POST OPERATIVE CARE

SPEAKER:-UMAR TARIQ

MODERATOR:-DR MADHAVI SANTPUR

Post operative period is the most crucial and critical span of time after completion of surgery

In this period numerous complications occur and if not treated on time can prove fatal hence increasing the mortality rate

INTRODUCTION

POST OPERATIVE CARE

The specialized care provided to the patient after completion of surgery till the patient is fully conscious

This specialized care is provided in a specialized area called PACU

This specialized care is provided according to the type of anaesthesia administered and nature of surgery done

LOCATION The PACU should be situated as close as possible to

the operation theatre.

AREA AND CAPACITY The number of recovery beds should be 1.5-2 times

the number of operating theatres Ideally the space allotted per bed should be at least

15-20 sq meters There should be enough space to allow

unobstructed access for trolleys, equipments and staff

DESIGN OF PACU

MHYPOXIA Gradual decrease in oxygen saturation in blood

Mechanical obstruction may be caused by the patients tongue, an incorrect held airway, secretions, blood and vomit .

The airway should be cleared under direct vision using a laryngoscope, the patient turned on his or her side and supplement O2 given.

POST OPERATIVE COMPLICATIONS

If the patient develops hypoxia , the management is O2 by face mask ,after giving jaw thrust and chin lift

Diffusion hypoxia is caused when N2O diffuses out of the blood faster than oxygen from air is taken up such that alveolar PO2 is reduced. Supplementary postoperative oxygen is essential

Blood pressure may be low in the immediate postoperative period because of hypovolemia or because of the continuing pharmacological effects of the anaesthetic techniques

HYPOTENSION

If the BP is low because of anaesthesia technique used, the head end of the bed may be tilted head down (although not immediately after spinal or epidural procedure as this might extend the block)

Ephedrine diluted in 5 or 10 ml 0f NS and given in small boluses(5-10mg) up to 30 mg IV (especially after spinal or epidural anaesthesia).

Severe hypotension must be treated. Oxygen and IV fluids should be given to combat hypovolaemia , Use vasopressors ( e,g diluted ephedrine)

If the cause of hypotension is thought to be cardiac , a 12 lead ECG should be taken.

An increased systolic BP is due to pain , extubation pressor response ,anxiety or fear and also could be due to full bladder.

Increased diastolic BP is seen in treated or untreated hypertensive patients who may develop rebound hypertension .

HYPERTENSION

BRADYCARDIA A slow pulse may be normal in young , fit adults or may be caused by drugs , vagal stimulation , conduction block

Its treatment is necessary if the patients cardiac output is being compromised by the slow pulse

Glycopyrrolate (0.2 -0.4 mg IV) or if there is urgency in treatment atropine 0.6 mg IV should be administered

If the patient is receiving beta –adenoceptor blocking drugs it may be necessary to double the dose of atropine

The cause of fast pulse is often pain , anxiety, hypercarbia , fever or inadequate neuromuscular reversal

If the tachycardia is compromising the patients condition it should be treated by fluid administration and in some cases blood transfusion is needed

TACHYCARDIA

Usually due to reversible causes like hypokalemia, hypoxemia, alkalosis and stress after the operation.

Could be the 1st sign of a post-OP MI

Usually asymptomatic but could present with chest pain, palpitations or dyspnea.

Atrial flutter\fibrillation:-If the patient is stable, the heart rate could be controlled with β-blockers, digitalis or Ca channel blockers. -If the patient is unstable (eg. In shock) cardioversion is used.

-If hypokalemia is present, it should be corrected

ARRHYTHMIAS

Body temperature below 35° C Causes : Trauma, exposure to cold enviornment and cold fluids – IV

/ Irrigation Mild: 32 – 35C Mod: 28 – 32C Severe: 25 – 28C Hypothermia could lead to

◦ Coagulopathy◦ Platelet dysfunction◦ Increased O2 consumption due to shivering

Treatment with warmers like forced air devices and warm fluids. Meperidine (opioid analgesic) small doses can be used to stop the

shivering.

HYPOTHERMIA

Patients may be hypovolaemic when they arrive in the recovery room due to inadequate pre-operative resuscitation and/or intra operative fluid replacement

Blood loss should be replaced by blood only after 15 -20 % of the blood volume has been lost

If significant hypovolemia is present ,a CVP line and urinary catheter should be inserted to monitor replacement of fluids

HYPOVOLAEMIA

Overzealous fluid replacement can result in hypervolaemia. In fit patients, the kidneys will deal with the overload, but in the paediatric ,elderly & sick, pulmonary oedema and cardiac failure may result.

Diuretics e.g. Frusemide IV 5 – 10 mg will off load acute pulmonary oedema

HYPERVOLAEMIA

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage .

o Assessment of pain The intensity of pain should be assessed , as for as

possible, by the patient as long as they are able to communicate.

