34

4
Postoperative Care

Jennifer E. Rosen, MD

The modern surgeon is involved with the management of a and all other aspects of the care not directly related to the
patient from preoperative evaluation, through the conduct effects of anesthesia. The patient can be discharged from
of the operation into the postoperative care period and often the recovery room when cardiovascular, pulmonary, and
into generating a long-term plan. As the operating surgeon, neurologic functions have returned to baseline, which usu-
he/she is best situated to apply evidence-based scientific ally occurs 1-3 hours following operation. Patients who
knowledge and a deep understanding of potential complica- require continuing ventilatory or circulatory support or who
tions to that patient’s care. The recovery from major surgery have other conditions that require frequent monitoring are
can be divided into three phases: transferred to an intensive care unit. In this setting, nursing
personnel specially trained in the management of respiratory
1. An immediate, or postanesthetic phase
and cardiovascular emergencies are available, and the staff-
2. An intermediate phase, encompassing the hospitaliza- to-patient ratio is higher than it is on the wards. Monitoring
tion period equipment is available to enable early detection of cardiore-
3. A convalescent phase spiratory derangements.
During the first two phases, care is principally directed at
maintenance of homeostasis, treatment of pain, and preven- `` Postoperative Orders
tion and early detection of complications. The convalescent
Detailed treatment orders are necessary to direct postop-
phase is a transition period from the time of hospital dis-
erative care. The transfer of the patient from OR to PACU
charge to full recovery. The trend toward earlier postopera-
requires reiteration of any patient care orders. Unusual or
tive discharge after major surgery has shifted the venue of
particularly important orders should also be communicated
this period.
to the nursing team orally. The nursing team must also be
advised of the nature of the operation and the patient’s con-
THE IMMEDIATE POSTOPERATIVE PERIOD dition. Errors in postoperative orders, including medication
errors and omission of important orders, are diminished
The primary causes of early complications and death follow- by electronic order entry systems that can contain postop-
ing major surgery are acute pulmonary, cardiovascular, and erative order sets. Careful review of order sets is still war-
fluid derangements. The postanesthesia care unit (PACU) ranted, as individual patients require specialized attention.
is staffed by specially trained personnel and provided with Postoperative orders should cover the following.
equipment for early detection and treatment of these prob-
lems. All patients should be monitored in this specialized
A. Monitoring
unit initially following major procedures unless they are
transported directly to an intensive care unit. While en 1. Vital signs—Blood pressure, pulse, and respiration should
route from the operating room to the PACU, the patient be recorded frequently until stable and then regularly until
should be accompanied by a physician and other qualified the patient is discharged from the recovery room. The fre-
attendants. In the PACU, the anesthesiology service gener- quency of vital sign measurements thereafter depends upon
ally exercises primary responsibility for cardiopulmonary the nature of the operation and the course in the PACU.
function. The surgeon is responsible for the operative site When an arterial catheter is in place, blood pressure and

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Postoperative Care
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pulse should be monitored continuously. Continuous elec- oxygen by mask or nasal prongs, preferably with humidi-
trocardiographic monitoring is indicated for most patients fication. These orders should be specified. For intubated
in the PACU. Any major changes in vital signs should be patients, tracheal suctioning or other forms of respiratory
communicated to the anesthesiologist and attending sur- therapy must be specified as required. Patients who are not
geon immediately. intubated should be instructed on how to cough and do deep
breathing exercises frequently to prevent atelectasis.
2. Central venous pressure—Central venous pressure
should be recorded periodically in the early postoperative
period if the operation has entailed large blood losses or fluid
C. Position in Bed and Mobilization
shifts, and invasive monitoring is available. A Swan-Ganz The postoperative orders should describe any required
catheter for measurement of pulmonary artery wedge pres- special positioning of the patient. Unless doing so is con-
sure is indicated under these conditions if the patient has traindicated, the patient should be turned from side to side
compromised cardiac or respiratory function. every 30 minutes until conscious and then hourly for the
first 8-12 hours to minimize atelectasis. Early ambulation
3. Fluid balance—The anesthetic record includes all fluid is encouraged to reduce venous stasis; the upright position
administered as well as blood loss and urine output dur- helps to increase diaphragmatic excursion. Venous stasis
ing the operation. This record should be continued in the may also be minimized by intermittent compression of the
postoperative period and should also include fluid losses calf by pneumatic stockings. Safety considerations are para-
from drains and stomas. This aids in assessing hydration mount, including special alerts to fall risk (such as using red
and helps to guide intravenous fluid replacement. A bladder socks and bed rails), one-on-one monitoring, and assistance
catheter can be placed for frequent measurement of urine with all transfers. Support under the knees and heels can
output. In the absence of a bladder catheter, the surgeon help reduce back pain and tension from immobility during
should be notified if the patient is unable to void within surgery.
6-8 hours after operation to determine whether intermittent
catheterization may be warranted. D. Diet
4. Other types of monitoring—Depending on the nature Patients at risk for emesis and pulmonary aspiration should
of the operation and the patient’s preexisting conditions, have nothing by mouth until some gastrointestinal func-
other types of monitoring may be necessary. Examples tion has returned (usually within 4 days). Most patients
include measurement of intracranial pressure and level of can tolerate liquids by mouth shortly after return to full
consciousness following cranial surgery and monitoring of consciousness.
distal pulses following vascular surgery or in patients with
casts, evaluating for expanding hematoma in patients after E. Administration of Fluid and Electrolytes
thyroid surgery et cetera.
Orders for postoperative intravenous fluids should be based
5. The “postoperative check”—Most patients who remain on maintenance needs, operative losses, and the replacement
in the hospital beyond the immediate postoperative period of gastrointestinal losses from drains, fistulas, or stomas.
require an evaluation by a physician or adjunct during the
4-6 hours following surgery. This evaluation should include F. Drainage Tubes
a review of the patient’s overall subjective status, any objec-
tive alterations during that time period, an assessment Drain care instructions should be included in the postop-
of whether the postoperative orders are appropriate and erative orders. Details such as type and pressure of suction,
adequate and if the patient has developed any signs or symp- irrigation fluid and frequency, skin exit site care and support
toms indicative of a complication related to their particular during ambulation or showering should be specified. The
procedure or the anesthesia and medications administered surgeon should examine drains frequently, since the charac-
since that time. A thorough understanding of the patient’s ter or quantity of drain output may herald the development
history and surgical course will help in anticipating, pre- of postoperative complications such as bleeding or fistulas.
venting, and identifying any complications. Any worrisome Careful positioning and reinforcement of anchors can pre-
findings should be directly and quickly communicated to the vent the dreaded early loss of key placement of nasogastric
attending surgeon, who is in the best position to determine if tubes, chest tubes, and drains.
an intervention is warranted.
G. Medications
B. Respiratory Care Orders should be written for antibiotics, analgesics, gastric
In the early postoperative period, the patient may remain acid suppression, deep vein thrombosis prophylaxis, and
mechanically ventilated or be treated with supplemental sedatives. If appropriate, preoperative medications should

