Postoperative care.pptx

Postoperative care

1. Postoperative care. By: Dr. Shabih Ayeshah . 1 st year resident of Surgery unit: 1 Dow University Hospital, Karachi.

2. Contents. Aim of postoperative care. Post operative period. Immediate phase . General management. Common compications . Intermediate phase. General management. Pain management. Fluid and electrolyte management. Nutritional support. Pulmonary care. GIT care. Renal care. Convalescent phase.

3. Aim of Postoperative care. To enable a successful and faster recovery of the patient post operatively. To reduce post operative mortality rate. To reduce the length of hospital stay of the patient.

4. Postoperative period. It is the time period which begins from the time the patient leaves the operating room and ends with the follow up visit by the surgeon. It is divided into three phases; 1 . Immediate phase (Post anesthetic phase). 2. Intermediate phase (Hospital stay). 3. Convalescent phase (After discharge to full recovery).

5. Immediate phase. It is the time period immediately after shifting the patient to recovery room from operation theatre till the patient is fully recovered from anesthesia and shifted to ward . General Management. A ) Monitoring Vital sign (pulse, BP, R.R, Temp) every 15-30 min. C.V.P ( for pulmonary artery wedge pressure) and arterial line for continuous BP measurement. ECG Fluid balance ( intake and output) ? Needs urinary catheter. Other types of monitoring : Arterial pulses after vascular surgery. Level of consciousness after neurosurgery.

6. B ) Respiratory Care: O 2 mask. Ventilator. Tracheal suction. Chest physiotherapy. C) Position in bed and mobilization: Turning in bed usually every 30 min. until full mobilization. Special position required sometimes. DVT prevention mechanically ( intermittent calf compression).

7. D) Diet: NPO Liquids. Soft diet. Normal or special diet. E) Administration of I.V. fluids: Daily requirements. Losses from G.I.T and U.T. Losses from stomas and drains. Insensible losses. Care of renal patients. If care of drainage tubes

8. . G) Medication: Antibiotics. Pain killers. Sedatives. Pre-operative medication. Care of patients on Pre-Op. Steroids. H 2 Blockers specially in ICU patients. Anti-Coagulants. Anti Diabetics. Anti Hypertensives . H) Lab. Tests and Imaging: To detect or exclude Post-Op. complications.

9. Complications in Immediate phase . Acu te pulmonary problems. Including; Hypoxaemia , Hypercapnia , Aspiration. Cardiovascular problems . Including; Hypotension, Arrhythmias, MI . Fluid derangement . Such as; hypovolemia or fluid overload.

10. The Intermediate Post-Operative period Starts with complete recovery from anesthesia and lasts for the rest of the hospital stay. General Management. Care of the wound. Epithelialisation takes 48 hs . Dressing can be removed 3-4 days after operation. Wet dressing should be removed earlier and changed. Symptoms and signs of infection should be looked for, which if present compression, removal of few stitches and daily dressing with swab for C & S. R.O.S. usually 5-7 days Post-Op. Tensile strength of wound minimal during first 5 days, then rapid between 5 th - 20 th day then slowly again (full strength takes 1-2 years). Good nutrition.

11. Case: 1. 40 yr old male K/C COPD underwent paraumbilical hernioplasty . On 5th POD, a gush of serosanguinous discharge is noted from wound. What do you think is a cause of wound dehiscence in this patient? A) Poor suture material. B) Raised intraabdominal pressure secondary to COPD. C) Choice of incision. D) Unavailability of abdominal binder.

12. Wound dehiscence. It is disruption of any or all the layers in a wound. Most commonly occurs at 5 th to 8 th postoperative day. Most patients require resuturing in OT, some patients can be left with wound open and treated with daily dressing or vacuum assisted closure pumps. Management of drains. To drain fluids accumulating after surgery, blood or pus. Open or closed system. Other types (Suction, sump, under water etc.) Should come out throw separate incision to minimize risk of wound infection. Inspection of contents and its amount. Should be removed as long as no function or when the output is <25ml/day.

