Postoperative management is a critical phase of perioperative care, serving as the bridge between preoperative preparation, surgery, and postoperative recovery.
Routine Management
Postoperative Orders
Postoperative orders typically include the diagnosis, the performed surgical procedure, monitoring methods, and treatment measures such as pain management, antibiotic use, nursing level, intravenous fluid therapy, as well as the management of various tubes, catheters, drains, and oxygen therapy.
Monitoring
Most patients can return to their original ward following surgery, while certain high-risk patients may be transferred to the surgical intensive care unit (ICU). Routine monitoring includes vital signs such as body temperature, pulse rate, blood pressure, respiratory rate, and urine output, with fluid intake and output recorded. Dynamic monitoring of arterial oxygen saturation is performed using a peripheral oxygen saturation sensor.
Intravenous Fluid Therapy
The volume of postoperative intravenous fluids is calculated based on intraoperative blood loss, fluid loss, and the volume of transfusions and fluids administered, in conjunction with the patient's postoperative oral intake of food and water. The volume, composition, and infusion rate are determined by the extent of surgery, the functional status of the patient's organs, and the severity of the condition. Excessive fluid infusion can lead to pulmonary edema and congestive heart failure, while patients with shock or sepsis may develop systemic edema due to extravascular fluid accumulation in the interstitial spaces. Therefore, accurate estimation of fluid requirements is crucial.
Drains
Details about the type of drain, suction pressure, type and frequency of lavage, location of the drain, and care protocols should be included in the postoperative orders. The condition of the drain should be frequently examined for obstruction or kinking. During dressing changes, attention should be given to securing the drain to prevent slippage or displacement into the body. The volume and nature of drainage should be documented, as it may indicate potential complications such as bleeding or fistula formation.
Positioning
Postoperative positioning is determined by the type of anesthesia used, the patient’s general condition, the surgical procedure, and the nature of the disease, ensuring a position that balances comfort and mobility. For patients under general anesthesia who are not fully awake, unless contraindicated, a supine position with the head turned to one side is generally used to allow secretions or vomitus to drain from the mouth, reducing the risk of aspiration into the airway. Patients who undergo spinal anesthesia may lie flat for six hours to prevent low-pressure headaches caused by cerebrospinal fluid leakage. After full recovery from general anesthesia, or six hours after spinal anesthesia, or following epidural or local anesthesia, positions are adjusted as required by the surgery.
For patients undergoing cranial surgery, a 15°–30° head-elevated position can be adopted if there is no shock or coma. For neck or thoracic surgeries, a semi-upright position is often preferred to facilitate breathing and effective drainage. After abdominal surgery, a low semi-upright or inclined position may help reduce abdominal wall tension. Patients undergoing spinal or hip surgeries can assume a prone or supine position. For patients with intra-abdominal contamination, if permitted by their condition, an early switch to a semi-upright position or head-elevated position can promote drainage by gravity. For patients experiencing shock, a special position with the lower limbs elevated 15°–20° and the head and torso elevated 20°–30° may be used. Obese patients may benefit from a lateral position to facilitate breathing and venous return.
Management of Various Postoperative Discomforts
Pain
Pain occurs after the effect of anesthesia wears off and the surgical incision causes irritation. Postoperative pain can influence respiratory, circulatory, gastrointestinal, and musculoskeletal functions and may even lead to complications. Pain following thoracic or upper abdominal surgery may discourage deep breathing, resulting in atelectasis. Reduced activity caused by pain may lead to venous stasis and thrombus formation. Pain also triggers the release of catecholamines and other stress hormones, which may cause vasospasm, hypertension, and, in severe cases, stroke, myocardial infarction, or bleeding. Effective pain management can improve surgical outcomes. Multimodal analgesia is recommended for postoperative pain control. To manage incision pain, continuous thoracic epidural analgesia (PCEA) combined with non-steroidal anti-inflammatory drugs (NSAIDs) is recommended for open abdominal surgery. PCEA carries a risk of complications such as hypotension, epidural hematoma, and urinary retention, necessitating close monitoring and preventive measures. For laparoscopic surgeries, analgesic plans may include local infiltration analgesia or continuous infiltration analgesia at the incision, peripheral nerve blockade combined with low-dose opioid-based patient-controlled intravenous analgesia (PCIA), and NSAIDs.
