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Post-operative care presentation
- 2. POST-OPERATIVE CARE DR. ADNAN BILAL PGR-SU4 BVH, BAHAWALPUR
- 3. LEARNING OBJECTIVES: • Need of immediate post-op care • Common post-operative problems • Anticipation & prevention of common complications • Identification & Treatment • Enhancement of recovery • Systematic discharge
- 4. INTRODUCTION: • To provide quick, painless & safe recovery from surgery as soon as possible.
- 5. Good Surgeon?? “A good surgeon is a good physician first”
- 6. POST- ANESTHESIA CARE • Patient is handed over to a dedicated PACU working under observation of trained staff, along with complete patient information & nature of surgical intervention. PACU management involves: • Resuscitation • Difficult airway management • Scheduled vitals monitoring • Drugs • Discharge criteria out of PACU
- 7. PACU DISCHARGE CRITERIA • Conscious • Maintaining SPO2 • Normothermic • Vitally stable & Pain free • Proper medications prescribed • No concern related to surgical procedure
- 8. POST-OP COMPLICATIONS • Classification • Immediate: within 06 hours • Early: (06-72 hours) • Late: (>72 hours)
- 9. IMMEDIATE RESPIRATORY COMPLICATIONS • Upper airway obstruction Causes Vocal Cord dysfunctio n Laryngo -spasm Persistent relaxation of Airway Muscles Soft tissue edema Hematom a Foreign body
- 10. CONTINUED… • Impaired adequacy of ventilation (NM blockade, Anesthetic agents, Opioids) • Supplemental O2 • Hypoxemia (Ac. Pulmonary Edema, bronchospasm, pneumothorax, Aspiration, PE) • If spontaneously breathing, supplemental oxygen 15L/min using a non re-breathing mask • If not breathing spontaneously, Endotracheal tube insertion or other invasive intervention • Surgery specific (Vocal cord Palsy, Neck hematoma, bleeding)
- 11. EARLY AND LATE RESP. COMPLICATIONS • Fever • Malignant Hyperthermia 104˚due to Halothane or Succinylcholine( IV Dantrolene, 100% Oxygen, correct Acidosis, Cooling blankets) • Bacteremia 30-45 mins (Blood Culture and Empiric Antibiotics) • Atelectasis 1st POD (Auscultation, Chest X-ray, Improve ventilation, Bronchoscopy) • Pneumonia 3rd POD (Sputum culture, Antibiotics) • UTI 3rd POD (UCE, Antibiotics) • DVT 5th POD (Doppler USG, Anti-coagulation therapy) • Wound infection 7th POD • Deep Abscesses 10-15th POD (USG guided drainage or Surgery)
- 12. CONTINUED… • Cough • Dyspnea • Bronchospasm • Hypercapnia • Pleural effusion • Pneumothorax • Respiratory failure • Aspiration • Pulmonary embolism
- 13. IMMEDIATE CARDIOVASCULAR COMPLICATIONS • Hypotension • Hypovolemia • Myocardial impairment • Vasodilation due to Spinal anesthesia • Sepsis • Arrythmias • Tension Pneumothorax • Cardiac tamponade • Anaphylaxis
- 14. CONTINUED… • Hypertension • Pain • Agitation • Anxiety • Bladder Spasm • Pre-existing Hypertension • Myocardial Infarction • Arrythmias • Stroke
- 15. EARLY AND LATE CARDIOVASCULAR COMPLICATIONS • Myocardial Infarction • Congestive Heart Failure • Arrythmias • Stroke
- 16. RENAL AND URINARY SYSTEM • Acute Kidney Injury Causes • Pre-Renal Hypotension Hypovolemia • Renal Nephrotoxic drugs NSAIDS Renal vascular surgery Myoglobinuria Sepsis • Post-Renal Ureteric injury Blocked urinary catheter
- 17. CONTINUED… • Urinary retention • Catheterization should be done if when an operation is expected to last 3 hours or more, or when large volumes of fluids are administered. • UTI • Low Urine Output (less than 0.5 ml/kg/hour) 1. Fluid deficit (Urinary Na < 10-20 mEq/L) 2. Acute renal failure (Urinary Na > 40 mEq/L)
- 18. CENTRAL NERVOUS SYSTEM • Post operative disorientation/coma may result from various causes: • Hypoxia • May be secondary to sepsis • Blood gas analysis and Respiratory support • ARDS • B/L pulmonary infiltrates, hypoxia with no evidence of CCF • Positive end expiratory pressure therapy • Correct sepsis
