to temperature in tropical climates, must be kept in mind.
    • Maintenance fluid requirements for adults are approximately 1.5–2.5 L daily.
  • Goals of fluid management:
    • Guard against ongoing physiologic fluid loss in patients who cannot or should not eat/drink; these losses may be increased due to: 
      • Drains
      • GI losses: vomiting, diarrhea
      • Insensible losses: tachypnea, perspiration
    • Support cardiac preload
    • Maintain intravascular volume 
    • Electrolyte balance
  • Provide maintenance fluid:
    • 4 ml/kg/hour (or 100 ml/kg/24 hours) for the 1st 10 kg of body weight
    • 2 ml/kg/hour (or 50 ml/kg/24 hours) for the 2nd 10 kg 
    • 1 ml/kg/hour (or 20 ml/kg/24 hours) for each kilogram after the 20th
  • Nutrition:
    • Enteral nutrition (e.g., oral intake) is preferred and should start as soon as possible as long as there are no contraindications (e.g., intestinal obstruction).
    • Total parenteral nutrition (TPN) may be initiated, if prolonged nil per os (NPO; nothing by mouth) state is anticipated.
  • It is not necessary to replace potassium within the first 24–48 hours after surgery because potassium is released from injured cells.

Pain management

  • Pain should be regularly assessed and addressed.
  • Therapeutic options:
    • Parenteral analgesics:
      • Opioids: morphine, hydromorphone, fentanyl
      • Patient-controlled analgesics: opioids
      • IV NSAIDs
      • IV acetaminophen
      • Ketamine
    • Oral analgesia: opioids, NSAIDs, acetaminophen, gabapentin
    • Regional analgesia: intrathecal opioids, epidural block, peripheral nerve block
  • Use a multimodal approach.
  • Maximize the use of nonopioid analgesics before administering opioids. 
  • Typical example regimen:
    • NSAID + acetaminophen (scheduled)
    • Opioid as needed or opioid by patient-controlled analgesia
    • Additional measures:
      • Consider adjuvant analgesia (e.g., gabapentin) and/or regional analgesia
  • Start with IV forms and transition to oral as tolerated.
  • Stay alert: Uncontrolled pain may indicate a complication, such as internal hemorrhage or infection.

Postoperative nausea and vomiting

  • Risk factors:
    • Patient-specific:
      • Women
      • Nonsmokers 
      • Previous history of postoperative nausea and vomiting
      • Motion sickness  
    • Procedure-specific:
      • Volatile anesthetic agents (e.g., nitrous oxide)
      • Postoperative opioids 
      • Type of surgery (e.g., cholecystectomy) 
  • Major complications may result from postoperative nausea and vomiting, including:
    • Wound dehiscence and bleeding 
    • Dehydration
    • Prolonged hospital stay
    • ↑ Intracranial pressure (a concern for neurosurgical patients)
  • Postoperative nausea and vomiting treatment:
    • Antiemetic agents:
      • Serotonin 5-hydroxytryptamine-3 receptor antagonists: ondansetron
      • Dopamine antagonists: metoclopramide, prochlorperazine
    • May combine agents from different classes

Mental status changes

  • Delirium or confusion may occur postoperatively.
  • Rule out stroke with history, exam, and potentially brain imaging.
  • Presentation:
    • Anxiety 
    • Incoherent speech
    • Decreased level of consciousness
    • Destructive behavior (e.g., pulling out drains)
  • Risk factors:
    • Older age
    • Preexisting dementia
    • Alcohol withdrawal 
    • Benzodiazepine/opioid use 
    • Electrolyte disturbances 
    • Infection
  • Treatment:
    • Treat the underlying cause. 
    • Haloperidol in severe agitation
  • Anxiety, disorientation, and minor changes in behavior or appearance can be early manifestations of complications.

Prophylaxis

  • DVT prophylaxis:
    • Mechanical methods, which are used in almost all patients:
      • Elastic stockings 
      • Intermittent pneumatic compression 
      • Early ambulation
    • Pharmacologic methods:
      • Used for moderate- to high-risk patients (e.g., bariatric, orthopedic, or cancer patients) 
      • Typically use low-molecular-weight heparin or unfractionated heparin
  • Atelectasis prophylaxis:
    • Referred to as “pulmonary hygiene”
    • Atelectasis can result in decreased oxygenation, poorer wound healing, and respiratory infections.
    • Techniques used:
      • Early mobilization
      • Deep breathing and/or incentive spirometry
      • Adequate analgesia (prevents shallow breathing due to pain)
      • Continuous positive airway pressure (CPAP)

Outpatient Care after Discharge

Patients are typically ready for discharge when they meet the following criteria:

  • Stable vital signs and exam
  • Able to ambulate and provide basic self-care (or have help in doing so) 
  • Able to tolerate nutrition and hydration
  • Pain controlled on oral medications
  • Voiding and defecating appropriately for their clinical situation

Review all restrictions and instructions with patients prior to discharge:

  • Include any limitations to work/school (e.g., no heavy lifting for 6 weeks).
  • Teach patient how to care for their incisions.
  • Explain what to expect in terms of recovery.
  • Explain what requires more immediate evaluation.
  • Provide phone numbers and resources so patients know who to call or where to go in case of concerns.
  • Provide documentation (“doctor’s note”) for work/school as needed. 

Ensure patient is set up with:

  • Appropriate rehabilitation/physical therapy (may be required depending on the patient and/or procedures)
  • Required medical equipment and/or supplies

Most patients should have a postoperative appointment around 7–14 days after discharge:

  • Assess surgical wound healing.
  • Assess functional status, pain, and symptoms.
  • Review pathology/findings and next steps in the plan of care. 

