The period following surgery can be as trying as the nervous anticipation that always precedes the operation. The information in Chapter 5 was designed to prepare you for surgery, the information contained in this chapter should help you know what to expect in the period immediately after your operation. Remember again, the postoperative care of each patient is as individualized as the patient. The following description provides a rough estimation of what you can expect after your operation, and why the things which happen are important.
The experience of postoperative pain is varied and depends upon many things, including your personal tolerance to pain, the location of your operative incision, and the type of pain control prescribed. Some people have a high tolerance to pain, and I have seen people undergo major operations without using any postoperative pain medication. I have also seen people suffer tremendously after small procedures. You can not, in all likelihood, change your tolerance to pain. You can, on the other hand, use the medications currently available to manage your discomfort successfully. Many patients, particularly those over 60, feel that the use of pain medication is dangerous, a sign of weakness, or addictive. Let me clear up this myth right now: pain medication, when properly utilized, is a safe and important part of your postoperative care. The real danger in the postoperative phase is a lack of pain control. Pain causes several spontaneous responses, including elevation of blood pressure, increase in heart rate, decrease in lung expansion, and splinting (or decrease in spontaneous movement). These responses place additional stress on your heart; and in patients who have coronary artery disease, it may increase the chance of suffering a heart-related complication. Decreased lung expansion predisposes you to areas of lung collapse (called atalectasis), which in turn causes fever and increases the risk of pneumonia. Splinting aggravates the process of atalectasis and also contributes to the development of blood pooling and thus increases the likelihood of blood-clot formation in the veins (particularly in the legs). These blood clots, in turn, increase the risk of the potentially fatal complication of pulmonary embolus (when a blood clot breaks off and travels to the lungs, causing failure of gas exchange in the lung).
Thus, good pain control is important to ensure a quick and normal recovery. To maintain good pain control, sufficient medication must be administered at the proper time interval. A general rule of thumb is that you should be able to take a deep breath and get up and walk without experiencing severe pain. It is frequently impossible to give enough medication to remove all discomfort, so you should expect that you will experience some for the first several days after the operation. With that said, here is a quick explanation of how both drug dose and time between doses are important in achieving adequate pain control. For the most part, we are talking about narcotic analgesics (derivatives of morphine), which constitute the mainstay of postoperative pain medication. These drugs work by providing a certain level of drug in your bloodstream. Immediately after taking the drug, either by the intravenous or oral route, the level in the blood rises until all of the drug has been absorbed. This is your peak blood level and is probably higher than the level you need to control pain. Slowly the drug will be eliminated, and eventually the blood level will decrease to where you begin to experience pain again. If you wait long enough before the next drug dose, the level will actually go back to zero. As you can see, this will lead to periods where you are pain free and periods where you may experience severe pain. To limit this, the dosing interval (time between administration of the drug) becomes important. If you take a repeat dose before the drug level goes below the threshold required to prevent pain, you can effectively prevent the return of pain and increase the level of comfort. This allows for lower drug doses, because you will already have some level of the drug in your system. Once the level reaches zero, another large dose of medication is needed to achieve the peak level again. There are several ways to administer analgesics to achieve the goal of around the clock comfort, and every surgeon has his or her own personal method.
In my opinion, the best way to control pain is to use a device that allows patients to administer their own pain medications when they feel they need it. This is called Patient Controlled Analgesia (PCA), which has been shown to decrease patient complaints of pain postoperatively. With PCA, you are given a button to push any time you feel pain. This button is connected to a microcomputer that administers a standard drug dosage each time it is pushed. To prevent you from receiving too much medication, a computer monitors the time between dosages, so if the time interval is too short, it will not administer the drug. Your physician will then be presented with a readout of the number of doses you received, how frequently you asked for medication, and how often the computer delayed the drug administration. With this information, the dose and dosing interval can be adjusted safely to achieve optimal comfort.
If PCA is not available, a similar effect can be achieved by requesting pain medication from your nurse at regular time intervals. In this case, you should ask for the medication early, as soon as you notice an increase in discomfort, because there will be a lag time between when you ask for the medication and when you receive it. This method works for both intravenous and oral pain medications. The key here is to remember to ask for your medication early, that way your blood level will not drop to the point were you would need higher doses of medication to remain comfortable.
If you find you are having side effects from your analgesics, such as nausea, headaches, hot flashes, or confusion, ask to be switched to another medication. There are several narcotic analgesics available, each of which has slightly different side effects. With a little experimentation, your surgeon should be able to find one that controls your pain with minimal side effects. Also, other medications that do not utilize narcotics are available to control pain. If you find that your pain is not well controlled on high doses of narcotics or you are experiencing unwanted narcotic side effects, such as confusion or hallucinations, your surgeon can add a non-narcotic pain medication to your pain control regimen, thus reducing the needed narcotic dose.
