Postoperative Management

Day before surgery

1. Protein/glucose drink

2. Bowel prep as directed

3. Ibuprofen 800 mg tid

Preoperative holding area

1. Gabapentin 600 mg po 1–2 h prior to induction

2. Alvimopan 12 mg po 1–2 h prior to induction

3. Thromboprophylaxis low-dose unfractionated heparin 5,000 U SC

4. Antibiotics prior to induction 30–60 min prior to induction

Postanesthesia recovery unit

1. Morphine PCA for all patients

2. DC antibiotics unless therapeutic indication

Nursing floor – general orders

1. CBC, BMP POD #1, 3 unless otherwise indicated

2. Ambulate in hallway 5 times/day

3. Sit out of bed 4–6 h/day

4. Foley removed POD#1 if laparoscopic, POD#2 if open

5. Heplock IVF POD#1 if laparoscopic, POD#2 if open

Nursing floor – dietary orders

1. Clear liquids as tolerated

2. Protein/glucose drink 1 can BID

3. Soft diet POD#1 if laparoscopic, POD#2 if open

4. Chewing gum 1 stick TID × 60 min

Nursing floor medication orders

1. Gabapentin 300 mg po TID while in hospital

2. Alvimopan 12 mg po BID Å~7 days while in hospital

3. Ketorolac 15 mg IV Q6 h Å~72 h while in hospital

4. Ibuprofen 800 mg TID while in hospital

5. Heparin 5,000 U SC TID while in hospital. This may be continued following discharge in high-risk patients

6. Lactulose 10 mL po BID

Nursing floor – oral analgesia

1. Transition to oral analgesia – POD#1 if laparoscopic, POD#2 if open

2. DC PCA

3. Acetaminophen #3 1–2 pills po q4–6 h, first dose 30 min prior to stopping PCA

4. Hold morphine except break through pain

The above guidelines should be modified as clinically appropriate and do not replace clinical evaluation and experience

POD postoperative day, PCA patient controlled analgesia

In a study center familiar with the fast-track protocol, the percentage of patients discharged upon meeting criteria was 66 % versus less familiar centers where only 26 % of patients were immediately discharged (p < 0.001).
Many studies have now analyzed the cost-effectiveness of fast-track protocols.
The mean cost per hospital stay was $19,997.35 ± $1,244.61 for patients in the historical control group, $20,835.28 ± $2,286.26 for those in the simultaneous control group, and $13,908.53 ± $1,113.01 for those in the enhanced recovery group (p < 0.05 vs. other groups).
After implementation of a fast-track protocol, length of stay was reduced from 6.6 to 3.7 days (p < 0.001), and costs were reduced from $9,310 ± $5,170 to $7,070 ± $3,670 (p = 0.002).
Kariv et al. looked exclusively at patients undergoing ileal pouch anal anastomosis and found shorter hospital stays (4 days vs. 5 days) (p = 0.012) and lower direct 30-day costs reduced from $6,672 to $5,692 (p = 0.001).

Fluid Management

Postoperative fluid management is complicated by perioperative changes in homeostasis, and appropriate fluid management is essential to optimizing postoperative care.
Basic fluid requirements are approximately 2,500 cc/day in a 70 kg adult. This allows for both insensible losses from respiration, perspiration, and feces as well as the 1,500 cc of urine necessary to excrete waste products including urea, potassium, and sodium.
A basic formula for calculating fluid needs is 1,500 cc for the first 20 kg and 20 cc/kg for the rest of the weight.
After surgical stress, there is an increase in renin, aldosterone, and antidiuretic hormone release and activation of the sympathetic system resulting in sequestration of fluid (third spacing) and increased volume requirements.
Additional losses may occur from evaporation from exposed abdominal cavity, blood loss, diarrhea, nasogastric tubes, and abdominal drains; each of these must be accounted for.
In recovering patients, fluid retention begins to resolve with a return of the hormones and sympathetic nervous system toward normal in approximately 72 h.
Data have shown that insufficient perioperative fluid resuscitation increases the risk of hypotension, inadequate tissue perfusion, and renal failure.
Over-resuscitation is associated with hypoalbuminemia, delayed gastrointestinal recovery, pulmonary complications, and increased cardiac demand.
Transesophageal Doppler monitoring has been used to guide resuscitation. Monitoring of ejection fraction and stroke volume aids in assessing oxygen tissue delivery.
Optimization of stroke volume as determined by Doppler is compared with typical postoperative hemodynamic parameters such as urine output, heart rate, and blood pressure.
Several studies have shown reduced postoperative gastrointestinal and overall complications and earlier return of bowel function.
Resuscitation with colloid versus crystalloid did not further improve length of stay.
The rate of anastomotic leaks was not increased in the study groups.
Three studies demonstrated a statistically reduced postoperative length of stay by 1.5–2 days confirmed in two separate meta-analyses in favor of Doppler-guided resuscitation.

Postoperative Gastrointestinal Recovery: Nausea, Vomiting, Feeding, Gum Chewing, and Ileus

Postoperative Nausea and Vomiting (PONV)

Approximately 25 % of patients experience PONV within 24 h.
Among high-risk patients, the incidence may be as high as 70–80 %.
PONV delays recovery of patients after inpatient surgery and accounts for a significant proportion of unanticipated hospitalizations following ambulatory surgery.

Consensus guidelines for managing PONV highlight patient, anesthetic, and surgical risk factors as listed in (Table 9.2).

Table 9.2

Risk factors for postoperative nausea and vomiting

Patient-specific risk factors

1. Female sex

2. Nonsmoking status

3. History of PONV/motion sickness

Anesthetic risk factors

1. Use of volatile anesthetics

2. Nitrous oxide

3. Use of intraoperative or postoperative narcotics

Surgical risk factors

1. Duration of surgery

2. Type of surgery

Adapted from Gan TJ. Risk factors for postoperative nausea and vomiting. Anesth Analg. 2006;102:1884–98

PONV postoperative nausea and vomiting

Instruments that predict PONV have been validated with a high level of correlation to patient outcome.

Among the simplest is the Koivuranta score (Table 9.3), which uses only the five strongest risk factors – female gender, previous PONV, duration of surgery, history of motion sickness, and nonsmoking status – as predictors of PONV.

Table 9.3

Koivuranta score II for evaluation of postoperative nausea and vomiting

Scoring: Patient risk is calculated based on cumulative number of risk factors.
Risk factors:
Female gender
Previous PONV
Duration of surgery over 60 min
History of motion sickness
Nonsmoker
# of risk factors	Risk of nausea (%)	Risk of vomiting (%)
0–1 factor	17–18	7
2 factors	42	17
3 factors	54	25
4 factors	74	38
5 factors	87	61

Adapted from Koivuranta M, Laara E, Snare L, Alahuhta S. A survey of postoperative nausea and vomiting. Anaesthesia. 1997;52:443–9

PONV postoperative nausea and vomiting

Prevention of PONV is centered on reducing anesthetic and surgical risks while appropriately adding pharmacologic prophylaxis.
Use of regional anesthesia, minimization of narcotics, and avoidance of nitrous oxide and volatile anesthetics have efficacy in reducing PONV.
Propofol induction, increasing hydration, and use of supplemental oxygen are associated with reduction in risk in patients undergoing colorectal surgery.

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