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Surgical Patient Care

4.00 Contact Hours
A score of 80% correct answers on a test is required to successfully complete any course and attain a certificate of completion.
Author:    Berthina Coleman (MD, BSN,RN)

Outcomes

The purpose of this course is to enable the learner to evaluate, prevent and treat adverse events of patients in the operative setting.

Objectives

After completing this course, the learner will be able to perform the following:

  1. Given a scenario of a patient in the perioperative setting, correctly apply the ASA classification based on the patient's physical status.
  2. List the two most common causes of adverse events as a it pertains to perioperative morbidity and mortality.
  3. Define poor exercise tolerance as it pertains to predicting perioperative adverse events.
  4. Describe the recommendations for the perioperative management of beta blockers in patients receiving this class of medication prior to surgery.
  5. List two most common causes of hypotension in the post-anesthesia care unit.

Preoperative Evaluation

In modern healthcare systems, operative treatment of disease has been on the increase in the last decades. In the United States in 2005, it was estimated that over 1 million patients out of the 26 million who underwent a surgical procedure experienced adverse events. These adverse events were estimated to cost approximately $25 billion for that year alone.1 It has become increasingly important for healthcare systems to focus on perioperative care and the first step in that process is the preoperative evaluation of patients to see if they are fit enough to undergo the planned surgical procedure.

When evaluating a patient for perioperative risk, their prior history should be completely evaluated including the patient’s functional capacity, the past medical history, the risk of the proposed surgery and the patient’s individual risk profile as it pertains to the specific surgery.  Traditional risk factors such as a history of tobacco use, dyslipidemia, hypertension and other comorbid conditions such as peripheral vascular disease, renal insufficiency, chronic obstructive pulmonary disease, cerebrovascular disease and cardiovascular disease are all important to document in the preoperative evaluation.1,2

Every patient who has a surgical procedure planned in the United States usually gets classified based on The American Society of Anesthesiologists (ASA) classification. This classification is based on the patient’s physical status. Class 1 is reserved for normal healthy patients. Patients in Class 2 have mild systemic disease with no evidence of functional limitations. Class 3 patients have severe systemic disease with some degree of functional limitations. Class 4 patients have severe systemic disease with a constant threat to life. These patients are usually functionally incapacitated. Class 5 patients are moribund patients who are not expected to survive without the planned surgery. Class 6 patients are brain dead patients who are having organs removed for donor purposes. Finally, there is a separate designation; E which is used to indicate that the procedure is an emergency. When using this designation, the physical status is usually written followed by the letter E. For example, ASA class 3E.2

Cardiovascular Complications

Cardiovascular complications are one of the most common causes of perioperative adverse events in patients who undergo noncardiac surgery and have been estimated to be associated with a mortality rate as high as 70%.1,3 It is critical for clinicians to understand the importance of evaluating preoperative cardiac risk in noncardiac surgery patients. The whole point of preoperative cardiac assessment is to understand the patient’s cardiac conditions, determine the risk that the specific surgery planned poses as well as determine whether an intervention is warranted to decrease the patient’s perioperative risk.4

Ischemic heart disease is a major predictor of cardiovascular complications. It is defined as a history of current angina, history of myocardial infarction, use of sublingual nitroglycerin, the presence of Q waves on an electrocardiogram, positive exercise test results. Cerebrovascular disease is defined as a history of a prior stroke or a prior transient ischemic attack.

Some patients are at intermediate risk or high-risk for surgery and therefore require a more thorough clinical evaluation before they undergo major surgical procedures. High-risk surgical procedures are defined as intrathoracic, intraperitoneal and supra inguinal vascular procedures. Often, physicians evaluate these patients with a screening questionnaire which may then trigger a more comprehensive evaluation. Comprehensive evaluation usually involves a thorough history and physical with a specific focus on occult cardiopulmonary diseases.4

Symptoms of cardiovascular disease include shortness of breath, chest pain at rest, anginal equivalent symptoms, claudication, syncope and presyncope. Worsening exercise intolerance is a good predictor of overall perioperative risk especially in patients who self-report cardiopulmonary symptoms which are exercise induced.

