1. Post-operative Pain Management
Case 5
Group E

2. 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 .

3. 1- Discuss the Methods for post-operative management for this case.

4. 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.

5. 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).

6. 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.

7. 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.

8. 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

9. 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.

10. 2- what are the differential diagnosis?

11. 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.

12. 3- Discuss the Management .

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

14. - 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

15. - 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

16. - 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

17. Thank
You !