Post-operative care by Dr Nipun Bansal
•Download as PPT, PDF•
3 likes•1,276 views
As a part of short description of Basics of Surgery, these slides are "Must-read" for the new undergraduates and new postgraduates
Recommended
Recommended
More Related Content
What's hot
What's hot (20)
Similar to Post-operative care by Dr Nipun Bansal
Similar to Post-operative care by Dr Nipun Bansal (20)
Recently uploaded
Recently uploaded (20)
Post-operative care by Dr Nipun Bansal
- 1. P0ST-OPERATIVE CARE Dr. Nipun Bansal Senior Resident, Department of General Surgery Government Medical College Surat
- 2. Post-Operative Care • Meaning: The management of a patient after surgery . This includes care given during the immediate postoperative period , both in the operating room and postanesthesia care unit , as well as during the days following surgery . • The goal of postoperative care : 1. to prevent, detect and manage complications during post- operative period. 2. to promote healing of the operative site 3. to return the patient to a state of good health. 4. To treat pain during post-op period
- 3. Phases • IMMEDIATE ( POST-ANAESTHETIC ) PHASE (1) • INTERMEDIATE ( HOSPITAL STAY / Ward ) PHASE (2) • CONVALESCENT ( After discharge from hospital )
- 4. Check list for 1st postoperative assessment • Instructions given to PACU Staff: General info (name, age, surgery, etc) Past medical History Medications Allergies Intraoperative course and management Intraoperative complications- anesthetic or surgical Recommended Rx & prophylaxis ( e.g. fluids, nutrition, antibiotics , analgesia , anti-emetic , thromboprophylaxis) The patient is transferred to PACU after the surgical procedure, anesthesia reversal, and extubation (if it was necessary). Mental status/ Level of consciousness: Patient conscious and normally responsive? (AVPU: Alert, respond for Verbal & Painful stimuli, unresponsive)
- 5. • Respiratory assessment status: O2 saturation. Effort of breathing Respiratory rate Trachea central or not. Symmetry of inspiration and expiration. Breath sounds. Percussion. Check list for 1st postoperative assessment Volume status assessment: Hands-warm or cool; pink or pale. Pulse- rate , volume and rhythm. blood pressure. Conjunctival pallor. Jugular venous pressure. Urine color & output . Drainage from drains, wound & NG tube
- 6. Other assessment categories: • surgical site (intact dressings with no signs of overt bleeding) • patency (proper opening) of drainage tubes/drains • body temperature (hypothermia/hyperthermia) • rate of intravenous (IV) fluids • circulation/sensation in extremities after vascular or orthopedic surgery • level of sensation after regional anesthesia • pain status • nausea/vomiting • RECORD any significant symptoms (e.g. chest pain, breathlessness, diaphoresis) The amount of time the patient spends in the PACU depends on • Length of surgery • Type of surgery • Status of regional anesthesia (e.g., spinal anesthesia) • level of consciousness
- 7. • Acute pulmonary problems • Cardio-vascular problems • Fluid and Electrolyte derangements Complications & Deaths in Immediate Post-op Period Prevention is by Continuous Monitoring of Patient’s Vitals in Recovery Room Discharge from RR should be after complete stabilization of cardio-vascular, pulmonary and neurological functions (If not under special care in icu) Prevention is by Continuous Monitoring of Patient’s Vitals in Recovery Room
- 8. Post-operative orders A) Monitoring • Vitals (pulse, BP, RR, Temp) every hourly. • CVP • ECG • Fluid balance ( input and output) • Urine. • Other types of monitoring : • Arterial pulses after vascular surgery. • Level of consciousness after neurosurgery. B) Respiratory Care: • Tracheal suction. • Chest physiotherapy. C) Position in bed and mobilization: Turning in bed usually every 2 hours until full mobilization to prevent pressure sores/ bed sores. DVT prevention mechanically ( intermittent calf compression). D) Diet: NPO / Liquids / Soft diet / Normal or special diet. E) Administration of I.V. fluids: Daily requirements. Losses from GI and UT Losses from stomas and drains. Insensible losses
- 9. Intermediate Post-op period Starts with complete recovery from anaesthesia and lasts for the rest of the hospital stay.
- 10. Care of the wound • Epithelialisation takes 48 hs. • Dressing should be removed 3-4 days after operation. • Soaked dressing changed earlier. • Symptoms and signs of infection should be looked for, which if present; a few stitches removed 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.
- 11. Management of drains • To drain fluids accumulating after surgery, blood or pus. • Should come out through separate incision to minimize risk of wound infection. • types e.g Suction, sump, under water etc. • Soft drains e.g. Penrose should not be left more than 40 days because they form a tract and acts as a plug. • Inspection of color, contents, amount, consistency and odour. * Notify if there is excessive or abnormal drainage • Should be removed as long as no function.