Hiccups
Postoperative hiccups are relatively common, often transient, yet sometimes persistent. Hiccups may arise from stimulation of the nervous system or the diaphragm. Early postoperative hiccups can be managed using measures such as compression of the supraorbital ridge, short-term inhalation of carbon dioxide, aspiration of gastric gas or fluids, and administration of sedatives or antispasmodic medications. Persistent hiccups following upper abdominal surgery warrant caution, as they may suggest subphrenic fluid or infection. In such cases, imaging studies like CT or ultrasound are required to confirm the presence of subphrenic fluid or infection, which necessitates timely intervention.
Gastrointestinal Function
Anesthesia and surgery have minimal effects on small bowel peristalsis, while gastric motility recovers more slowly. The recovery of right-sided colonic activity typically requires 48 hours, whereas left-sided colonic activity may take 72 hours. For gastric and jejunal surgeries, upper gastrointestinal function usually takes 2–3 days to recover. In patients who have undergone esophageal, gastric, or small bowel surgery, those with significant intestinal obstruction, impaired consciousness, or acute gastric distension, a nasogastric tube is typically placed, with regular flushing to maintain its patency until gastrointestinal motility returns. Gastric or intestinal stoma drainage should utilize gravity-assisted positioning or apply intermittent negative pressure. For jejunostomy, nutritional fluid may start being infused through the feeding tube on the second postoperative day. Stoma tubes should only be removed after stable adhesions have formed between visceral and peritoneal layers, which usually takes about three weeks postoperatively.
Postoperative Activity
Early postoperative mobilization contributes to the recovery of multiple systems, including respiratory, gastrointestinal, and musculoskeletal functions. It helps prevent complications such as pulmonary infection, pressure ulcers, and deep vein thrombosis (DVT) in the lower limbs, and it supports the restoration of bowel peristalsis and bladder contraction, reducing the likelihood of abdominal distension and urinary retention.
Postoperative mobilization activities should align with the patient’s tolerance, with daily activity goals gradually increased. Once the patient has regained consciousness and the effects of anesthesia have worn off, activities in bed, such as deep breathing, voluntary limb movement, and intermittent repositioning, can be initiated. Alternating flexion and extension exercises of the toes and ankle joints, as well as alternating relaxation and contraction of the lower limb muscles, promote venous return.
Suture Removal
The timing of suture removal depends on factors such as the location of the incision, local blood supply, patient age, and nutritional status. Typically, sutures are removed 4–5 days postoperatively for incisions on the head, face, or neck; 6–7 days postoperatively for the lower abdomen or perineum; 7–9 days postoperatively for the chest, upper abdomen, back, or buttocks; and 10–12 days postoperatively for limbs (longer if near joints). Tension-reducing sutures are generally removed around day 14. Suture removal time may be slightly shortened in adolescent patients but delayed in elderly or malnourished patients. Staggered suture removal may also be considered based on the individual patient’s condition.
For primary, fully closed incisions, the healing process should be documented during suture removal. Wound healing may be categorized into three types:
- Clean Wounds (Type I Incisions): These refer to sterile, closed wounds, such as those following subtotal thyroidectomy.
- Potentially Contaminated Wounds (Type II Incisions): These refer to sutured wounds with a likelihood of contamination during surgery, such as gastrectomy. Incisions at body sites that are difficult to fully disinfect, wounds sutured after debridement within six hours, or newly sutured incisions reopened also fall into this category.
- Contaminated Wounds (Type III Incisions): These refer to incisions near infected areas or those directly exposed to contamination or infected material, such as perforated appendectomy wounds or surgeries for bowel obstruction with necrosis.
Wound healing is further graded into three levels:
- Grade A Healing: Denoted by the letter "A," indicating excellent healing with no adverse reactions.
- Grade B Healing: Denoted by the letter "B," referring to wound healing accompanied by inflammatory reactions such as redness, swelling, induration, hematoma, or fluid accumulation but without suppuration.
- Grade C Healing: Denoted by the letter "C," indicating suppuration of the wound, necessitating interventions such as incision and drainage.
This classification and grading system may be applied to monitor and document wound healing outcomes. For example, excellent healing following subtotal thyroidectomy is documented as "I/A," whereas a gastrectomy wound with a hematoma is documented as "II/B." Similar entries can be made for other scenarios.