pre-operative & post- operative care begashaw m (md)
TRANSCRIPT
PRE-OPERATIVE & POST-OPERATIVE CARE
Begashaw M (MD)
General consideration
General medical & surgical historyComplete P/E Lab:
_Complete blood count
_Blood typing & Rh-factor, crossmach
_Urinalysis
_Chest x-ray
Assessment
Cardiovascular SystemPulmonary systemRenal systemHematologic systemEndocrine system
Cardiovascular System
Heart diseasehigh-risk
• chest pain, dyspnea, pretibial edema or orthopnea
• Recent history of CHF
• Recent MI
• Severe hypertension
• DVT
Pulmonary system
High risk:
• Upper airway infections
• Pulmonary infections
• Chronic obstructive pulmonary diseases chronic bronchitis, emphysema, asthma
Elective surgery should be postponed
Renal system
Renal function test:
-history of kidney disease
-diabetes mellitus
-hypertension
-over 60 years of age
-proteinuria, casts or red cells creatinine clearance, blood urea nitrogen and
electrolyte
Haematological system
Anemiaaffects the oxygen carrying capacity of the blood Iron deficiency MegaloblasticHemolyticAplastic anemia Patients with iron deficiency anemia respond to
oral or parenteral iron therapy
Thrombocytopenia
Normal platelet 150,000 to 450,000/ml Manifestations:
• Petechia
• Epistaxis
• Menorhagia
• Uncontrolled bleeding Treatment
-treat the underlying cause
-support with platelet transfusions & clotting factors
Diabetes mellitus
poorly controlled DM -susceptible to post-operative sepsis
In type - II patients-avoid hypoglycemia not use longer acting oral hypoglycemic agents -2
days before operation Insulin dependent diabetics with good control-
sliding scaleChronic cxs - Hypertension, myocardial ischemia
which may be silent-proper workup & treatment
Thyroid disease
Elective surgery should be postponed when thyroid function is either excessive or inadequate
In Hyperthyroidism, the patient should be rendered euthyroid before surgerymay take up to 2 months with anti-thyroid medications
Post-operative care
is care given to patients after an operation in order to minimize postoperative complications
Early detection & treatment of post operative complications
Post-operative care
Aims: Comfortable, pain free recovery from operation
– Immediaterecovery room
– Intermediate ward
– Long term home
Immediate care
a. Vital sign
b. Chest auscultation
c. Input and output monitoring
d. Checking for bladder & abdominal distention
e. Potent analgesics for pain relief
On subsequent post-operative days
a. Oral intake can be started
b. Patients encouraged to ambulate
Post Op Complications
General Immediate
1. Primary hemorrhage
2. Reactive hemorrhage
3. Basal Atelectasis
4. Minor lung collapse
5. Shock
6. Blood loss
7. MI, Pulmonary Embolism
8. Low Urine Output
Cardiac complications
1. Abnormal ECG
2. Acute MI
3. Arrhythmia
4. Pulmonary embolus
Shock
Postoperative efficiency of circulation depends on blood volume, cardiac function, neurovascular tone
Shock: Excessive blood loss Third spacing Marked peripheral vasodilatations Sepsis Pain or emotional stress
Treatment
Arresting hemorrhage Restore fluid & electrolyte balance Correct cardiac dysfunction Establish adequate ventilation Control pain & relief apprehension Blood transfusion if required
Thrombophlebitis
Superficial thrombophlebitis
-within the first few days after operation Clinical features
A segment of superficial saphenous vein becomes inflamed manifested by:
RednessLocalized heatSwellingTenderness
Treatment
Warm moist packs Elevation of the extremity Analgesics Anticoagulants
Thrombophlebitis of the deep veins
Occurs most often in the calf
Clinical features asymptomatic dull ache tender & spasm swelling of calf Dorsiflexion of the foot may elicit pain in the calf Homan’s sign
pulmonary embolism
Treatment