One final mode of analgesia that bears mentioning is epidural analgesia. In certain circumstances, you may have a small catheter placed in your epidural space (the space around your spinal cord). This is a safe and effective technique that allows the administration of medication in the region where pain signals are transmitted to your brain. In many cases, epidural analgesia is superior to the techniques described above. It also has some drawbacks, which limit its use in some patients, so it is not routinely used. In general, if you find yourself with an epidural catheter in place, it will be used for 1 to 3 days postoperatively; and once it is removed, you will be started on narcotic analgesics.
Complications of Narcotic Analgesics
Narcotic analgesics are effective in controlling pain; however, they have numerous undesirable side effects, which must be balanced against their positive effects. One major side effect is the alteration of mental status. That is to say, narcotics can cause confusion, hallucinations, and a sensation of disconnection. Many patients, particularly the elderly, find these side effects distressing. In some circumstances, these side effects are so severe that patients become irrational and combative. In theses cases, the administration of the drug is stopped, and the changes resolve as the medication is cleared from your body.
Another side effect is constipation. This can become a severe problem, particularly in those patients who suffer from some degree of constipation preoperatively. For this reason, many surgeons will put you on a high fiber diet or recommend that you take Metamucil, Citrucel, or some other similar product for a week or two postoperatively. Given that the average American eats a diet low in insoluble fiber to begin with, this is a good recommendation to follow. Another safe and inexpensive class of medication that may be prescribed is the stool softener. These medications work by increasing the amount of water retained in your stool, thus preventing the formation of hard, difficult to pass stool. If these two interventions don’t prevent constipation, you may be given a mild laxative such as Milk of Magnesia or Dulcolax. These medications stimulate bowel contractions, and help to propel undigested material through the colon. Constipation is a problem best treated before it develops, and if you are placed on these medications while on narcotic analgesics, you should have few problems. If, however, you find yourself having fewer bowel movements after surgery than you did beforehand, let your surgeon know sooner rather than later; you’ll both be glad you did.
Perhaps the event that most surprises people immediately postoperatively is the process of mobilization. In general when you feel poorly, the most comfortable way to spend the day is lying in bed. You won’t be allowed to do this in the postoperative period. Typically within 24 hours of your operation, you will be sitting up in a chair; and within 48 hours you will be walking the halls of the hospital with a nurse or therapist at your side. This isn’t done out of cruelty, but rather as a preventative measure. Just as inadequate pain control leads to shallow breathing, lung collapse, and blood clot formation, so too does inactivity. The most common complaint I hear postoperatively is that a nurse got me out of bed or made me walk today; and my response is always the same: good. There is no substitute for early mobilization; and it is a simple, inexpensive way to minimize some very severe complications, including atalectasis, pneumonia, blood clots, and pulmonary embolism. It also lets you know that you remain in one piece and are capable of getting up and moving about. Don’t worry about your stitches being torn out or your wound opening. We are not asking you to lift a house, only to sit up and walk. So remember, no excuses and no complaints; when the nurse comes in the day after surgery and tells you to get out of bed, get up and do it.
Depending upon your condition before surgery and the type of operation you have, you may have to work with a physical and/or an occupational therapist. Therapists are highly trained, deeply committed individuals who have one of the toughest jobs in the hospital. They are tasked with getting people to meet the limitations of their physical ability. In the postoperative period, as I mentioned above, most people feel they should be allowed to rest and recuperate. While rest is essential to recovery, it is not the solution to it. Our bodies are extremely efficient at allocating resources where they are most needed. Failure to use our muscles, joints, and bones sets in motion a process whereby these parts break down to supply other areas with raw materials. You will quickly lose your ability to walk or even stand if you do not continually use the muscles and joints associated with these activities. Another point to remember, especially when you feel a therapist is asking you to do something that you just can’t do: therapists work on the same types of problems day after day. They may ask you to do something you can’t quite do, but they won’t ask you to do anything unsafe. In my experience, most people start physical therapy resenting their therapist and by the end, feel the therapist is their greatest ally and friend. Keep this in mind when you are undergoing therapy, and look at it as a challenge and aid to recovery. Remember that once a surgeon has completed the operation, the difficult task of recovery is in your hands. The harder you work at it, the better you will do.
