#. General post-op template

S:
Date of Service:

General:
Acute complaints:

Diet: PO intake w/o n/v.
GI: +BM, +flatus
GU: urinating
Infection: no F/C, no drainage
Pain: well-managed, rx:
ADLs: ambulating

O:
VS:
I/Os:

PE:
General: afebrile, comfortable in bed
Pulm:
CV:
Abdo: bowel sounds, tension, guarding
Surgical: incision site



A+P:
POD# s/p
#. Pain:
#. ADLs:
#. I/Os:

PPx: VTE, GI
Diet:
Disposition:

#. Operative Clearance / Risk
see Clinic >
Surgery Clearance


#. Abx PPx

Pre-Op Antibiotics: Ancef (non-abd), ancef + flagyl (abd), vanc if MRSA

Bite: Timentin/Augmentin
Cellulitis: Ancef (non-MRSA); Vanco (MRSA) other choices Bactrim, Clinda, Linezolid
NSTI: PCN, Gent (or Cipro), clind, +/- Vancomycin
Biliary tree: Unasyn
Diverticulitis: Cipro/Flagyl (many choices)
Intra-adbominal Infection: Unasyn, Zosyn (if think pseudomonas), Imipenem
UTI: Cipro or Bactrim Community acquired pna: Moxiflox or Augmentin or Ceftriaxone.
VAP: see protocol for each institution Time Courses: Often vary so always discuss with attending. VAP: 8 days UTI: Uncomplicated: 3 days; Complicated: (foley, men, manipulated): 7-10days Line infection: remove line and treat Bacteremia: 14 days Intraabdominal abscess: Until afebrile with normal wbc + 1-2 days



#. VTE Management
Cat 1:
fractures of long bones, pelvis, spine (with or without neurologic deficits) : LMWH + SCD + duplex
Cat 2: age>40, major venous injury, prolonged immobilization, CNS injury (GCS<10 without CNS bleed), femoral venous lines, multisystem injury, previous history of DVT, oral contraceptive agents/estrogens, active malignancy : UFH SC + SCD
Category III: CNS injury (GCS<10 w/CNS bleed), nonoperative hepatic or splenic injury: SCD

#. Pain Management
Morphine 2-10mg IVP q1h PRN Preferred agent for most patients
Fentanyl 25-100mcg IVP q30min PRN Alternative if: HD instability, Renal insufficiency


#. Post-op fever
• >100.4 is common post-op.
• immediate (hrs), acute (1st wk), subacute (1-4wks), delayed (>1 mo)
• immediate: rxn to surgical rx / blood products, tissue trauma (typically resolve 2-3 days)
• acute: SSI (surgical site infection), PNA, UTI (esp w/ foley), PE / MI etc. also.
• subacute: lines, rx allergies, VTE / thrombophlebitis

Wind:
Atelectasis (most common POD #1-2), pneumonia
Water: UTI (POD#3-5)
Wound: infection (POD4-7)
Walking: DVT, PE
Wonder Rx: reaction

#. Fluids & Electrolytes
Blood loss and 3rd spacing: 3rd spacing is fluid accumulation in tissue interstitium and in the bowel lumen, typically occurring for 24-48 h following surgery. Replace with isotonic solution (NS or LR). Typically resolves on day 3 when this fluid shifts back into the intravascular space, at which time overhydration can be a problem (particularly in heart failure pts). Diuresis typically occurs with this fluid shift on post-op day 3.

References
Washington University Surgery Survival Guide
Surgery Wiki