Clinical Relevance: General Surgical Complications

The following conditions include common complications that can occur in any patient undergoing a surgical procedure that requires general anesthesia.

Respiratory complications

  • DVT: formation of a clinically important intravascular thrombus in the deep venous plexus of the lower limbs.
  • PE: when a clot becomes lodged within the pulmonary circulation. A pulmonary embolism obstructs gas exchange and may be life-threatening.
  • Pneumonia: infection of the pulmonary parenchyma, most commonly by bacterial pathogens. 
  • Aspiration pneumonitis: Patients who vomit while intubated may aspirate the vomitus and develop inflammation of the pulmonary parenchyma due to the gastric contents.
  • Respiratory failure: inability to maintain normal PO2 and PCO2 in arterial blood, rendering the body unable to support systemic metabolic requirements. Respiratory failure can be due to inadequate oxygenation of blood or inadequate ventilation.
  • Acute respiratory distress syndrome: severe inflammatory reaction of the lung that is characterized by the presence of pulmonary infiltrates due to alveolar fluid accumulation, without evidence suggestive of a cardiogenic etiology.
  • Pleural effusion: accumulation of fluid within the pleural space, which can be due to a multitude of causes.
  • Pneumothorax: potentially life-threatening condition in which air is trapped in the pleural space and there is complete or partial collapse of the lung. Pneumothorax may arise because of procedural complications or increased pulmonary pressures during mechanical ventilation.

Cardiovascular complications

  • MI: ischemia and subsequent injury of the myocardial tissue due to severely reduced blood flow to a coronary artery. MI is diagnosed on the basis of an increase in cardiac enzymes and ECG changes suggestive of ischemia. 
  • Heart failure: inability of the heart to supply the body with a normal cardiac output sufficient to meet metabolic demands.
  • Atrial fibrillation: supraventricular arrhythmia produced by chaotic atrial depolarization, characterized on ECG by absent P waves and an “irregularly irregular” ventricular rhythm.

Urinary complications

  • Urinary tract infection (UTI): infection of the urinary system most commonly caused by Escherichia coli. In the postoperative patient, UTI is most commonly due to use of an indwelling Foley catheter.
  • AKI (acute renal failure): characterized by increases in serum creatinine and reductions in urinary output and glomerular filtration. This condition may be due to periods of intraoperative hypotension leading to ischemia either caused by blood loss and/or effects of anesthesia, use of nephrotoxic drugs, or embolic events.

Infectious complications

  • Sepsis: life-threatening syndrome resulting in multiorgan dysfunction caused by an unregulated and disproportionate host response to infection.

References

  1. Lal, P. (2018). Postoperative care and complications. In: Garden, O. James et al. Principles and practice of surgery (pp. 128–136). Retrieved June 8, 2021, from https://www.clinicalkey.es/#!/content/3-s2.0-B9780702068591000091
  2. James, Mollie M.,D.O., M.P.H., & Beilman, G. J., M.D. (2012). Mechanical ventilation. Surgical Clinics of North America, The, 92(6), 1463-1474. http://dx.doi.org/10.1016/j.suc.2012.08.003
  3. Ferri, Fred F. ,M.D., F.A.C.P. (2014). Pulmonary and critical care. In Ferri, Fred F., MD, FACP (Ed.), Ferri’s Practical Guide: Fast facts for patient care. Elseverier, pp. 340–371. Retrieved June 8, 2021, from https://www.clinicalkey.es/#!/content/3-s2.0-B9781455744596000118
  4. Thompson, B. T., Chambers, R. C., & Liu, K. D. (2017). Acute respiratory distress syndrome. N Engl J Med 377:562–572. doi:10.1056/NEJMra1608077
  5. Quick, Clive R.G. et al. (2020). Complications of surgery. In Quick, Clive R.G. et al., Essential Surgery: Problems, Diagnosis, and Management. Elsevier, pp. 170–184. Retrieved June 8, 2021, from https://www.clinicalkey.es/#!/content/3-s2.0-B9780702076312000122
  6. Goldstein, L. B. (2020). Ischemic cerebrovascular disease. In L. Goldman MD, & A. I. Schafer MD (Eds.), Goldman-Cecil medicine (pp. 2396-2407.e3). Retrieved June 8, 2021, from https://www.clinicalkey.es/#!/content/3-s2.0-B9780323532662003799
  7. Ko S. B. (2018). Perioperative stroke: pathophysiology and management. Korean Journal of Anesthesiology 71:3–11. https://doi.org/10.4097/kjae.2018.71.1.3
  8. Alexander JW, Solomkin JS, Edwards MJ. (2011). Updated recommendations for control of surgical site infections. Ann Surg 253:1082–1093. 
  9. Barbul A, Efron DT, Kavalukas SL. (2014). Wound healing. In: Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE. eds. Schwartz’s Principles of Surgery, 10th ed. New York: McGraw-Hill. 
  10. Beilman GJ, Dunn DL. (2014). Surgical infections. In: Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, Pollock RE. eds. Schwartz’s Principles of Surgery, 10th ed. New York: McGraw-Hill. 
  11. Culver DH, Horan TC, Gaynes RP, et al. Surgical wound infection rates by wound class, operative procedure, and patient risk index. National Nosocomial.

Study on the Go

Lecturio Medical complements your studies with evidence-based learning strategies, video lectures, quiz questions, and more – all combined in one easy-to-use resource.

Learn even more with Lecturio:

Complement your med school studies with Lecturio’s all-in-one study companion, delivered with evidence-based learning strategies.

🍪 Lecturio is using cookies to improve your user experience. By continuing use of our service you agree upon our Data Privacy Statement.

Details