Immediate Postoperative Care
Friday, March 6, 2009
The postoperative care of surgical neonates and children begins upon completion of wound closure. The level of postoperative care administered is dependent upon the procedure performed but some general guidelines are provided below. Specific guidelines for postoperative management of many pediatric surgical conditions are provided throughout this handbook.
Wound and Dressing Care
Prior to the removal of the sterile surgical drapes, the skin surrounding the surgical wound is cleansed with warm saline-soaked sponges or lap pads to remove any debris, blood, or prep solutions surrounding the wound. The area is gently padded dry and a sterile towel or dressing is placed over the wound to prevent contamination at the time of drape removal. The type of dressing applied to surgical wounds is selected according to surgeon preference, the type of wound created, and the method of closure. For clean procedures, a dry, sterile dressing (i.e., gauze, steristrips, Opsite®, Tegrederm®) is suitable. Antibiotic ointments and other wound applicants are generally not necessary. To minimize the stress and pain of later dressing removal, dressings are secured in position with the minimal amount of tape or occlusive barrier that achieves coverage of the wound.
Extubation and Transfer
Intraoperative monitoring devices should be left in place until after extubation. A physician member of the surgical team should be present at the time of extubation and assist in the transfer of the pediatric surgical patient to the postanesthesia care unit or appropriate intensive care unit. If respiratory rate or inspiratory tidal volumes are inadequate, the child should be observed in the OR until breathing has improved. Special attention to body temperature and measures to prevent hypothermia after drape removal should be instituted including infrared heating lights, wrapping with warm blankets, and increasing the ambient room temperature.
Postoperative Orders
The postoperative orders are individualized for each patient. In general, outpatient procedures will require only simple postoperative care and specific wound care instructions for the parents. Arrangements for office follow-up visits are discussed. A general outline for writing postoperative orders in postsurgical pediatric patients is provided below.
Admission Order
Specific information regarding the type of bed and/or location within the hospital to which the patient goes after recovery is listed. Arrangements for intensive care unit beds are made preoperatively. If observation status or discharge from the recovery unit is desired, specific instructions regarding wounds, medications, and anticipated clinical course/problems are provided to the parents or primary caregiver.
Attending Physician and Consultants
List the attending physician and all consultants who will participate in the care of the patient. In addition, one specifies which physician(s) and/or service(s) will be the primary providers of postoperative care and orders. The nursing staff must be clearly informed regarding who is contacted for questions about care and for any problems that arise.
Diagnosis
List the primary diagnosis and/or the procedure that has been performed.
Allergies
List any known drug allergies or other sensitivities (i.e., latex, tape, antibiotics, pain medications, etc.)
Admission Weight
The patient’s preoperative weight is specified. This is the weight that is used to calculate medication dosages, fluids, nutritional requirements, etc.
Vital Signs
Provide instructions for the frequency at which vital signs are monitored and recorded. Parameters for changes in vital signs that require notification of the surgical team are clearly specified.
Monitoring Equipment
List any special monitoring devices that are appropriate for postoperative care including pulse oximetry, apnea and/or cardiac monitors, etc.
Ventilator Settings and Respiratory Care
For patients requiring postoperative ventilatory support, specific instructions regarding ventilator mode, tidal volume, peak inspiratory pressure, inspired oxygen concentration, etc. are provided. If other respiratory interventions (i.e., nebulizers, chest physiotherapy, frequent suctioning) are required, specific written orders are made.
Intravenous Fluids
Maintenance and replacement fluid orders are provided.
Diet
Special diets (i.e., clear liquids, general diet) or oral restriction (i.e., NPO) are specified, including orders for initiation of enteral tube feedings when applicable.
Activity
Level of activity and/or restriction (i.e., bedrest, ambulation, etc.) is specified. Physical therapy may be helpful to some hospitalized patients and is initiated when appropriate.
Medications
All medications including doses, routes of administration, and frequencies of administration are recorded clearly and accurately. Analgesic and antiemetic medications are ordered when appropriate. Doses are calculated on a per weight basis.
Wound Care
Special instructions for dressing care or surgical wounds are provided when applicable.
Drains
Drain care orders include specific requests for suction, stripping, frequency of emptying, and quantification of output. Nasogastric tubes are placed to suction or gravity drainage according to attending surgeon preference. Foley catheters are placed to gravity drainage.
Special Studies
Any radiographic exams or follow-up studies are specified, and the radiology department and/or attending radiologist should be notified of all requests. Chest radiographs are obtained in the recovery room or intensive care unit for all patients who remain intubated or who had intraoperative placement of central venous lines or catheters.
Laboratory Tests
Routine laboratory testing is often not necessary in pediatric surgical patients, especially those who have procedures in the surgicenter and are discharged shortly after surgery. Specific laboratory studies are obtained if the results are expected to alter clinical management of the patient. Laboratory tests are often indicated in children who undergo extensive and complicated procedures.
Pain Management
Achieving adequate pain relief is important in children, although children often do not or cannot complain specifically of pain. Pain may adversely affect recovery of infants since painful stimuli may result in decreased arterial saturation and increased pulmonary vascular resistance. Effective pain control allows earlier ambulation and faster recovery in older children.
Local anesthetics administered in the operating room can provide prolonged pain control. Local wound infiltration or regional nerve blocks with bupivicaine (Sensorcaine®) provide pain control for 4-6 hours following an operation. The maximum dose is 3 mg/kg given as a 0.25–0.75% solution.
