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POST OPERATIVE CARE:

The care of a patient who has had a surgical procedure in order to prevent, detect and or handle complications that may arise, with main objectives being reduction in morbidity and mortality from surgery and anaesthesia.

PHASES OF POST-OP CARE:

Three phases are considered.

Phase I  -   Immediate post-operative period

This can be in either the recovery ward or the Intensive care unit (ICU) depending on the patients needs and the nature of the operation done.

  1. The recovery ward
  2. usually located within the theatre complex
  3. Staff involved – trained nurses assisted by an anaesthetist
    1. Equipment – Monitoring facilities which should include today Pulse Oximeters in addition to e.g Bp machines etc

The recovery room should be ready to deal with immediate life threatening complications eg  haemorrhage, cardiac arrest and possibility of immediate re-access to theatre.

  1. ICU or HDU (High Dependency Unit)
    • For patients who need intensive monitoring and life support
    • The ICU should be easily accessible from theatre
    • ICU care involves anaesthetist (or intensive care specialist), the surgeon and well trained ICU nurses, other supportive staff (lab technicians, physiotherapists etc)

Phase II Intermediate

This could be in the ward for patient who was in the recovery ward or sometimes continued in the ICU or HDU for some category of patients.

Phase III Late

This involves rehabilitation and follow up.

DOCUMENTATION AND POST-OPERATIVE INSTRUCTIONS

Proper documentation by the surgeon is important.
The operation notes should be written clearly and should be comprehensive.

The data should include

Patient details  Name, age, sex hospital registration number
Date of operation
Diagnosis

Operation

Describe the Incision/approach

Details of the procedure

  • Operative findings
  • Actual surgical procedure performed (detailed)

Name of the surgeon(s) and assistant(s)
Name of anaesthetist (s)
Type of anaesthesia used eg general , LA regional etc
Name of scrub nurse

The post operative instructions to be followed by others looking after the patient should include –

The observations to be taken  and how often eg., blood pressure, respiratory rate,  pulse, temp ¼ hourly x 2 hours, then hourly for 4 hours etc.

  • Special investigations required eg. X-rays of chest, Ultra sound, etc. Blood gases

Post-operative prescriptions for

  • Drugs (for pain, antibiotics, etc)
  • Fluids I.V or per other routes
  • Transfusions etc

Other instructions eg

  • Feed or not – Nil by mouth
  • Prop – up in bed
  • Elevation of limbs etc.

Post-op care therefore involves;-

  1. A) monitoring
  2. C) prescriptions or orders to maintain, restore normal homeostasis or avoid complications
  • Pain relief
  • Fluid + electrolytes
  • Nutrition
  • Transfusions
  • Anticoagulation
  • Anti ulcer therapy etc

Monitoring

Is necessary to recognize or detect early any physiological derangements or surgical complications that may occur.

It involves:-

  1. a) Clinical observations
  • Vital signs taken eg ¼ hourly or even continuously
  • General examination of the patient
  • System oriented approach – physical examination

of the various organ systems.

However parameters normally monitored

Eg CVS              -  Pulse (rate, volume, rhythm)

  • Bp
  • CVP
  • ECG

Renal eg urine output

CNS level of consciousness/alertness etc

RS – RR etc (Blood gases etc)

Others output from drains

Invasive monitoring.  The use of eg in-dwelling probes eg pressure cannulas for BP, CVP, TEMPERATURE probes in the oesophagus or per rectum usually in ICU and may be on a continuous basis.

  1. b) Lab data e.g. – Hb or Hct

-  Blood gas analysis

-  Urea and electrolytes + creatinine

  1. c) Radiological assessments eg – CXR’s

-  Ultrasound scans

-  CT Scans, MRI etc

Other special tests where indicated eg Echocardiography

PAIN RELIEF

Need for pain relief

  1. a) Patient comfort and avoidance of adverse psychological effects.

Its inhuman for anyone to be allowed to undergo pain if something can be done.  “Comfort always, cure sometimes”.

