Skip to Content

Post-op Orders

Last modified by Hussein Abdallah on 2025/04/20 02:06

Universal Orders

  • Ancef x 24hr unless attending tells you otherwise 
  • Admission order
    • if floor: Neuro admission order w/ comments saying 8D/6D/5G/8G in that order
    • if ICU, it is the responsibility of anesthesia to arrange for this during surgery so give them a heads up ASAP in the case and always confirm its been done at end of case 
  • Diet order
  • Post-op imaging orders (STAT) 
  • Post-op pain meds +/- AIPPS consult
  • Post-op anti-emetics (at least Zofran +/- Reglan) 
  • Post-op bowel reg (at least Miralax + Senna +/- PRN suppositories)
  • Vitals q4-6hr - may be different for ICU
  • Neuro checks q4-6hr unless a concern requires more frequent checks 
  • Daily AM labs (04:00) - CBC/BMP/Coags
  • Comprehensive rehab services ordered for next day (this is PT/OT) 
  • Elevate HOB - usually 30 degrees 
  • Random BS: 
    • Lower extremity dopplers error
    • qM/R Prealbumin
    • Inspiratory spirometer (especially Nitin patients)
    • OOB TID for meals 
    • OOB with assistance - do this or PT/OT will not work with them
    • Nutrition goodies (especially for posterior spine cases) 

NOTE: This is a lot of orders, but with a well-constructed favorites folder, should eventually take you < 30 seconds. 

Special Orders

  • Keppra or Dilantin for seizure prophylaxis
  • Dexamethasone
    • Pepcid, anytime you prescribe dexamethasone 
    • Sliding scale insulin anytime you prescribe dexamethasone
  • MAP goals - most important for spinal cord injury patients, modify PRN 
  • CAP - usually <140 for intracranial hemorrhages or <160 for brain or spine tumors 
    • 'CAP order' with systolic specified
    • Also order PRN labetalol/hydralazine with systolic cap in comment
    • NOTE: we almost never CAP traumas however 
  • Hemovac / JP drain orders if applicable (need to specify if on suction vs gravity) 
  • Lumbar drain order if you placed a LD
  • EVD order if you placed an EVD
  • Brace Order and Rules (C-collar / CTO / TLSO / LSO)
    • Call De La Torre and order the brace / collar 
    • Place an Activity order specifying when ok to get out of bed 
    • Place an Activity order saying "ok for OOB for PT/OT with brace" or else they'll page you endlessly or just won't work with the patient

Steps AFTER Every Case

  • Log your case
  • Ask attending/senior resident (ask during case/right at the end): 
    • Ok for foley out? 
    • Any specific orders you want besides routine Ancef/pain/bowel/antiemetics? 
    • Any CAP? 
    • ICU vs floor (if it's not obvious) 
    • Will this patient need a feeding tube we can just place now? 
  • Write an immediate post-op surgical note documenting: 
    • Procedure and pertinent complications (e.g. CSF leak repaired primarily vs. duragen or EBL > 3L) 
    • Drains - must label each with a letter and document side each drain is on as well as location in the closure. For example
      • Drain A - LEFT - subfascial
      • Drain B - RIGHT - supra-fascial 
      • THIS IS CRITICAL ESPECIALLY IF THERE IS A CSF LEAK 
    • Cultures: 
    • Path/biopsy/results:
    • Closure:
    • Flaps/Packings:  
  • Med rec if patient is coming from SDS (do not dump this onto the service residents). You must restart or hold all home meds. If you're not sure, just ask the attending or chief of service.

Medication Reconciliation

  • First of all, you can only do this after the nurse has done a medication history upload - this is not your job, call the nurse/charge and ask them to promptly do it so you can medrec them
  • It is especially important to ask about use of anticoagulants (aspirin, Coumadin, Plavix, Eliquis, Xarelto, Pradaxa), steroids, and antiepileptics 
  • Ask attending or chief for plan for each of those meds. The importance of this step cannot be understated!  
  • The attending will almost always hold anticoagulation at admission, unless the patient has an intracranial stent, aneurysm coil, or symptomatic carotid stenosis 
  • If the patient doesn't know what meds they're taking and at what doses, call the patient’s pharmacy (ask nurse/charge to do that) 

Signout Text

  • Before leaving OR and even before pt wakes up for an exam, text-sign out to all resident and APP members of service the patient is on (chief, senior, and junior) using following template (remove bullets if not applicable) 

    POST-OP TEXT SIGNOUT TEMPLATE
    • Patient Name
    • Attending initials
    • Procedure and pertinent findings/complications (CSF leak/ high EBL?)
    • Drains, specify suction type and location in the closure (e.g. LEFT subfascial) 
    • CAP < _____ (or lack thereof) 
    • MAP 
    • Cx (specify pre or post- ABx or wash)
    • Pertinent lines (e.g. foley until 6AM POD1)
    • Post-op Imaging
    • Any abnormal activity restrictions/Bracing rules (e.g. TLSO precautions) 
    • Immediate labs to follow-up on (e.g. DIC labs) 
    • Admit to floor vs. ICU 
    • Exam to follow (then text exam as soon as patient wakes up, noting any pertinent pre-op deficits as applicable) 

TIP: this is a long text so for your efficiency, you can email this to yourself on the computer and send it from your phone as a text. 

 

  • Call or text attending to tell them how patient woke up. Better yet if they are in another OR, find out and let them know personally if at an appropriate part of case.  Do not call much less text Moossy, find him around PACU or surgeon's lounge.
  • Transport patient to ICU directly vs. drop off at PACU (if patient is going to floor) 

Transporting / Signing out patient

OPTION 1: If patient is going straight to the floor post-op, you deliver them to the PACU and they take it from there. 

  • How to sign-out to PACU nurse / ICU nurse
    • What procedure you did and why
    • Number and location of incisions and what they are dressed with 
    • Drains, specify suction vs. gravity 
    • Pre-operative deficits if applicable 
    • CAP / MAP floor if applicable (or lack thereof)
    • what imaging is ordered and whether the patient needs imaging done by PACU nurse before leaving PACU to floor 

OPTION 2: If patient is going straight to the ICU post-op, you deliver them straight to the ICU. If you must get a scan on the way to ICU, you must accompany everyone to scan and then drop off to ICU. This is why you ask attending if they truly are concerned enough to get a scan literally on the way to ICU (meaning anesthesia from OR must go with you) versus dropping off at ICU and having ICU nurses/CCM take the patient (often the latter is enough). 

  • How to sign out to ICU CCM and ICU Nurses: need to make sure both nurses and CCM are present!
    • Start by calling the ICU CCM as you roll out of the OR. Even if anesthesia gave nurse heads up, CCM is not always aware and would appreciate the call, plus you save yourself time by having them ready when you arrive. Never hurts to over-communicate.
      • CCM 6FG: F-side (beds LOW 1-10) 578-9460, G-side (beds 11-20) 864-1521 
      • CCM 4F/5F: 692-2193 
      • CCM 4G: 864-2373
    • What procedure you did and why
    • Number and location of incisions and what they are dressed with 
    • Drains, specify suction vs. gravity 
    • Pre-operative deficits if applicable 
    • CAP / MAP floor if applicable (or lack thereof)
    • what imaging is ordered and whether the patient needs imaging done by PACU nurse before leaving PACU to floor 
    • SPECIFIC ICU SIGN-OUT
      • CRITERIA FOR EXTUBATION (e.g. "we'll call you if scan looks good") 
      • All pertinent orders (labs/imaging needed) and whether they are ordered or need ordering