by: Trajan Cuellar MB BCh and Adrian Vlada, MB, BCh

June 2015

Post-Operative Management
of the Surgical Patient
Post Operative Patients
 General Surgery
 MIS
 BMS
 CRS
 PBS
 Vascular
 Plastics
 Transplant
 Trauma
 Burn
 Paediatric
What is Post-Operative Management?

The management of the patient after surgery.

This includes care given during the immediate
post operative period, both in the operating
room and the post anaesthesia care unit
(PACU), as well as the days following surgery.
But hey I’m just a new intern…

 Relish in your position

 Enjoy the fruits of your labour in medical
school
 Grow into the physician/surgeon role
 You will often stand alone with the family in
the room
 You are the first line of defense
Post Op Management starts with pre-operative
considerations

 Past Medical History

 Past Surgical History

 Social History

 Family History
Post Op Management starts with pre-operative
considerations

 Past Medical History

 CNS – prior TIA, CVAs, mobility post op.
 CVS – CHF, prior MIs
▪ Antiplatelet agents
▪ IVF administration
 Resp – COPD home O2, CPAP for OSA
 FEN/GI - Renal Failure – prescribe/dose all medications
appropriately (no Enoxaparin for renal impairment
patients), dialysis days, dialysis access?
 Endo – DM (no dextrose in IVF, Insulin Sliding Scale),
Steroids – dose stress steroids appropriately
Post Op Management starts with pre-operative
considerations

 Past Surgical History

 Prior surgical intervention often makes further

surgical intervention more complex
 Prior post operative issues are often relevant
again
Post Op Management starts with pre-
operative considerations

 Social History
 Home support structure, if any
 EtOH
▪ Delirium Tremens (not unique to VA system)
 Smoking
▪ Pulmonary toliet, O2 requirements
 Drugs
Post Op Management starts with pre-
operative considerations

 Family History
 Familial Medical Conditions
▪ DM, CAD, amongst many others
 Commonest bleeding disorder in the USA is von
Willebrands Disease
▪ Best way to determine its presence is a sound history
Operating Theatre

 If you did the case, you may be asked to…

 Write the brief operative note
 Talk to the family regarding the outcome of the
surgery
 Write post operative orders
 Dictate the case

 Skin/Fascial closure, Final dressings, abdominal

binder, transport the patient to PACU
Immediate Post Operative Care
Same Day Procedures
 Day case surgery
 Final review
 Appropriate Discharge Paperwork
 Discharge Prescriptions
 Follow up Appointment
For Shands 352-265-0535
7:30am – 5pm, get an appointment for every pt.
 Family questions
Post Op Orders
 Admitting Team/Attending
 Diagnosis
 Condition
 Specify Vital Sign monitoring (Neuro exams?)
 New Medications/Home Medications
 Diet order, Mobility orders, Elevate HOB
 Wound care, IVF, Analgesia, DVT prophylaxis, Abx
 NG, Foley Catheter, Drain orders
 Post Op Labs and/or Imaging Ordered

 ENSURE THE PATIENT IS ON THE LIST

Post Operative Check (1)

 Post Operative Check – to be performed on

EVERY patient, ABSOLUTELY NO
EXCEPTIONS
 Consists of
 Chart review
▪ Surgical procedure (EBL, IVFs, intraoperative events)
▪ Pre-Operative medical/surgical conditions
▪ Pre-Admission Medications
▪ Current Post-Operative Medications
Post Operative Check (2)

 Review of Vital Sign trends

 Pyrexia (Febrile)
 HR/BP/O2 Sats
▪ Tachycardia
▪ Tachypnoea
 I/O, hourly urine outputs
 Analgesic Requirements
 RN notes – pt received resting soundly vs.
obtunded
Post Operative Check (3)

 Finally go see the patient.