  1. b) Avoidance or prevention of pulmonary complications

Pain may cause poor respiratory effort and poor effective coughing leading Inability to clear the airways of secretions (low tidal volume) causing alveolar collapse and lung collape

-  Bronchopneumonia (-hypoxia etc)

  1. c) Avoidance of DVT (Thrombo-embolism).

Pain leads to reluctance to move : venous Stasis : DVT formation and finally Thrombo-embolism

METHODS OF PAIN RELIEF

  1. Intramuscular inj. Of opioids
  2. Intravenous infusions
  3. Subcutaneous infusions
  4. Spinal opioids
  5. Rectal opioids
  6. Transdermal opioids
  7. Local anaesthesia

-  infiltrations

-  nerve blocks

-  epidural

SOME CONCEPTS IN PAIN RELIEF

  1. PRE-EMPTIVE ANALGESIA  - To avoid hypersensitisation to painful sensory input and prolongation of duration of pain beyond duration of tissue injury.
  2. PATIENT CONTROLLED ANALGESIA (PCA)

-  Devise that allows patient to press a button that self administers   analgesia when required

  1. MULTIMODAL ANALGESIA optimizes the pain control and reduces side effects of the individual analgesic

FLUID . ELECTROLYTES . NUTRITION

Consideration of this is important in patients who:

  • Have had GIT surgery
  • Are very sick – who are unlikely to start feeding immediately.

In such cases

  1. I.V. fluids
  2. Parenteral nutritional support may be necessary
  3. Other forms of enteral feeding eg NG tube, jejuostomy etc

I.V. Fluids:

Most adults will require about 3L/day given usually as 500mls/4 hourly eg as 5% dextrose alternating with Hartmans solution.

NB with increased losses eg from drains this is adjusted upwards accordingly.

Electrolytes

Esp K+ is important in patients who are not feeding as urine losses continue hence K+ supplementation may be necessary.

Nutritional Supplements

If the non feeding phase is prolonged especially with pre-existing malnutrition, TPN through a central line to give nutritional supplements or other form of nutritional supplementaion.

OTHERS

  1. i) ANTIBIOTICS

-  As prophylaxis depending on indications

-  As treatment

  1. ii) TRANSFUSIONS

iii)   H2 Antagonists/proton Pump inhibitors for stress ulcers.

  1. iv) ANTICOAGULANTS

Prophylaxis for thrombo-embolic disease

POST –OPERATIVE COMPLICATIONS

“Regardless of how technically gifted, bright, and capable a surgeon is, surgical complications are a virtually guaranteed aspect of life”.

“The possibility of post-operative complications is a part of every surgeon”s thought process – something with which all surgeons will be required to deal’.

“strive for the best but be prepared for the worst”.

-  After every operation, complications may occur which if not recognized  early and acted upon can cause morbidity or even death.

-  Complications may be related to the disease process per se, or errors of  omission or commission in technique.

Can be classified as

  1. a) General complications related to any surgical procedure or  anaesthesia
  2. b) Complications associated with specified operations
  3. Classify by organ systems eg. Renal, cardiac etc
  • Chronologic approach eg early, intermidiate, or late

GENERAL POST OP COMPLICATIONS

  1. HAEMORRHAGE

Post-operative bleeding may be internal

External (wound)

Early

Delayed

Reasons for post.op bleeding

  1. Poor surgical technique
  2. Coagulation problems
    1. Thrombocytopenia (after over transfusion of stored blood CPB)
    2. DIC
    3. Missed mild coagulations defects (underlying medical conditions).

*  Some surgical conditions are associated with increased tendency to bleeding eg

Obstructive jaundice, post open heart surgery.

*  Prevention of bleeding can be achieved by:

  1. a) Careful Pre-operative assessment (good history, physical exam and

investigations to rule out bleeding disorders (congenital or acquired)

and proper pre-operative preparation of patients.

  1. b) Proper surgical techniques.

THROMBO-EMBOLIC EVENTS

      Incidence not clear but may be responsible for 12 – 15% of deaths incritical care situations.

Majority of cases death occurs before diagnosis of DVT is made.

*  High index of suspicion and prevention are vital.

