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Post Operative Care
- 1. POST-OPERATIVE CARE Presented by : Dr. Raashi Mandal Dr. Alina Timilsina Dr. Shaishav Dhital Neurosurgery department AKMMCH
- 2. MULTIPLE CHOICE QUESTION • An otherwise healthy 65-year-old man is 16 hours postoperative from laparoscopic left colectomy for stage II colon adenocarcinoma. You are called by the nurse because over the last 3 hours his urine output has been less than 15cc/hour.
- 3. • On evaluation, he reports feeling moderately anxious. His HR is 102 bpm and his BP is 120/80 mmofHg. His physical examination is unremarkable. The appropriate immediate next step(s) in the workup and treatment of the patient include :
- 4. A. Measure haematocrit B. Give 1 L fluid bolus C. Return to the operating room for reexploration D. A, B and C E. A and B
- 5. OBJECTIVES • To understand what is required to deliver immediate postoperative care. • To discuss about common postoperative problems. • To understand how to recognise, treat and prevent such complications.
- 6. • “0” POD following ………… • Morning/Evening follow up • Subject : • Examination : Temperature BP Pulse SpO2 Heart Lungs Bowel Bladder / Catheterised Drain tube collection Bandage • Assessment : • Plan :
- 7. INTRODUCTION • Aim ; to provide the patient with quick, painless and safe recovery from surgery. • requires appropriate knowledge and skills to manage medical as well as surgical postoperative problems.
- 8. STANDARD IN THE IMMEDIATE POSTOPERATIVE PERIOD • Standards for equipment and drugs • Schedules of measurement of patient vital signs • Discharge criteria
- 9. IMMEDIATE POSTOPERATIVE CARE • Starts with a ‘sign out’ as part of the WHO check list. • Patient handed over to postanaesthetic care unit staff formally with necessary information like :
- 10. • patient’s name and surgical procedure • existing medical problems, allergies • fluid replacement, urine output, blood loss • surgical or anaesthetic problems encountered or expected • plan of management of pain.
- 11. POSTOPERATIVE OBSERVATIONS • Patients vitals signs • Level of consciousness • Pain and hydration status • Surgery-specific observations : Drain tube collection Regular neurological evaluation ABG analysis
- 12. DISCHARGE CRITERIA • Patient is fully conscious. • Respiration and oxygenation are satisfactory. • Patient is normothermic, not in pain and not nauseous. • Cardiovascular parameters are stable. • Oxygen, fluids and analgesics have been prescribed • There are no concerns related to the surgical procedure. DISCHARGE OF THE PATIENT FROM POST-OP
- 13. SYSTEMIC COMPLICATIONS • Neurological • Cardiovascular • Pulmonary • Renal • Gastrointestinal • Infectious complications • Thrombotic complications
- 14. NEUROLOGIC COMPLICATIONS • Altered sensorium • Focal neurological deficits
- 15. DIFFERENTIAL DIAGNOSIS • Respiratory insufficiency • Stroke • Hypoglycaemia • Hypotension • Arrythmia • Electrolyte imbalance • Infection • Seizure • Delirium • Alcohol withdrawal • Medication side effect
- 16. EXAMINATION • Vitals • Level of consciousness • Patient’s complaints of any pain. • Systemic examination
- 17. INVESTIGATIONS • CBC • ABG • RBS • Serum electrolyte • ECG • CT scan (MRI – if needed)
- 18. TREATMENT • General supportive measures - ensure airway maintenance - supplemental oxygen - IV fluid - nutritional supplements
- 19. • Specific treatment. - Postoperative delirium ; correcting any reversible cause, pain control involving relatives or friends the patient knows haloperidol - Ischemic stroke ; Aspirin - Seizures ; Recurrent : Phenytoin Status epilepticus : Lorazepam Fosphenytoin Phenobarbital
- 20. CARDIOVASCULAR COMPLICATIONS • Post-operative hypotension • Hypertension • Myocardial Ischemia • Arrythmias