 Eyeball test – comes with experience
 Talk to the patient
 Examine the patient
 HS 1-2, Lungs, Abdomen, Incision sites
▪ Pulse check, Neurological exam
 Don’t forget Drains
 Volume, colour, consistency, smell
 Check Line sites, IVs, a-lines, CVLs, Urinary
catheters, Chest tube sites.
Post Operative Check (4)

 Go back to the computer

 Final chart review
 Check Labs (perhaps order them)
 Check Imaging (perhaps order CXR/KUB)
 Monitoring (perhaps add a continuous pulse ox or
telemetry)

 DOCUMENT your findings with a PLAN

 With experience this takes 10mins to perform

PitFalls

 Well its 3pm they’ll be out of the OR in a hour

or two I’ll tell the Chief Resident then.
 I’ll call the Chief when things settle down
after intubation and transfer to the ICU.
 I’ll call when I figure out exactly what’s going
on. A plan doesn’t have to be exact.
 I have to work on my animal research grant
rather than check on patients overnight.
Immediate Post Operative Care, the
PACU
 PACU
 If called to the PACU attend immediately.

 Face to face discussion with MDs or RNs and address their concerns directly

 Perform a Post Operative Check

 Ordering appropriate investigations –
▪ Labs
▪ ABG, CBC, BMP, etc.,
▪ 12-lead EKG
▪ Imaging
▪ CXR, CT brain
 Report concern to the Operating Team
 Know what room they are in or where they can be found
 Come with an Assessment and a PLAN
Overnight this is you, NIGHTFLOAT

 Keep eye on vitals

 Certain Chiefs will want to be called with
information (i.e. post op checks, CT scan
results), make sure you do this.
 No major moves overnight, keep watch till
morning
 A change in condition of a patient, a
transfusion, or change level of care
mandates a prompt call to the primary team
First 24hrs Post Operative Care, Floor
Patients
 Early post operative period
 Mobilization
 Incentive Spirometers
 Analgesia Plan
 Diet/Nutrition Plan
 Wound Care Plan
 Antibiotics Plan
 Urinary Catheter Plan
 Drain Plan
 Medication review
First 24hrs by Service (not a complete
list)
 Surgery Specific Management
 MIS - Swallow studies
 BMS - Drain care, Physical Therapy
 CRS - NG management, Ostomy volume consistency
management
 PBS - Drains for amylase, nutrition plan (TPN)
 Vascular - Wound care, dialysis
 Transplant - Immunosuppressive therapy, dialysis
 Trauma - Follow up consult service…Disposition
 Paediatric - Dose medications by pt. weight
First 24hr Post Operative ICU patients

 Plans by System
 Neurological
 CVS
 Respiratory
 FEN/GI
 Endo
 ID
 Haematological

 Communication with ICU service

Always - LISTEN CAREFULLY

 Write everything down on your list

 Have tick boxes or equivalents to help you
manage your patient related tasks
 Do not move on to the next patient until your
questions are answered
 Plans may change during rounds with the
Attending Surgeon
 You may be asked to ‘run the list’ and list out
your jobs with the patients
Intern Role in Post Operative Daily
Housekeeping
 Daily notes to be written on all in-patients no
exceptions
 Daily notes on consults
 Laboratory investigations
 AM labs ordered?
 AM CXR ordered?
 Electrolytes replaced?
 Daily contact with consulting Services
Prioritization

 Identify with your team your ‘sickest’ patients

and ensure their tasks are performed first
 Put in all orders on all patients at once
 Call consults early (UF Surgery is not like
certain services that drop the 5:30pm
bombshell)
 Half fill in boxes of tasks that have follow up
 CT scan order and reviewed
POD 2,3,4,5….

