Chapter 33 – General Principles of Postoperative Recovery




Chapter 33 General Principles of Postoperative Recovery


Giampaolo Ugolini and Federico Ghignone




Variability is the law of life, and as no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike under the abnormal conditions which we know as disease.


Sir William Osler (1849–1919)



Introduction


The outcomes for elderly patients are strongly correlated to the perioperative care offered when surgery is planned. Treatment tolerance may be impaired in many elderly patients, mostly when physical status is low (Braga et al. 2017); hence, the postoperative period, with prevention strategies for surgical and medical complications, is crucial in promoting a safe, rapid recovery. Before planning surgery, the healthcare team should be aware of comorbidities and functional reserve, and, in accordance with the prehabilitation principles (see Chapter 12), preoperative optimization of general medical conditions should be carried out whenever possible. The lack of adequate preoperative information and family involvement (see Chapter 10) has a detrimental impact on patient acceptance and compliance toward treatments proposed after surgery.


Compared to younger patients, the elderly need a tailored postoperative care pathway, since their needs could be totally different, such as postoperative fluids, nutrition and physical therapy support. Even the ward setting should be planned to host elderly surgical patients; for example, an “unlimited access” policy should be adopted for caregivers to prevent disorientation and reduce the risk of delirium. All surgical tubes, catheters, drains and invasive monitoring devices should be removed as soon as possible. Prompt restoration of preoperative conditions, such as diet, preoperative medications and ambulation, should be encouraged. Malnutrition, prolonged bed rest and delirium are correlated with a higher risk of complications (above all pulmonary complications and urinary tract infections) and mortality in elderly patients; careful evaluation of the risk factors should be undertaken and strategies should be adopted to reduce postoperative events.


Early mobilization, aggressive physical therapy and nutrition play a key role in this context, and also in preventing pressure ulcers and overall functional decline. The entire healthcare team should be involved in a collaborative approach towards elderly patients in order to tailor the optimal perioperative management pathway, which will ultimately influence their functional recovery.



Intake-Output Balance and Postoperative Hydration


The goal of maintenance fluid therapy in surgical patients is to preserve water and electrolyte balance, to provide nutrition and to maintain a euvolemic state. Intravenous fluids should be withdrawn and oral fluid intake started as soon as possible. For patients who require maintenance of intravenous fluids, have normal or near-normal renal function and are otherwise stable, it is suggested to begin with one-half isotonic saline in 5% dextrose to which 20 mEq/l potassium chloride is added. Balanced salt solutions are even more “physiological.” Dextrose is helpful for patients who are fasting to provide enough carbohydrates to prevent proteolysis.


When intravenous fluids must be maintained, a 1–1.2 ml/kg/h infusion rate should be considered as the standard of care (approximately 1700–2000 ml/24 h for a 70 kg patient), avoiding fluid overload, especially in patients with significant cardiac problems. Electrolyte balance should be maintained carefully, especially for sodium, potassium, magnesium, calcium and phosphorus; any alteration must be promptly identified and corrected.


Fluid balance is a critical element in the postoperative management of elderly patients. Major surgery requires accurate input and output measurements, at least for the first five postoperative days. In patients with normal renal function, urine output is considered normal when it is between 0.5 ml/kg/h and 1 ml/kg/h; this should be considered to be the endpoint of fluid resuscitation, in addition to the normalization of vital signs. However, oliguria as low as 0.3 ml/kg over 24 hours could be a physiological response to surgery, and the need for additional intravenous fluid boluses should be assessed within the clinical context. Timely identification and the correction of postoperative oliguria is crucial because acute oliguric renal failure is strongly associated with poorer outcomes (Biteker et al. 2014).


A Foley catheter should be discontinued as soon as possible in the postoperative period (possibly within 24 hours) to reduce the risk of urinary tract infections (UTIs). It is well known that UTI incidence is one of the most frequent postoperative events, especially in the elderly population, with a significant increase in healthcare costs and patient distress (Wald et al. 2008). However, in certain situations a precise evaluation of urine output is mandatory, requiring invasive monitoring (Box 33.1).