- 21. DIFFERENTIAL DIAGNOSIS • Postoperative hypotension : hypovolaemia, surgical bleeding, myocardial impairment, anaesthetic drugs, analgesics, sepsis • Hypertension : essential hypertension, hypertensive urgency, pain, ethanol withdrawal, hypoxemia • Myocardial Ischemia : Pulmonary embolism, pleuritis, pneumonia, pericarditis, incisional pain, pneumothorax
- 22. EXAMINATION • Vitals : BP pulse SpO2 • Urine output • Capillary refill time • Level of consciousness
- 23. INVESTIGATIONS • CBC • Serum electrolytes • ECG (Echo if needed) • CXR • Troponin I • Renal function test
- 24. TREATMENT • Post-operative hypotension : IV fluid infusion catheter to monitor urine output vasopressors and ionotropes • Hypertension : Antihypertensive agents : Labetalol, hydralazine
- 25. TREATMENT • Myocardial Ischemia : Pain management : morphine Sublingual GTN Aspirin Beta-blocker • Arrythmia : Tachycardia : Beta-blocker Bradycardia : Atropine
- 26. PULMONARY COMPLICATIONS • Dyspnoea • COPD and asthma exacerbations
- 27. DIFFERENTIAL DIAGNOSIS • Atelectasis • Lobar collapse • Pneumonia • Pleural effusion • Pneumothorax • Aspiration • CHF • MI • Systemic sepsis • Fever
- 28. EXAMINATION • Vitals : RR, SpO2 • Jugular venous distension • Asymmetry • Increased respiratory efforts • Auscultation of chest and precordium
- 29. INVESTIGATIONS • CBC • ABG analysis • CXR • ECG (Echo if needed)
- 30. TREATMENT • General supportive measures - Propped up position - Supplemental oxygen • Specific treatment : Treatment of the cause
- 31. RENAL COMPLICATIONS • Acute kidney injury • Urinary retention • Urinary infection
- 32. EVALUATION • Patients complaint: Inability to void and pain • Urine output < 0.5 ml/kg/hour for more than 6 hours • Cause: hypovolemia from under resuscitation or bleeding comorbidities
- 33. INVESTIGATIONS • Serum creatinine • Serum electrolyte • Hematocrit or Hemoglobin level • Bladder ultrasound
- 34. TREATMENT • General measures: Adequate hydration Proper bladder drainage Catheterization : should be performed prophylactically • Specific measures : Antibiotic - for urinary infection
- 35. GASTROINTESTINAL COMPLICATIONS • Post operative nausea and vomiting • Post operative paralytic ileus
- 36. DIFFERENTIAL DIAGNOSIS • Bowel obstruction • Constipation • Intraabdominal infection • Retroperitoneal bleeding
- 37. EVALUATION • Patients complaint: Pain or Constipation • Bowel sound • Bowel movement
- 38. INVESTIGATIONS • Radiographs of abdomen • CT with oral contrast (if needed)
- 39. TREATMENT • NPO • NG tube feeding • TPN (If persists beyond 7 days)
- 40. INFECTIOUS COMPLICATIONS • Local : SSI • Generalised : Fever
- 41. DIFFERENTIAL DIAGNOSIS • Intraoperative fever - Secondary to malignant hyperthermia - Transfusion reaction - Pre existing infection
- 42. DIFFERENTIAL DIAGNOSIS • Fever in first 24 hours - Wound infection -Aspiration pneumonitis -Pre existing infection -In trauma and burn patients: expected inflammatory response
- 43. DIFFERENTIAL DIAGNOSIS • Fever that occurs > 72 hours after surgery -Wound infection -Pneumonia -Urinary tract infection -Deep vein thrombosis, thrombophlebitis -Drug allergy
- 44. EVALUATION • Patients complaint: Pain and burning micturition • Vitals • Inspection of all wounds, dressings, tubes and catheter sites
- 45. INVESTIGATIONS • CBC • Urinalysis • Gram staining and c/s of blood, sputum, urine and wound • Appropriate imaging
- 46. TREATMENT • General : Antipyretics Emperic antibiotics (before obtaining c/s report) • Specific : Wound is opened to allow drainage Operative debridement
- 47. THROMBOTIC COMPLICATIONS • Deep vein thrombosis • Pulmonary Embolism
- 48. EVALUATION Deep vein thrombosis Look- Edema , Erythema Feel- Warmth, Palpable cord, Calf tenderness Move- