Moshe Schein
We repeat: “As long as the abdomen is open you control it. Once closed it controls you.”
The long operation is finished, leaving you to savor the sweet postoperative
“high” and elation. But soon, when your serum level of endorphins declines, you start worrying about the outcome. And worry you must, for the cocksure, macho attitude is a recipe for disasters. We do not intend to bring here a detailed discus- sion of postoperative care or to write a new surgical intensive care manual. We only wish to share with you some basic precepts, which may be forgotten, drowned in a sea of fancy technology and gimmicks. The following are a few practical “com- mandments” for postoperative care.
1. Know Your Patient
This is no joke! How often do we encounter a postoperative patient looked af- ter by someone who has no clue about the patient’s pre- and intra-operative details?
Mistakes in management are more commonly done by those who “temporarily adopt” the case. Once you operate on a patient he or she is yours! Shared responsi- bility means that no one is responsible!
2. Touch-Examine Your Patient
Not only from the foot of the bed. Examining the chart or the ICU monitor is
not enough. Look at the patient, smell and palpate him at least once a day. Wouldn’t
it be embarrassing to load your patient with intravenous antibiotics or CT scan
his abdomen, while an unsuspected abscess is cooking under the wound dressing,
begging to be simply drained at the bedside?
3. Treat the Pain
You know the different drugs, and their modes of administration. Sure, you always prescribe postoperative analgesia, but ordering is not nearly enough. Most randomly questioned postoperative patients complain that they are under-treated for pain. Nurses tend to be stingy with analgesia. You are the man on the spot; see that your patient does not suffer unnecessarily.
4. Do not “crucify” your patient in the horizontal position
Typically the “modern” patient is “crucified” horizontally, tethered by the spaghetti of monitoring cables, nasogastric tubes, venous lines, drains, leg pumps and urinary catheters.Free the patient from these paraphernalia as soon as possible;
the nurses won’t do it without your order. The earlier your patient is out of bed, sitting or walking about, the faster he will be going home. Conversely, keeping the patient in the supine position increases the incidence of atelectasis/pneumonia, deep vein thrombosis, decubitus ulcers, and prolongs paralytic ileus, all adding fuel to the inflammatory fire of SIRS (systemic inflammatory response syndrome).
5. Decrease the Plastic and Rubber Load
Monitoring functions as an early warning system to detect physiological dis- turbances so that prompt corrective therapy could be instituted. The invasiveness of monitoring employed in the individual patient should be proportionate to the severity of disease: “The sicker the patient, the greater number of monitoring tubes used, the less likely is survival”.
Complete discussion of the continuously growing number of monitoring methods available today is beyond the scope of this chapter. However, please note:
In order to be able to respond to monitoring-generated warning signs you must fully understand the technology being employed. You should be able to distinguish between real acute physiological changes and electrical or mechanical artifacts of observation.
Understand that all methods of monitoring are liable to a myriad of potential errors,specific to the technique or caused by patient-related variables.Alertness and sound clinical judgment are paramount!
Because of improving technology, monitoring is becoming more and more
sophisticated (and expensive).Furthermore,monitoring techniques are responsible
for a significant number of iatrogenic complications in the surgical intensive care
unit.Use monitoring discriminatingly and do not succumb to the Everest syndrome:
“I climb it because it is there”. Before embarking on invasive monitoring ask your- self “Does this patient really need it?” Remember there are safer and cheaper alter- natives to invasive monitoring: for example, in a stable patient, remove the arterial line, as the blood pressure can be measured with a conventional sphigmomano- meter, PO
2determined transcutaneously, and blood tests drawn by phlebotomy.
Each time you see your patient ask yourself which of the following can be removed:
nasogastric tube, Swan-Ganz catheter, central venous line, arterial line, peripheral venous line, Foley’s catheter?
Nasogastric (NG) Tubes Prolonged postoperative NG decompression to combat gastric and intestinal ileus is a common baseless ritual. The concept that the NG tube “protects”distally-placed bowel anastomosis is ridiculous as liters of juices are secreted each day below the decompressed stomach. Nasogastric tubes are ex- tremely irritating to the patient, interfere with breathing, cause esophageal erosions and promote gastroesophageal reflux.Traditionally,surgeons keep the tube until the daily output drops below a certain volume (e.g., 400 ml); such a policy often results in unnecessary torture. It has been repeatedly demonstrated that most post- laparotomy patients do not need nasogastric decompression – not even following upper gastrointestinal procedures – or need it for a day or two at most. In fully conscious patients, who are able to protect their airway from aspiration, NG tubes can be safely omitted in most patients. Following an emergency abdominal operation, nasogastric decompression is compulsory though, in mechanically ventilated patients, in obtunded patients, and after operations for intestinal ob- struction. In all other cases, consider removing the NG tube on the morning after surgery.
