THE POSTOPERATIVE EVALUATION

Different hospitals have varying models regarding medical consultation.  Some medicine consult services predominantly perform preoperative evaluations; others also work in the inpatient setting providing postoperative expertise.  This section is for those medical consultants who provide care postoperatively.

PACU (Post Anesthesia Care Unit) Assessment:
Assessing patients in the Post Anesthesia Care Unit following surgery provides a great opportunity to avert problems and enhance continuity of care.

• Vital signs: 
1. Check the temperature.  Postop patients are often hypothermic which increases their risk of complications.  The nurses are usually attuned to this and will put a warming blanket (Bair Hugger) on the patient.
2. Patients may have transient hypertension due to pain.  Make sure the pain is acceptably controlled before aggressive BP management.  Shivering can also lead to a spuriously elevated BP reading on the automatic BP cuff.  When in doubt, check it manually.
• Chart review:  Did the patient receive the surgery that was planned, or were there unanticipated changes or complications?  Check the estimated blood loss (EBL).  This can be found on the anesthesia record, the op report (if available), or from verbal report to the PACU RN.
• History and exam:  Ask patients about chest pain, shortness of breath, nausea, and level of pain.  Remember that they are still coming out of anesthesia so that a negative response does not necessarily mean there is no problem.  Don’t let a lack of chest pain steer you away from ordering an ECG and cardiac enzymes on a patient at substantial risk for postop MI.
• Management:  Check the surgeon’s orders to make sure the medications are correct and that your preop recommendations are being followed.  Common items to review:
• Diabetes management:  check insulin orders
• Cardiovascular medications:  check for correct hold parameters for blood pressure meds and beta-blockers. 
• If you write orders (after discussion with the primary team), make sure to let the patient’s nurse know—often the admission orders have already been sent to the floor, and new orders may be missed in the loose stacks of papers.

If the patient’s condition warrants a change in post PACU care (ICU or telemetry), make those recommendations and call the primary team.

Daily postop evaluation:

• Review interval history, examination, medication list, labs/studies as you would any medical patient.
• Review drains and catheters—these may not be as common in medical patients
• What is the surgery team’s plan?  Discuss with the surgery team if in doubt.
• All patients:  is there appropriate VTE prophylaxis?
• Lung expansion maneuvers: are they indicated, and if so, being done?
• Pay attention to side effects of pain medications and sedatives.
• Comment on each problem you are asked to evaluate, especially the medical concerns.
• Know the patient’s current and anticipate bowel function status and whether they are able to receive PO medications.

If you’ve never seen the patient before:
For the new postop consult, the above information still needs to be gathered.  In addition, make sure you:

• Obtain the information for the requesting provider (name, service, contact number).
• Understand the clinical question clearly.
• Give the requesting provider a time frame in which you expect to see the patient and contact them.
• Review the surgery—were there complications?  What was the duration, EBL, method of anesthesia?
• Postop course to date—have there been complications?  Is the recovery going as expected?  You should have a general sense of the length of stay, average blood loss, and recovery period for the procedure—see “Surgery Notes” and keep in mind there may be site-specific and patient-specific differences, and of course, if in doubt—ask your surgical colleagues.
• You may need to seek other collateral information—the patient may have postop delirium or still be recovering from anesthesia.  If you need better history, you may need to seek out the patient’s family, the surgeon, and nursing staff.  The preop med list is not always correct if there was no formal medical consultation preop—you may need to double check the patient’s baseline meds.

 

 

Updated May 2011