- 12. Post-op Pulmonary care • Functional residual capacity (FRC) and VC decrease after major intra-abdominal surgery down to 40% of the Pre-Op. Level. • Post-anesthesia pulmonary oedema. • Accentuated by obesity, heavy smoking or Pre-existing lung diseases specially in elderly. • Post-Op. atelectasis - enhanced by shallow breathing, pain, obesity and abdominal distension (restriction of diaphragmatic movements) • Post-Op. Chest physiotherapy especially deep inspiration helps. • Periodic hyperinflation using spirometer. • Adequate management of fluids help to reduce pulmonary edema.
- 13. Post-op Fluid & Electrolytes • Considerations: • Maintenance requirements. • Extra needs resulting from systemic factors e.g. fever, diarrhoea 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. • Requirement - fever and increased catabolic states. • Estimation of electrolytes daily is only necessary in critical patients. • 5% dextrose in normal saline or in lactated Ringer’s solution is suitable for most patients.
- 14. Post-op Care Of GIT • NPO until peristalsis returns. • Ausculate for bowel sounds. • Gradual return of oral feeding from liquids to normal diet. • NGT is necessary after esophageal and gastric surgery. • NGT is NOT necessary after cholecystectomy, pelvic operation or colonic resections. • RT Aspiration is important e.g. in GJ • Gastrostomy and jejunostomy tube feeding can start on 2nd Post-Op. day • Early Ambulation and Repositioning helps in passage of flatus • STOMA CARE: Look for color (Pink/ dusky), functionality, Prolapse, Retraction, excoriation.
- 15. 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, cultural • Complications of Pain: • Causes vasospasm -> Hypertension. • Nausea/ vomiting • May cause CVA, MI or bleeding. • Management of Post-Op. pain: • Physician – patient communication (reassurance). • Analgesics (NSAIDS). • Parenteral opioids. • Anxiolytics potentiates action of opioids, anti-emetic effects. • Suppositories e.g. Tylenol. • Epidural analgesia • Nerve block (Post-thoracotomy and hernia repair).
- 16. Urinary Assessment • Urine examined for • Note color, amount, consistency . • Assess indwelling catheters for patency • Urine output should be at least 0.5 ml/kg per hour or 30cc/hr.
- 17. Post-op Surgical Complications • Age both extremes • Obesity • Chronic Smokers • Co-morbid conditions • Drug therapy e.g. steroids , immunosuppressant, antibiotics and contraceptive pills General Risk Factors :
- 18. Anaesthetic Complications Depend on: • The mode (General, Regional &Local) • Type ofanesthetic (the anesthetic agent toxicity). Local Anaesthesia: Injection site: Pain, hematoma, Nerve trauma, infection Vasoconstrictors: ( C.I in nose , fingers , penis , scrotum , ears , toes ) it may lead to ischemic necrosis Systemic effects of LA agent: Allergic reactions, toxicity SPINAL, EPIDURAL &CAUDAL ANESTHESIA: Headache due to loss of CSF Intrathecal bleeding Permanent Nerve/ cord damage Paraspinal infection Severe hypotension Urinary retention General Anasthesia : Direct trauma to mouth or pharynx. Hypothermia due to long operations with extensive cold fluids replacement.
- 19. Complications due to surgery : •Immediate (0-24hrs) Primary hemorrhage Basal atelectasis Shock •Early (2nd day- 3weeks) •Mental state change •Fever •2ndry hemorrhage •Wound infecton •Paralytic ileus Late (Weeks –months) Bowel obstruction Incisional hernia Hemorrhage Wound Infection Cardiovascular Respiratory Gastrointestinal Urinary tract Cerebral Septicemia
- 20. HEMORRHAGE Primary Hemorrhage : • Inadequate hemostasis. • Unrecognized damage to blood vessels. • Defective vascular anastamoses. • Clotting factor deficiency. • Intra-operative anticoagulants Early recognition & management Surgical re-exploration is usually required Secondary hemorrhage: Usually Related to infection.