13. Nausea and Vomiting. PONV can precipitate bleeding and dehiscence of wound. Women, nonsmokers and those who have past history of PONV, migraine and motion sickness are at higher risk. Duration and type of surgery also affect incidence of PONV, volatile anaesthetic agents, opiods and nitrous oxide increase risk. Adequate treatment of pain, anxiety, hypotension and dehydration minimize the risk of PONV. Administer antiemetics that work at different sites, such odansetron , dexamethasone , prochlorperazine , cyclizine , atleast one antiemetic should be given on regular bases in high risk group and a 2 nd one written up to be given when needed.

14. Bleeding. All Hospitals should have a major haemorrhage protocol in place. No need to transfuse blood in the absence of continued bleeding in patients with Hb > 8g/dl. If there is continuous bleeding which is more then expected for the given procedure, then apply pressure to the site and send blood samples for CBC, CP and cross match. Start fluid resuscitation. Arrange U/S or CT scan to assess hematoma. If haemostasis not successful by conventional method then shift the patient to OT for reexploration and anastamosis of leaking vessel. Radiological embolisation of bleeding vessels can also prove useful.

15. Case: 2. 55 yr old obese female underwent APR for rectal ca. Patient is very reluctant to mobilize despite ur encouragement & counseling. On 7th POD you noticed swelling of Left leg with associated erythema & edema. What you should advice her to prevent this complication? A) Compression Stockings. B) Vena Caval Filter. C) Low molecular weight heparin. D) Weight reduction.

16. Deep Vein Thrombosis. Patient mostly presents with calf pain, swelling, warmth, redness and engorged veins, but can be asymptomatic. Venography or duplex doppler ultrasound helps in diagnosis. High risk patients should be kept on DVT protocol prophylactically , which includes use of stockings, calf pumps and pharmacological agents like LMWH. Treatment involves use of I/V heparin initially followed by long term warfarin , in patients with large DVT or those who have chance of PE a caval filter should be placed.

17. Case: 3. 32 yr old male S/p incisional hernioplasty , On 1st POD staff told you that patient has a spike of 101 fever. You see the patient & found decrease air entry on right side of chest. What could be cause of patient's fever? A) UTI. B) Wound infection. C) Atelectasis . D) inadequate analgesia.

18. Fever. Common causes of fever according to postoperative day are as follows ,

19. Pressure sores. Recognize patients at risk. Address nutritional status. Keep patients mobile, if bed bound regularly turn the patient every 30 minutes or use an air filter mattress in high risk group.

20. Post-Operative Pain. Factors affecting severity : Duration of surgery. Degree of Operative trauma (intra-thoracic, intra-abdominal or superficial surgery). Type of incision. Magnitude of intra-operative retraction. Factors related to the patient : Anxiety. Fear. Physical and cultural characteristics. Complications of Pain: Causes vasospasm. Hypertension. May cause CVA, MI or bleeding. Management of Post-Op. pain: Physician – patient communication (reassurance). Analgesics (NSAIDS). Anxiolytic agents ( Hydroxyzine ) potentiates action of opioids and has also an anti-emetic effects. Oral analgesics or suppositories e.g. Tylenol. Parenteral opioids . Epidural analgesia (for pelvic surgery). Nerve block (Post- thoracotomy and hernia repair).

21. Post-Operative fluid & Electrolytes management . Considerations: Maintenance requirements. Extra needs resulting from systemic factors e.g. fever, burn diarrhea and vomiting etc. Losses from drains and fistulas. Tissue oedema (3 rd space losses) The daily maintenance requirements in adult for sensible and insensible losses are 1500-2500mls. depending on age, sex, weight and body surface area. Rough estimation of need is by body weight x 30/day. e.g. 60 KG x 30 = 1800ml/day. Requirements is increased with fever, hyperventilation and increased catabolic states. Estimation of electrolytes daily is only necessary in critical patients. Potassium should not be added to IV fluid during first 24hs. Post-Op. (because Potassium enters circulation during this time and causes increased aldosterone activity). Other electrolytes are corrected according to deficits. 5% dextrose in normal saline or in lactated Ringer’s solution is suitable for most patients. Usual daily requirements of fluids is between 2000-2500ml/day.

22. Case: 4. A 55 yr old male S/P exploratory laprotomy & stoma formation secondary to gut perforation, appears lethargic on his 4th POD. Physical examination reveals diminished skin turgor , dry mucous membranes & rapid tready pulse. His stoma output is 3500ml in last 24 hrs. Patient is orally allowed on soft diet. How will you manage the patient ? A ) Ask him to drink plenty of water. B ) Replace the deficit via I/V fluids. C ) Start NG feeding of the patient . D ) Reduce ongoing losses.