- 20. CENTRAL NERVOUS SYSTEM • Delirium Tremens • Alcoholics • Hallucinations and combative behavior • Intravenous Benzodiazepines • Hyponatremia • May occur after surgery due to combination of large volumes of sodium free fluids (like DW) and elevated ADH levels in response to trauma/surgery. • Confusion, convulsions, coma and death • Include Na in IV fluids • Osmotic diuretics might help
- 21. CENTRAL NERVOUS SYSTEM • Hypernatremia • Induced by large unreplaced water loss • Confusion, lethargy, coma • Do rapid fluid replacement with half DW or DS soln. • Ammonium intoxication • Occurs in cirrhotic undergoing a portocaval shunt procedure
- 22. ABDOMINAL SURGERY COMPLICATIONS • Paralytic ileus • Nausea, Vomiting, Anorexia, mild bowel distension with no pain, absence of flatus and bowel movements • Adequate hydration and maintain electrolyte levels • Return of intestinal function occurs as Small bowel > Larger bowel > Stomach • Local infection / Anastomotic leakage • Persistent abdominal pain, focal tenderness and fever spike (masked if deep seated abscess) • USG or CT for collection along with guided drainage
- 23. CONTINUED… • Early mechanical bowel obstruction • Paralytic ileus not resolving after 5-7 days after surgery • X-ray: dilated gut loops and air fluid levels • CT scan Abdomen helps • Surgical intervention is required • Ogilvie Syndrome • Paralytic ileus of colon • Seen in elderly sedentary patients ( Alzheimer’s, Nursing homes) who become further immobile due to surgery • Larger abdominal distension (Tense but no pain), x-ray : massively dilated colon • Iv Neostigmine and long rectal tube
- 24. CONTINUED… • Stoma complications • Skin irritation • Prolapse • Retraction • Ischemia • Stenosis • Parastomal hernia • Bleeding • Fistulation
- 25. Skin irritation Prolapse Retraction Ischemia Stenosis Parastomal hernia Fistulation
- 26. COMPLICATIONS OF ORTHOPEDIC SURGERY • Damage to the neurovascular supply of the extremity • Compartment Syndrome • Increased pressure in Osseo-fascial compartments that hinder adequate tissue perfusion • Pain, pallor, pulselessness, paralysis, paresthesia • Treatment: • Circumferential cast split and dressings cut down to skin • Limb elevation • Fasciotomy
- 27. NECK SURGERY • Hematoma • Nerve damage
- 28. THORACIC SURGERY • Fluid overload • Drain failure • Bronchopleural fistula • Continuous bubbling in drain
- 29. NEUROSURGERY • Raised ICP • Deterioration of state of consciousness • Neurological signs and symptoms
- 30. UROLOGY • Loss of urinary catheter patency • Transurethral resection syndrome • Problems related to continued bladder irrigation
- 31. GENERAL POST-OP PROBLEMS • Hemorrhage • Primary -- At the time of surgery • Reactionary -- within 24 hours of surgery • Secondary -- Several days after surgery
- 32. CONTINUED… • PONV • Risk Factors: • Female gender (1) • Non-smoker (1) • History of motion sickness or PONV (1) • Post-op opioid treatment (1) • Apfel Scoring for probability of PONV • 0 =10 % • 1= 21 % • 2= 29 % • 3= 61 % • 4= 78 %
- 33. CONTINUED… • Treatment of PONV • Relieve Pain & Anxiety • Maintain BP • Proper hydration • Combination of various drugs may help: • HT3 receptor antagonists (Ondansetron) • Steroids • Phenothiazines • Anti-histamines
- 34. CONTINUED… • Hypothermia & Shivering • Causes • Loss of thermo regulatory control due to anesthesia • Exposure of patient during surgery • Evaporation of ani-septic • Treatment: • Temperature monitoring intraoperatively • Active warming devices
