P0ST-OPERATIVE CARE

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P0ST-OPERATIVE CARE
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PHASES

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

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AIM OF PHASES 1 2

• HOMEOSTASIS
• TREATMENT OF PAIN
• PREVENTION EARLY DETECTION OF COMPLICATIONS

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IMMEDIATE POST-OPERATIVE PERIOD
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CAUSES OF COMPLICATIONS DEATH

• ACUTE PULMONARY PROBLEMS
• CARDIO-VASCULAR PROBLEMS
• FLUID DERANGEMENTS

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PREVENTION

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

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• 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.

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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.

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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).

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• 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.

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• 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.

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The Intermediate Post-Operative period

• Starts with complete recovery from anaesthesia
  and lasts for the rest of the hospital stay.

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Care of the wound

• Epithelialisation 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.
• R.O.S. usually 5-7 days Post-Op.
• 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.

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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.

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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.

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• 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.

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Respiratory failure

• Early
• 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 gt 25-30/min.
• Low tidal volume lt 4ml /kg
• High Pco2 gt 45mmHg.
• Low Po2 lt 60mmHg.

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• Treatment
• 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

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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.

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• 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
  Ringers solution is suitable for most patients.
• Usual daily requirements of fluids is between
  2000-2500ml/day.

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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.

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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.
• 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.

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• 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 e.g. Tylenol.
• Epidural analgesia (for pelvic surgery).
• Nerve block (Post-thoracotomy and hernia repair).