Physician Assistant Exam: How to Care for the Post-Op Patient
The Physician Assistant Exam (PANCE) will expect you to know that when the patient gets out of the OR, your first consideration is ensuring that the patient is hemodynamically stable. Pay attention to the vital signs.
If the blood pressure is low, then he or she needs volume resuscitation to ensure adequate tissue perfusion. Pressors may or may not be needed. Sometimes you need to monitor the patient closely, and a central venous pressure (CVP) monitor or a Swan-Ganz catheter may be necessary.
Over the next several days, the goal is to get the patient eating, sitting up, and walking as soon as possible. Complications can occur post-operatively. In particular, maintaining adequate deep venous thrombosis (DVT) prophylaxis is important for as long as the patient isn’t walking around.
Monitor for fever
A high-yield surgical topic on the PANCE/PANRE is the etiology of fever in the patient post surgery. Not all fever is related to infection. Common causes of fever in the post-surgical patient can include atelectasis as well as DVT — yet another reason DVT prophylaxis is so important! Using the incentive spirometer frequently after surgery prevents atelectasis.
The timing of the fever is important in determining the etiology:
1 to 2 days after surgery: Atelectasis is a very common cause of fever the first day or two after surgery.
3 days after surgery: If the fever persists after 3 days, then examine the surgical sites for any wounds that may be infected. Does the person have a decubitus ulcer? Look at the sacral area to make sure a sacral decubitus isn’t present.
Also look at the urinary tract as a possible source of the fever, and make sure you’re not dealing with a DVT. If you have a high clinical suspicion of a DVT, you may need to order a Doppler ultrasound of the lower extremities.
More than 3 days after surgery: If the fever persists for more than 3 days, then dig deeper. Review the medications. Do you see a rash or peripheral eosinophilia? Sometimes these are signs that the fever is due to a medication. If nothing turns up, again look at the surgical site. You may need to order imaging studies, or the patient may need to go back to the OR.
Reduce the clot risk
Most surgical patients are going to be flat on their backs for at least 24 hours after surgery, depending on the procedure. It may take several days before they’re sitting in a chair, let alone walking around. You need to make sure your patient doesn’t get blood clots. Be aggressive in reducing the risk of a deep venous thrombosis (DVT) in your patient.
Different surgeries have different types of DVT risk. Orthopedic procedures such as hip or knee surgery have a very high risk. The risk also increases with
The person’s age (the older the person, the higher the risk)
The seriousness of the surgery
History of a clotting disorder
History of cancer
Fluids and nutrition
Knowing the principles of managing fluids and nutrition is important not only for test-taking purposes but also for taking care of patients.
If the blood pressure is low, then 0.9 percent saline is usually the first fluid you administer to the patient. It fills the vascular space and can help restore blood pressure but doesn’t provide any free water content.
If after a few days of normal saline you obtain blood work and notice a rising sodium level, switch the saline to a more hypotonic fluid to give more free water, especially if the patient is still NPO or has a nasogastric tube and is being suctioned. If the patient can’t drink water, you need to provide it intravenously.
Examples of more hypotonic solutions include 0.45 percent saline and D5W. Think of the 0.45 percent saline as a hybrid bag, providing half sodium and half free water. D5W is a very dilute solution providing only free water. Think of it as the equivalent of water you’d drink from the tap.
Nutrition is especially important in the post-operative period. Many patients don’t eat well prior to coming to the hospital, especially if they have abdominal complaints. If the patient is unable to take nutrition PO, then your options are to either administer tube feedings or to provide intravenous nutrition (TPN/total parenteral nutrition). Here are two key points about providing nutrition:
Remember the law of the gut: If you have it, use it.
Patients after surgery are catabolic and have greater caloric needs and protein requirements. When you prescribe TPN, make sure you’re meeting that person’s caloric needs and providing the optimal number of calories from protein, calories, and lipids. Without nutrition, the patient won’t be able to heal properly.
You are on the surgical service and are evaluating a 55-year-old man in the ICU admitted with acute upper gastrointestinal bleeding. On admission, his vitals are the following: blood pressure 82/40 mmHg, heart rate 120 bpm. The monitor shows sinus tachycardia. You’re waiting for blood to be brought up from the blood bank. Given the above vital signs, which of the following would you do next?
(A) Administer a beta blocker for the tachycardia.
(B) Give a fluid bolus with normal saline.
(C) Administer D5W to provide for free water needs.
(D) Give 0.45 percent saline at 70 mL/hr with no bolus.
(E) Give intravenous dextran.
The correct answer is Choice (B). This patient is in hypovolemic shock. You need to give isotonic (normal) saline to fill the vascular space. You wouldn’t give a beta blocker because the tachycardia is compensatory for the acute blood loss.
If the patient were hypernatremic, then you’d administer D5W, but it has no role in volume repletion. Intravenous dextran isn’t used much, if at all; if anything, it can increase bleeding risk. The 0.45 percent saline, although it provides some volume, isn’t aggressive enough for volume resuscitation for a patient in hypovolemic shock.