post op management

8/4/2019 Post Op Management

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POST OPERATIVEMANAGEMENT

Dr Frank Wang (senior surgical registrar)


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Topics

Pyrexia

Oliguria/anuria

Fluid & electrolyte balance


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Post operative pyrexia


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Scenario 1

58 year old male

Day 1 post right hemicolectomy

BP/HR stable Temp 38.7 oC

WCC 11


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Treatment options ?

1. Urine & blood culture

2. Above plus CXR

3.

1. & 2. plus iv A/B4. Call surgical registrar

5. Give paracetamol

Ans. 5


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Causes:

Common after surgery

27-58% in first 24 hours

Incidence of infection


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Time since surgery

First 24 hours Systemic response to

trauma

Pre-existing infection

24-72 hours Atelectasis

3-7 days Urinary tract infection

Chest infection

Wound infection

Intra-abdominal sepsis

Anastomotic leak

Thromobophlebitis

Cl. Diff colitis

7-10 days DVT/PE

Prosthetic infection


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Others

Non infectious causes

Medications (drug fever, malignant hyperthermia)

Blood transfusion reactions

Haematoma

Adrenal insufficiency

AMI

Thyrotoxicosis Alcohol withdrawal

Pancreatitis/acalculous cholecystitis


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Management

ABCD

Check BSL

History Physical examination

Review chart

Investigations

Treatments


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History & chart review

Indication for surgery

Operative details

Type of procedure

Prosthesis

Prophylactic A/B

Blood transfusion

Intra-operative complications Co-morbidities

In-hospital progress & interventions


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Examination

Observations & trend

Cardio-respiratory examinations

Abdominal examination

Abdominal signs Wounds

Drains

Calf tenderness

Vascular access sites

IDC/UA

Blood transfusion


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Investigations

Guided by clinical features

Ix:

Haematological

FBC/EUC/LFT ABG

Microbiology

Blood

MSU

Drainage fluid

Wound

Lines

Radiological

CXR

Abdo U/S or CT

V/Q or CTPA

Other

ECG


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Treatments - 1

Atelectasis

Pain control

Chest physio & early mobilisation

A/B for pneumonia UTI

A/B

IDC removal

Wound infection Open drainage

A/B


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Treatments - 2

Intra-abdominal sepsis/anastomotic leak

Drainage

Radiological

Surgical

Iv A/B

Analgesia

s

HDU/ICU


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Fluid replacement

1. Maintenance requirement

2. Replacement of losses

3. Ongoing losses


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Maintenance

Variable

Usually 2.5-3L/day

Rough guide:

2-3mmol NaCl/kg/day

1-2mmol K/kg/day

Volume Electrolytes


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Replacement of losses

1. Actual losses

Bleeding

Vomiting/diarrhoea

2. Ongoing losses

Stoma

Drains

Fistulae NGT

U/O


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IV fluids

Crystalloids

N/S

Hartmanns/Ringers lactate

4% Dex N/5

5% Dex

Colloids

Blood products Albumin

Gelofusin


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Composition of crystalloids

Hartmanns N/S 4% Dex N/5

Na 131 150 30

Cl 111 150 30

K 5 nil nil

HCO3 29 nil nil

Ca 2 nil nil


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Example of IVF order

Maintenance (patient of average weight):

1L N/S + 20mmol KCl

1L 4% Dex N/5 + 20mmol KCl

1L 4% Dex N/5 + 20mmol KCl

Note:

Gastric outlet obstruction N/S + KCl

SBO Hartmanns solutionMost of ongoing surgical losses are rich in Na


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Hypovolaemic shock

Definition:

Systemic hypoperfusion from C.O. or effective

circulating blood volume

Hypotension

Impaired tissue perfusion

Cellular hypoxia


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Grades of hypovolaemic shock

Grade 1 (15% BV, 750ml)

Mild tachycardia

Grade 2 (15-30% BV, 750-1500ml)

Mod tachycardia, pulse pressure, cap return

Grade 3 (30-40% BV, 1500-2000ml)

BP, HR, low U/O

Grade 4 (40-50% BV, 2000-2500ml) Above plus profound hypotension


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Post operative oliguria


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Causes:

Pre-renal:

Hypovolaemia Blood loss

Under resuscitation

Shock Sepsis

Cardiogenic

Renal:

ATN Hypovolaemia

Contrast Nephrotoxic drugs

Acute pyelonephritis

Acute glomerulonephritis

Post-renal:

Calculi

Blood clot

Ureteric injury

BPH Blocked IDC


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Management

Treat underlying cause

Volume resuscitation

Aim U/O 0.5ml/kg/hr (adult)

Monitor vital signs

ICU R/V

? Inotropic support

Invasive monitoring Art line

CVL

post op management

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