Box 33.1 Indications for an indwelling urinary catheter in the postoperative setting





  • Patients undergoing extensive pelvic surgery



  • Need for careful postoperative monitoring of urinary output for patient-related medical conditions (e.g., renal impairment, cardiac/pulmonary dysfunction)



  • Need for monitoring of urine output in critically ill patients (e.g., hemodynamically unstable patients)



  • Need for promotion of healing of pressure ulcers in incontinent patients (alternative strategies should always be considered)



  • Patient preference for improving comfort



Urinary catheters should never be considered as an alternative to proper nursing care. All output should be carefully monitored, taking into account that, in certain situations, the maintenance of fluid and electrolyte balance could require intensive correction (e.g., postoperative ileus with elevated nasogastric tube output, high ostomy output, enterocutaneous fistula, fever).



Postoperative Nutrition


Up to 40% of elderly, hospitalized patients present with signs of malnourishment and several studies have demonstrated an association with postoperative adverse events and risk of death (Huisman et al. 2015). Whenever possible in the postoperative period, oral feeding should always be preferred to enteral or parenteral nutrition. Only patients expected to have inadequate energy or fluid intake for more than one to two weeks should be considered for nutritional support. Nutritional supplementation, particularly with high protein content, can reduce the risk of developing pressure ulcers. For individual patients, the need for nutritional support can be influenced by several factors (Table 33.1).




Table 33.1 Factors correlated to the need for postoperative nutritional support












  • Age



  • Pre-existing malnutrition



  • Cancer



  • Preoperative dysphagia




  • Severity of surgical procedure



  • Comorbidities



  • Length of time before oral nutrition



Oral Feeding


The oral intake of fluids and food should be started on the day of surgery or as soon as possible thereafter, depending on the type of procedure and anesthesia performed. The need for postoperative intravenous fluids beyond 12–24 hours is rarely needed in an uncomplicated recovery after minor to medium surgery, colorectal and hepatic surgeries included. When starting oral feeding, elderly patients should be carefully evaluated for their ability to take in, chew and swallow food, and to tolerate sufficient nutrition. The healthcare team and the caregivers should be aware of the risk of aspiration, and a tailored dietary evaluation and swallowing assessment should be undertaken when necessary. Several organizational issues could become obstacles to regular oral intake leading to malnutrition (Table 33.2).




Table 33.2 Organizational issues determining reduction in oral diet intake












  • Failure to help patients to eat



  • Failure to recognize malnutrition risk



  • Inadequate education of staff and caregivers regarding the pivotal role of nutrition



  • Unappetizing food or lack of personalized dietary regimens




  • Leaving patients in bed too long



  • Lack of staff



  • Inappropriate drug prescription



  • Lack of adequate facilities for meal consumption (e.g., dining room)


Simple precautions must be adopted when feeding any elderly patients after surgery:




  • check patient for mental status alteration/alertness



  • involve caregivers or healthcare staff at meal times (the time needed to feed elderly patients can be much longer compared to younger patients)



  • keep dentures easily accessible



  • promote strategies to keep patients sitting while consuming their meal and for at least for one hour after



  • quantify the daily amount of food and liquids intake.


The prevalence of dysphagia in the elderly population varies from 5–20%; the incidence in those who live in assisted facilities and nursing homes could be as high as 50–60% (Rofes et al. 2011). A preoperative assessment of dysphagia may be necessary to plan intraoperative/postoperative strategies to prevent malnutrition (e.g., dietary consultation, oral nutritional supplementation, placement of feeding tubes after major procedures). Several dysphagia assessment tools are available and can be used in daily practice, such as the EAT-10 swallowing tool (Belafsky et al. 2008).



Enteral Nutritional Support


When malnourishment or risk of limited oral intake are present, the use of oral nutritional supplementation should be considered in order to maintain or improve nutritional status. Flavored high-energy protein drinks three times a day are safe and can bridge the postoperative period by restoring a normal diet to ensure protein and calorie intake early in the recovery process. Food fortification, intended as an increased concentration of macronutrients, is considered a reliable strategy for preventing postoperative undernourishment in elderly people, given their often small appetites. They are usually 200–250 ml in volume with approximately 150 kJ/100 ml of carbohydrates and 3–6 g/100 mL of protein, with the addition of vitamins, minerals and trace elements.


When oral feeding is not possible, enteral nutrition should be considered and administered with nasogastric tubes or directly into the stomach or small bowel with feeding tubes. Complete bowel rest produces atrophy of the intestinal mucosa after only a few days of fasting. In particular, proteins and glutamine play a key role as primary nutrients for the mucosal epithelium. The presence of nutrients in the bowel lumen preserves the trophic effect on the mucosal barrier, which prevents luminal organisms from entering the blood stream. The mechanism of bacterial translocation is well recognized as a common source of sepsis in elderly, hospitalized patients and is considered the initial step leading to multiorgan failure (Sigalet et al. 2004). The main indications and contraindications of enteral tube feeding are indicated in Table 33.3.