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be reinstituted. Medication reconciliation is important, as Dressings over closed wounds should be removed by
interactions are possible and potentially harmful. Route of the third or fourth postoperative day. If the wound is dry,
administration of medications and medication substitution dressings need not be reapplied; this simplifies periodic
should be discussed with the pharmacy when necessary. inspection. Dressings should be removed earlier if they are
Careful attention should be paid to replacement of corti- wet or placed in a contaminated setting, because soaked
costeroids in patients at risk, since postoperative adrenal dressings increase bacterial contamination of the wound.
insufficiency may be life threatening, but over-supplemen- Dressings should also be removed if the patient has new man-
tation can affect wound healing. Other medications such as ifestations of infection (such as fever or increasing wound
antipyretics, laxatives, and stool softeners should be used pain). The wound should then be inspected and the adjacent
selectively as indicated. Prophylaxis for postoperative nausea area gently compressed. Any drainage from the wound
and vomiting can be useful; the type and route of medication should be examined by culture and Gram-stained smear.
remains controversial and should be tailored to the patient. Vacuum dressings should usually be replaced within
24-72 hours. Pain management around the time of dressing
H. Laboratory Examinations and Imaging change is important to consider, as proper prophylaxis can
make the procedure less difficult for both the patient and the
Postoperative laboratory and radiographic examinations
surgical team.
should be used to detect specific abnormalities in high-risk
Generally, skin sutures or skin staples may be removed
groups. The routine use of daily chest radiographs, blood
by the fifth postoperative day and replaced by tapes. Sutures
counts, electrolytes, and renal or liver function panels is not
should be left in longer (eg, for 2 weeks) for incisions that
useful. Identification and treatment of hyperglycemia should
cross creases (eg, groin, popliteal area), for incisions closed
be instituted in patients who require management.
under tension, for some incisions in the extremities (eg, the
hand), and for incisions of any kind in debilitated patients.
THE INTERMEDIATE POSTOPERATIVE PERIOD Sutures should be removed if suture tracts show signs of
infection. If the incision is healing normally, the patient may
The intermediate phase begins with complete recovery be allowed to shower or bathe by the seventh postoperative
from anesthesia and lasts for the rest of the hospital stay. day (and often sooner, depending on the incision).
During this time, the patient recovers most basic functions
and becomes self-sufficient and ready to continue conva-
lescence at home. Transfer from the PACU/SICU to a less `` Management of Drains
monitored setting usually occurs at the start of this period.
Drains are used either to prevent or to treat an unwanted
Communication within the care team is important dur-
accumulation of fluid such as pus, blood, or serum. Drains
ing this transition; this team can include surgeons, nurses,
are also used to evacuate air from the pleural cavity so that
nutritionists, social workers and case managers, respiratory,
the lungs can re-expand. When used prophylactically, drains
physical and occupational therapists, residents and consult-
are usually placed in a sterile location. Strict precautions
ing physicians. Isolation and specialized management of
must be taken to prevent bacteria from entering the body
patients colonized or infected with drug-resistant organisms
through the drainage tract in these situations. The external
or highly contagious infectious agents continues from the
portion of the drain must be handled with aseptic technique,
OR through stay in the PACU and then with appropriate
and the drain must be removed as soon as it is no longer use-
barrier devices and room determination throughout the
ful. When drains have been placed in an infected area, there
hospital stay.
is a smaller risk of retrograde infection of the peritoneal
cavity, since the infected area is usually walled off. Drains
`` Care of the Wound should usually be brought out through a separate incision,
Within hours after a wound is closed, the wound space fills because drains through the operative wound increase the
with an inflammatory exudate. Epidermal cells at the edges risk of wound infection. Closed drains connected to suction
of the wound begin to divide and migrate across the wound devices (Jackson-Pratt or Blake drains are two examples)
surface. By 48 hours after closure, deeper structures are are preferable to open drains (such as Penrose) that predis-
completely sealed off from the external environment. Sterile pose to wound contamination. The quantity and quality of
dressings applied in the operating room provide protection drainage should be recorded and contamination minimized.
during this period. When drains are no longer needed, they may be withdrawn
Removal of the dressing and handling of the wound dur- entirely at one time if there has been little or no drainage or
ing the first 24 hours should be done with aseptic technique. may be progressively withdrawn over a period of a few days.
Medical personnel should wash their hands before and after Sump drains (such as Davol drains) have an airflow sys-
caring for any surgical wound. Gloves should always be used tem that keeps the lumen of the drain open when fluid is not
when there is contact with open wounds or fresh wounds. passing through it, and they must be attached to a continuous

