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).

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.

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 :

• 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 : • 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 : • 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).