Postoperative Care

Introduction

• Postoperative care involves a multidisciplinary approach to manage patients after surgery, with the goal of preventing complications and promoting recovery, as recommended by the American College of Surgeons 1

Nutrition and Bowel Function

• The American Society for Parenteral and Enteral Nutrition recommends avoiding routine nasogastric decompression when possible, as its avoidance may reduce the duration of postoperative ileus 2
• Enteral nutrition is preferred over parenteral nutrition when possible, as suggested by the World Journal of Emergency Surgery and Clinical Nutrition 3, 4
• Promote early oral feeding by removing nasogastric tubes, encouraging early oral feeding as soon as the patient is lucid, and considering a progressive diet approach, although the exact approach may vary, as recommended by the World Journal of Emergency Surgery 3 and the American Society for Parenteral and Enteral Nutrition 2
• Oral magnesium oxide may promote postoperative bowel function, though evidence is mixed, and Bisacodyl (10 mg, p.o. twice daily) may improve postoperative intestinal function, according to the Clinical Nutrition guidelines 2
• Avoidance of drainage systems that significantly impair independent mobilization is recommended to stimulate bowel function, as suggested by the Clinical Nutrition guidelines 2
• For patients who can tolerate oral intake, consider liquid feeds as gastric motility may be less deranged for liquids than solids, and implement frequent small meals with low-fat, low-fiber content, as suggested by the European Society of Parenteral and Enteral Nutrition 5
• Monitor for micronutrient deficiencies, particularly iron, vitamin B12, and fat-soluble vitamins, to ensure adequate nutritional support 5

Fluid Management

• Administer an initial fluid bolus of 20 mL/kg in patients with tachycardia and potential sepsis, as recommended by the American Society of Clinical Oncology 6
• Continue IV hydration until pulse, perfusion, and mental status normalize, and monitor fluid balance with a goal of adequate central venous pressure and urine output >0.5 mL/kg/h, as suggested by the American Society of Clinical Oncology 6
• Administer isotonic IV fluids (lactated Ringer's or normal saline) based on degree of dehydration, as recommended by 7, 8
• Avoid fluid overload, as excessive IV fluids can worsen ileus, and administer isotonic IV fluids based on degree of dehydration, as recommended by 2

Pain Management

• Thoracic epidural analgesia is the optimal approach for pain control in ileus, as it effectively prevents and treats postoperative ileus while providing superior analgesia compared to opioid-based regimens, according to the American Society for Parenteral and Enteral Nutrition 2, 9
• Use low-dose concentrations of local anesthetic combined with short-acting opiates for effective pain control, as recommended by 2, 9
• Acetaminophen/Paracetamol is recommended as an adjunct to decrease pain intensity and reduce opioid requirements, with a dosing of 1g IV every 6 hours, as suggested by the Society of Critical Care Medicine 10
• Nefopam is recommended as an opioid-sparing agent, with a dosing of 20mg IV, and has no detrimental effects on intestinal motility, as per the Society of Critical Care Medicine 10

Prevention of Constipation

• Drinking at least 1.5 L of fluids daily can help prevent constipation, with a strength of evidence level of high, as recommended by 11
• Eating small, frequent meals (4-6 meals/day) rather than large meals can help manage postoperative gas and constipation, as recommended by the American Gastroenterological Association 11
• Increasing fiber intake gradually through fruits, vegetables, and whole grains can help prevent constipation, with a strength of evidence level of high, as recommended by 11
• Laxatives may be necessary if other measures fail, with a strength of evidence level of high, as recommended by 11

Monitoring and Complications

• Monitor vital signs every 4 hours, monitor intake and output, and daily abdominal examinations to assess for return of bowel sounds, reduction in abdominal distention, and passage of flatus or stool, as recommended by 7, 8
• Intra-abdominal hypertension is a potential complication of ileus found in up to 20% of critically ill patients, as recommended by 12
• Consider multidisciplinary team involvement for complex cases, including gastroenterologist, pain specialist, and nutritionist, as suggested by Gut 5
• Ensure adequate staffing for IV fluid administration and monitoring, and consider transfer to an acute care facility if the patient shows signs of clinical deterioration, suspected mechanical obstruction requiring surgical intervention, severe electrolyte abnormalities, or evidence of peritonitis or sepsis, to ensure patient safety, as recommended by 7, 8

Surgical Intervention

• Surgical intervention is rarely needed for functional ileus but may be necessary if there is evidence of mechanical obstruction, perforation is suspected, patient shows signs of peritonitis, or clinical deterioration despite medical management, as recommended by the American College of Surgeons 1

Mobilization and Rehabilitation

• Early and regular mobilization can stimulate bowel function, as recommended by the Physical Medicine and Rehabilitation section of the American Academy of Physical Medicine and Rehabilitation, and Clinical Nutrition guidelines, as well as the World Journal of Emergency Surgery guidelines and the ERAS protocols 3, 13, 3

Management of Ileus

Thrombosis Prophylaxis

• The World Health Organization recommends administering venous thromboembolism prophylaxis with Low Molecular Weight Heparin (LMWH) due to the high risk of thrombotic events, as stated in the World Journal of Emergency Surgery guidelines 1