Introduction Postoperative inpatient management requires a coordinated effort from physician (orthopedic surgeon +/- hospitalist) physical therapist occupational therapist case manager nursing staff patient and patient's family Care can be broken down into different phases including preoperative teaching inpatient acute care (hospital) - this topic inpatient extended care (rehab/SNF) outpatient home care Inpatient Acute Care (Hospital) Pain management preoperative NSAIDS and Acetaminphen are commonly given immediately before procedure to reduce postoperative pain Some use Gabapentin and opiods but the data to support this is not as robust intraoperative regional anesthesia (spinal and/or epidural) preferred over general anesthesia periarticular multimodal drug injection decrease postoperative pain with minimal risks postoperative multimodal oral drug therapy gold standard Medical management surgical stress response can lead to exacerbation of underlying medical conditions these conditions may require consultation with a hospitalist for workup and treatment hypertension defined as >140/90mm Hg however no set threshold for treatment evaluate for reversible causes (missed medication, pain or anxiety, constipation, etc) consider increasing home dose, IV antihypertensives (HTN emergency), or oral antihypertensives (preferred) hypotension defined as systolic BP <90 or drop in SBP by 40 from baseline most common cause is intravascular volume depletion treatment should include holding antihypertensives, IV fluid administration, +/- further testing (CBC/BMP, EKG, troponins, CXR, CTPE) hypoxia a combination of decreased cardiac output and oxygen tissue uptake results in hypoxia all patients should be encouraged to use incentive spirometry or other pulmonary hygiene may be a sign of acute cardiac ischemia, exacerbation of COPD/asthma, heart failure exacerbation, or PE oxygen supplementation to keep O2 saturation >90% with those patients with an inability to maintain O2 saturation and respiratory distress should be taken to an intensive care unit decreased urine output most common causes are hypovolemia, urinary retention and acute kidney injury (AKI) urinary retention bladder dysfunction or urethral obstruction acute kidney injury prerenal (hypovolemia/hypotension), intrinsic, postrenal (urinary tract obstruction) treatment for urinary retention includes straight cath, minimize anticholinergic/opioids, and consider tamsulosin treatment for AKI includes correcting reversible cause, maintaining euvolemia, and remove nephrotoxics agents, renal dosing of other medications altered mental status mental status change that may wax and wane identify underlying causes based on physical exam, laboratory values, and medication review reorient and normalize sleep wake-cycle chest pain differential can include angina (myocardial ischemia), pleuritic chest pain, dyspepsia (epigastric discomfort), or chest wall pain if cardiac origin is suspected check troponins and EKG treatment can include immediate aspirin and cardiology eval (myocardial ischemia), NSAIDs (pleuritic or chest wall pain), or antiacid/PPI (dyspepsia) nausea, vomiting, and abdominal pain postoperative nausea and vomiting (PONV) is a side effect of opiates and anesthetic agents treatment includes antiemetics, hydration, and electrolyte replacement ileus may require placement of a nasogastric tube Ogilvie's syndrome results in colonic obstruction without underlying mechanical cause and is a scenario where laxatives may make symptoms worse postoperative fever cytokine-mediated fever commonly occurs from surgical inflammation from orthopedic surgery on day 1-2 fevers after POD#3 have numerous causes broadly classified as infectious (UTI, cellulitis, pneumonia, C. diff, etc) or noninfectious (PE, withdrawal, transfusion reaction, medication reaction, etc) observation is appropriate up to POD#2 if patients appear well empiric antibiotics should be reserved for those patients who upon focused investigation have an infectious source of postoperative fever Physical therapy should start the day of surgery decrease LOS reduces pain and improves function exercises bed supported ROM exercises - ankle pumps, knee bends, glut sets, quad contractions, hip abduction, straight-leg raise sit to edge of bed, sit in a chair, standing with a walker, gait training stairs (up with the good, down with the bad) going up should lead with nonoperative leg going down should lead with operative leg ambulation walkers should be used in the immediate postoperative period Occupational therapy activities of daily living should be assisted by devices such as raised toilet seats, shower seats, and raised sitting chairs goals of therapy sitting upright --> gait training, ambulation with walker, out of bed to chair --> transfers, gait normalization --> independence Discharge home criteria independent ambulation with assistive device (50-100ft) independent transfers independent ADLs 2 stairs with supervision follows dislocation precautions if present appropriate home assistance (spouse, family, visiting nurses) Inpatient Extended Care (Rehab) Earlier discharge to rehab from hospital associated with improved outcomes Discharge criteria to home similar to those in hospital Levels of rehab include inpatient rehab and skilled nursing facility(SNF) or subacute rehab (SAR) SNF/SAR those patients who do not meet the above discharge criteria and do not qualify for inpatient rehab considered a complement to acute care hospital and more cost-effective than inpatient rehab inpatient rehab for total joint arthroplasty patients must be able to participate in 3 hours of therapy/day and be >85 yo, BMI >50, or have undergone bilateral total joint arthroplasty intensive rehabilitation services rarely utilized following total joint arthroplasty