Post-operative care

SURGERY PRESENTATION
BRIAN NOLAN
Post-operative care…

What should we be looking out for post-op?

(as per WHO)

• Airway obstruction
• Hypoxia
• Haemorrhage: internal or external
• Hypotension and/or hypertension
• Postoperative pain
• Shivering, hypothermia
• Vomiting, aspiration
• Falling on the floor
• Residual narcosis
Recovery Unit
•THE PATIENT IS TRANSFERRED TO THE PACU AFTER
THE SURGICAL PROCEDURE, ANESTHESIA REVERSAL,
AND EXTUBATION.
•THE AMOUNT OF TIME THE PATIENT SPENDS IN THE
UNIT DEPENDS ON THE LENGTH OF SURGERY, TYPE OF
SURGERY, STATUS OF REGIONAL ANESTHESIA (E.G.,
SPINAL ANESTHESIA), AND THE PATIENT'S LEVEL OF
CONSCIOUSNESS.

•RATHER THAN BEING SENT TO RECOVERY, SOME

PATIENTS MAY BE TRANSFERRED DIRECTLY TO THE
CRITICAL CARE UNIT. FOR EXAMPLE, PATIENTS WHO
HAVE HAD CORONARY ARTERY BYPASS GRAFTING ARE
SENT DIRECTLY TO THE CRITICAL CARE UNIT.
The recovering patient is fit for the ward when:

• Awake, opens eyes

• Extubated
• Blood pressure and pulse are satisfactory
• Can lift head on command
• Not hypoxic
• Breathing quietly and comfortably
• Appropriate analgesia has been prescribed and is safely
established
Enhanced Recovery After Surgery…

Commonly employed in colorectal and ortho surgery…

In the pre-op stage… optimisation. In the intra-op stage, decrease physical stress.

Post-op: Early return to function and mobilisation

- Aggressive management of pain and nausea

- Early mobilisation and physiotherapy
- Early resumption of oral intake (including carb drinks)
- Early discontinuation of IV fluids
- Remove drains and urinary catheters ASAP
 Post-op… PAIN
Pain management as essential part of post-operative care.

Important injectable drugs for pain are the opiate analgesics.

NSAIDS such as diclofenac (1 mg/kg) and ibuprofen can also be given orally and rectally, as can paracetamol (15
mg/kg).
• There are three situations where an opiate might be given:
Preoperatively
Intraoperatively
Postoperatively
• Opiate premedication is rarely indicated, although an injured patient in pain may have been given an opiate before
coming to the operating room.

• Opiates given pre- or intraoperatively have important effects in the postoperative period since there may be
delayed recovery and respiratory depression, even necessitating mechanical ventilation.

• Short acting opiate fentanyl is used intra-operatively to avoid this prolonged effect. Naloxone reverses effects of
opioids.
Ideal way to give analgesia postoperatively is to:

o Give a small intravenous bolus of about a quarter or a third of the maximum dose (e.g. 25 mg pethidine
or 2.5 mg morphine for an average adult)

o Wait for 5–10 minutes to observe the effect: the desired effect is analgesia, but retained consciousness

o Estimate the correct total dose (e.g. 75 mg pethidine or 7.5 mg morphine) and give the balance
intramuscularly.

o With this method, the patient receives analgesia quickly and the correct dose is given
• If opiate analgesia is needed on the ward, it is most usual to give an intramuscular regimen

Note:
Morphine has about ten times the potency and a longer duration of action than pethidine.
LMWH + Antibiotics (image on right)

LMWH
Venous thromboembolism: most common
preventable cause of death in surgical patients.

Thromboprophylaxis, using mechanical

methods to promote venous outflow from the
legs and antithrombotic drugs, provides the
most effective means of reducing morbidity
and mortality in these patients

Factor Xa inhibitors. Examples:

Dalteparin
Enoxaparin
Beniparin
Tinzaparin
Post-operative general complications:
• Haemorrhage:
- Primary: continuous bleeding starting during surgery
- Reactive: Bleeding at the end of surgery or early post-op. Due to increased BP and CO.
- Secondary: Bleeding >24hrs post-op… usually due to infection

Post-op Urinary Retention

- Causes… DRUGS (opioids, epidural, anti ACHM)
PAIN… activates the SNS (sphincter contraction)
PSYCHOGENIC: in the hospital environment

- Management? Conservative (Privacy, Amulation, Analgesia)

Catheterise +/- Gent 2.5mg/kg IV stat… Trial w/o catheter
Post-operative Delirium

Mnemonic for remembering Common Causes:

D.E.L.I.R.I.U.M

- Drugs: opiates, sedatives, L-DOPA

- Eyes, ears and other sensory deficits
- Low oxygen states: MI, stroke, PE
- Infection
- Retention: urine or stool
- Ictal
- UNDER hydrated/nourished
- Metabolic: Na, AKI, glucose, EtOH withdrawl
Pulmonary Atelectasis

Occurs after nearly every GA

Mucous plugging with absorption of distal air leading to… collapse

Causes: Pre-op smoking, Anaesthetics (increased mucous production with decreased mucociliary clearance), Pain inhibits respiratory excursion
and cough.

Presents… usually within first 48 hours, Pyrexia (Mild), Dyspnoea and Dull bases

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Wound Infection

5-7 days post-op. Organisms: S. Aureus and Colioforms

Management: Antibiotics, Abscess drainage

_______________________________________________________________________________________________________

Wound dehiscence

Occurs roughly 10 days post-op. Preceded by serosanguinous discharge from wound.

Management: Replace abdom. Contents and cover with sterile soaked gauze. IV Antibiotic. Opioid analgesia. Call senior, arrange theatre…
repair in theatre. May require VAC dressing/grafting.
Wound infection – Atelectasis – Wound
Dehiscence
THANK
YOU.