The topic of nursing care in recovery could generate a book in and of itself. As I have mentioned, it is now your responsibility to complete your recovery. Your surgeon can guide you through this process, but ultimately the effort you make is the most important determinant of success. Nurses provide the support and know how to help you make the most of your recovery. Unfortunately, in today’s medical and economic climate, nurses are being asked to do more and more with fewer and fewer resources in a larger numbers of patients than ever. These changes impact the amount of time your nurse can spend with you and, therefore, the amount of teaching he or she can provide. In response to the increased demands on nurses, many hospitals have expanded their use of nurse’s aids to help the overworked nursing staff complete their appointed duties. This places people with less training and experience in a position that requires much of both.
To make the most of your interactions with your nurses, I suggest you listen to their advice and training as intently as possible. Do not expect your nurse to help you every time you want to roll over or have a fresh glass of water. There simply is no longer enough time for nurses to do all those things while still assessing vital signs, administering medications, writing notes, communicating with families, and helping to coordinate the discharge of a dozen or more patients at a time. In short, have patience with the nursing staff, and remember that they are doing their best to speed you safely through your recovery. These are the people who you will deal with most directly, both before and after your operation; and they understand the challenges you face (possibly better than you physician). If you show them respect and heed their advice, your hospitalization will be more pleasant, and your recovery more successful.
Postoperative diets vary, depending upon the type of operation you have had, as well as on surgeon preference. Some surgeons are very conservative, and will advance your diet very slowly in the days following surgery; on the other hand, some surgeons will let you eat whatever you would like. In general, if you have had abdominal surgery, you will not be given a diet until there is some evidence of return of bowel function. Basically, this means that after abdominal surgery or surgery on any portion of the digestive tract, your bowels will cease to function for a period of hours to days. The first indication that your bowels have resumed function are “bowel sounds” which can be heard by placing a stethoscope on your abdomen. The next sign of return of bowel function is the passage of flatus, sometimes called passing gas. Once this event has occurred, you will typically be started on a liquid diet. Over the next several days, more substance will be returned to your diet until you are once again eating solid food. For a variety of reasons, this may take several days; so if you experience episodes of nausea or vomiting, you may be returned to a liquid diet or again be asked not to eat or drink anything (in medical terminology this is called NPO, which basically means nothing per mouth).
If your operation did not involve your abdomen or digestive organs, you may be allowed to eat as early as the day after surgery. In general, you will be asked not to eat anything immediately after your operation because if a complication should develop that requires a return to the operating room on an emergency basis, it is much safer to do so on an empty stomach. You may find your appetite is slow to return or you feel nauseated after eating, even if your operation was not related at all to the digestive organs. This is common and typically resolves within a few days. If it does not, or if nausea is associated with the administration of pain medication, you may need to have some of your medications altered.
Stockings and Compression Devices
When you wake from surgery, you may find yourself in knee-high or thigh-high stockings. These stockings are designed to compress the superficial veins in your legs to prevent blood clots from developing in your lower extremities. Many people find these stockings uncomfortable, particularly in combination with compression devices. Compression devices come in many forms but, in general, work to mimic the contraction of leg muscles that force blood out of the legs and back to the heart. These devices are typically worn while you are in bed and prevent the pooling of blood in your legs. This, in turn, decreases the incidence of lower extremity blood clots.
It is generally safe to stop wearing both the stockings and compression devices once you have been up walking and are able to do so on a regular basis. Thus, a major motivation to begin active walking is the removal of these cumbersome devices. Many patients attempt to remove these devices on their own, as they are often uncomfortable. Remember that by doing this, you are increasing the chance of developing a blood clot in the legs, which in turn predisposes you to a life-threatening and dreaded complication known as pulmonary embolism (blood clot of the lung). My advice to you is to tolerate the discomfort of stockings and compression devices for the first few days after surgery and to work as hard as you can to get up and walk. This will reward you by speeding your recovery and having the stockings and compression devices removed as early as safely possible.
Not everyone gets these devices after surgery, as there are other ways to prevent blood clot formation. Some surgeons prefer to administer a blood-thinning drug postoperatively. Several different drugs are now available that serve this purpose, some of which are taken orally and some which require an injection. Furthermore, some surgeons (myself included) prefer to use both blood thinner and the stockings/compression boots. Whatever the case, remember that the most important thing you yourself can do is to get up and walk as soon as possible after the operation.
Rounds and Residents
The process of visiting each patient in the hospital on a daily basis is known as “rounds.” Some surgeons make their rounds very early in the day, and some prefer to make rounds after all of the work in the operating room has been completed. Generally, you will see your surgeon on a daily basis until you are discharged from the hospital. This gives your surgeon the opportunity to assess your progress and add, modify, or delete medications or therapies you are receiving. If you are admitted to a “teaching hospital,” which trains residents and/or medical students, you may also find that they will visit you on a daily basis as well.