Energy used by muscles either at rest or during activity is expressed as a function of the total body oxygen uptake (VO2). VO2 has been shown to be equal to the product of the cardiac output and the oxygen extraction in the peripheral tissues. The result of this product is defined as metabolic equivalent (MET) levels. A MET level 1 defined as the energy expended at rest which is approximately 3.5mlO2/kg body weight/min. Essentially, this is a convenient way of expressing energy spent during activity compared to energy spent at rest. MET activity levels are based on age, sex, exercise habits and cardiovascular levels. Of note, the metabolic equivalent level is defined as oxygen consumption of a 70 kg man at rest.5

Poor exercise tolerance as it pertains to predicting perioperative events is defined as an inability to climb two flights of stairs or walk four blocks at a normal pace. In addition, it is defined as an inability to meet a metabolic equivalent (MET) level of 4.

Every patient who is scheduled for a major surgery does not require preoperative noninvasive cardiac evaluation. Most clinical providers use a risk stratification model based on clinical parameters. Patients with a high cardiac risk index should be sent for further evaluation, and the need for revascularization should be carefully considered. Noninvasive cardiac testing consists of a measurement of blood pressure and heart rate, electrocardiography, exercise and pharmacologic stress test. Occasionally, providers choose to use medications for preventive measures in the preoperative setting. Some examples include; statins, antiplatelet agents, beta blockers and alpha agonists with the goal being to reduce adrenergic stimulation, inflammation and ischemia in the perioperative setting.4

Cardiac Risk Indices

Cardiac risk indices have been used for perioperative risk stratification which provides a baseline assessment of risk in the perioperative setting. Thus, the revised cardiac risk index (RCRI) was created to identify patients at risk. The risk factors included in the revised cardiac risk index include; high-risk surgery, ischemic heart disease, congestive heart failure, preoperative treatment with insulin, a history of cerebrovascular disease and preoperative serum creatinine greater than 2 mg/dL.6

Common Medications to Treat Cardiovascular Complications

Beta blockers

Beta blockers should be used in patients with surgery specific cardiac risk that is RCRI greater than or equal to 2, and they should be titrated to maintain the heart rate between 60-80 beats per minute in patients in the operative and the postoperative setting. Ideally, patients should receive the medication preoperatively on the day of the surgery and should be continued in the postoperative setting for at least 7 days, but 30 days is preferable. Providers should avoid abrupt beta blocker withdrawal due to the increased risk of angina and myocardial infarction. 

The American Cardiology College (ACC) and the American Heart Association (AHA) both recommend that beta blockers should be continued in patients with active cardiac conditions who are already receiving beta blockers and are undergoing surgery. According to the ACC and AHA, beta blockers receive a “probable recommendation” for patients undergoing vascular surgery who are at high cardiac risk either from cardiac ischemia or coronary artery disease usually detected on preoperative testing. In general, high-risk patients are defined as patients with a RCRI greater than or equal to 2.2,4,7

Both the ACC and AHA agree that beta blockers are “reasonable” for high-risk patients who undergo vascular surgery. Additionally, they also agree on a reasonable recommendation for high-risk patients or patients with known coronary artery disease who undergo an intermediate risk surgery. Lastly, their recommendation is a contraindication for non-titrated administration of high dose beta blockers in patients who have never been treated with a beta blocker.2,4,7

Statins

Several studies have supported the perioperative prophylactic use of statins in patients with established atherosclerosis for the reduction of cardiac complications. Statins are felt to be valuable besides just lowering the cholesterol. It is also useful in other regards such as decreasing new thrombus formation as well as stabilizing plaque by decreasing inflammation. Currently, the indication is to continue statin therapy if the patient is already on statins or if there is a clear indication for statin therapy based on their history.