- 35. CONTINUED… • Deep Venous thrombosis • Thrombosis of one or more deep veins usually of the lower limb • Calf pain, swelling, erythema, warm limb and engorged veins • Investigations • Duplex Doppler Ultrasound • Venography • Prevention • Non-Pharmacologic: Compression stockings and Calf pump • Pharmacologic: Parenteral anticoagulation initially followed by longer term warfarin or new anticoagulants • Surgical: Caval filter to avoid PE
- 36. STRATIFICATION OF THE SURGICAL PROCEDURE AND ASSOCIATED RISK OF DVT • Low • Maxillofacial surgery • Neurosurgery • Cardiothoracic surgery • Medium • Inguinal hernia repair • Abdominal surgery • Gynecological surgery • Urological surgery • High • Pelvic Surgery • Total knee and hip replacement
- 38. DRAINS • Placed to avoid collection of blood, serosanguinous purulent fluid • Quantity and character of fluid drained may allow early intervention • Complications: • Damage to surrounding tissues • Infection • Removal: • As soon as possible • When the drainage has stopped or became less than 25 ml/day
- 39. WOUND • Wound dehiscence • Disruption of any or all layers in a wound • Around 5-8th POD after laparotomy • Wound looks intact but the dressing is soaked with “Salmon Pink” colored fluid • May need wound washout and re-suturing • In some wound may be left open and treated with dressings or VAC pumps • Evisceration is a catastrophic complication and may need emergency re-closure • Re-operation for possible ventral hernia may be required but is not an emergency
- 40. CONTINUED… • Fistula of GI tract • Bowel contents leak out of a wound site or through drain site • Fistulas not draining freely but leaking after a collection develops cause sepsis & peritoneal irritation and require complete drainage • Fistulas draining freely won’t cause peritoneal irritation or fever • Potential problems due to fistula • Fluid & electrolyte loss • Nutritional depletion • Digestion of abdominal wall
- 41. CONTINUED… • Types of fistulas • Low GI fistula (in distal colon) – up to 200-300 ml/day • High GI fistula (in stomach, duodenum, upper jejunum – several liters per day • Management • Fluid & electrolyte replacement • Nutritional support • Protection of abdominal wall though suction tubes and ostomy bags • Avoid the risk factors that prevent healing • Keep the patient alive until the nature heals the fistula
- 42. CONTINUED… • Pressure Sores • Friction or persistent pressure on soft tissues in patients undergoing surgery for prolonged periods of time • Pressure points: Sacrum, Greater trochanter and Heels • Prevention & Treatment • Early mobilization and posture changes • Air mattress for high risk patients • W/W and W/D
- 43. WOUND CARE • Within hours of surgical wound closure the dead space fills with inflammatory exudate • Within 48 hours epidermal cell in wound edge bridge the gap • Only inspect the wound if there is concern about its condition or the dressing needs changing • Infected wound or hematoma may require drainage and packing • Send pus for culture & sensitivity (before giving antibiotics) • Skin sutures or clips can be removed 6-10 days later or may be left longer in sutures applied under tension • Exclude factors that prevent healing
- 44. RECOVERY • Factors that enhance recovery are • Early physiotherapy and mobilization • Earl oral intake • Opioid sparing analgesia • Support of nursing staff and community care providers
- 45. DISCHARGE LETTER • Final diagnosis • Treatment given • Laboratory results • Complications that might have occurred • Discharge plan comprising of further care and management of complications, physiotherapy and referrals for comorbidities • Support needed by community care providers • Follow-Up plan • Prognosis (if appropriate)