Basic Post-operative Management

- Pain control
o PCA
 Discontinue when tolerating PO intake
 Acute Pain Service runs and adjusts
o Epidural
 Placed pre-operatively usually
 Discontinue on post-op day along with Foley
o Toradol – an NSAID
 Avoid in patients with CKD, increased Cr
 Use is very attending-dependent, can be very good for analgesia
o Scheduled acetominophen with oxycodone
 Don’t combine with Norco – already as APAP in it
o PO pain control options
 Norco or oxycodone – 1-2 tabs PO q4-q6h
 Often with morphine 2-6g IV for breakthrough pain
- IV Fluids
o Major fluid losses – insensible losses, bleeding, and third-spacing
o Resuscitative fluids = LR and NS
 Normal saline – can cause hyperchloremic metabolic acidosis if used for long periods of time
 Lactated Ringers (LR) – much more physiologic concentrations of ions
o Maintenance = 4ml/kg/hr for first 10 kg, 2ml/kg/hr for next 10, then 1mg/kg/hr thereafter – or just 40 + 20
+ (body weight in kg – 20)
 D5% ½ Normal Saline + 20mEq K is good for maintenance
 With NS – 1/3 stays in the intravascular space
 Add dextrose if NPO (post-op)
 Use Urine Output to titrate
 Discontinue with adequate UOP and tolerating PO fluid intake
- Labs
o Always look at the trend of lab values!
o CBC daily often
 Most services transfuse when Hb>7
 Surprisingly high WBC in absence of other signs of infection – consider C. diff colitis
o Basic metabolic panel + Ca/Mg/Phos qAM
 Ileus (among many other things such as vomiting, ostomies) can lead to electrolyte abnormalities
o ICU – serum lactate, ABG daily
o Consider what service you’re on – should coags, lactate, etc be drawn?
o Always look for an active type and cross
- Diet
o NPO post-op usually
o If NG tube present – if output <150-200 for 2 consecutive shifts, can be put to DD (dependent drainage)
 If no significant output then – pull NG
 Learn how to fool around with NGT so you can keep it sumping
o Passing gas – better marker of return of bowel function than stooling
 If passing gas – start clear liquids
 Then advance as patient can tolerate (clear liquids , full liquids, possibly soft mechanical [esophageal
or gastric cases], full diet [think about if patient needs diabetic diet/cardiac diet/renal diet])
 Think about how big case was, bowel manipulation, attending preferences
o Nutrition
 Supplement electrolytes as necessary – ask the interns how to do this
 Remember abnormal K’s don’t resolve until Mg normalized
 Learn about TPN if you do a surgery subI
- Ambulate
o As early as possible – prevent atecletasis and post-op pneumonia
 Patients will be resistant to this and will complain
o If you have time – walk the patient yourself
 Call the nurse to the room to help the patient stand – don’t do this without the nurse or else he/she
will get pissed at you
- Prophylaxis
o DVT
  SCDs
 Check the algorithm for subQ heparin dosing
o GI prophylaxis for GI surgery and in ALL ICU patients
 H2 blocker or PPI
 IV PPI if unable to tolerate PO intake or intubated
- Drains
o On rounds – describe amount of drainage per shift and the type of drainage (sanguinous, serosanguinous,
purulent, clear, grey, etc)
o If < 30cc/shift x 2-3 consecutive shifts – can think about pulling