Perioperative Management of Pulmonary Risk

It has been shown that postoperative pulmonary complications are just as prevalent as postoperative cardiac complications in terms of the length of the hospital stay, morbidity and mortality. There are several factors which increase the risk of postoperative pulmonary complications which are; age older than 60 years, functional dependence, congestive heart failure, chronic obstructive pulmonary disease and American Society of Anesthesiologists (ASA) class II or greater. In addition, low serum albumin (<35 g/dL) has been shown to increase the risk of perioperative pulmonary complications significantly.7,8

Other patient-related factors include; an abdominal or thoracic surgical site which can lead to impaired diaphragmatic excursion from the pain; head and neck procedures; use of general anesthesia and prolonged procedures over 3 hours long; and vascular procedures, especially abdominal aortic aneurysm.8

Routine testing using a chest radiograph and pulmonary function tests is not indicated in all surgical patients especially since they have not been routinely shown to predict perioperative pulmonary complications. The exception is patients undergoing lung reduction surgery or other intrathoracic procedures. Some interventions have been shown to be helpful in decreasing perioperative pulmonary complications such as incentive spirometers, selective use of a nasogastric tube for gastric decompression if necessary and deep breathing exercises.8,9

Obstructive Sleep Apnea

Recently, it has been shown that obstructive sleep apnea has been linked to an increased risk of postoperative complications (both cardiac and pulmonary). It has also been associated with increased critical care unit admissions. These are usually linked to increased rates of pneumonia and respiratory collapse. Obstructive sleep apnea is considered at least a moderate risk of postoperative complications as such patients not diagnosed with obstructive sleep apnea but with at least 2 clinical signs and symptoms of the disease. Symptoms of obstructive sleep apnea include snoring, witnessed daytime apnea or a crowded oropharynx.7,9

Perioperative Management of Antiocoagulation

Venous thromboembolism includes both pulmonary embolism and deep vein thrombosis, and it is a common cause of morbidity and mortality in the perioperative patient population. Venous thromboembolism prophylaxis has been shown to improve patient outcomes and decrease hospital costs. Consequently, clinicians must seriously consider the risk of venous thromboembolism in every surgical patient. Postoperative deep vein thrombosis (DVT) is usually asymptomatic, and sometimes the first sign may be a massive pulmonary embolism. Screening all preoperative patients for a DVT is not practical and, in asymptomatic patients, it will have a low sensitivity for detecting clot. Ideally, all patients should receive VTE prophylaxis and interventions based on the procedure-related risks and the individual patient-related risks.11 

Non-pharmacologic means of venous thromboembolism prevention include compression stockings, early ambulation and intermittent compression devices. Pharmacologic interventions include aspirin, low molecular weight heparin, heparin and warfarin. Additionally, patients can have an inferior vena cava filter.

Perioperative Management of Medications

In general, medications with a significant withdrawal potential that are unlikely to affect the planned surgery or administration of anesthesia should not be discontinued in the perioperative period. These include medications such as alpha blockers and beta blockers. Conversely, medications which increased perioperative risk and are not essential for short-term quality of life can be discontinued. Providers should weigh in individually on medications which do not fall in this category. Ideally, all cardiovascular medications should be continued throughout the perioperative period with a few exceptions which need to be evaluated on a case by case basis, namely, anticoagulants and diuretics. Angiotensin receptor antagonists and angiotensin converting enzyme inhibitors are associated with profound hypotension with the induction of anesthesia usually requiring pressor support.6,7

Anti-Inflammatory agents such as clopidogrel and NSAIDs such as aspirin are commonly used. Aspirin and clopidogrel are used in patients who have preexisting cerebral, peripheral vascular or coronary vascular disease. Although the use of these agents decreases inflammatory events, they also come at the risk of increased bleeding intraoperatively or in the postoperative setting. It has been shown that stopping these medications for the short term in the perioperative setting does not lead to adverse side effects. Currently, the recommendation is to discontinue these anti-inflammatory agents 7 to 10 days before an elective surgical procedure. An exception to discontinue these medications is in patients who had a drug-eluting stent placed recently in a coronary artery since this can cause thrombosis of the stent.6,7