 Gradual return to preoperative state

 Improved mobility and mood
 Reduction in IVF, toleration of PO intake
 Return to home medication regiment
 Return of Bowel Activity (flatus then BMs)
 Reduced Analgesia requirements and transition to
oral pain medications.
 Wound healing
 Disposition and home environment
Good signs…

 Look better/feels better

 No fever, normal VS, normal WCC, stable HCT/plt

count, normal electrolytes

 Mobilisation of fluid
 Spontaneously negative I/O fluid balance

 Patient crosses legs in bed and starts to complain

about hospital food
Bad signs - Failure to progress is a
surgical regression
 Fever
 Rising WCC
 Drop in HCT, Hb
 Electrolyte imbalance
 Drain output change
 Reduced Urine Output

 Pt has little to say for him/herself

 Surgery Specific Concerns

 POD 5 Colorectal pt with fever, elevated WCC
 Salmon coloured fluid escaping from a previously dry abdominal wound
Ugly signs…

 Arrest

 Sudden change in mental status

 Sudden respiratory compromise

 Sudden cardiovascular embarrassment

 Audible Bleeding
What can happen…
 Bleeding, bleeding, bleeding
 Surgical bed
 GI tract
 Anticoagulation
 Sepsis (UTIs, RTI, Intraabdominal Abscesses)
 Myocardial Infarction
 Cerebrovascular Accident
 Acute Urinary Retention
 Confusion
 Atelectasis
 Mucus plug
 Pneumothorax
 DVT
Is there anything else?

Surgery specific complications…

 MIS – Anastomotic leak
 BMS – Haematoma
 Colorectal – Anastomotic leak
 PBS – Bleeding, Sepsis
 Transplant – Organ rejection
 Vascular – Bypass occlusion, pseudoaneurysms
 Trauma – DTs, withdrawal
 Paediatric – Necrotizing enterocolitis
How am I supposed to catch it all?

 Know your surgical procedures and their

expected post operative courses

 Attention to detail
 Check vitals carefully looking for clues
▪ Tachycardia (gradually developing)
▪ Tachypnoea (gradually developing)

 Dare to think
Bedside Assessment (your weapon in
the war against unwellness)
 Eyeball
 Distressed, obtunded, tachypnoeic, tachycardic
 Vital Signs
 IV access?
 Lines working
 Finger stick glucose
 Labs
 Imaging
 Monitoring (continuous pulse ox, telemetry)
 Level of care (floor, IMC, ICU)
Communication

 Contact senior resident early with concerns

and Plan

 Communication continues until resolution of

the concern (may occur over days)

 Follow through on plan – CT scan etc…

Danger Zones

 PACU

 During Transfer

 CT scanner

 Interventional Radiology
Document document document

 Date/Time/Venue on all notes

 Time of incident to time of initiation of legal

action averages 18 months, how good is your
memory?
I’m still worried…What now?

 Call your covering chief with information

regarding –
 Current state of patient
 Your working diagnosis
 Your plan of action
 You will receive gentle guidance
 Calling is what you are expected to do
 As your experience level increases you will feel
more confident and identify routine calls from
serious pathology.
Dos

 Communicate, ask questions

 Be proactive
 Know and utilize allied staff
 Instruct and utilize students
 Be detail oriented and document thoroughly
 Be seen around the OR
Don’ts

 Being rude to allied/nursing staff

 Assuming an order equivalates action
 Assuming anything
 Calling without an assessment and plan
 Making students do your work
 Text anything urgent/emergent/HIPAA
related
 Take pictures on your phone
University of Florida, Shands

 Tertiary Level University Teaching and

Academic Center

 We take the cases that local and sometimes

distant hospitals refer to us for ‘Complexity of
Care’

 Level 1 Trauma care for the local population

University of Florida, Shands

 Standards are high

 Expectations are high

 You are all here for a reason

 Everyone here is capable of performing the

tasks required
Goodbye and Good Luck!

‘I have given my name and day clothes to the nurses and

my history to the anaesthetist and my body to surgeons.’

Excerpt from ‘Tulips’ by Sylvia Plath 1961

QUESTIONS?

Trajan A. Cuellar MB BCh MRCSI

352-413-0313 (pager)
352-642-2704 (mobile)