Residents are physicians who have graduated from medical school and are licensed to practice medicine or surgery under the supervision of a more senior physician. Depending upon their intended specialty, residents spend between 3 to 10 years in training before they are eligible to take the board examination that qualifies them to practice their given medical specialty. Some people object to being seen by residents, as they feel they are being utilized as “guinea pigs.” My feeling is that if a trained physician with a minimum of 4 (and potentially up to 14) years of medical education and training wants to provide care for me (at no charge, incidently), then so be it. Remember that no decisions regarding your medical care will be made by a resident without the advice and consent of your attending surgeon In general, the most respected and specialized surgeons serve as mentors for residents; however, there are many excellent surgeons who are not involved in “academic surgery” and do not teach residents. If your surgeon does train residents, expect that resident rounds will be a part of your hospitalization. If you wish to avoid this completely, you will need to choose a hospital and a surgeon with no resident coverage.
While in the hospital, unquestionably the most important thing on your mind is the care you receive. To most people, this equates with a daily visit by their surgeon. Realistically, no one person can work every day of the week, every week of the year. Surgeons are people, first and foremost. They cannot work 24 hours a day, every day of the year, any more than you can. Therefore, it is highly likely that you will not see your surgeon every single day. To accommodate patients who are in the hospital on days when they are not, surgeons typically practice in groups or arrange off-day coverage with other surgeons they trust and respect. Covering surgeons are told about the pertinent facts of your case and have a plan of care outlined. They will not know everything about your operation or postoperative management. If problems or unexpected complications arise, they will typically know how to contact your primary surgeon but will do so only in an emergency. Please don’t feel slighted by a visit from a covering surgeon, and don’t expect that person to be able to recite every detail about your history, operation, and recovery period. They are there to make sure you are progressing as expected and are able to handle any problems that arise in the absence of your surgeon.
Early in your hospital stay people will discuss discharge planning with you and your family. This is not an attempt to rush you out of the hospital, rather it is a system to help make certain that when you are ready for discharge, all eventualities will have been considered, and specialized equipment that needs to be procured will have been ordered. In some hospitals, nurses serve as discharge planners; in other hospitals there are people whose primary job is to plan discharges. Some insurance companies even have a discharge planning staff of their own. As I have mentioned before, the best recovery is one that occurs at home; therefore, when your doctor feels that it is safe for you to leave the hospital, and the discharge planning has been completed, you should try to leave the hospital as soon as possible.
While in the hospital, you may also see a visiting nurse. Visiting nurses are a response of the health care profession to the decreased time now spent in hospitals. In days gone by, patients who had undergone simple operations, such as hernia repairs, were observed in a hospital for days to weeks. Today, these surgeries are performed on an outpatient basis, so to minimize problems or complications that arise after patients leave the hospital, visiting nurses check on them from time to time. Visiting nurses measure vital signs, look at incisions, access mobility and appetite, and look for problems or situations that could require a surgeon’s intervention. They also administer medications or draw blood so your surgeon can continue to monitor your condition. Most patients who have had a major operation will be seen by a visiting nurse one or more times after discharge.
Nasogastric tubes (or NG tubes) are an uncomfortable but important part of surgical care. These tubes are inserted through your nose and passed down your esophagus to your stomach. They can be used to remove air and fluids that accumulate in your stomach for a variety of reasons. These tubes are placed while you are under anesthesia, by either your surgeon or anesthesiologist, to drain the contents of your stomach while you operation proceedes. Your stomach produces 1 to 1.5 liters (about half a gallon) of gastric juice a day, and if your bowels have ceased functioning due to your operation, this fluid can accumulate and make you feel distended, nauseated, or just plain old uncomfortable. In general, these tubes are removed 1 or 2 days after your operation, when your bowel function returns.
In some cases, you may be required to have an NG tube for days or even weeks after your operation. This can be quite trying, as these tubes are uncomfortable. There are a few solutions to the discomfort of NG tubes; so if you require one for more than a day or two, you can ask your doctor for either throat lozenges or an anesthetic spray to decrease discomfort. On occasion, NG tubes have to be replaced after they have been removed. This too is an unpleasant process, but if you comply with your surgeon’s instructions while the tubes are being replaced, they can be quickly navigated into your stomach. Typically, this is done to resolve postoperative distention or frequent vomiting.
Foley catheters are thin rubber tubes that are inserted into the urethra and passed into the urinary bladder. They allow for the elimination of urine without effort and enable accurate measurements of the production of urine. This is an important measurement, as urine formation gives a rough estimate of body perfusion (how well your body is supplied with fluid and blood). A general rule of thumb is that these catheters should be removed as soon as no longer needed because they can provide an access site for bacteria to enter your bladder. Bacteria that find their way into your bladder can cause urinary tract infections; and in worst case scenarios, the infection can travel to your bloodstream causing a life-threatening infection.