Elevation Application of full leg gradient pressure
elastic hose Anticoagulants Prevention: Early ambulation
Pulmonary embolism
Pre-disposing factors
-Pelvic surgery
-Sepsis
-Obesity
-Malignancy
History of pulmonary embolism or deep vein thrombosis
7th to 10th post-operative day cardiac or pulmonary symptoms occur abruptly
Clinical features
chest pain; severe dyspnea, cyanosis, tachycardia, hypotension or shock, restlessness and anxiety
pleuritic chest pain blood-streaked sputum, and dry cough pleural friction rub
Investigation
Chest X-ray=pulmonary opacity in the periphery-triangular in shape with the base on pleural surface, enlargement of pulmonary artery, small pleural effusion and elevated diaphragm
ECG Treatment
Cardiopulmonary resuscitation measures
Treatment of acid-base abnormality
Treatment of shock
Immediate therapy with Heparin
Respiratory complications
1. Atelectasis
2. Aspiration pneumonitis/Pneumonia
3. Pulmonary edema
4. Pneumonia
5. Respiratory failure
Atelectasis
early postoperative period-48 hrsairway collapse distal to an occlusion Predisposing factorschronic bronchitis, asthma, smoking and
respiratory infectionInadequate immediate postoperative deep
breathing and delayed ambulation
Clinical features
Fever Increased pulse , respiratory rate Cyanosis Shortness of breath Dull with absent breath sounds
Investigation and Treatment
CXR - patchy opacity
- mediastinal shift
Prevention and treatment stop smoking Treat chronic lung diseases Postpone elective surgery encourage sitting, early ambulation Adminster analgesics Supplemental oxygen
Pneumonia and aspiration pneumonitis
Pneumonia -atelectasis or aspiration Preexisting bronchitis Clinical features Fever Respiratory difficulty Cough becomes productive pulmonary consolidation
Chest-x-ray _diffuse patchy infiltrates or lobar consolidation
Prevention and treatmentminimized by
- Fasting
- Naso-gastric tube decompression Treatment Deep breathing and coughing Change position Broad spectrum antibiotics
Paralytic Ileus
functional intestinal obstruction usually noted within the first 48-72 hours
Clinical features Abdominal distention Absent bowel sounds Generalized tympanicity on percussion
Investigation Plain x-ray-generalized dilatation and gaseous distention of the bowel
loops
Treatment NGT decompression Fluid and electrolyte balance
Post operative intestinal obstruction
Causes _Peritonitis,Peritoneal irritation, Fibrinous adhesion Clinical features between the 5th and 6th POD vomiting Crampy abdominal pain Focal typmpanicity Exaggerated bowel sounds Investigation Plain film _distension of small bowel with air fluid levels Treatment Hydration & electrolyte keet NPO NGT After 48-72 hours, reoperation
Urinary and renal complications
Urinary retention
Acute renal failure
Urinary tract infection
Urinary retention
pelvic operations spinal anesthesia Pain
Mx encouraged to get out of bed Bladder drainage _a urethral catheter
Urinary tract infection
Predisposing factor
contamination of the urinary tract
Catheterization Clinical presentation
Fever
Suprapubic or flank tenderness
Nausea and vomiting Investigation
Urine analysis Treatment
Increase hydration
Encourage activity
appropriate antibiotic therapy
Wound infections
Pre disposing factors
Age
General health
Nutritional status
hygiene
Malignancy
Poor surgical technique
Diagnosis: clinical
Fever during the 4th to 5th POD
Redness or induration
Treatment Sutures _remove wound exploration and culture drainage wound care antibiotics if systemic manifestations like
fever
Hematoma, Abscess and Seromas
may occur in the pelvis or under the fascia of abdominal rectus muscle
falling of hematocrit low-grade feverSmall hematoma or seroma _resolve
spontaneouslyUltrasonography Drainage of infected hematoma