For larger operations, intravenous narcotics provide excellent pain control. Liberal use of patient controlled analgesia devices and epidural catheters improve postoperative pain control after many abdominal or thoracic operations.
Wound and Dressing Care
Prior to the removal of the sterile surgical drapes, the skin surrounding the surgical wound is cleansed with warm saline-soaked sponges or lap pads to remove any debris, blood, or prep solutions surrounding the wound. The area is gently padded dry and a sterile towel or dressing is placed over the wound to prevent contamination at the time of drape removal. The type of dressing applied to surgical wounds is selected according to surgeon preference, the type of wound created, and the method of closure. For clean procedures, a dry, sterile dressing (i.e., gauze, steristrips, Opsite®, Tegrederm®) is suitable. Antibiotic ointments and other wound applicants are generally not necessary. To minimize the stress and pain of later dressing removal, dressings are secured in position with the minimal amount of tape or occlusive barrier that achieves coverage of the wound.
Extubation and Transfer
Intraoperative monitoring devices should be left in place until after extubation. A physician member of the surgical team should be present at the time of extubation and assist in the transfer of the pediatric surgical patient to the postanesthesia care unit or appropriate intensive care unit. If respiratory rate or inspiratory tidal volumes are inadequate, the child should be observed in the OR until breathing has improved. Special attention to body temperature and measures to prevent hypothermia after drape removal should be instituted including infrared heating lights, wrapping with warm blankets, and increasing the ambient room temperature.
Postoperative Orders
The postoperative orders are individualized for each patient. In general, outpatient procedures will require only simple postoperative care and specific wound care instructions for the parents. Arrangements for office follow-up visits are discussed. A general outline for writing postoperative orders in postsurgical pediatric patients is provided below.
Admission Order
Specific information regarding the type of bed and/or location within the hospital to which the patient goes after recovery is listed. Arrangements for intensive care unit beds are made preoperatively. If observation status or discharge from the recovery unit is desired, specific instructions regarding wounds, medications, and anticipated clinical course/problems are provided to the parents or primary caregiver.
Attending Physician and Consultants
List the attending physician and all consultants who will participate in the care of the patient. In addition, one specifies which physician(s) and/or service(s) will be the primary providers of postoperative care and orders. The nursing staff must be clearly informed regarding who is contacted for questions about care and for any problems that arise.
Diagnosis
List the primary diagnosis and/or the procedure that has been performed.
Allergies
List any known drug allergies or other sensitivities (i.e., latex, tape, antibiotics, pain medications, etc.)
Admission Weight
The patient’s preoperative weight is specified. This is the weight that is used to calculate medication dosages, fluids, nutritional requirements, etc.
Vital Signs
Provide instructions for the frequency at which vital signs are monitored and recorded. Parameters for changes in vital signs that require notification of the surgical team are clearly specified.
Monitoring Equipment
List any special monitoring devices that are appropriate for postoperative care including pulse oximetry, apnea and/or cardiac monitors, etc.
Ventilator Settings and Respiratory Care
For patients requiring postoperative ventilatory support, specific instructions regarding ventilator mode, tidal volume, peak inspiratory pressure, inspired oxygen concentration, etc. are provided. If other respiratory interventions (i.e., nebulizers, chest physiotherapy, frequent suctioning) are required, specific written orders are made.
Intravenous Fluids
Maintenance and replacement fluid orders are provided.
Diet
Special diets (i.e., clear liquids, general diet) or oral restriction (i.e., NPO) are specified, including orders for initiation of enteral tube feedings when applicable.
Activity
Level of activity and/or restriction (i.e., bedrest, ambulation, etc.) is specified. Physical therapy may be helpful to some hospitalized patients and is initiated when appropriate.
Medications
All medications including doses, routes of administration, and frequencies of administration are recorded clearly and accurately. Analgesic and antiemetic medications are ordered when appropriate. Doses are calculated on a per weight basis.
Wound Care
Special instructions for dressing care or surgical wounds are provided when applicable.
Drains
Drain care orders include specific requests for suction, stripping, frequency of emptying, and quantification of output. Nasogastric tubes are placed to suction or gravity drainage according to attending surgeon preference. Foley catheters are placed to gravity drainage.
Special Studies
Any radiographic exams or follow-up studies are specified, and the radiology department and/or attending radiologist should be notified of all requests. Chest radiographs are obtained in the recovery room or intensive care unit for all patients who remain intubated or who had intraoperative placement of central venous lines or catheters.
Laboratory Tests
Routine laboratory testing is often not necessary in pediatric surgical patients, especially those who have procedures in the surgicenter and are discharged shortly after surgery. Specific laboratory studies are obtained if the results are expected to alter clinical management of the patient. Laboratory tests are often indicated in children who undergo extensive and complicated procedures.
Pain Management
Achieving adequate pain relief is important in children, although children often do not or cannot complain specifically of pain. Pain may adversely affect recovery of infants since painful stimuli may result in decreased arterial saturation and increased pulmonary vascular resistance. Effective pain control allows earlier ambulation and faster recovery in older children.
Local anesthetics administered in the operating room can provide prolonged pain control. Local wound infiltration or regional nerve blocks with bupivicaine (Sensorcaine®) provide pain control for 4-6 hours following an operation. The maximum dose is 3 mg/kg given as a 0.25–0.75% solution.
For larger operations, intravenous narcotics provide excellent pain control. Liberal use of patient controlled analgesia devices and epidural catheters improve postoperative pain control after many abdominal or thoracic operations.
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