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suction device. Sump drains are especially useful when the in patients with a higher risk of pulmonary complications
amount of drainage is large or when drainage is likely to plug (eg, elderly, debilitated, or markedly obese patients). Early
other kinds of drains. Some sump drains have an extra lumen mobilization, encouragement to take deep breaths (espe-
through which saline solution can be infused to aid in keep- cially when standing), and good coaching by the nursing
ing the tube clear. After infection has been controlled and staff suffice for most patients.
the discharge is no longer purulent, the large-bore catheter Postoperative pulmonary edema is caused by high hydro-
may be progressively replaced with smaller catheters as the static pressures (due to left ventricular failure, fluid overload,
cavity closes. decreased oncotic pressure, etc), increased capillary perme-
Drains that have clot or thick material within them or ability, or both. Edema of the lung parenchyma narrows
that have lost their drainage capacity can be stripped or small bronchi and increases resistance in the pulmonary
flushed to restore function; this should be performed only vasculature. In addition, pulmonary edema may increase
under the supervision and approval of the attending sur- the risk of pulmonary infection. Adequate management of
geon as doing so could disrupt the operative bed in some fluids postoperatively and early treatment of cardiac failure
circumstances. are important preventive measures.
Systemic sepsis increases capillary permeability and can
lead to pulmonary edema. In the absence of deranged car-
`` Postoperative Pulmonary Care diac function or fluid overload, the development of pulmo-
The changes in pulmonary function observed following nary edema postoperatively should be regarded as evidence
anesthesia and surgery are principally the result of decreased of sepsis. Signs and symptoms of pulmonary complications
vital capacity, functional residual capacity (FRC), and pul- include fever, tachypnea, tachycardia, and an alteration
monary edema. Vital capacity decreases to about 40% of in mental status. Development of atrial fibrillation or an
the preoperative level within 1-4 hours after major intra- abnormal cardiac rhythm can often precede identification of
abdominal surgery. It remains at this level for 12-14 hours, pulmonary complications.
slowly increases to 60%-70% of the preoperative value by Patients who smoked tobacco up until the time of surgery
7 days, and returns to the baseline level during the ensu- should be considered at higher risk for postoperative pulmo-
ing week. FRC is affected to a lesser extent. Immediately nary complications. Symptoms of withdrawal from nicotine
after surgery, FRC is near the preoperative level, but by can be managed with a nicotine patch or gum.
24 hours postoperatively, it has decreased to about 70% of Many patients undergoing surgery are offered vaccina-
the preoperative level. It remains depressed for several days tion against pneumococcal or influenza infection during
and then gradually returns to its preoperative value by the their hospital stay; these should be considered where there
tenth day. These changes are accentuated in patients who are no contraindications.
are obese, who smoke heavily, or who have preexisting lung
disease. Elderly patients are particularly vulnerable because
they have decreased compliance, increased closing volume,
RESPIRATORY FAILURE
increased residual volume, and increased dead space, all of Most patients tolerate the postoperative changes in pul-
which enhance the risk of postoperative atelectasis. In addi- monary function described above and recover from them
tion, reduced forced expiratory volume in 1 second (FEV1) without difficulty. Patients who have marginal preoperative
impairs the aged patient’s ability to clear secretions and pulmonary function may be unable to maintain adequate
increases the chance of infection postoperatively. ventilation in the immediate postoperative period and may
The postoperative decrease in FRC is caused by a breath- develop respiratory failure. In these patients, the operative
ing pattern consisting of shallow tidal breaths without peri- trauma and the effects of anesthesia reduce respiratory
odic maximal inflation. Normal human respiration includes reserve below levels that can provide adequate gas exchange.
inspiration to total lung capacity several times each hour. If In contrast to acute respiratory distress syndrome (see
these maximal inflations are eliminated, alveolar collapse Chapter 12), early postoperative respiratory failure (which
begins to occur within a few hours, and atelectasis with develops within 48 hours after the operation) is usually only
transpulmonary shunting is evident shortly thereafter. Pain a mechanical problem; that is, there are minimal altera-
is thought to be one of the main causes of shallow breathing tions of the lung parenchyma. However, this problem is life
postoperatively. Complete abolition of pain, however, does threatening and requires immediate attention.
not completely restore pulmonary function. Neural reflexes, Early respiratory failure develops most commonly in
abdominal distention, obesity, and other factors that limit association with major operations (especially on the chest
diaphragmatic excursion appear to be as important. or upper abdomen), severe trauma, and preexisting lung
The principal means of minimizing atelectasis is deep ­disease. In most of these patients, respiratory failure ­develops
inspiration and cough. Using an incentive spirometer can over a short period (minutes to 1-2 hours) without evidence
facilitate periodic hyperinflation. This is particularly useful of a precipitating cause. By contrast, late postoperative

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r­espiratory failure (which develops beyond 48 hours after For patients requiring intravenous fluid replacement
the operation) is usually triggered by an intercurrent event for a short period (most postoperative patients), it is not
such as pulmonary embolism, abdominal distention, or necessary to measure serum electrolytes at any time dur-
opioid overdose. ing the postoperative period, but measurement is indicated
Respiratory failure is manifested by tachypnea of 25-30 in patients with extra fluid losses, sepsis, preexisting elec-
breaths per minute with a low tidal volume of less than trolyte abnormalities, renal insufficiency or other factors.
4 mL/kg. Laboratory indications are acute elevation of Pco2 Assessment of the status of fluid balance requires accurate
above 45 mm Hg, depression of Po2 below 60 mm Hg, or evi- records of fluid intake and output and is aided by obtaining
dence of low cardiac output. Treatment consists of immediate the patient’s body weight prior to surgery and weighing the
endotracheal intubation and ventilatory support to ensure ade- patient daily.
quate alveolar ventilation. As soon as the patient is intubated, As a rule, 2000-2500 mL of 5% dextrose in normal saline
it is important to determine whether there are any associated or in lactated Ringer solution is delivered daily (Table 4–1).
pulmonary problems such as atelectasis, pneumonia, or pneu- Potassium should usually not be added during the first
mothorax that require immediate treatment. 24 hours after surgery, because increased amounts of potas-
Prevention of respiratory failure requires careful post- sium enter the circulation during this time as a result of
operative pulmonary care. Atelectasis must be minimized operative trauma and increased aldosterone activity.
using the techniques described above. Patients with preexist- In most patients, fluid loss through a nasogastric tube is
ing pulmonary disease must be hydrated carefully to avoid less than 500 mL/d and can be replaced by increasing the
hypovolemia or hypervolemia. These patients must hyper- infusion used for maintenance by a similar amount. About
ventilate in order to compensate for the inefficiency of the 20 mEq of potassium should be added to every liter of fluid
lungs. This extra work causes greater evaporation of water used to replace these losses. However, with the exception of
and dehydration. Hypovolemia leads to dry secretions and urine, body fluids are isosmolar, and if large volumes of gas-
thick sputum, which are difficult to clear from the airway. tric or intestinal juice are replaced with normal saline solu-
High fraction of inspired oxygen (Fio2) in these patients tion, electrolyte imbalance will eventually result. Whenever
removes the stabilizing gas nitrogen from the alveoli, pre- external losses from any site amount to 1500 mL/d or more,
disposing to alveolar collapse. In addition, it may impair the electrolyte concentrations in the fluid should be measured
function of the respiratory center, which is driven by the periodically, and the amount of replacement fluids should be
relative hypoxemia, and thus further decrease ventilation. adjusted to equal the amount lost. Table 4–1 lists the compo-
The use of epidural blocks or other methods of local analge- sitions of the most frequently used solutions.
sia in patients with chronic obstructive pulmonary disease Losses that result from fluid sequestration at the opera-
(COPD) may prevent respiratory failure by relieving pain tive site are usually adequately replaced during operation,
and permitting effective respiratory muscle function. but in a patient with a large retroperitoneal dissection, severe
pancreatitis, etc, third space losses may be substantial and
should be considered when postoperative fluid needs are
`` Postoperative Fluid & Electrolyte assessed.
Management Fluid requirements must be evaluated frequently.
Postoperative fluid replacement should be based on the fol- Intravenous orders should be evaluated every 24 hours or
lowing considerations: more often if indicated by special circumstances. Following
an extensive operation, fluid needs on the first day should
1. Maintenance requirements be reevaluated every 4-6 hours. Potassium administration
2. Extra needs resulting from systemic factors (eg, fever, can be added to the intravenous infusion only if the patient
burns, loss during surgery) has good urine flow, has a demonstrated deficiency after
3. Losses from drains significant pathologic fluid losses, and is not anticipated to
start enteral feedings shortly. Postoperative ionized serum
4. Requirements resulting from tissue edema and ileus calcium in patients who have undergone thyroid or parathy-
(third space losses) roid surgery should be monitored and replaced as per the
Daily maintenance requirements for sensible and insen- operating surgeon.
sible loss in the adult are about 1500-2500 mL depending on
the patient’s age, gender, weight, and body surface area. A
rough estimate can be obtained by multiplying the patient’s
`` Postoperative Care of the Gastrointestinal
weight in kilograms times 30 (eg, 1800 mL/24 h in a 60-kg
Tract
patient). Maintenance requirements are increased by fever, Following laparotomy, gastrointestinal peristalsis temporar-
hyperventilation, and conditions that increase the catabolic ily decreases. Peristalsis returns in the small intestine within
rate. 24 hours, but gastric peristalsis may return more slowly.

