P0ST-OPERATIVE CARE

1. P0ST-OPERATIVE CARE Omar alnoubani MD,MRCS

2. PHASES • IMMEDIATE ( POST-ANAESTHETIC ) PHASE (1) • INTERMEDIATE ( HOSPITAL STAY ) PHASE (2) • CONVALESCENT ( AFTER DISCHARGE TO FULL RECOVERY )

3. AIM OF PHASES 1 & 2 • HOMEOSTASIS • TREATMENT OF PAIN • PREVENTION & EARLY DETECTION OF COMPLICATIONS

4. IMMEDIATE POST-OPERATIVE PERIOD

5. CAUSES OF COMPLICATIONS & DEATH • ACUTE PULMONARY PROBLEMS • CARDIO-VASCULAR PROBLEMS • FLUID DERANGEMENTS

6. 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.)

7. 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.

8. 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.

9. 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).

10. 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.

11. 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.

12. The Intermediate Post-Operative period Starts with complete recovery from anaesthesia and lasts for the rest of the hospital stay.

13. 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.

14. 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.

16. 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.

17. 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.

19. 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.

20. 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

21. 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.

22. 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.

23. 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.

25. 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. • Paintransmission: • Splanchnic nerves to spinal cord. • Brain stem due to alteration in ventilation, BP and endocrine functions. • Cortical response from voluntary movements and emotions.

26. 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).