Perioperative Management of Diabetes

Good glycemic control has been associated with decreases in length of stay in the intensive care unit, wound infections in the perioperative setting as well as overall mortality. It is estimated that approximately half of the dose of insulin is used for non-nutrient metabolic needs. Currently, the recommendation to patients taking intermediate-acting insulin such as NPH insulin is to take at least half to two-thirds of their evening dose on the morning of their surgery. Clinicians should consider administering the full dose of long-acting insulin to patients on the day of surgery. Insulin sliding scales use is usually associated with several episodes of hypoglycemia and hyperglycemia which is less conducive to good perioperative outcomes.

Perioperative Management of Psychiatric Medications

Psychiatric medications should be continued in the perioperative setting in order to prevent a decompensation of psychiatric conditions which may increase perioperative morbidity. The most commonly used medications, benzodiazepines and selective serotonin reuptake inhibitors, are deemed safe to continue in the perioperative period.6,7

Preventing Surgical Site Infections

Surgical site infections affect 500,000 patients every year, and they are associated with an increased risk of postoperative mortality by up to 11 times compared to patients without surgical site infections. Surgical site infections can occur in approximately 4% of general surgery and vascular surgery procedures. Surgical site infections are associated with increased hospitalization by 7 or more days.12

There are certain factors which increase the risk of a surgical site infection: obesity, older age, diabetes mellitus, heavy alcohol consumption and multiple medical comorbidities. However, the main determinant of a surgical site infection is the surgical site.

The use of prophylactic antibiotics has been shown to reduce the incidence of surgical site infections. For example, in colorectal surgery cases, prophylactic antibiotic use has been shown to decrease the incidence of surgical site infections by up to 50%. Additionally, in the use of preoperative antibiotics within 2 hours of surgery has been shown to decrease the 60-day mortality amongst Medicare patients by up to two-fold.6  This study also suggested that the use of a single dose of preoperative antibiotics is just as effective as a multidose regimen which is administered both in the preoperative and postoperative period. Nasal colonization with Staphylococcus aureus has been linked to an increased risk of surgical site infections. Currently, the American Academy of Orthopedic Surgeons recommends against antibiotic prophylaxis before prosthetic joint procedures. In addition, the American Dental Association recommends against the use of antibiotics prior to dental procedures.13

All surgical wounds are contaminated to some degree in spite of the implementation of strict antiseptic technique. Most SSIs occur at 5 to 10 days after the procedure. Usually, antibiotics are not needed for simple wounds which are drained. On the contrary, SSI in deep spaces require both surgical drainage as well as systemic antibiotics.  Clinical signs and symptoms of a wound infection include, pain, purulent drainage from the site and fevers. Most postoperative leaks occur between days 5 and 7.12

Surgical Drains

Surgical drains are usually used to collect normal postoperative physiologic collections, evacuate postoperative abscesses or leaks as well as minimize potential dead spaces in the postoperative setting. In this section, we will review the common used surgical drains and their indications. It is important for nurses to understand the purpose and location of all surgical drains in the patients they are caring for as well as how the drains should be manipulated with guidance from the primary surgical team.

Chest Tubes

These are placed in the pleural space and are usually used to drain pleural effusions, pneumothoraces or hemothoraces. In general, these are used during cardiothoracic surgery, trauma and in cases of infection. Chest tubes come in varied sizes and are typically placed in the fourth or fifth intercostal space in the midaxillary line or along the anterior axillary line. The tubes are then connected to a three-chamber drainage system. The water chamber is used to prevent air from being sucked into the pleural space as the patient inhales. The suction chamber is usually attached to continuous wall suction which helps clear the pleural space from air or fluid. The suction can be placed on “water seal mode” in which there is no active suction mechanism. The last chamber which is the drainage chamber is used to collect the fluid draining from the pleural space.14 