Most people find the catheters somewhat uncomfortable (particularly men) and are happy to have them removed. A word of caution, do not attempt to remove these catheters yourself. They are anchored in your bladder with an inflatable balloon, which must first be deflated before removal. Any attempt to pull the balloon through the urethra without deflating it will cause severe pain and tissue trauma. Another word of caution, Foley catheters are not designed for long-term use, so leaving them in to avoid trips to the bathroom is not a wise practice. Like most medical devices, a urinary catheter is helpful when needed and dangerous when improperly used. Follow your surgeon’s advice as to the timing of removal.
A frequent finding in hospitalized patients, particularly the elderly, is confusion and disorientation in the evening hours. The exact cause of this condition, known as “sundowning” among medical professionals, remains unknown. It is believed that sleep deprivation, narcotic medications, and an unfamiliar setting combine to produce a state of delirium in certain patients. This can be a severe problem, as patients become agitated, unreasonable, and, in some situations, violent. Sundowning is especially troublesome for visiting friends and family members, as the patients may tell tales of mistreatment and imprisonment. Some patients even fail to recognize members of their immediate family or claim to have been visited by dead relatives.
There is no “cure” per se for this condition. When a patient begins to sundown, usually several blood tests will be ordered to ensure that there is no biochemical imbalance responsible for the symptoms. If the tests return normal (which they almost always do), then an attempt to withhold narcotics and sedatives is made. Frequent reassurance from the medical staff and family members may help, but often the patients are simply beyond reason. In these cases it often becomes necessary to restrain the patients, to prevent them from injuring themselves (they frequently try to climb out of bed or remove intravenous lines, catheters, and monitoring equipment).
Fortunately, the simple measures listed above typically result in a return to normalcy within several days, and no permanent damage is done. It is a frightening situation for the patient and his or her family and friends, which is not taken lightly. It helps somewhat to understand that this is a very common event, and not a dangerous one.
There are two varieties of intravenous lines, central and peripheral. The most common by far is the peripheral IV. This is a small plastic catheter that is inserted through the skin into a vein. It allows the administration of fluid, medications, and blood during your hospitalization. Peripheral lines are safe, have few complications, but have some drawbacks. The first is that they don’t last very long. Typically, an IV site must be changed every few days to prevent the development of an infection or damage to the small vein. Occasionally these lines will “blow,” or puncture the vein into which they were placed. This can result in an accumulation of fluid under the skin, which may be painful and disfiguring but which typically resolves quickly. They also can be painful when certain medications are run through them. The final problem with peripheral lines is that certain medications cannot be administered through them.
Central intravenous lines, on the other hand, can be used to administer a wide variety of medications, are not associated with painful drug administration, and rarely need to be changed. Their use, however, is associated with more complications than with peripheral lines. Central lines are more difficult to place, and their use is reserved for very ill patients or patients who have no usable peripheral veins.
A typical surgical patient will have an intravenous line placed prior to surgery, and one will remain in place until all intravenous medications have been discontinued and the patient is eating a regular diet. In certain circumstances intravenous access is required for prolonged periods of time. In these cases, special lines are inserted that can be used for months at a time or longer.
The Intensive Care Unit
Depending upon the operation scheduled and your baseline physical condition, you may be required to spend time in the intensive care unit (ICU), either before or after your operation. This can be an overwhelming experience, as ICUs are very active places with numerous mechanical and electronic devices, as well as a large medical staff. If you are sent to the ICU on an elective basis after your surgery, it is typically for close monitoring to ensure that no problems develop in the immediate postoperative period. ICUs have the capacity to closely monitor your heart and the level of oxygen in your blood, provide mechanical support for your lungs, and allow you to be cared for almost constantly by at least one highly trained nurse. The benefit is that even small changes in your condition can be detected early, thus allowing your surgeon or intensive care physician to alter your therapy to prevent problems from developing. The down side to an ICU stay is the difficulty it presents for your state of mind. You will find it very difficult to sleep in the ICU, as you will be connected to multiple monitoring devices and assessed at least hourly by a nurse. Add to this the noise of hundreds of monitors, the confusion of emergency situations in nearby beds, the needle pricks required for multiple blood draws, and the administration of medications and intravenous fluids, and you can see why it is difficult to find peace and quiet in the ICU.
Elective admission to the ICU preoperatively is done to optimize your physical condition before the operation. This allows your surgeon to place a heart monitor, administer medications and intravenous fluids, and monitor your response to stress prior to your operation. It has become much less common in the past several years, but fortunately, anesthesiologists are able to successfully perform many of these functions in the operating room immediately prior to surgery.