Drains Despite the widely publicized dictum that it is impossible to effec- tively drain the free peritoneal cavity, drains are still commonly used and misused
(
>Chap. 12). In addition to the false sense of security and reassurance they provide,
drains can erode into intestine or blood vessels and promote infective complica- tions.We suggest that you limit the use of drains to the evacuation of an established abscess, to allow escape of potential visceral secretions (e.g. biliary, pancreatic) and to establish a controlled intestinal fistula when the bowel cannot be exteriorized.
Passive, open-system drainage offers a bi-directional route for microorganisms and should be avoided. Use only active, closed-system drainage systems, placed away from the viscera. Leaving a drain close to an anastomosis in the belief that a possible leak will result in a fistula rather than in peritonitis is a long-enduring dogma; drains have been shown to contribute to the dehiscence of a suture line.
A policy like “I always drain my colonic anastomoses for 7 days” belongs to the
dark ages of surgical practice. Remove drains as soon as they have fulfilled their
purpose.
6. Obtain Postoperative Tests Selectively
Unnecessary diagnostic procedures or interpretative errors in indicated diagnostic procedures commonly result in false-positive findings, leading, in turn, to an increasingly invasive escalation of diagnostic or therapeutic measures.Added morbidity is the invariable price. If the results of a test are not going to affect your management, don’t order the test!
7. Realize that the Problem Usually Lies at the Operative Site The cause of fever or “septic state” in the surgical patient is usually at the primary site of operation unless proven otherwise. Do not become a “surgical os- trich”by treating your patient for “pneumonia”while he is slowly sinking in multiple organ failure from an intra-abdominal abscess (
>Fig. 40.1).
Fig. 40.1
8. Temperature is Not a Disease; Do Not Treat it as Such
Postoperative fever represents the patient’s inflammatory response (SIRS) to different insults including infection as well as surgical trauma, atelectasis, trans- fusion and others. SIRS does not always mean sepsis (sepsis = SIRS + infection).
Therefore, fever should not be treated automatically with antibiotics. It also should not be stifled with antipyretics as the febrile response may be beneficial to the host’s defenses. The absolute level of temperature is of less importance than its trend and it’s difficult to assess this important sign when you are artificially suppressing it.
“Fever is,in a measure,a beneficial process operating to protect the economy.”
(Augustus Charles Bernays, 1854–1907)
9. Avoid Poisoning Your Patient with Antibiotics:
Tailor Antibiotic Administration to the Patient
Avoid the common practice of administering antibiotics for as long as the patient is in the hospital and beyond (
>Chap. 42).
10. Be Frugal with Blood-Product Transfusions
Generally, the amount of blood or derived products transfused inversely and independently correlates with the outcome of the acute surgical disease. Donated blood is immunosuppressive and is associated with an increased risk of infection, sepsis and organ failure, not to mention the other well-known hazards. Cancer patients in particular fare worse in the long term if they receive a transfusion.Trans- fuse your patient only if absolutely necessary. A patient requiring only 1 unit of blood does not require any at all. For the vast majority of patients, a hematocrit of 30% is more than satisfactory.
11. Do Not Drown Your Patient in Salty Water
The current, exaggerated “protocols” of postoperative fluid management provide too much water and salt, resulting in obligatory weight gain and swelling of tissues. And edematous tissues do not function well and do not heal well – causing a higher rate of medical and surgical complications. (See Editorial Comment in
>
Chap. 6). All your patient needs is enough water to replace insensible losses
(500–1000 ml) and provide for urinary flow of 0.5 ml/kg per hour.Additional losses
(e.g. NG tube) should be replaced selectively on an ad hoc basis but writing an order for 150 ml/hour of saline and going to sleep will result in a swollen patient. You have to read the article by Brandstrup et al. (2003)
1to see how postoperative fluid restriction may help your patient. And get rid of the intravenous line as soon as possible!
“Fluids given intravenously bypass all the defenses set up by the body to protect itself against excess of any constituent, against bacterial entry…they give the patient what the surgeon thinks his tissues need and what they are damned well going to get.” (William Heneage Ogilvie, 1887–1971)
12. Do Not Starve or Over-Feed Your Patient;
Use the Enteral Route Whenever Possible (
>Chap. 41)
Please do not torture your patient with the useless and baseless ritual of slowly increasing the permitted consumption of oral fluids from 30 mls hourly to 60 then 90 and so on over several days.
13. Recognize and Treat Postoperative Intra-abdominal Hypertension (
>Chap. 36)
14. Prevent Deep Vein Thrombosis (DVT) and Pulmonary Embolism
It is easy to forget DVT prophylaxis in the pre-operative chaos of emergency surgery. As a pilot goes over a checklist prior to any flight – you should be the one to inject the subcutaneous heparin and/or to place the anti-DVT pneumatic device – before the operation. DVT prophylaxis should be continued postoperatively as long as the patient continues to be at high risk of thrombosis.
15. Be the Leader and Take Responsibility
Many people tend to dance around your postoperative patient, giving consults and advice.But remember,this is not their patient; he or she is yours.At the Mortality
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