Indications for a chest tube include pneumothorax, a persistent or a large pleural effusion or a hemothorax. Hemothoraces and pneumothoraces usually need immediate chest tube placement as these injuries can be life-threatening. In the postoperative setting, chest tubes are commonly placed after thoracic surgery procedures to aid with lung re-expansion. All chest tubes have a radiopaque marker which is usually a line along the longitudinal axis of the tube. When the chest tube is appropriately connected, there should be respiration variations in the fluid within the collecting chamber which is known as tidling. Immediately after the chest tube is placed, a chest x-ray should be obtained to ensure appropriate placement. Subsequent chest x-rays should be obtained at the discretion of the team that placed the chest tube. The chest tube should be placed on continuous suction usually -20 mmHg to evacuate the air within the pleural space. When air bubbles are seen in the water chamber in a patient without a pneumothorax, this is called an air leak. In the cases of a pneumothorax, bubbles seen in the water chamber is considered normal. In patients without a pneumothorax, once the air leak has stopped the chest tube is usually placed on water seal which mimics normal physiology. Once it is on water seal, the leak should stop to confirm that the pneumothorax has stopped. Anytime that the tube is changed from water seal to continuous suction or vice versa, a chest x-ray should be obtained to ensure that the pneumothorax does not worsen.14

The tube may become occluded from a kink or blood or debris within the tube and troubleshooting can be performed using a CT scan or lytics within the chest tube. Occasionally the tube will have to be removed or replaced if it can be successfully declogged. As a general rule, the chest tube is usually placed on water seal to ensure there is no pneumothorax prior to removal. Ideally, a chest tube should never be advanced into the pleural space at the risk of introducing infection into the pleural space. In addition, in patients with a pneumothorax, the chest tube should not be clamped at the risk of causing a tension pneumothorax.

Nasogastric Tube

This is typically placed in the stomach as the name suggests. Its primary uses are either for feeding or for gastric decompression. Common conditions which require the use of a nasogastric tube include bowel obstruction, ileus, dysphagia or proximal bowel surgery. Orogastric tubes are commonly placed intraoperatively to keep the stomach decompressed under general anesthesia. The most common use of nasogastric tubes is for the management of small bowel obstructions or bowel ileus. There are two types of nasogastric tubes; sump tubes and weighted feeding tubes. Ideally, gastric sumps tubes which may have a double lumen should be placed in the most dependent portion of the stomach. The gastric tube is usually placed on intermittent or continuous wall suction. Suction should be set at 60 mmHg or less in order to avoid mucosal injury and avulsion.

Persistently high gastric output in a patient with evidence of bowel function (such as bowel movements or flatus) is suggestive of postpyloric placement. Patients with a high output from the NGT tube are at increased risk of electrolyte imbalances and should have their electrolytes checked and replaced as necessary.14

Occasionally NGTs are useful for the diagnosis of upper gastrointestinal (GI) bleeds. Likewise, clear gastric output from an NGT in the setting of a GI bleeding can help rule out an upper GI bleed. In general, prior to removal, an NGT should be placed to gravity for four hours. After 4 hours, the aspirate should be checked, and if it is less than 100 cc, this implies that it is ready for removal. If the output increases over 100 cc within the 4 hour period, this usually indicates that the NGT should be placed on suction once again.

Duodenal tubes are usually smaller bore tubes, softer and more flexible. Duodenal tubes are usually placed by experienced operators. Occasionally, placement of duodenal tubes may have to be done under fluoroscopy or bronchoscopy guidance to ensure appropriate placement.

Gastrostomy Tubes

The gastrostomy tube (G tube) is typically placed in the stomach with the primary uses being for prolonged feeding or gastric decompression. It is usually used in cases of gastric outlet obstruction or prolonged mechanical ventilation. Gastrostomy tubes are commonly used for feeding needs in patients with prolonged mechanical ventilation or those with head and neck pathology who need nutritional supplementation. Gastrostomy tubes can be placed by gastroenterologists or interventional radiologists.