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Table 4–1  Composition of frequently used intravenous solutions.
~ ~
Solution Glucose (g/dL) Na+ (mEq/L) C l (mEq/L) HCO3 (mEq/L) K+ (mEq/L)

Dextrose 5% in water 50 … … … …
Dextrose 5% and sodium 50 77 77 … …
chloride 0.45%
Sodium chloride 0.9% … 154 154 … …
Sodium chloride 0.45% … 77 77 … …
Lactated Ringer solution … 130 109 28 4
Sodium chloride 3% … 513 513 … …

Function returns in the right colon by 48 hours and in the who have slow gastric emptying beyond the first postopera-
left colon by 72 hours. After operations on the stomach tive week. Routine use of promotility agents or chewing gum
and upper intestine, propulsive activity of the upper gut has not demonstrated benefit in terms of quicker return to
can remain disorganized for 3-4 days. In the immediate GI function.
postoperative period, the stomach may be decompressed Gastrostomy and jejunostomy tubes should be connected
with a nasogastric tube. Nasogastric intubation was once to low intermittent suction or dependent drainage for the
used in almost all patients undergoing laparotomy to avoid first 24 hours after surgery. Absorption of nutrients and flu-
gastric distention and vomiting, but it is now recognized ids by the small intestine is not affected by laparotomy, and
that routine nasogastric intubation is unnecessary and may enteral nutrition through a jejunostomy feeding tube may
contribute to the occurrence of postoperative atelectasis and be started on the second postoperative day even if motility
pneumonia. For example, following cholecystectomy, pelvic is not entirely normal. Gastrostomy or jejunostomy tubes
operations, and colonic resections, nasogastric intubation should not be removed before the third postoperative week
is not needed in the average patient, and it is probably of once firm adhesions have developed between the viscera and
marginal benefit following operations on the small bowel. the parietal peritoneum. The length of tube from its point
On the other hand, nasogastric intubation is probably useful of entry into the abdominal cavity should be measured and
after esophageal and gastric resections and should always be similar between the time of insertion and the time of use;
used in patients with marked ileus or a very low level of con- dislodgement of the tubes can be catastrophic if unrecog-
sciousness (to avoid aspiration) and in patients who mani- nized before use. Any pills or medication used through the
fest acute gastric distention or vomiting postoperatively. tube should be crushed (and crushable) and flushed carefully
The nasogastric tube should be connected to low inter- to ensure that the tube is not clogged and rendered unusable.
mittent suction and assessed frequently to ensure patency. After most operations in areas other than the peritoneal
The tube should be left in place for 2-3 days or until there cavity, the patient may be allowed to resume a regular diet
is evidence that normal peristalsis has returned (eg, return as soon as the effects of anesthesia have completely resolved.
of appetite, audible peristalsis, or passage of flatus). Suture Short-term use of parenteral nutrition in patients with
placement is usually unnecessary but careful placement good preoperative nitrogen balance and caloric intake is
of the tube and tape fixation in a natural curve can enable ill-advised; patients with preoperative catabolic states may
the patient to move their head without risk of inadvertent benefit from longer-term nutritional support.
removal. The nasogastric tube enhances gastroesophageal
reflux, and if it is clamped for a period to assess residual
volume, there is a slight risk of aspiration. Most tubes are
IDENTIFICATION & MANAGEMENT OF
used as a “sump” where one port is for suction and the other
PERIOPERATIVE HYPERGLYCEMIA
left open to air to allow for continuous flow. This sump port Patients should be assessed at admission for history of diabe-
should not be clamped, tied, or flushed with saline unless tes and should undergo blood glucose testing on admission.
clogged with material. Point of care assessment should be made in cases of elevated
Once the nasogastric tube has been withdrawn, fasting blood glucose for patients with known diabetes regarding
is usually continued for another 24 hours, and the patient monitoring, testing schedules, and glycemic targets to allow
is then started on a liquid diet. Opioids may interfere with for careful coordination of blood glucose control and return
gastric motility and should be limited if possible for patients to reinstitution of preadmission regimens. For patients not