23. Postoperative Nutritional Support. For people with mild to moderate illness give; 25-35kcal/kg/day. 0.8-1.5g protein/kg/day. 30-35ml fluid/kg/day. Adequate electrolytes, minerals, vitamins. For severely ill patient give; <50% of the energy and protein levels over the first 24-48h. Start at upto 10Kcal/kg/day increasing to full needs over 4-7 days. Start immediately before and during feeding: oral thiamine (200-300mg/day), magnesium (0.2-0.4 mmol /kg/day).

24. Case: 5. 48 year old male k/c IHD underwent Exploratory laprotomy , sigmoid resection and stoma formation secondary to sigmoid volvulus . 2 hours after the surgery pt became short of breath, cough up frothy sputum and start dropping his O2 Saturation. You gave him a shot of lasix and ordered a CXR which shows bilateral bat wing appearance. What is the most likely diagnosis ? A ) Pneumonia. B ) Atelectasis . C ) Pulmonary edema. D ) Pulmonary embolism.

25. Post-Operative pulmonary Care . Functional residual capacity ( FRC) and vital capacity (VC) decrease after major intra-abdominal surgery down to 40% of the Pre-Op. Level. They go up slowly to 60-70% by 6 th -7 th day and to normal Pre-Op. Level after that. FRC, VC, and Post-Op. pulmonary oedema (Post anaesthesia ) Contribute to the changes in pulmonary functions Post-Op. The above changes are accentuated by obesity, heavy smoking or Pre-existing lung diseases specially in elderly. Post-Op. atelectasis is enhanced by shallow breathing, pain, obesity and abdominal distension (restriction of diaphragmatic movements) Post-Op. physiotherapy especially deep inspiration helps to decrease atelectasis . Also O2 mask and periodic hyperinflation using spirometer . Early mobilization helps a lot. Antibiotics and treatment of heart failure Post-Op. by adequate management of fluids will help to reduce pulmonary oedema .

26. Case: 6. 36 yr old female underwent elective incisional hernia repair. You break her NPO after 8 hrs post surgery and allow sips of water then gradually proceed to liquids. After 2 hrs of allowing liquids, patient had 3 episodes of vomiting and developed abdominal distension. She deny any bowel activity. What could be cause of patient's condition ? A ) Postoperative paralytic illeus . B ) Excessive fluid intake. C ) Lack of mobilization. D ) She developed gastroenteritis.

27. Post-Operative Care of GIT. NPO until peristalsis returns. Paralytic ileus usually takes about 24hs. NGT is necessary after esophageal and gastric surgery. Gastrostomy and jujenostomy tubes feeding can start on 2 nd Post-Op. day because absorption from small bowel is not affected by laparotomy . Enteral feeding is better than parenteral feeding. Gradual return of oral feeding from liquids to normal diet.

28. Case: 7. 22 yr old male pt develop pain in subrapubic region and unable to void after 6 hrs of elective inguinal hernioplasty under spinal anesthesia. What should you order to staff? A) Give him bolus of 500ml N/S. B) Catherize the patient. C) Encourage mobilization. D) Give him analgesia.

29. Postoperative Renal Care. Inability to void after surgery is common with pelvic and perineal operations and procedures performed under spinal anaesthesia . Prophylactically catheterize the patient for surgeries expected to last more than 3 hours or in which large volume of fluid is administered. UTI is common in postoperative period, especially in immunocompromised and diabetic patients, treatment involves adequate hydration, proper bladder drainage and antibiotics. Decatheterize patient as soon as possible as it is the biggest source of infection. Look for signs of ARI, prophylactic measures to prevent renal failure in high risk cases, if urine output is less than 0.5ml/kg for 6 or more hours check for catheter blockage, electrolyte disturbance, correct hypovlaemia and stop nephrotoxic drugs.

30. Convalescent phase Starts from discharge of patient from hospital till their follow-up visit. Discharge card/ letter. Should have following details; Diagnosis. Treatment. Laboratory results. Complications. Discharge plan. Support needed. Follow-up. Patient can be discharged from hospital as soon as they can manage their care. Follow up. Follow up can be done in 2 ways; Through telephone. In clinic.

31. Thank you.