Table 33.3 Indications and contraindications for full enteral support with tube feeding in the postoperative period













Indications Contraindications



  1. Malnourished patients unable to tolerate oral diet for at least five days



  2. Well-nourished patients unable to eat for 7–10 days



  3. Patients after massive small bowel resection



  4. Patients with neurological dysphagia



  5. Patients with moderate to severe dementia



  6. Low output enterocutaneous fistula (< 500–600 ml/24 h)




  1. Clinical shock



  2. Bowel obstruction



  3. Intestinal ischemia



  4. Prolonged ileus



  5. Severe diarrhoea



  6. High output enterocutaneous fistula


Nasogastric tubes should be avoided whenever possible to limit patient discomfort and the risk of pulmonary complications (e.g., aspiration pneumonia). Correct tube placement and a check of the tube position is mandatory before starting tube feeding. A percutaneous endoscopic gastrostomy can be positioned preoperatively to improve nutritional condition before surgery in severely malnourished patients or in well-nourished patients scheduled for extensive head and neck procedures (glossectomy, pharyngo-laryngectomy, etc.) when dysphagia will occur postoperatively. A feeding jejeunostomy could be beneficial to patients undergoing major gastrointestinal surgery, such as esophagectomy or pancreaticoduodenectomy; the feeding tube can be placed intraoperatively and can be used for enteral nutrition soon after surgery.



Total Parenteral Nutrition (TPN)


TPN is currently considered only when the period of fasting and loss of bowel function could be prolonged due to surgical issues. The risks of an intravenous route and the benefit of enteral feeding should always be considered before starting TPN. Complications can develop in more than 50% of patients receiving TPN, mainly related to intravenous catheters, to the biochemical/metabolic effects of the TPN solution and bowel atrophy/bacterial translocation or acalculous cholecystitis (Braga et al. 2009).


Even if there is no evidence of how many days of fasting could be tolerated without complications, it is suggested that parenteral support is not started before five to seven days after surgery. When TPN is considered inevitable, a nutritional specialist should be involved to tailor the composition of the solution and to consider the type of intravenous access (short-term central venous catheter, peripherally inserted central catheter, Hickman/Broviac catheter, etc.).



Principles of Blood and Hemo-derivate Transfusion


Preoperative anemia and intraoperative extended blood loss are correlated with a higher risk of morbidity (Wu et al. 2007). Thus, preoperative correction of a low hemoglobin level should be considered, taking into account the concurrent risk of blood transfusion-related adverse events (volume overload, immunosuppression, lung injury, etc.) There is still no consensus regarding the ideal threshold for transfusing elderly patients preoperatively. Nevertheless, the National Institute of Health (NIH) Consensus Statement on Perioperative Red Cell Transfusion and the American Society of Anesthesiologists practice guidelines (ASA 2006) suggest that red blood cell transfusion is usually indicated in patients with hemoglobin values of 7 g/dl or less and is rarely indicated in patients with hemoglobin values >10 g/dl. Furthermore, a retrospective analysis including 239,286 elderly patients who underwent major non-cardiac surgery suggested that a preoperative hematocrit level <24% requires red cell transfusion since a statistically significant reduction in short-term mortality was observed (Wu et al. 2010). Increased risk of death and postoperative complications were, instead, observed in patients with hematocrit levels >30% who were perioperatively transfused. The same study concluded that elderly patients having intraoperative blood loss <500 ml should not be considered for transfusion.


Since it is well demonstrated that elderly patients have the same oncological survival for the first two years after surgery as younger patients, a “liberal transfusion policy” should be avoided in order to reduce the risk of immunosuppression associated with blood transfusion and worse oncological outcomes (Amato and Pescatori 2006).


Other blood products (plasma, platelets and albumin) are rarely used and are limited to specific clinical situations, such as severe liver failure, septic/volemic shock unresponsive to crystalloid loading, coagulopathies and low platelet counts (<20 × 109/l).

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Jan 16, 2021 | Posted by in ANESTHESIA | Comments Off on Chapter 33 – General Principles of Postoperative Recovery
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