PAIN

1. Verbal rating scale (VRS): The patient is asked to rate their pain on a

five point scale as “ none, mild, moderate, severe, very severe

2. Numerical rating scale (NRS) : This consists of a simple 0 to 10 scale Zero indicates to no pain, while 10 indicates

worst possible pain

ANALGESICS Opioids Opioids may be administered by IM ,IV and

by epidural route Paracetamol It is the most commonly used analgesic and

antipyretic drug. It is a weak analgesic .It is only suitable for mild pain

Treatment of post operative pain

Nonsteroidal anti-inflammatory drugs(NSAIDs)

NSAIDs should not be given in asthmatics or to patients with a history of indigestion or peptic ulcer, hypovolaemia , renal dysfunction.

)Epidural analgesia It is effective in preventing dynamic pain It also reduces the endocrine –metabolic

stress response to surgery & thus reduce post op complications

(b)peripheral nerve blocks & plexus blocks

REGIONAL ANALGESIA:

Incidence of post operative nausea and vomiting PONV is 25 – 30 %.It may be central,peripheral,vestibular in origin

Factors influencing PONV:1.Patients factor:- Post operative nausea and vomiting is more

in following patients. Patient factor: Women, young, positive history of PONV

2.ANAESTHETIC FACTOR:-Certain anaesthetic agents and techniques

increase the incidence of PONV: Opioids Inhalational agents specially N2O Neostigmine Hypoxia3.SURGICAL FACTOR:- Gynaecological surgeries Ophthalmic ENT Neurosurgeries

Use of regional technique when possible Use of propofol rather than sodium

thiopentone as an inducing agent Perioperative oxygen supplementation

o TREATMENT Inj metoclopromide Inj ondensetron Inj Dexamethasone

Prevention of PONV

Utmost care should be taken while transportation of patient

Bleeding should be observed by checking soaked dressings/drain for amount, colour, odour

Encourage the patient for deep breathing & coughing to prevent collapse of lung alveoli

Remove secretions by suctioning

CARE OF PATIENT IN THE RECOVERY ROOM

Pain management should be done according to instructions

Change position of the patient frequently and do mobilization to prevent venous stasis

In case of intubated patients check ET tube for blockage tube cuff should not be over or under inflated

I.V fluids, blood transfusion are administered & reactions are managed in event of occurrence

An unconscious/semi-concious patient should not be left alone

Oxygen therapy should be given as appropriate

The recovery room should be equipped by following equipments:-

Equipment required for airway management and oxygen therpy i.e oxygen outlets, face masks, ET tubes, oxygen tubing, humidifier, breathing system , difficult airway devices,suction machine with suction catheter

Defibillator, laryngscope with all blades, resuscitation trolley

EQUIPMENT AND DRUGS

Crash cart

Paediatric equipment trolley containing face masks,airways ET tubes and connectors of various sizes

Monitoring equipments e.g, NIBP monitor, pulse oximeter, capnography,ECG recording,

Drugs for resuscitation (Emergency drug tray), airway management, pain relief, intravenous fluids,anti emetics

In gynecological, laparoscopic, gastrointestinal surgeries and female gender are at the greater risk of having post operative nausea and vomiting . These patients require additional anti emetics

DRUGS

NIBP SPO2 ECG Urine output Temperature Respiratory monitoring

MONITORING

Temperature should be monitored especially in long operations. Hypothermia can lead to a number of problems e.g. delayed recovery, impaired coagulation, shivering or even arrhythmias

It can be treated by body surface warming,blankets and warm I.V fluids

Tramadol 1mg/kg body weight can be used to treat shivering

Temperature

Fluid management reduces adverse outcomes and improves patients comfort and satisfaction

Certain procedures involving significant loss of blood or fluids may require additional fluid management

Fluids

Urine output is a good indicator of adequate perfusion and should be monitored in all post op patients

In addition to this loss of body fluids through vomitus, naso gastric tube drainage and wound drainage should be recorded

The intake of fluid and output should be carefully matched

Excess blood in the wound drainage tube indicate bleeding inside the wound .In this situation surgeon must be informed

Urine and other losses

Many times blood is transfused in the immediate post operative period . The recovery room staff must match the patients details with those given on the blood bag to prevent mismatched transfusion

They must monitor the patient throughout the blood transfusion to recognize and treat the blood transfusion reaction at the earliest

Blood Transfusion

Any kinking or pulling out of catheters and drainage tubes should be prevented and their patency and their proper function should be maintained

The side rails of the bed should be kept raised to prevent patient from falling down

If the patient vomits the head end of the bed should be lowered the vomitus and secretions should be removed immediately by suctioning to prevent aspiration

Always wash hands before and after working with all patient to prevent transmission of infection from one patient to another

If the patient is alert encourage him for deep breaths to improve lung function and to prevent accumulation of secretions

Other parameters

The patients level of consciousness should be assessed and documented. It is done by talking to the patient and then looking for orientation and the response of the patient to stimuli.

The following criteria can be used for level of consciousness

LEVEL OF CONSCIOUSNESS

Comatose: unconscious, unresponsive to stumuli

Stupor: lethargic and unresponsive; unaware of surroundings

Drowsy: half asleep; sluggish; respond to touch and sounds

Alert: able to give appropriate response to stimuli

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