Jejunal Tube (Jejunostomy or J-tube)

Jejunostomy tubes are usually exclusively placed for feeding needs. The ideal location is 10 to 20 cm distal to the ligament of Treitz. J-tubes frequently clog up due to their small lumens. Most practitioners agree that pills ideally should not be administered via this tube. Ideally it takes 2 weeks for the tract of a percutaneously placed tube to mature, and once that happens, the tube can be replaced at the bedside by experienced team members including practitioners who are not part of the surgical team.14

It is placed in the jejunum. Typically, it is used in cases of gastric outlet obstruction, high aspiration risk cases or in cases of prolonged post gastric feeding tube placement. Typical clinical scenarios necessitating its use include aspiration pneumonia, gastric outlet obstruction or prolonged mechanical ventilation.

Duodenal Tubes

It is usually placed in the duodenum, and it is used for high aspiration risk, postgastric feeding and gastric outlet obstruction. It is useful in clinical scenarios such as mechanical ventilation, acute aspiration and dysphagia.

When enteric tubes get clogged up carbonated fluids, enzymatic fluids and meat tenderizer fluids are helpful in unclogging them. When a gastrostomy tube is placed to suction, daily labs should be drawn to replete large electrolyte loses. Enteric tubes should be flushed every 4 to 6 hours with approximately 30 cc of water. Percutaneous tube sites should be examined routinely by nursing and other providers for signs and symptoms of infection.

Penrose Drain

It is usually placed in the duodenum, and it is used for high aspiration risk, postgastric feeding and gastric outlet obstruction. It is useful in clinical scenarios such as mechanical ventilation, acute aspiration and dysphagia.

When enteric tubes get clogged up carbonated fluids, enzymatic fluids and meat tenderizer fluids are helpful in unclogging them. When a gastrostomy tube is placed to suction, daily labs should be drawn to replete large electrolyte loses. Enteric tubes should be flushed every 4 to 6 hours with approximately 30 cc of water. Percutaneous tube sites should be examined routinely by nursing and other providers for signs and symptoms of infection.

Closed Suction Drainage (Jackson Pratt, Blake, or Hemovac Drains)

It is usually placed within a surgical space. It is used to evacuate blood or fluid within a surgical cavity. It is used to prevent a seroma, aid in wound healing by increasing tissue apposition. Common clinical scenarios include orthopedic surgery, gastrointestinal anastomosis, plastic surgery cases, mastectomies and hernia repair cases.

Ideally closed suction drains are left in place until the output is less than 20 cc per day. These drains can be left in place for weeks. If these drains become clogged, management is often left up to the primary surgical team. Occasionally the output from these drains can become bloody, and the primary surgical team should be promptly notified as well. In general, the output from these drains should be monitored closely and if the volume and the consistency of the drainage changes the surgical team should be promptly notified.14

Postoperative Pain

Patients in the PACU are not always able to fully verbalize their pain due to the effects of anesthesia. Clinicians can rely on blood pressure, heart rate, respiratory rate, signs of agitation and nonverbal signs of pain to correctly assess the patient’s pain.

Postoperative Hypertension and Hypotension

Pain can lead to elevated blood pressure and increased heart rate. Beta blockers should be used in patients who were taking it prior to surgery. Hypertension in the PACU should be treated with aggressive blood pressure management in certain procedures such as carotid endarterectomy in order to avoid debilitating consequences including neurologic damage.  In patients who were hypertensive prior to surgery, most antihypertensives can be used in the PACU with the exception of diuretics.7

Hypotension in the PACU is usually caused by hypovolemia and medication side effects. Signs and symptoms of hypovolemia include altered mental status and low urine output. If the patient remains hypotensive despite efforts at resuscitation, then invasive blood pressure monitoring should be considered such as via an arterial line. Note that epidural anesthesia can blunt sympathetic system response which is exacerbated in the setting of hypovolemia. Note that urine output less than 0.5 cc/kg/hour should prompt immediate evaluation for hypovolemia.7

