POST OPERATIVE CARE

Presented by:-Dr.Mohsin KhanPG Resident MS (General Surgery)GRMC Gwalior

The long operation is finished,leaving you to savour the sweet postoperative HIGH and Elation.But soon ,when your serum level of endorphins declines ,you start worrying about the outcome.And worry you must,for the cocksure,macho attitude is a recipe for disasters.

We do not intend here to have a detailed discussion of postoperative care or to write a new surgical intensive care manual.

We only wish to share with you some basic precepts,which may be forgotten,drowned in a sea of fancy technology and gimmicks.

The post operative period begins from the time the patient leaves the operating room and ends with the follow up visit by the surgeon.

The post operative care is provided by -

PACU SICU

Transferring of the patient from the OR to the PACU is the responsibility of the anesthesiologist.

During transport the anesthesiologist remains at the head part of the patient and a surgical team member remains at the opposite side.

Transporting the patient involves the special consideration of the incision site, potential vascular changes and exposure.

Location: ◦ Close to Operating Rooms◦ Easy access to Lab, X-ray, Blood bank◦ Close to ICU

Size:◦ Ideal 1.5 PACU bed for every OT◦ 120 square foot per patient◦ Minimum of 7 feet between beds

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Facilities:◦ Fowler’s cot with side rails◦ Piped Oxygen, Vacuum and Air◦ Multiple electrical outlets◦ Large doors◦ Good lighting◦ Isolation for Immuno-compromised patients

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Tray with labeled Emergency drugs Airway maintenance kit:◦ Laryngoscope with all size blades◦ All sizes Endotracheal tubes◦ Face masks, Airways, Ambu Bag, Venturi masks◦ Tracheostomy set◦ ICD set◦ Transport ventilator

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Personnel:◦ Requirement varies◦ 1 : 1 ratio good◦ 1 : 3 ratio acceptable for busy OR’s

Monitors:◦ ECG◦ Pulse oximeter◦ Non invasive BP ◦ EtCO2◦ Invasive pressure monitor◦ Temperature

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Before receiving the patient, there should be proper functioning of monitoring and suctioning devices, oxygen therapy equipment, and all other equipment. The following initial assessment is made by the nurse in the PACU.

1. Verify the patient’s identity, the operative procedures, and the surgeon who performed the procedures.

2. Evaluate the following signs & verify their level of stability with the anesthesiologist.

Respiratory Status Circulatory Status Pulses Temperature Hemodynamics Values 

A) All vitals 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.

Diet:◦ NPO ◦ Liquids.◦ Soft diet.◦ Normal or special diet.

Extreme care in 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.

Maintain airway By proper positioning of patient’s head. By clearing airway.◦ O2 mask.◦ Ventilator.◦ Tracheal suction.◦ Chest physiotherapy.

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).

Hypovolemic shock: can be avoided by timely administration of IV Fluids, blood and blood products and medication.

Replacement of fluids.[colloids and crystalloids]

Keep the patient warm. Monitor intake and output balance. Monitor the vitals continuously

with the patient condition.

HaemorrhageIt is a serious complication of surgery that resulting death.

It can occur in immediate post operatively or upto several days after surgery.

If left untreated,cardiac output decreases and blood pressure and Hb level will fall rapidly.

Blood transfusion only absolutely if necessary.

The surgical site+incision should always be inspected.

If bleeding,pressure dressing are placed.

If the bleeding is concealed,the patient is taken in OR for emergency exploration of concealed haemorrhage in body cavity.

Use warmer(Bair

Hugger) blankets Use warm lights

1. Monitor temperature hourly to be alert from malignant hyperthermia or to detect hypothermia.

2. A temperature over 37.7 c (100F) or under 36.1 c (97F) is reportable.

 

3. Monitor for post anesthesia shivering (PAS) it is most significant in hypothermic patients 30 to 45 minutes after admission to the PACU. It represents a heat gain mechanism and relates to regaining thermal balance.

4. Provide a therapeutic environment with proper temperature and humidity, when cold, provide the patients with warm blanket.

Perhaps the most useful factor in trying to establish the cause of a patient's fever is THE RELATIONSHIP BETWEEN THE TIME OF ONSET OF THE FEVER AND THE PROCEDURE .

Fever within the first 24 hours of an operation is common and may reflect little more than the body's metabolic response to injury.

Atelectasis is common during this time and may produce a self-limiting low-grade fever.

A fever that is evident between 5 and 7 days after an operation is usually due to infection.

While pulmonary infections tend to occur in the first few days after surgery, fever at this later stage is more likely to reflect infection of the wound, operative site or urinary tract.

Cannula problems and deep vein thrombosis (DVT) should also be considered.

A fever occurring more than 7 days after a surgical procedure may be due to abscess formation.

Apart from infection as a cause of fever, it is important to remember that drugs, transfusion and brainstem problems can also produce an increase in the body's temperature.

Administer opioid analgesia as per Doctor’s order.

Epidural analgesia. NSAIDS. Psychological support to

relieve fear+To give support.

These are common problem in post operative period.

Medication can be administered as per doctor’s order.

Example: Inj Metaclopramide Inj Ondansetron ( Emeset )

General and specific 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.

Lab. Tests and Imaging:◦ To detect or exclude Post-Op. complications.