- 21. WOUND COMPLICATIONS Infection: Classification 1. Superficial (skin and SC tissue) 2. Deep (fascia and muscle ) 3. Space (anatomical space and organ) Symptoms & signs: Local rise in temp, redness , pain, Swelling + Fever, chills Treatment 1. Superficial >> incision and drainage with or without systemic antibiotic 2. Deep >>> surgical debridement with systemic antibiotic 3. Space >>> CT scan guided percutaneous drainage & may need open drainage Etiology : It based on the site of operation Staph: In thoracic , neuro , vascular, breast G –negative for GIT and urologic operation Strept. Head and neck
- 22. Hematoma : Localized collection of blood. Seroma : Localized collection of serous fluid. Common sites : breast and abdominal surgery Treatment Small hematoma/ seroma : spontaneously absorbed Large hematoma/ seroma : may required drainage Wound dehiscence Evisceration – wound edges separate so that the intestine protrudes through gap. – Emergency; in cases of increased Straining. Incisional hernia Risk Factors: chronic cough, Increased abdominal pressure like lifting Heavy object etc Treatment : Herniorrhaphy Hernioplasty ( with mesh)
- 23. HYPOTHERMIA • Body temperature below 35° C. • Causes : Trauma, Exposure to Cool Fluids – IV / Irrigation • Hypothermia can lead to: • Increased O2 consumption due to shivering • Coagulopathy • Platelet dysfunction • Mild: 32 – 35 ° C • Mod: 28 – 32 ° C • Severe: 25 – 28 ° C • Treatment with warmers like forced air devices and warm fluids. • Meperidine (opioid analgesic) in small doses can be used to stop the shivering.
- 24. • Within 48 Hours - Usually Atelectasis • After 48 Hours - UTI - Catheter related phlebitis - Pneumonia • After the 5th PO day - Wound infection - Anastomotic breakdown - Intra-Abdominal abscess • After the 7th PO day - Deep vein thrombosis - Pulmonary embolism •Regular work up includes: • CBC • Blood cultures • Urine analysis and urine cultures • CXR • Sputum cultures POSTOPERATIVE FEVER Body temperature > 38.5° C 40% of patients after a major surgery. In most patients it resolves without specific treatment, however a patient must be evaluated for: •Pneumonia / Atelectasis •Wound Infections/ Abscess •UTI •Deep vein thrombosisPulmonary embolism •Medications
- 25. Myocardial Infarction • Risk factors: -Previous history/ Angina / Advanced age/ Lifestyle • Investigations: -ECG/ Troponin I CKMB • Presentation: -Often asymptomatic; Symptoms include: breathlessness, new onset dysrhythmia, hypotension, chest pain, tachycardia... • Treatment: -Nitrates, Aspirin, Oxygen, Pain control, Heparin and ICU monitoring Reversible causes like hypokalemia, hypoxemia, alkalosis and stress after the operation. Could be the 1st sign of a post-OP MI. Atrial flutterfibrillation: -If the patient is stable, the heart rate could be controlled with β-blockers, digitalis or Ca channel blockers. -If the patient is unstable (eg. In shock) cardioversion is used. Premature Ventricular contractions (PVC) : Oxygen, sedation, analgesia Ventricular Tachycardia: Can lead to the life threatening ventricular fibrillation. Rx: Lidocaine Complete Heart Block: Insertion of a pacemaker is necessary. correction of fluidelectrolyte disturbances Arrhythmia
- 26. DVT • Risk Factors: • Advanced age, Obesity, Hormonal therapy , Immobilization, Smoking, DMHTN • Symptoms: Can be asymptomatic; Pulmonary embolism, lower limb pain, tenderness and swelling • Homan’s sign: Calf pain with dorsiflexion of the foot • Moses sign: Calf pain on squeezing. • Investigation: Duplex US. • DVT prophylaxis • Leg exercise (10-12/Q 1-2 hr) • Elastic stockings • Sequential compression devices • Anticoagulants (Heparin, LMWH) • Early ambulation
- 27. • Early : • Occurs minutes to 1-2 hours. Post-Op. • Occurs suddenly. • Late : • Occurs 48 hs. Post-Op. • Due to pulmonary embolism, abdominal distension or opioid overdose. Manifestation : • Tachypnea > 30/min. • Low tidal volume < 4ml /kg • High Pco2 > 45mmHg. • Low Po2 < 60mmHg. • Treatment : • Immediate intubation and mechanical ventilation if required. • Treatment of underlying lung disease. • Prevention: • Physiotherapy (Pre. & Post-OP.) to prevent atelectasis. • Treatment of any Pre-existing pulmonary diseases. • Hydration of patient to avoid hypovolemia and later on atelectasis and infection. Respiratory failure
- 28. Pulmonary embolism • Symptoms: Dyspnea, fever, tachypnea and hemoptysis. • Investigations: ABG, CT angiogram, Pulmonary angiogram [Gold Standard]. • Treatment: -Stable Patient: Low molecular weight heparin or a green field filter. -Unstable Patient: Thrombolytic therapy, pulmonary artery embolectomy or catheter suction embolectomy. • Prophylactic measures for DVTPE: • Preoperative heparin. • Elastic stockings. • Early ambulation. Risk Factors: Prolonged ventilation support, peritoneal infection, atelectasis and aspiration. SignsSymptoms: Fever, tachypnea, increased secretions and signs of pulmonary consolidation. Investigations: Sputum culture and CXR showing consolidation. Treatment: Antibiotics and clearing the airway of secretions. Post-Op Pneumonia
- 29. ATELECTASIS Collapse of the alveoli. Occurs within the first 48 hours post op. Affects 25% of patients who have abdominal surgery. Risk Factors: Thoracicabdominal surgery, COPD, smoking poor pain control and poor ventilation during surgery. Signs: Fever, decreased breath sounds, tachypnea, tachycardia and increased density on CXR. Treatment: Incentive spirometry, deep breathing, coughing, early ambulation and chest physical therapy. Prophylaxis Smoke cessation and good pain control.
