Post-operative Pain Management Case 5 Group E

A55 years old patient had explorative laparotomy with midline incision under general anesthesia the intraoperative course was uneventful and surgery lasted 3 hours the final diagnosis was perforated duodenal ulcer, patient extubated and send to recovery room .

1- Discuss the Methods for post-operative management for this case.

Analgesia Multimodal analgesia is used, which works on the principle that drugs acting by different mechanisms can result in additive or synergistic analgesia with lowered adverse effects. In particular there is an attempt to minimize opioids (‘opioid sparing’) to reduce their adverse effects. Pain is subjective Most pain is self-limiting, with analgesic requirements falling by 48 hours, even after major surgery. Safety is paramount in pain management.

Fluids Patients will require i.v. fluids until they are able to drink normally Fluid is required for the following: • maintenance and inter-operative fluid losses. • replacement of pre-existing losses (e.g. dehydration preoperatively). • replacement of postoperative losses (e.g. nasogastric losses, bleeding). The types of fluid are: • isotonic crystalloid (most often used); • colloids (for maintaining intravascular volume, early bleeding); • blood and blood products (for significant haemorrhage, coagulopathy).

Oxygen therapy Depending on the magnitude of surgery, this effect may be short lived for peripheral surgery (<30 minutes) but more prolonged with major upper abdominal or thoracic surgery (>3 days), especially if postoperative opioids are used (e.g. PCA). Oxygen delivery devices are divided into two categories: Fixed These supply a fixed and known concentration of oxygen. The device must be able to match the patient’s peak inspiratory flow rate (>30L/min) Variable These devices consist of a simple face masks and nasal prongs, which give an unknown concentration of oxygen; however, they are commonly used.

Oxygen therapy We check the vital signs frequently, Oxygen saturation and urinary output. we also check the site of incision for any signs of bleeding or infection. Others anticoagulants. antibiotics. insulin.

Referral to high dependency unit/intensive care unit Postoperatively, some patients require more clinical input on a high dependency unit (HDU) or an intensive care unit (ICU). Level of post-operative care 0 (ward) Patients needs met on normal ward 1 (HDU) Patients at risk of their condition deteriorating, or who require advice from the ICU team
 2 (ICU) Patients with a single failing organ system or requiring detailed observation/intervention 3 (ICU) Patients requiring ventilation (alone), advanced respiratory support alone or support of at least two organ systems

Blood pressure was 176/89 HR: 98/min bolus of 5 mg morphine intravenous was given. Patient started to be tachycardia HR: 128/ min tachypnea SPO2 dropped to 65 % with expiratory wheezing on chest examination.

2- what are the differential diagnosis?

Differential diagnosis 1-Allergy to morphine. 2-Respiratory depression (caused by morphine): Both bradypnea and hypopnea are observed. The body retains the hypoxic drive to breathe but this may be overridden by the CNS sedative effects of a severe overdose. 3- Airway Obstruction. 4-Postoperative nausea and vomiting. 5-overdose of Vasopressors. 6-Fluid Overload. 7- Residual anesthesia.

3- Discuss the Management .

The patient may have an obstruction of the air way because he is: - tachypnic - SPO2 is dropped - expiratory wheezing - tachycardia

- tachypnic - SPO2 is dropped - expiratory wheezing - tachycardia 1. Airway obstruction Causes: Tongue fall back Residual anesthesia - tachypnic - SPO2 is dropped - expiratory wheezing - tachycardia Management: Oral Airway (if unconscious) Nasal Airway Tracheal intubation Cricothyroidotomy Tracheotomy

- tachypnic - SPO2 is dropped - expiratory wheezing - tachycardia 2. Hypoventilation - tachypnic - SPO2 is dropped - expiratory wheezing - tachycardia Causes: Residual anesthesia Narcotics Inhalation agent Muscle Relaxant Post-operative Intravenous Analgesia (Morphine) Management: Reverse (or Antidote): Muscle relaxant Neostigmine Opioids Naloxone Midazolam Anexate

- tachypnic - SPO2 is dropped - expiratory wheezing - tachycardia 3. Hypertension - tachypnic - SPO2 is dropped - expiratory wheezing - tachycardia Causes: - Pain - Hypertensive patients - Fluid overload - Excessive use of vasopressors Management: Sedation Anti-hypertensives: Beta blockers Alpha blockers Hydralazine (Apresoline) Calcium channel blockers

Thank You !