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previously known to have diabetes or those who may have of saline, at an approximate hematocrit of 75%. Anemic
new glucocorticoid- or surgery-induced diabetes, discharge patients with recurrent or severe allergic reactions benefit
planning may need to include management of this new from washed RBCs. Patients with severe IgA deficiency who
diagnosis. test positive for anti-IgA antibodies should receive RBCs
washed with 2-3 L of saline or receive blood collected from
TRANSFUSION THERAPY IgA-deficient donors.
Determination of the need for transfusion and what type `` Leukocyte-Reduced Red Blood Cells
of transfusion is necessary can do much to improve patient
outcome or can obfuscate a complication when performed Third-generation leukocyte reduction filters remove more
without consideration of the underlying etiology of the than 99.9% of the contaminating leukocytes, leaving less
patient’s need. Knowledge of the patient’s preoperative sta- than 5 × 106 white blood cells (WBCs) per unit. Filtration
tus, the course of the operation and any complications, and done soon after collection (prestorage leukoreduction) is
proper preparation for potential complications should help more effective than bedside filtration. Patients experienc-
the physician who is considering transfusion. Restrictive ing recurrent febrile nonhemolytic transfusion reactions
transfusion thresholds may minimize patient exposure to (FNHTRs) to RBCs or platelets should receive leukocyte-
adverse outcomes. Ultimately, the attending surgeon should reduced products. The prophylactic use of leukoreduced
determine the need for transfusion, as patients can have defi- RBCs and platelets in patients with long-term transfusion
cits even when laboratory values appear transiently normal. needs decreases the likelihood of human leukocyte antigens
(HLA) alloimmunization and protects from immune plate-
`` Whole Blood let refractoriness and recurrent FNHTRs. Leukoreduction
also decreases the risk of transmission of cytomegalovirus
Whole blood is composed of 450-500 mL of donor blood, (CMV) infection in immunosuppressed CMV-seronegative
containing RBCs (hematocrit, 35%-45%), plasma, clotting patients.
factors (reduced levels of labile factors V and VIII), and
anticoagulant. Platelets and granulocytes are not functional.
It is indicated for red cell replacement in massive blood loss `` Irradiated Red Blood Cells
with pronounced hypovolemia. However, whole blood for RBCs are irradiated with 25 Gy of gamma irradiation. All
transfusion is not routinely available. cellular products should be irradiated for patients who are
at risk for transfusion-associated graft-versus-host disease
`` Red Blood Cells (TA-GVHD). Adult patients at risk for TA-GVHD include,
Red blood cells (RBCs) are obtained by apheresis collection but are not limited to, the following: those with congen-
or prepared from whole blood by centrifugation and removal ital severe immunodeficiency, hematological malignancy
of plasma, followed by supplementation with 100 mL of ade- receiving intensive chemoradiotherapy, Hodgkin and non-
nine-containing red cell nutrient solution. The hematocrit Hodgkin lymphoma, certain solid tumors (neuroblastoma
is 55%-60%, and the volume is 300-350 mL. RBCs collected and sarcoma), peripheral blood stem cell and marrow trans-
in CPDA-1 anticoagulant have a hematocrit of 65%-80% plants, or recipients of fludarabine-based chemotherapy,
and a storage volume of 250-300 mL. RBC transfusions are and those receiving directed donations from blood relatives
indicated to increase oxygen-carrying capacity in anemic or HLA-matched platelets. Acellular products such as fresh
patients. Hemoglobin levels of 7-9 g/dL are well tolerated frozen plasma (FFP) and cryoprecipitate are not irradiated.
by most asymptomatic patients. A transfusion trigger of Leukoreduction is not an acceptable substitute for irradiation.
7 g/dL is commonly used in most stable patients. Symptomatic
patients with cardiac, pulmonary, or cerebrovascular disease `` Frozen-Deglycerolized Red Blood Cells
may require RBC transfusions to achieve higher hemoglobin
RBCs frozen in glycerol are washed extensively in normal
levels. In a nonbleeding 70-kg recipient, transfusion of 1 unit
saline to remove the cryoprotectant and then resuspended
of RBCs should increase hemoglobin level by 1 g/dL and the
in saline at a hematocrit of approximately 75%. More
hematocrit by 3%. Patients can donate autologous blood in
than 99.9% of the plasma is removed, and few leukocytes
the month before surgery when appropriate; directed donors
remain in the product. Patients who are alloimmunized to
do not necessarily reduce the risk of transfusion or transfu-
multiple antigens or those with antibodies against high-
sion reaction.
frequency antigens are supported with blood collected from
donors with rare phenotypes. Most patients with severe
`` Washed Red Blood Cells
IgA deficiency can safely receive RBCs washed with 2 L or
RBCs are washed with saline to remove more than 98% of more of saline. Frozen-deglycerolized RBCs are an equally
plasma proteins and resuspended in approximately 180 mL safe and effective, albeit more cumbersome, alternative for