Postoperative Respiratory Insufficieny

Dyspnea, tachypnea, wheezing and other signs of respiratory distress are not expected postoperative responses and should raise suspicion that the patient may be in respiratory distress. Most patients do need oxygen in the postoperative setting and clinicians should remain watchful in case there is a need for immediate reintubation.  Multiple factors contribute to postoperative respiratory insufficiency such as longer duration of surgeries, endotracheal intubation, use of narcotics and upper abdominal and thoracic surgeries. Poor pain control also leads to increased chance of respiratory insufficiency. Pulmonary edema is a sign of respiratory distress in the postoperative period, and a chest x-ray can be used to evaluate the patient in the postoperative setting. Patients who had a central line placed intraoperatively who become short of breath suddenly should be reevaluated for a pneumothorax.7

Postoperative Nausea and Vomiting

Nausea and vomiting is a common complaint in the PACU setting, and the etiology is multifactorial. Factors which can contribute to nausea and vomiting include the use of volatile anesthetics; procedures involving the eyes or ears; and patients who had surgeries performed lasting more than 3 hours. Prophylactic antiemetics have been shown to alleviate the effects of postoperative nausea and vomiting.7

Postoperative Fevers

Within the first 48 hours after surgery, a low-grade fever is considered normal, and it could be caused by atelectasis (lung collapse) and inflammatory changes. It is usually not from an infectious cause. After 48 hours, any fever over 100.4 degrees Fahrenheit should be evaluated for a potential source of infection. The first sources that should be evaluated include the surgical site, central lines, urinary catheters and the lungs.

Delirium

Delirium is common in patients in the postoperative setting, especially in older patients, those with dementia, and those with a history of alcohol and drug abuse.  Symptoms of delirium usually wax and wane in intensity over time. Confusion, hallucination, and agitation are commonly seen in this patient population.

Urinary Tract Infections

Urinary tract infections are more common in women compared to men and occur after vaginal or urologic surgery especially procedures which require the use of an indwelling catheter in the postoperative setting. The most common causative bacteria are Escherichia coli, Staphylococcus aureus and Proteus mirabilis. Common clinical practice is to remove indwelling catheters postoperatively within the first 48 hours, and if that is not possible, then the patient should be assessed daily for the need of an indwelling Foley catheter. In general, most patients in a procedure lasting longer than 3 hours should have a Foley catheter placed. If a patient has not voided in over 8 hours, they should be evaluated with a bladder ultrasound at the bedside. And if bladder retention is greater than 500 cc, then the patient requires intermittent catheterization.7

Scenario

Case study:

You are a nurse working in a post-anesthesia care unit caring for Mr. Suh who is status post a laparoscopic cholecystectomy which was converted to an open procedure about 1 hour into the procedure. Mr. Suh is a 45 male, ASA class 2E who presented in the ED with acute abdominal pain. He was eventually diagnosed with cholecystitis in the setting of cholelithiasis. During the procedure, the case was extremely difficult to complete laparoscopically, and eventually it was converted to an open procedure. He is now recovering in the PACU complaining of right shoulder pain when he suddenly becomes hypotensive with his blood pressure dropping as low as 75/40 with his heart rate in the low 100’s. You are the primary nurse caring for him, what should you do?

Discussion

The first priorities, like in any other unstable patients, are airway, breathing and circulation. Based on the clinical scenario, circulation is primarily of concern in this patient. A quick check of the patient’s vital signs can help guide the clinical team. As discussed above, the most common causes of hypotension in the postoperative setting are hypovolemia and medication use. Specifically, medications such as angiotensin receptor antagonists and angiotensin converting enzyme inhibitors.

The patient received 2 liters of fluid, but his blood pressure persistently remained low. He eventually needed pressor support while in the PACU which was continued for approximately 12 hours after discharge from the PACU. The remainder of his stay was uneventful.