Aetiology:

Stasis, initial injury, hyperioagulation states.  (Virchow’s triad) may exist in surgical conditions eg

Patient undergoing surgery who is supine for long time, paralysed during anaesthesia hence pooling of blood in soleal sinuses with vasodilator effect of G.A (Stasis) coupled with hypercoaguable state in some surgical conditions, especially obesity, cancer, chronic venous insufficiency, long operations.

Signs of DVT may include tenderness, swelling pain on movement and fever.

Diagnosis  Doppler u/s + venography etc

Prevention  1)  Early post-op ambulation

2)   Use of compression stockings

3)   Low dose peri-operative heparin.

  1. INFECTION

       Introduction of aseptic techniques, sterilization of surgical equipment,clean operating environment and antimicrobial agents -; has reduced post-op infection rates, though infection still remains a major concern.

Infection can be

=  local wound infection (superficial surgical site infection)

=  Deep incisional surgical site infection

=  Organ/space surgical site infection eg peritonitis,  sub phrenic absess, empyema thoracis.

=   Systemic

Aetiological factors

  1. a) Patient factors

Age, nutrition, diabetes mellitus, smoking, obesity, co-existent infections at another site, colonization, with particular microorgansisms, immunosuppression, length of preoperative stay, blood transfusion, anaemia, malignmancy.

  1. b) The operation

Category of surgical procedure, skin asepsis, pre-op shaving, duration, antibiotic prophylaxis, sterilization of equipment, FB in surgical site, drains, poor hemostasis, dead space, tissue trauma etc).

Classification of surgical wounds      Infection rate

  1. Clean 1 – 3%
  2. Clean contaminated 5 – 8%
  3. Contaminated 20 - 25%
  4. Dirty 30 – 40%

Prevention – patient preparation

-  Surgical techniques

-  prophylaxis if indicate

  1. 4. WOUND COMPLICATIONS

Can be – Haematomas and Seromas

Sepsis – discussed above

Dehiscense – commonly occurs after one week after surgery.

Can involve – skin only – simple repair

Fasical layer – which has the problems

1)  requires operative repair

2)  often associated with infection

3)  may lead to evisceration

  1. RESPIRATORY COMPLICATIONS

     Causes of post-operative respiratory failure

  1. a) Ventilatory failure
  2. Loss of ventilatory drive eg

-  sedative drugs (eg midazolum, anaesthesia)

-  Opioids (eg morphine, fentanyl)

  1. Airway obstruction

-  reduced level of consciousness

-  trauma

-  neck haematomas eg in thyroid surgery

  • Respiratory muscle failure

-  Persistent muscle relaxant effect

-  Electrolyte abnormality eg hypokalaemia

-  Splinting of the diaphragram eg due to pain, raised intrabdominal pressure, subphrenic abscess etc.

Pulmonary pathology (Pneumothorax, haemothorax pleural effusion, broncho-spasm).

  1. b)  Failure of Gas Exchange

  Alveolar causes

  • Atelectasis
  • Pneumonia
  • Aspiration
  • Pulmonary oedema – eg fluid overload, LV failure
  • ARDS
  • Pulmonary haemorrhage

Vascular causes

  • Pulmonary embolism

GIT COMPLICATIONS

May include

  1. Post-op nausea and vomiting, may lead to
    • aspiration
    • stress on suture line

should be controlled by anti-emetics.

  1. Paralytic ileus – which can be due to
    • infection eg peritonitis
    • mechanical after gut handling
    • electrolyte imbalance eg low K+
  • hiccups
  1. Stress ulcers

RENAL COMPLICATION

Oliguriea or even ARF may occur

Can be due to – low cardiac output (caused by hypovolaemia or cardiac failure).

Hypovolaemia may be due to blood loss, dehydration

  1. OTHERS

-  CARDIAC – Low cardiac output

  • arrythmias
  • myocardial infarction

-   LIVER

-   CNS       -  Disorders of consciousness

-  Confusion

-  Psychiatric disturbances,

-  CVA

-   ANAESTHETIC COMPLICATIONS

-    FEVER  (Wind,  Water, wound + phlebitis. Etc.

-   MODS


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