P0ST-OPERATIVE CARE Omar alnoubani MD,MRCS

PHASES IMMEDIATE ( POST-ANAESTHETIC ) PHASE (1) INTERMEDIATE ( HOSPITAL STAY ) PHASE (2) CONVALESCENT ( AFTER DISCHARGE TO FULL RECOVERY )

AIM OF PHASES 1 & 2 HOMEOSTASIS TREATMENT OF PAIN PREVENTION & EARLY DETECTION OF COMPLICATIONS

IMMEDIATE POST-OPERATIVE PERIOD

CAUSES OF COMPLICATIONS & DEATH ACUTE PULMONARY PROBLEMS CARDIO-VASCULAR PROBLEMS FLUID DERANGEMENTS

PREVENTION RECOVERY ROOM : ANAESTHETIST RESPONSIBILITIES TOWARDS CARDIO- PULMONARY FUNCTIONS. SURGEON’S RESPONSIBILITIES TOWARDS THE OPERATION SITE. TRAINED NURSING STAFF : T0 HANDLE INSTRUCTIONS. CONTINUOUS MONITORING OF PATIENT (VITAL SIGNS etc.)

DISCHARGE FROM RECOVERY SHOULD BE AFTER COMPLETE STABILIZATION OF CARDIO-VASCULAR, PULMONARY AND NEUROLOGICAL FUNCTIONS WHICH USUALLY TAKES 2-4 HOURS. IF NOT SPECIAL CARE IN ICU.

Post-Operative Orders A) Monitoring Vital sign (pulse, BP, R.R, Temp) every 15-30 min. C.V.P ( Swan – gins 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.

Post-Operative Orders B) Respiratory Care: O2 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).

E) Administration of I.V. fluids: 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.

H) Lab. Tests and Imaging: G) Medication: Antibiotics. Pain killers. Sedatives. Pre-operative medication. Care of patients on Pre-Op. Steroids. H2 Blockers specially in ICU patients. Anti-Coagulants. Anti Diabetics. Anti Hypertensives. H) Lab. Tests and Imaging: To detect or exclude Post-Op. complications.

The Intermediate Post-Operative period Starts with complete recovery from anaesthesia and lasts for the rest of the hospital stay.

Care of the wound Epithelialization 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. Tensile strength of wound minimal during first 5 days, then rapid between 5th 20th day then slowly again (full strength takes 1-2 years). Good nutrition.

Management of drains To drain fluids accumulating after surgery, blood or pus. Open or closed system. Other types (Suction, sump, under water etc.) Should be removed as long as no function. Should come out throw separate incision to minimize risk of wound infection. Inspection of contents and its amount. Soft drains e.g. Penrose should not be left more than 40 days because they form a tract and acts as a plug.

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 6th -7th 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.

Respiratory failure Early : Late : Manifestation : Occurs minutes to 1-2 hs. Post-Op. No definite cause. Occurs suddenly. Late : Occurs 48 hs. Post-Op. Due to pulmonary embolism, abdominal distension or opioid overdose. Manifestation : Tachypnea > 25-30/min. Low tidal volume < 4ml /kg High Pco2 > 45mmHg. Low Po2 < 60mmHg.

Treatment : Prevention: Immediate intubation and mechanical ventilation. Treatment of atelectasis, pneumonia or pneumothorax if any. Prevention: Physiotherapy (Pre. & Post-OP.) to prevent atelectasis. Treatment of any Pre-existing pulmonary diseases. Hydration of patient to avoid hypovolaemia and later on atelectasis and infection. May be hyperventilation to compensate for insufficiency of lungs. Use of epidural block or local analgesia in patients with COPD to relieve pain and permits effective respiratory muscle functions

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 (3rd 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.

Post-Operative Care of GIT NPO until peristalsis returns. Paralytic ileus usually takes about 24hs. NGT is necessary after esophageal and gastric surgery. NGT is NOT necessary after cholecystectomy, pelvic operation or colonic resections. Gastrostomy and jujenostomy tubes feeding can start on 2nd 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.

Post-Operative Pain Factors affecting severity : Pain transmission: 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. Pain transmission: Splanchnic nerves to spinal cord. Brain stem due to alteration in ventilation, BP and endocrine functions. Cortical response from voluntary movements and emotions.

Complications of Pain: Causes vasospasm. Hypertension. May cause CVA, MI or bleeding. Management of Post-Op. pain: Physician – patient communication (reassurance). Parenteral opioids. Analgesics (NSAIDS). Anxiolytic agents (Hydroxyzine) potentiates action of opioids and has also an anti-emetic effects. Oral analgesics or suppositories. Epidural analgesia (for pelvic surgery). Nerve block (Post-thoracotomy and hernia repair).