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.)

The major goals include: Restoration of optimal respiratory function Relief of pain Optimal cardiovascular function Increased activity tolerance Unimpaired wound healing Maintenance of body temperature Maintenance of nutritional balance Resumption of usual bowel and bladder elimination Acquisition of sufficient knowledge to manage self-care after

discharge Absence of complications

1. Keep side rails up until the patient is fully awake.2. Protect the extremity to which IV fluids are running so

the needle will not become accidentally dislodged. 3. Avoid nerve damage and muscles train by properly

supporting and padding pressure areas.4. Recognize that the patient may not be able to complain

of injury such as the pricking of an open safety pin or clamp that is exerting pressure. 

5. Check dressing for constriction.6. Determine return of motor control following anesthesia

indicated by how the patient responds to a pinprick or a request to move a part.

Complications:a. Urinary retention- inability to urinate as a result of the

recumbent position, effects of anesthesia and narcotics, inactivity, altered fluid balance, nervous tension or surgical manipulation of the pelvic area.

Nsg Mgt: a.1 assess for bladder distension a.2 monitor I & Oa.3 maintain IVF as prescribed a.4 increase daily oral intake 2500-3000La.5 insert straight or IFCa.6 promote normal urinary elimination

b. Bowel elimination- frequently altered after pelvic or abdominal surgery and sometimes after other surgery. Return to normal GI function may be delayed by general anesthesia, narcotic analgesia, decreased mobility or altered fluid and food intake during perioperative period.

Nsg Care: 1. Assess for return or normal peristalsis:

a. auscultate bowel sounds every 4 hours while the client is awakeb. assess the abdomen for distentionc. determine whether the client is passing flatus d. monitor for passage of stool including consistency

2. Encourage ambulation within prescribed limits3. Facilitate a daily intake of fluids 2.5-3L4. Provide privacy when the patient is using the bedpan, commode or

bathroom 5. If no BM has occurred for 3-4 days post op, a suppository or an

enema may be ordered.

A patient remains in the post op unit, untill the patient has fully recoverd from anesthesia.

Following measures are used to determine the patient ready for disharge from post operative unit.

Stable vital signs Orientation to Person Place Time or events Adequate oxygen saturation level. Urine out put at least 30ml/hour Minimal pain. Adequate respiratory function. Aldrete score more than ‘ 9 ‘ before shifting from Post Operative Anaesthesia Care Unit

“ Neither an arbitrary t ime l imit nor a discharge score can be used to define a medically appropriate length stay in the recovery room accurately ”

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DISCHARGE FROM RECOVERY SHOULD BE DISCHARGE FROM RECOVERY SHOULD BE AFTER COMPLETE STABILIZATION OF AFTER COMPLETE STABILIZATION OF CARDIO-VASCULAR, PULMONARY AND CARDIO-VASCULAR, PULMONARY AND

NEUROLOGICAL FUNCTIONS WHICH NEUROLOGICAL FUNCTIONS WHICH USUALLY TAKES 2-4 HOURS.USUALLY TAKES 2-4 HOURS.

IF NOT SPECIAL CARE IN ICU.IF NOT SPECIAL CARE IN ICU.

Starts with complete recovery from anaesthesia and lasts for the rest of

the hospital stay.

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.

Drains- are tubes that exit the peri-incisional area, either into a portable suction devise(close) or into the dressing(open)

To drain fluids accumulating after surgery, blood or pus. Open or closed system. Other types (Suction, sump, under water etc.) Should come out throw separate incision to minimize risk of wound infection. Inspection of contents and its amount. Drains are not highly reliable.we should always have a confirmation by inv

(usg) etc when in doubt, bcoz sometimes drain may get blocked by omentum or intestine or may get displaced as in cholecystectomy

Should not be left long periods because they form a tract and acts as a plug.

Drain should be kept till it drains.

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.

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

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.

NPO until peristalsis returns. Paralytic ileus usually takes about 24hs. NGT is necessary after esophageal and gastric surgery. NGT is NOT necessary after cholecystectomy and pelvic operation. 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.

Complications of Pain:◦ Causes vasospasm.◦ Hypertension.◦ May cause CVA, MI or bleeding.

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.

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).

Expected outcomes:1. Indicates that pain is decreased .2. Maintains optimal respiratory function

a. performs DBEb. displays clear breath soundsc. uses incentive spirometry as prescribedd. splints incisional site when coughing

3. Does not develop DVT4. Exercises and ambulates as prescribed

a. alternates periods of rest and activity b. progressively increases ambulation c. resumes normal activities with prescribed time framed. performs activities r/t self care

5. Wounds heal without complications

6. Resumes oral intake and normal bowel function◦ takes at least 75% of usual diet ◦ is free of abdominal distress and gas pains ◦ exhibits normal bowel elimination pattern

7. Acquires knowledge and skills necessary to manage therapeutic regimen

8. Experiences no complications and has normal Vs

Expected out comes Immediate post

operative changes Written instructions like Wound care Activity+dietary

recommendation Medications Follow up

‘Seek consultation even if it is not sure to help;never be a lone wolf’

It is much better in this modern surgical age to form a close working relationship with colleagues who share your philosophy of care and who have expertise in areas beyond your own.

Because once you operate on a patient he or she is all yours!