If you should develop a complication intraoperatively or postoperatively, you may be transferred to the ICU. In this case, you may be unaware of your transfer, as typically only seriously ill patients are admitted to intensive care units under these circumstances. We will talk more about the intensive care unit in the chapter on complications. On a positive note, even gravely ill patients transferred to ICUs tend to do very well with appropriate care. If you or a loved one should end up in an intensive care unit under these circumstances, take solace in the fact that in a well staffed ICU, you will be receiving the very best care available.
One of the most unpleasant things for patients to deal with postoperatively is the presence of surgical drains. From an aesthetic standpoint, it is difficult to accept the sight of a plastic or rubber tube protruding from your skin. From a practical standpoint, a drain represents an object tethered to your body that you must protect while attempting to sleep, sit up, get dressed, or walk. It also serves as a constant reminder of your procedure. On the other hand, the surgical importance of drains cannot be underestimated.
The purpose of a drain is to prevent the accumulation of fluid in the open space created by a surgical incision. Drains also hold tissue together to allow them to heal. The body’s response to injury is the release of fluid from the injured blood vessels and capillaries. Following surgery, the tissues beneath the incision are separated, leaving a space where this fluid can accumulate. As this fluid accumulates, the space between the tissues expands, preventing healing. Depending upon the type of operation and the type of tissue producing the fluid, this drainage can resolve in a matter of days or may persist for a matter of months. Maintaining adequate drainage of the operative space promotes healing and deters the collection of fluid.
Fluid collections also can become contaminated by bacteria, resulting in the formation of an abscess. The infected fluid incites an inflammatory response, which in turn stimulates the release of more fluid. This self-fueling cycle continues until the space beneath your incision is filled with pus. If this happens, the wound will need to be reopened to allow the drainage of this infected material. Again, the use of a drain at the time of surgery serves to prevent this from developing.
Now that we see why drains are important, the next issue is how to deal with drains that are present. Several types of drains are available; but for the purpose of discussion, we will divide them into open and closed drains.
Open drains represent a way to evacuate fluid from under an incision and release it above the skin. If you have an open drain, gauze pads will be placed over (or under) the drain to collect the fluid. These gauze pads have to be changed periodically to prevent the underlying skin from becoming injured. Open drains are typically used only when the drainage is expected to resolve quickly, or when the area in question was severely infected at the time of the operation. The care of these drains typically requires a trained professional, as they can be very messy. If you are discharged from the hospital with an open drain, you will probably be cared for by a visiting nurse or, at the very least, will require some additional training so you can care for the drain yourself.
Closed drains, on the other hand, make use of a suction device to remove and collect the fluid produced by the wound. Typically, this suction device is a closed bulb that is evacuated of air, causing a vacuum effect. As the fluid is removed from the wound, the bulb is filled and the vacuum decreased. The bulb reservoir is then emptied, and the process begins again. There are several advantages to this type of drain. First, the drainage fluid is collected in a reservoir and not emptied onto the skin, therefore it is much cleaner and easier to manage. Second, since the system is closed to the outside environment (except when it is emptied), there is less chance that bacteria will use the drainage device as a passage beneath the skin, thus decreasing the chance of infection. Third, the volume of drainage can be accurately recorded, giving your surgeon an accurate representation of how much fluid is being produced on a daily basis. The downside to a closed drain is its bulk and weight. Some of these drains can hold a pint of fluid, and as you can imagine, a container of this size hanging from your skin can be difficult to carry and protect.
Most surgical drains are removed within a few days of surgery, so you may never have to care for the drain yourself. The removal of most drains is quite simple and, surprisingly, relatively painless. After removing the stitch that secures the drain to your skin, it is simply pulled through the skin exit site. A dry gauze dressing or Band-Aid is then placed over this small incision until it seals. It is not uncommon for a small amount of fluid to leak from this wound for a few days after the drain has been removed, so this should not concern you. If, however, you notice an increase in the amount of drainage, the drainage becomes foul smelling, or the skin around the drain site becomes red or painful, you should notify your surgeon at once.
If you leave the hospital with a drain in place, remembering a few simple tips will go a long way toward helping you manage the drain. When emptying the drain, do so in a clean, well-lit room. If the drain has volume markings on it, record the date, time, and amount of fluid emptied each time on a sheet of paper, which you can show to your doctor at your follow-up appointment. Before emptying the drain, disinfect the spout with a small alcohol wipe (available at most pharmacies and discount stores). Pour the fluid into a clean cup and replace the cap on the drain spout. You may then dispose of the fluid down a drain or into a toilet. The drain should also have some mechanism to secure it to your clothing, so that you may walk without carrying the reservoir. If there is no way to fasten the drain to your clothing, you can attach a piece of tape to the drain and then safety pin it to your clothing. Drains are frequently used after breast surgery, and bras that have a built-in pocket to carry the drain are now available at most surgical supply stores.
