1. Post-op Note and Fluid Management By Yasmin Kusow Assia Zakani Huda Matbuli

2. Post-operative Note

3. Post-op note Is a progress note that is written in the chart within several ours after the patient arrives on the floor. This SOAP note should include the following:

5. Heading Hospital day # __ Post op day # ___ S/P _____ (procedure)

6. Subjective Patient’s activity and symptoms: pain control, ambulation, flatus, bowel movement, urination, diet, breathing.

8. Objective Vitals: current temp (Tc), BP range, HR, RR, +/- O2 sats I/Os (ins and outs): Record total input and total output since surgery Physical exam: Briefly: Skin, Resp, Cardiac, Abdominal, Neurological ( global mental status ), Condition of wound ( i.e. dressed and dry, erythematous, drainage, tenderness ) Lab results

10. Assessment Summery and General condition, any significant improvements or concerns since last note. E.g: 50 year old man POD#1 after cholecystectomy, progressing well

12. Plan Includes: -Patient activity -Change in pain control -Antibiotics and other meds -Diet -Fluids -Drains -Investigations

14. Other way to do it… Regarding A/P: Written in the same section, Encounter patient’s problems and plan to manage each of them

15. E.g Neuro: Pain control adequate, continue PCA OOB, ambulate today CV: Mild tachycardia, will bolus with 500cc isotonic crystalloid and reevaluate Resp: No issues, continue spirometry GI: Await return of bowel function, continue NPO, NGT GU: U/O marginal, continue to monitor closely after volume load, Replete electrolytes Heme: HCT 27 and stable, continue SQ Heparin ID: Perioperative abx D/C'd, afebrile, check WBC today Endocrine: Continue ISS, BS well controlled

16. Fluid Management

17. What are the common causes of volume deficit in surgical patients? Insensible fluid loss: Skin and Lungs Urine output GIT fluid losses: NG suction, Vomiting, Diarrhea, Fistula, etc Blood loss Third spacing: obstruction, peritonitis, burns, etc

18. Classic fluid management 1)Maintenance Fluid 2)Deficit therapy 3)Replacement therapy

19. Maintenance Therapy The amount of fluid administered to replace insensible fluid loss and urine output Calculation: The 4-2-1 rule 4 ml/kg/hr for first 10 kg of body weight 2 ml/kg/hr for 2nd 10 kg of body weight 1 ml/kg/hr for each kg of body weight above 20 kg

20. Deficit Therapy Refers to the management of fluid and electrolyte losses that occur prior to presentation for surgery Calculates as : 1) Duration NPO x hourly maintenance + 2) Other estimated fluid losses Eg: Pre-op bowel preparation, Pre-op blood loss (trauma) or fluid loss (burns)

21. Replacement Therapy Replacement of ongoing abnormal fluid loss (e.g. surgical wound blood loss, nasogastric aspirate, drains, third space losses etc.) Blood Loss: 3 ml of crystalloid for every 1 ml of blood loss 1 ml of colloid for every 1 ml of blood loss Third space fluid loss: Minimal tissue trauma (e.g. herniorrhaphy) 2-4 ml/hr Moderate ( e.g. cholecystectomy) 4-6 ml Severe (e.g. bowel resection) 6-8 ml/hr

22. Fluid Balance

23. Introduction The three principles of management of fluid balance: 1- correct any abnormalities 2- provide the daily requirements 3- replace any abnormal and ongoing losses.

24. Ideally, any abnormalities will have been identified and corrected before or during the surgical procedure. In the calculation of a patient's fluid requirements, there is a distinction to be made between the volume required to maintain the body's normal functions and that required to replace any abnormal losses. The normal maintenance fluid requirements will vary depending on the patient's age, gender, weight and body surface area.

25. Fluid balance chart The fluid balance chart measures the patient’s hourly fluid intake and output over a 24 hour period. At the end of 24 hours, the total measured output (urine, drains, nasogastric drainage) is subtracted from the total measured intake (intravenous infusion, oral intake). The result is called the fluid balance.

26. A “positive” fluid balance means that there is more intake than output: that is, the patient is accumulating water. In fact, a positive fluid balance is not really positive because there are certain outputs that are not measured very accurately (e.g. faeces) and others that are not possible to measure at all (in sweat and respiration – so called “insensible” losses). A normal healthy adult will appear to have a positive fluid balance of about 1–1.5 litres a day

27. For these reasons, in the first 24 hours, the fluid balance chart will usually show a big positive balance, perhaps as high as 10 litres. In succeeding days, fluid balance should revert to the normal 1–1.5 litre positive per day.

28. In general, if a severely ill patient, such as a septic surgical case, shows a persistent positive fluid balance each day, it means an ongoing illness that is not resolving