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Postoperative Care
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these patients. Rarely, patients may require RBCs collected for active bleeding or if there is a risk for bleeding from an
from IgA-deficient donors. A national rare donor program emergent procedure. FFP is the only replacement product
facilitates the collection and storage of rare blood types. currently available for patients with rare disorders such as
isolated factor deficiencies (V, X, XI) or C-1 esterase inhibi-
`` Platelets tor deficiency. Patients with severe IgA deficiency should
be supported with IgA-deficient plasma. FFP is the first
Apheresis platelets are collected from single donors by
choice for fluid replacement in patients with TTP undergo-
apheresis and contain at least 3 × 1011 platelets in 250-300
ing therapeutic plasma exchange. FFP is not indicated for
mL plasma. Random-donor platelets (RDP) are platelet
volume replacement, nutritional support, or replacement of
concentrates prepared from whole blood and contain 5.5 ×
immunoglobulins.
1010 platelets suspended in approximately 50 mL of plasma.
To provide an adult dose, 5-6 units of RDP are pooled into a
single pack. Platelet transfusions are indicated for the man-
`` Cryoprecipitate
agement of active bleeding in thrombocytopenic patients. Cryoprecipitate is the cold-insoluble precipitate formed
Nonthrombocytopenic patients with congenital or acquired when FFP is thawed at 1-6°C. This is then resuspended in
disorders of platelet function may also require platelets to 10-15 mL plasma. It contains 150 mg or more of fibrinogen,
stop bleeding. Platelet transfusions are also indicated pro- 80 IU or more of factor VIII, 40%-70% of vWF and 20%-30%
phylactically in patients requiring line placement or minor of factor XIII present in the initial unit of FFP, and 30-60 mg
surgery when the platelet counts are less than 50,000/μL of fibronectin. Each unit (bag) of cryoprecipitate increases
and in patients undergoing major surgical procedures when fibrinogen level by 5-10 mg/dL. Eight to 10 bags are pooled
the count falls below 50-75,000/μL. Patients scheduled for and infused as a single dose in a 70-kg adult. Cryoprecipitate
ophthalmic, upper airway, or neurosurgical procedures is indicated for the correction of hypofibrinogenemia in
should have platelet counts above 100,000/μL. Platelets are dilutional coagulopathy and the hypofibrinogenemia/dys-
not usually recommended for the correction of thrombocy- fibrinogenemias of liver disease and DIC. Cryoprecipitate
topenia in patients with heparin-induced thrombocytopenia improves platelet aggregation and adhesion and decreases
(HIT), type IIB von Willebrand disease (vWD), idiopathic bleeding in uremic patients. It has been used for the cor-
thrombocytopenic purpura (ITP), or thrombotic thrombo- rection of factor XIII deficiency, and it is the source of
cytopenic purpura (TTP). The clinical indications for the use fibrinogen in the two-component fibrin sealant (Tisseel).
of washed, irradiated, and leukoreduced platelets are analo- Cryoprecipitate is no longer used to treat patients with
gous to those described in the section on RBCs. Patients with hemophilia A or vWD.
platelet refractoriness secondary to HLA alloimmunization
should be supported with HLA-matched platelets.
`` Granulocyte Transfusions
`` Fresh Frozen Plasma Granulocytes are collected by leukapheresis from donors
stimulated with granulocyte colony-stimulating factor
Fresh frozen plasma (FFP) is obtained by apheresis or pre- (G-CSF) and steroids to mobilize neutrophils from the mar-
pared by centrifugation of whole blood and frozen within row storage pool into peripheral blood. On average they
8 hours of collection. It contains normal levels of all clotting contain 1 × 1010 or more granulocytes suspended in 200-300
factors, albumin, and fibrinogen. FFP is indicated for the mL plasma. About 1-3 × 1011 platelets and 10-30 mL RBCs
replacement of coagulation factors in patients with deficien- are also present in the product. Granulocyte transfusions are
cies of multiple clotting factors as occurs in the coagulopa- indicated in severely neutropenic (absolute neutrophil count
thy of liver disease, disseminated intravascular coagulation < 0.5 × 103/μL) patients with bacterial sepsis who have not
(DIC), warfarin overdose, and massive transfusions. One mL responded to optimum antibiotic therapy after 48-72 hours,
of FFP contains 1 unit of coagulation factor activity; soon provided there is a reasonable expectation of recovery of
after the infusion of a 10-15 mL/kg dose, the activity of all bone marrow function. Transfusions are given daily until
coagulation factors is increased by 20%-30%. Coagulation clinical improvement or neutrophil recovery occurs.
tests should be monitored to determine efficacy and appro-
priate dosing intervals. FFP should be used only if the INR
is greater than 1.5 or the PT/aPTT are elevated more than
`` Erythropoietin Stimulating Agents & Other
1.5 times the normal. Patients with liver disease who have
Blood Substitutes
minimally altered PT/aPTT and nominal bleeding should Routine use of erythropoietin stimulating agents for patients
initially be managed with vitamin K replacement. Similarly, undergoing surgery is not recommended. Selective use in
most patients with warfarin overdose can be managed by patients with anemia undergoing major elective surgery is
stopping warfarin for 48 hours and monitoring coagulation under investigation. Likewise, the effectiveness of recom-
tests until they return to baseline levels. FFP is indicated only binant human factor VIIa and other coagulation factor

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replacement for routine prophylactic use in general surgery which may in turn lead to complications such as stroke,
in patients without hemophilia remains unproven. myocardial infarction, and bleeding. Prevention of postop-
erative pain is thus important for reasons other than the
pain itself. Effective pain control may improve the outcome
POSTOPERATIVE PAIN of major operations.
Severe pain is a common sequela of intrathoracic, intra-
abdominal, and major bone or joint procedures. About 60% `` A. Communication
of such patients perceive their pain to be severe, 25% moder- Close attention to the patient’s needs, frequent reassurance,
ate, and 15% mild. In contrast, following superficial opera- and genuine concern help to minimize postoperative pain.
tions on the head and neck, limbs, or abdominal wall, less Spending a few minutes with the patient every day in frank
than 15% of patients characterize their pain as severe. The discussions of progress and any complications does more to
factors responsible for these differences include duration of relieve pain than many physicians realize. Patients with pre-
operation, degree of operative trauma, type of incision, and operative drug and substance abuse still have postoperative
magnitude of intraoperative retraction. Gentle handling of pain needs and may require more medication than others.
tissues, expedient operations, and good muscle relaxation Communication among the patient care team can help in the
help lessen the severity of postoperative pain. Objective understanding of specific pain-control needs.
measures of pain remain elusive.
While factors related to the nature of the operation influ- `` B. Parenteral Opioids
ence postoperative pain, it is also true that the same opera-
tion produces different amounts of pain in different patients. Opioids are the mainstay of therapy for postoperative pain.
This varies according to individual physical, emotional, and Their analgesic effect is via two mechanisms:
cultural characteristics. Much of the emotional aspect of 1. A direct effect on opioid receptors
pain can be traced to anxiety. Feelings such as helplessness,
2. Stimulation of a descending brain stem system that
fear, and uncertainty contribute to anxiety and may heighten
contributes to pain inhibition
the patient’s perception of pain.
It was once thought that anesthesia and analgesia in neo- Although substantial relief of pain may be achieved with
nates and infants was too risky and that these young patients opioids, they do not modify reflex phenomena associated
did not perceive pain. It is now known that reduction of pain with pain, such as muscle spasm. Opioids administered
with appropriate techniques actually decreases morbidity intramuscularly, while convenient, result in wide variations
from major surgery in this age group. in plasma concentrations. This, as well as the wide variations
The physiology of postoperative pain involves transmis- in dosage required for analgesia among patients, reduces
sion of pain impulses via splanchnic (not vagal) afferent analgesic efficacy. Physician and nurse attitudes reflect
fibers to the central nervous system, where they initiate spi- a persistent misunderstanding of the pharmacology and
nal, brain stem, and cortical reflexes. Spinal responses result psychology of pain control. Frequently, the dose of opioid
from stimulation of neurons in the anterior horn, resulting prescribed or administered is too small and too infrequent.
in skeletal muscle spasm, vasospasm, and gastrointestinal When opioid usage is limited to temporary treatment of
ileus. Brain stem responses to pain include alterations in postoperative pain, drug addiction is extremely rare.
ventilation, blood pressure, and endocrine function. Cortical Morphine is the most widely used opioid for treatment
responses include voluntary movements and psychologic of postoperative pain. Morphine may be administered intra-
changes, such as fear and apprehension. These emotional venously, either intermittently or continuously. Except as
responses facilitate nociceptive spinal transmission, lower discussed below in the section on patient-controlled analge-
the threshold for pain perception, and perpetuate the pain sia (PCA), continuous intravenous administration requires
experience. close supervision and is impractical except in the PACU or
Postoperative pain serves no useful purpose and may intensive care unit. Side effects of morphine include respira-
cause alterations in pulmonary, circulatory, gastrointestinal, tory depression, nausea and vomiting, and clouded senso-
and skeletal muscle function that contribute to postop- rium. In the setting of severe postoperative pain, however,
erative complications. Pain following thoracic and upper respiratory depression is rare, because pain itself is a power-
abdominal operations, for example, causes voluntary and ful respiratory stimulant.
involuntary splinting of thoracic and abdominal muscles Meperidine is an opioid with about one-eighth the
and the diaphragm. The patient may be reluctant to breathe potency of morphine. It provides a similar quality of pain
deeply, promoting atelectasis. The limitation in motion due control with similar side effects. The duration of pain relief
to pain predisposes to venous stasis, thrombosis, and embo- is somewhat shorter than with morphine. Like morphine,
lism. Release of catecholamines and other stress hormones meperidine may be given intravenously, but the same
by postoperative pain causes vasospasm and hypertension, requirements for monitoring apply.