Summary

Caring for patients in the postoperative setting can be challenging given the increasing medical complexity of our patient populations. However, it is imperative that clinicians participating in the care of these patients are kept up to date on principles governing the management of patients in the perioperative setting. Nurses are the largest group of clinicians who interact with patients in the perioperative setting; often they are the first ones who recognize that a patient has become unstable. Therefore, it is of utmost importance that they understand the underlying principles governing perioperative care and be able to apply them aptly as the need arises.

References

  1. Carey WD, Whinney CM. Perioperative Evaluation. In: Current Clinical Medicine. Cleveland, OH: Cleveland Clinic; 2010.
  2. Apfelbaum JL, Silverstein JH, Chung FF, et al. Practice Guidelines for Postanesthetic Care. Anesthesiology. 2013;118(2):291-307. doi:10.1097/aln.0b013e31827773e9.
  3. DeFrances CJ, Cullen KA, Kozak LJ. National Hospital Discharge Survey: 2005 annual summary with detailed diagnosis and procedure data. National Center for Health Statistics. Vital Health Stat 13 2007. 165:1-209. doi:10.3886/icpsr20380.v2.
  4. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation. 2007;116(17). doi:10.1161/circulationaha.107.185699.
  5. Fletcher GF, Ades PA, Kligfield P, et al. Exercise Standards for Testing and Training: A Scientific Statement From the American Heart Association. Circulation. 2013;128(8):873-934. doi:10.1161/cir.0b013e31829b5b44.
  6. Papadakis  MA, McPhee SJ, Rabow  MW, Cheng  HQ. Preoperative Evaluation & Perioperative Management. In: Current Medical Diagnosis & Treatment. New York, NY: McGraw-Hill; 2018.
  7. Peter   N, Peetz AB, McKean SC, Ross JJ, Dressler DD, Scheurer DB. Postoperative Complications. In: Principles and Practice of Hospital Medicine. 2nd ed. New York, NY, NY: McGraw-Hill; 2017.
  8. Arozullah AM, Khuri SF, Henderson WG, Daley J. Development and Validation of a Multifactorial Risk Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery. Annals of Internal Medicine. 2001;135(10):847. doi:10.7326/0003-4819-135-10-200111200-00005.
  9. Arozullah AM, Daley J, Henderson WG, Khuri SF. Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery. Annals of Surgery. 2000;232(2):242-253. doi:10.1097/00000658-200008000-00015.
  10. Pelosi P, Abreu MGD, Guldner A. Nonventilatory strategies to prevent postoperative pulmonary complications. Current Opinion in Anaesthesiology. 2013;26(2):141-151. doi:10.1097/aco.0b013e32835e8bac.
  11. Ansell JE. The Perioperative Management of Warfarin Therapy. Archives of Internal Medicine. 2003;163(8):881. doi:10.1001/archinte.163.8.881.
  12. Najjar PA, Smink DS. Prophylactic Antibiotics and Prevention of Surgical Site Infections. Surgical Clinics of North America. 2015;95(2):269-283. doi:10.1016/j.suc.2014.11.006.
  13. Young H, Hirsh J, Hammerberg EM, Price CS. Dental Disease and Periprosthetic Joint Infection. The Journal of Bone and Joint Surgery-American Volume. 2014;96(2):162-168. doi:10.2106/jbjs.l.01379.
  14. Columbus   AM, Havens JB, Peetz A, McKean  SC. Surgical Tubes and Drains. In: Ross  JJ, Dressler  DD, Scheurer  DD, eds. Principles and Practice of Hospital Medicine. 2nd ed. New York, NY: McGraw-Hill.
     

This course is applicable for the following professions:

Advanced Registered Nurse Practitioner (ARNP), Certified Registered Nurse Anesthetist (CRNA), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Registered Nurse (RN)

Topics:

Medical Surgical, Perioperative, Pharmacology (All Nursing Professions)


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