- 30. Urinary Retention: • Enlarged bladder from spinal anesthesia or medication. • SymptomsSigns: Palpable bladder and inability to void. • Treatment: K-90 / Foley catheter. UTI Risk Factors: Urinary retention, preexisting contamination of urine and instrumentation. SymptomsSigns: Cystitis: Dysuria and mild fever. Pyelonephritis: High fever, flank tenderness and ileus. Diagnosis: Urine examination and cultures. Treatment: Hydration, proper drainage of the bladder and antibiotics.
- 31. POSTOPERATIVE ILEUS It is an obstruction due to paralysis of the bowel. • Risk factors: Hypokalemia, narcotics and GI surgery. • Symptoms and signs: Constipation, abdominal pain, absent bowel sounds and bowel distention with gases on CXR. • Treatment: Supportive until motility returns (usually within 3-5 days).
- 32. Neurologic • Drug Induced • ICU Psychosis • Neuropsychiatric Complications • Operative Nerve Injuries Late Complications Wound: Hypertrophic scar, keloid, wound sinus, implantation dermoids, incisional hernia Adhesions: Intestinal obstruction, strangulation Short gut syndrome, postgastric surgery syndromes, etc. Susceptibility to other diseases, Tuberculosis, etc. Enterocutaneous Fistula from GI tract to the skin. Causes: Anastomotic leak, traumainjury, infection , etc. Investigations: CT, fistulagram. Treatment: NPO, total parenteral nutrition, half will resolve spontaneously, but the other half will requir resection of the involved bowel segment.
- 33. 1. Education ( + family) : Encourage early mobilization: Deep breathing and coughing, 2. Active daily exercise, Joint range of motion, Muscular strengthening , Make walking aids available 3. Ensure adequate nutrition 4. Prevent skin breakdown and pressure sores: Turn the patient frequently o Keep urine and faeces off skin 5. Provide adequate pain control 6. Prescriptions 7. Follow up
Editor's Notes
- medication for nausea or vomiting, as well as pain. Patients with a patient-controlled analgesia pump may need to be reminded how to use it. If the patient is too sedated immediately after the surgery, the nurse may push the button to deliver pain medication. The patient should be asked to rate his or her pain level on a pain scale in order to determine his or her acceptable level of pain. Controlling pain is crucial so that the patient may perform coughing, deep breathing exercises, and may be able to turn in bed, sit up, and, eventually, walk.
- Respiratory exercises (coughing, deep breathing, and incentive spirometry) should be done every two hours. The patient should be turned every two hours to prevent pressure sores must perform respiratory exercises to prevent pneumonia; and that movement is imperative for preventing blood clots, encouraging circulation to the extremities, and keeping the lungs clear
- NOTIFY to the operating surgeon
- K causes increased aldosterone activity
- Paralytic ileus usually takes about 24hs. Normal frequency : absorption from small bowel is not affected by laparotomy. Enteral feeding is better than parenteral feeding.
- Pain transmission: Splanchnic nerves to spinal cord. Brain stem- alteration in ventilation, BP and endocrine functions. Cortical response from voluntary movements and emotions.
- Malignant hyperthermia is disease passed down through families that causes a fast rise in body temperature (fever) and severe muscle contractions when the affected person gets general anesthesia symptoms : High temperature, Tachycardia, Tachypnea, increased carbon dioxide production, increased oxygen consumption, acidosis, rigid muscle & rhabdomyolysis Treatment : Discontinue the anesthesia, wrapping the patient in a cooling blanket Benzodiazepine >>>((dantrolene))
- Virchow : Rubor, tumor, calor, dolor Celsius: Functiolasia
- Seroma is common in excessive fatty tissues Incsional hernia They occur more commonly among adults than among children
- Cardiovascular Complications are life threatening.
- Emboli get trapped in pulmnonary arteries; obstruct blood flow
- Most common Respi complication
- Pseudomembranous Colitis - antibiotic associated diarrhea usually caused by Clindamycin C.difficile toxin in stool, fecal WBCs and mucus membranes in the lumen of the colon Metronidazole orally or IV.
- Ambulation to prevent DVT Respiratory excersise .