One final point about drains. The timing of drain removal is designed to coincide with the cessation of drainage. Late removal of a drain increases the risk of infection and requires you to maintain and carry around the drain needlessly. On the other hand, premature removal of a drain may result in the development of a fluid collection in the site. In most instances, the accumulation of a small amount of fluid after drain removal has no consequence and can be safely monitored without action. If, however, the fluid collection (termed a seroma) becomes large or symptomatic, it may need to be drained in the surgeon’s office. This is accomplished by accessing the collection with a needle and withdrawing the fluid under sterile conditions. On occasion, this procedure needs to be repeated more than once. Although inconvenient, this minor complication usually resolves with careful attention and should not worry you unnecessarily.
Chest tubes are very similar to the drains described above, except they are placed into the chest cavity. Technically speaking, there are two types of chest tubes, pleural tubes and mediastinal tubes. The chest is actually divided into three major spaces (of which there are also subdivisions). Each lung is contained within a fibrous sack known as the parietal pleura. This sack is attached to the inside of the rib cage as well as the diaphragm (the muscle separating your abdomen from your chest: its contraction allows you to breathe in). The lung itself is not normally attached to the parietal pleura, thus there is a space (actually it is a potential space, since its volume in a state of health is very small) between the lung and the parietal pleura. This space is known as the pleural space, and a chest tube that enters this space (usually for the purpose of draining air, or blood, or fluid) is a pleural tube. The mediastinum is basically the space between the two lungs and their associated pleura. One major organ residing in this space is the heart. Following open-heart operations, it is typical for chest tubes to be left in the space around the heart, hence these tubes are known as mediastinal tubes.
One major difference between chest tubes and other surgical drains is the need to drain air. When injured or operated on, the lungs typically leak air. If this air were allowed to remain in the pleural space, it would eventually begin to take up volume normally used by the lung. The amount of air leaking from the lung depends upon the size of the lung injury. Once any air leaks have resolved (which they almost always do within a few days), the tubes may be removed. The removal of a chest tube is a little more complicated than the removal of other drains, since air can leak back along their path and collapse the lung when they are taken out. Thus, chest tubes are removed rapidly, and with the simultaneous application of a pressure dressing that prevents air from following the tract of the tube back up into the pleural or mediastinal space. On occasion, air moves into these spaces, and as a result, you can develop a slight (or rarely, a total) collapse of the lung. Normally this improves with no specific treatment, but sometimes a new chest tube has to be inserted to remove the air and re-expand the lung
In many circumstances, it is necessary to exteriorize a portion of bowel to divert the flow of stool. These openings of the bowel through the skin are collectively known as ostomies. Ostomies can be temporary (also known as diverting), or they may be permanent. There are many different types of ostomies, and they are named on the basis of the region of bowel brought through the skin. The two most common ostomies performed are the ileostomy, which is an exteriorization of the ileum (or end point of the small bowel), and the colostomy, which is an exteriorization of the colon (this can be performed at several points).
Ileostomies have the disadvantage of producing liquid stool; therefore, you may need to increase your fluid intake if you have an ileostomy. Colostomies, on the other hand, tend to produce solid stool. A wide variety of techniques are used when creating ostomies, and each technique alters the type of care that ostomy requires. Some empty on their own volition, while others require the patient’s intervention (so called continent ostomies). The bottom line in ostomy care is the proper application of the stoma (ostomy) appliance. Before leaving the hospital, you will need training in stoma care, irrigation, and appliance application. A nurse who specializes in ostomy care usually provides this training. Utilize this resource to its fullest potential, and make sure you really understand how to size, fit, and glue your stoma appliance (the device which holds the ostomy bag in place) before you go home. Given the diverse number of operations, locations, and functional characteristics associated with modern ostomies, it is not possible to go into further detail in this guide. Many books are published on this subject, and you may visit your local bookstore or an online retailer to obtain one. You should ask your surgeon if you will have an ostomy created at surgery; and if so, I suggest obtaining and reading a book on ostomy care before surgery.
A word to the wise, ostomy placement is sometimes a psychologically difficult event to deal with. If the thought of having an ostomy offends you, or if you find the care of an ostomy distasteful, you are not alone. However, remember to consider the alternatives. Often the creation of an ostomy is essential to the success of the surgery or may even be mandated by your disease process. I have never met a patient who was unable to come to terms with ostomy placement; and when properly educated and trained, patients with ostomies can participate in all of life’s pleasures. Don’t hesitate to ask your surgeon questions about your ostomy; and make use of all of the resources available, through the hospital and the press, to learn to live your life to its fullest.
