Safety after Surgery

• General surgery without clinical risk factors for thrombosis: Give low-dose unfractionated heparin two hours before and every 12 hours after the operation;
• General surgery with any clinical risk factors such as prolonged immobilization or paralysis, obesity, varicose veins, congestive heart failure, or pelvic or leg fractures: Administer low molecular weight heparin (LMWH) or low-dose unfractionated heparin every eight hours. If the patient is also prone to bleeding or infection, intermittent pneumatic compression (IPC) can be used instead;
• General surgery with multiple clinical risk factors or with a history of previous deep vein thrombosis, malignancy, stroke, spinal cord injury, or hip fracture: Use low dose unfractionated heparin or LMWH combined with intermittent pneumatic compression; for very high risk patients, perioperative warfarin is an alternative;
• Total hip replacement: Give postoperative LMWH every 12 hours; initiate low-intensity warfarin therapy—to keep International Normalized Ratio of 2-3—preoperatively or immediately postoperatively;
• Total knee replacement: Administer postoperative LMWH every 12 hours. IPC is the most effective non-pharmacologic regimen and is comparable to LMWH. Low-intensity warfarin can also be used; and
• Hip fracture repair: Start preoperative fixed-dose LMWH or low-intensity warfarin.

Urinary Retention

The incidence of postoperative urinary retention in elderly patients has been reported to be as high as 87%. Factors contributing to the development of this complication include immobility, analgesics and opiates, intravenous hydration, and general anesthesia. Urinary retention can lead to overflow incontinence and urinary tract infection and is associated with a decline in function and nursing home placement. The first indication of urinary retention may be a diminished urinary output after removal of an indwelling catheter, overflow incontinence, or the frequent voiding of small amounts of urine.

Urinary retention is treated with catheterization. This prevents bladder distension, which leads to reduced detrusor contractile function, and helps restore preoperative bladder function.

Recent studies have found that normal voiding resumes earlier with the use of intermittent catheterization (if begun at the onset of urinary retention and repeated every six to eight hours) than with the use of an indwelling catheter. Additionally, the use of indwelling catheters in the elderly after the immediate perioperative period is associated with an increased risk of urosepsis and a more dependent postoperative functional status.

Conclusion

The 65-and-up age group is the fastest growing section of the United States population. The vast majority of complications for this age group occur in the postoperative period. It’s important for hospitalists to remain involved in key areas of postoperative complications in the geriatric population—specifically, delirium, ileus, nutritional deficiencies, respiratory complications—including pulmonary embolism—and urinary retention. TH

Jill Landis is a frequent contributor to The Hospitalist.

References

1. Souders JE, Rooke GA. Perioperative care for geriatric patients. Ann Long Term Care. 2005;13(6):17-29.
2. Williams SL, Jones PB, Pofahl WE. Preoperative management of the older patient—a surgeon’s perspective: part I. Ann Long Term Care. 2006;14(6):24-30.
3. Palmer RM. Management of common clinical disorders in geriatric patients: delirium. ACP Medicine Online. June 7, 2006. Available at: www.medscape.com/viewarticle/534766. Last accessed January 11, 2007.
4. Manku K, Bacchetti P, Leung JM. Prognostic significance of postoperative in-hospital complications in elderly patients. I. Long-term survival. Anesth Analg. 2003 Feb;96(2):583-589.
5. Watters JM, McClaran JC, Man-Son-Hing M. The elderly surgical patient: introduction. ACS Surgery Online. June 7, 2006. Available at: www.medscape.com/viewarticle/535461?rss. Last accessed January 11, 2006.
6. Skelly JM, Guyatt GH, Kalbfleisch R, et al. Management of urinary retention after surgical repair of hip fracture. CMAJ. 1992 Apr 1;146(7):1185-1189.
7. Wittbrodt E. The impact of postoperative ileus and emerging therapies. Pharm Treatment. 2006 Jan;31(1):39-59.