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Other opioids useful for postoperative analgesia include (usually 6-8 minutes) between patient-initiated doses. The
hydromorphone and methadone. Hydromorphone is usu- possibility of overdosage is also limited by the fact that the
ally administered in a dose of 1-2 mg intramuscularly every patient must be awake in order to search for and push
2-3 hours. Methadone is given intramuscularly or orally in the button that delivers the morphine. The dose and timing
an average dose of 10 mg every 4-6 hours. The main advan- can be changed by medical personnel to accommodate the
tage of methadone is its long half-life (6-10 hours) and its needs of the patient. This method appears to improve pain
ability to prevent withdrawal symptoms in patients with control and even reduces the total dose of opioid given in a
morphine dependence. Patients who use methadone preop- 24-hour period. The addition of a background continuous
eratively should be continued postoperatively on their usual infusion to the patient-directed administration of analgesic
dose to avoid withdrawal; most clinics maintain records on appears to offer no advantage over PCA alone.
their patients and should be consulted to confirm the appro-
priate replacement. `` F. Continuous Epidural Analgesia
Opioids are also effective when administered directly into
`` C. Nonopioid Parenteral Analgesics the epidural space. Topical morphine does not depress pro-
Ketorolac tromethamine is a nonsteroidal anti-inflammatory prioceptive pathways in the dorsal horn, but it does affect
drug (NSAID) with potent analgesic and moderate anti- nociceptive pathways by interacting with opioid receptors.
inflammatory activities. It is available in injectable form Therefore, epidural opioids produce intense, prolonged
suitable for postoperative use. In controlled trials, ketorolac segmental analgesia with relatively less respiratory depres-
(30 mg) demonstrated analgesic efficacy roughly equivalent sion or sympathetic, motor, or other sensory disturbances.
to that of morphine (10 mg). A potential advantage over mor- In comparison with parenteral administration, epidural
phine is its lack of respiratory depression. Gastrointestinal administration requires similar dosage for control of pain,
ulceration, impaired coagulation, and reduced renal func- has a slightly delayed onset of action, provides substantially
tion—all potential complications of NSAID use—have not longer pain relief, and is associated with better preserva-
yet been reported with short-term perioperative use of tion of pulmonary function. Epidural morphine is usually
ketorolac. administered as a continuous infusion at a rate of 0.2-0.8
mg/h with or without the addition of 0.25% bupivacaine.
`` D. Oral Analgesics Analgesia produced by this technique is superior to that
of intravenous or intramuscular opioids. Patients managed
Within several days following most abdominal surgical pro- in this way are more alert and have better gastrointestinal
cedures, the severity of pain decreases and oral analgesics function. Side effects of continuous epidural administration
suffice for control. Aspirin is often avoided as an analgesic of morphine include pruritus, nausea, and urinary retention.
postoperatively, since it interferes with platelet function, Respiratory depression may occur.
prolongs bleeding time, and interferes with the effects of
anticoagulants; however, in some settings aspirin is used to
diminish the risk of cardiovascular complications by these `` G. Intercostal Block
mechanisms. For most patients, a combination of acetamin- Intercostal block may be used to decrease pain following
ophen with codeine (eg, Tylenol No. 3) or propoxyphene thoracic and abdominal operations. Since the block does
(Darvocet-N 50 or -N 100) suffices. Hydrocodone with acet- not include the visceral afferent nerve fibers, it does not
aminophen (Vicodin) is a synthetic opioid with properties relieve pain completely, but it does eliminate muscle spasm
similar to those of codeine. For more severe pain, oxycodone induced by cutaneous pain and helps to restore respiratory
is available in combination with aspirin (Percodan) or acet- function. It does not carry the risk of hypotension—as does
aminophen (Percocet, Tylox). Oxycodone is an opioid with continuous epidural analgesia—and it produces analgesia
slightly less potency than morphine. As with all opioids, for periods of 3-12 hours. The main disadvantage of inter-
tolerance develops with long-term use. costal blocks is the risk of pneumothorax and the need for
repeated injections. These problems can be minimized by
`` E. Patient-Controlled Analgesia placing a catheter in the intercostal space or in the pleura
through which a continuous infusion of bupivacaine 0.5% is
Patient-controlled analgesia puts the frequency of analgesic delivered at a rate of 3-8 mL/h.
administration under the patient’s control but within safe
limits. A device containing a timing unit, a pump, and the
analgesic medication is connected to an intravenous line. By
`` H. Direct Infiltration
pressing a button, the patient delivers a predetermined dose Direct administration of a combination of short- and long-
of analgesic (usually morphine, 1-3 mg). The timing unit acting local anesthetics can help significantly in management
prevents overdosage by interposing an inactivation period of postoperative pain in a variety of settings. Optimally,

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▲ Chapter 4

wound infiltration or local nerve block should occur follow-

Vonlanthen R, Slankamenac K, Breitenstein S, et al. The impact of
ing the induction of intravenous anesthesia and prior to skin complications on costs of major surgical procedures. Ann Surg.
incision but may still be beneficial after incision. 2011;254:907-913.

