A 58-year-old man is evaluated for hypertension in the postanesthesia care unit 3 hours after undergoing open left inguinal hernia repair with placement of mesh. The surgery, which lasted approximately 1 hour, was performed using both general anesthesia and local anesthetic. Medical history is significant for obesity and prior surgical hemorrhoidectomy. The patient is alert and reports vague lower abdominal discomfort. Blood pressure is 150/92 mm Hg and pulse is 104/min. A surgical dressing on the left groin is intact with a small amount of serosanguinous drainage. There is mild distension in the central part of the lower abdomen, where palpation increases the patient's discomfort. The rest of the abdomen is soft and nontender. Postoperative telemetry reveals sinus tachycardia. Which of the following is the best next step in management of this patient?

Question

A 58-year-old man is evaluated for hypertension in the postanesthesia care unit 3 hours after undergoing open left inguinal hernia repair with placement of mesh.  The surgery, which lasted approximately 1 hour, was performed using both general anesthesia and local anesthetic.  Medical history is significant for obesity and prior surgical hemorrhoidectomy.  The patient is alert and reports vague lower abdominal discomfort.  Blood pressure is 150/92 mm Hg and pulse is 104/min.  A surgical dressing on the left groin is intact with a small amount of serosanguinous drainage.  There is mild distension in the central part of the lower abdomen, where palpation increases the patient's discomfort.  The rest of the abdomen is soft and nontender.  Postoperative telemetry reveals sinus tachycardia.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This older male patient who underwent inguinal hernia repair now has vague lower abdominal discomfort and distension in the central, lower (ie, suprapubic) abdomen. This presentation is concerning for postoperative urinary retention (POUR) and should prompt portable bladder ultrasound. Urinary retention is a common postoperative complication. Factors associated with an increased risk of POUR include: Patient factors: increasing age and male sex (eg, prostatic enlargement) Type of surgery: hernia repair, joint arthroplasty, or anorectal operations Anesthetic factors: prolonged anesthetic duration, excessive fluid administration, and use of medications (eg, opioids, anticholinergics) that impair bladder emptying Patients with POUR may have suprapubic discomfort and/or bladder spasms; however, symptoms are often masked due to residual anesthesia or analgesia. Physical examination often shows suprapubic fullness that is uncomfortable when palpated and/or dull when percussed. In addition, hypertension and tachycardia may be present from sympathetic stimulation (ie, the distended bladder is a noxious stimulus). Portable bladder ultrasound (ie, bladder scan) is the best initial step in diagnosing POUR because it is quick, noninvasive, and can be performed at the bedside; if POUR is present (eg, >600 mL on ultrasound, with different sources listing different cutoffs), urinary catheterization is typically performed. (Choice A) Uncontrolled pain can cause postoperative hypertension and is often treated with opioids. However, opioid administration with failure to recognize POUR (suprapubic distension and pain) will likely exacerbate this patient's urinary retention because opioids both blunt the sensation of bladder fullness and impair bladder emptying. (Choice B) Abdominal CT scan may be indicated if an intraabdominal complication (eg, iatrogenic organ injury) is suspected. Given this patient's multiple risk factors (age, male sex, hernia repair) for POUR and his isolated suprapubic distension and discomfort, bladder ultrasound is a better next step. In addition, intraabdominal injury is less likely with open (as opposed to laparoscopic) hernia repair. (Choice C) Surgical site exploration is sometimes necessary for acute surgical site complications (eg, expanding postoperative hematoma). However, this patient has a normal-appearing surgical dressing (ie, a small amount of serosanguinous drainage is not alarming) with no underlying swelling (eg, hematoma); his complication (ie, urinary retention) is unrelated to the surgical site. (Choice D) Anti-hypertensive medication is not recommended when hypertension is due to urinary retention. Upon draining the bladder (removing the sympathetic stimulus), the hypertension will spontaneously resolve. Educational objective: Patients with postoperative urinary retention often have suprapubic discomfort and fullness, along with hypertension and tachycardia (ie, sympathetic stimulation); portable bladder ultrasound can confirm the diagnosis. References: Urinary retention in surgical patients. (http://www.ncbi.nlm.nih.gov/pubmed/27261788) Systematic review of interventions for the prevention and treatment of postoperative urinary retention. (http://www.ncbi.nlm.nih.gov/pubmed/30734011)

A 58-Year-Old Man Is Evaluated for Hypertension in the Postanesthesia