Vital Signs and Sleep
One of the biggest benefits of an overnight hospital stay is the ability to monitor a patient’s progress and vital signs. One of the worst parts of a hospital stay is being disturbed every few hours to have your vital signs checked. When a nurse or nursing assistant wakes you up 2 or 3 times an evening, it is difficult to get a restful sleep. This is an unintended consequence of an important monitoring function; and, unfortunately, there is presently no way around it. Please remember that checking your vitals is a good way for your surgeon to detect problems early, and that by not checking, serious consequences can ensue. Also, don’t blame the nurse taking your vitals for the frequent disturbances. It is being done by the order of your physician; and if you find it too annoying, it is an issue you must discuss with your doctor. Along the same lines, the amount of urine you produce on an hourly or daily basis is a very important piece of information that your surgeon needs to know, at least for the first few days after surgery. Try to make sure that each elimination is recorded in some way so that an accurate measure can be obtained.
Television and Phone Use
Most modern hospitals are equipped with televisions and telephones in every patient room. The big exception to this is the intensive care unit, but since most ICU patients are too sick to talk or watch TV, it does not turn out to be a problem. Unfortunately, in today’s cost-conscious world, you frequently will have to pay for the use of these items out of your own pocket. As I mentioned Chapter 3, you will probably want to have a little cash on hand to pay for use of these items. If you have a cellular phone, you will not be allowed to use it in the hospital, so don’t even bother bringing it with you. Cell phones have been found to interfere with many electronic devices used in hospitals, including monitoring systems and intravenous pumps. My guess is that you do not want your intravenous fluid running at the wrong rate, so why take the chance with the use of a cell phone. One final note, if you have a personal entertainment device, such as a Walkman or portable television, you are free to use it. Keep in mind, however, that valuables have a way of disappearing from patient’s night tables. As I stated in Chapter 3, bring to the hospital only what you are willing to lose.
Three predominant methods are used today to close wounds. They include the use of stitches, staples, or glue. All three seem to be adequate, but not every incision can be closed with every technique. The point I emphasize here is that surgical staples, which look rather menacing the first time you see them, are easily and comfortably removed. If you should notice that your wound is closed with staples, don’t worry. They are taken out with a tool specifically designed to remove them easily; and although you may feel a slight pinch with the staple removal, it is not an experience to fear. If you do not see anything holding your incision together, your surgeon either closed your incision with a subcuticular stitch (that is, a stitch below the skin) or with surgical glue. If you have a subcuticular stitch, the suture material will be absorbed by your body over time. Eventually, there will be nothing left of the stitch; however, it is not uncommon for small bits of the suture to poke through your skin for the first few weeks after your operation. This is especially true where knots were tied, as they take longer to dissolve. If you notice a thread poking out of your wound, do not worry; just point it out at your next office visit and your surgeon will tell you how he or she would like to manage it.
Most surgeons “dress” their wounds with sterile gauze pads at the conclusion of the operation. These gauze pads may be removed in a few days, but some surgeons prefer to leave them on for up to one week. You may also notice some staining on the gauze pads. This is normal, and as long as your dressing is not saturated with blood or fluid, there is no reason to worry. The removal of a dressing can sometimes be an uncomfortable experience, as the area below the dressing is sensitive because of the incision. In general, dressings come off without a problem, and you should not worry about them. By 48 hours after your operation, the edges of your wound have developed a weak seal; therefore, it is safe to leave you incision exposed to the air from this point forward. If you find a small amount of fluid leaking from the wound, your surgeon may choose to keep a dressing over it to prevent the fluid from staining your clothing or running down your skin. If your wound is dry and it is more than 2 days after your surgery, it is safe to leave it uncovered. The only reason to apply a dressing beyond this point is to protect the wound from being irritated by clothing or friction.
Chemotherapy or Radiation Therapy
If your operation was performed to remove a tumor or cancer, you will probably be evaluated by an oncologist (cancer specialist). There are literally hundreds of different techniques and drugs available to treat cancer, so I’m not going to talk about any one specifically. For some cancers, the drugs and radiation are very beneficial, and can help to achieve a complete cure. For others, there are no treatments that significantly change the outcome of surgery alone. Remember to discuss this with your oncologist before you begin a course of chemotherapy or radiation. In this instance, I will refer you to the discussion on managing expectations in the Chapter 3. You should know what the goal of the therapy is, and how often the therapy achieves its goal. Since chemotherapy and radiation therapy have consequences as well as benefits, make sure you understand both before agreeing to undergo further treatment.