`` Special Considerations
Fluid Therapy
Patients at the extreme of ages, who underwent acute/emer-
gency surgery or had a poor preoperative functional and Pearse RM, Ackland GL. Perioperative fluid therapy. BMJ. 2012
nutritional status require special postoperative consideration. Apr 26;344:e2865.
Infants and children can be both more easily taken out
of equilibrium and yet can return to health more quickly. Transfusion Therapy
Reassessment should occur more frequently with calculation
of fluid needs tailored to their body surface area and losses. Society of Thoracic Surgeons Blood Conservation Guideline Task
The nursing ratio is expected to be higher for more critically Force, International Consortium for Evidence Based Perfusion;
ill children. Elderly patients tend to have more complex Ferraris VA, Brown JR, Despotis GJ, et al. 2011 update to the
Society of Thoracic Surgeons and the Society of Cardiovascular
preoperative medical issues, require a careful preopera- Anesthesiologists blood conservation clinical practice guide-
tive functional assessment of their nutritional reserve, and lines. Ann Thorac Surg. 2011 Mar;91(3):944-982.
may have a more sensitive response to sedatives and other
medications with a prolonged return to full mental function.
Careful attention to even small changes in status should trig- Postoperative Analgesia
ger thoughtful appraisal of the patient.
Practice guidelines for acute pain management in the periop-
THE CONVALESCENT PHASE erative setting: an updated report by the American Society
of Anesthesiologists Task Force on Acute Pain Management.
Determination and planning for discharge should start even Anesthesiology. 2012 Feb;116(2):248-273.
before the operation and should be modified accordingly. It
is not uncommon for patients to be discharged to a setting
other than home; emergency or acute care surgery is more Hyperglycemia
likely to lend itself to a change in disposition of the patient. Umpierrez GE, Hellman R, Korytkowski MT, et al. Management
Plans should be made early for home assistance in the activi- of hyperglycemia in hospitalized patients in non-critical care
ties of daily living and in assisting recovery from surgery setting: an Endocrine Society clinical practice guideline. J Clin
including education on the care of ostomies, new tubes/ Endocrinol Metab. 2012 Jan;97(1):16-38.
drains, intravenous or intramuscular medications.
Daily rounds should include a plan for discontinuation
of drains, supplemental oxygen, nasogastric tubes, indwell-
Multiple Choice Questions
ing urinary catheters, medications including antibiotics, and
the need for ongoing antithrombotic therapy. Transition of
medication to oral route where possible should occur early; 1. A 65-year-old woman undergoes a thyroid lobectomy
otherwise, preparation for home administration of IV or for a follicular neoplasm. She has a history of coronary
SQ/IM medication should be made. artery disease, hypertension, insulin-dependent diabe-
tes, and stroke. The procedure lasted 2 hours during
`` References which the patient required occasional Neo-Synephrine
for brief interoperative hypotension. Two hours after
Postoperative Outcomes the procedure, the nurse calls from the PACU to report
that the patient is agitated and hypertensive. Which
Cronin J, Livhits M, Mercado C, et al. Quality improvement pilot of the following is unlikely to be the cause for her
program for vulnerable elderly surgical patients. Am Surg. 2011 agitation?
Oct;77(10):1305-1308. A. Hypoxia
Guillamondegui OD, Gunter OL, Hines L, et al. Using the National
Surgical Quality Improvement Program and the Tennessee
B. Stroke
Surgical Quality Collaborative to improve surgical outcomes. C. “Unmasking” of cognitive dysfunction
J Am Coll Surg. 2012 Apr;214(4):709-714; discussion 714-716. D. Hyperglycemia
Ingraham AM, Richards KE, Hall BL, Ko CY. Quality improve- E. Hypocalcemia
ment in surgery: the American College of Surgeons National
Surgical Quality Improvement Program Approach. Adv Surg.
2. A 43-year-old man with a distant history of intravenous
2010 Oct;44:251-267.
drug use is now status post a right inguinal hernia

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Postoperative Care
▲
repair and is complaining of severe groin pain on the B. Wound evaluation including assessment of drain
side of the operation. All of the following are appropri- output and content
ate maneuvers except C. Assessment of the adequacy of pain management
A. Evaluate the patient for necrotizing fasciitis D. Plan for removal of the nasogastric tube, Foley
B. Reassure the patient that his use of preopera- ­catheter, and advancement of diet
tive suboxone that morning may have blocked his E. All of the above except for D
­postoperative response to narcotics
C. Allow the nurse to administer a postoperative 5. A 72-year-old man underwent resection of hepatic
­parenteral nonopioid analgesic ­segments 5/6 for a hepatoma in the setting of hepa-
D. Discharge the patient with a prescription for pain tocellular carcinoma 2 days ago and was recently
medication and a plan for follow-up in 2 weeks discharged to the floor. Perioperatively, he required a
E. Perform a nerve block with local anesthetics large volume of fluid resuscitation. He now has bloody
output from his two Jackson-Pratt drains that are seated
3. A 56-year-old woman is being prepared for an elective in the liver bed, his hematocrit has fallen 7 points to
ventral hernia repair in the preoperative care unit. She 23 and his INR is 2.7, and he is febrile to 102.8°F and
is overweight, with a history of non–insulin-dependent confused. Which of the following is the most appropri-
diabetes, hypertension, and smoking. Her fingerstick ate order and choice of management?
glucose is 326, and you note that her most recent A. Evaluation of the patient, transfer to higher level of
HgA1C is 8.4%. She wants to proceed with the o ­ peration care, transfusion with 2 units of unmatched packed
and has traveled a long distance to see you and has RBCs, return to the operating room for surgical
taken the day off from work. The most appropriate ­control of bleeding
choice of management is B. Evaluation of the patient, transfusion with two
A. Proceed with the operation and plan for an packs of FFP and 2 units of matched packed RBCs,
­intraoperative insulin drip ­computed tomography with angiography for pos-
B. Repeat the fingerstick after insulin administra- sible embolization
tion and proceed with the operation if the glucose C. Evaluation of the patient, intubation for protection
is improved with the plan for consultation of the of airway, transfer to higher level of care, transfu-
­diabetes team postoperatively for management sion with cryoprecipitate, antibiotic administration,
C. Cancel the operation with the plan for improved return to the operating room for surgical control of
preoperative preparation bleeding.
D. Admit the patient for preoperative glucose manage- D. Evaluation of the patient, intubation for
ment and reschedule the operation for several days protection of airway, transfer to a higher level of
from now care, transfusion with 2 units of FFP and 2 units
of matched packed RBCs, antibiotic administration,
and computed tomography of the abdomen.
4. Which of the following are routine components of the
first 24-hour postoperative check in patients who have
undergone colon resection?
A. Vital signs including heart rate, blood pressure,
­oxygen saturation

CURRENT Diagnosis & Treatment

Surgery
14th Edition
Edited by Gerard M. Doherty, MD
McGraw Hill 2015

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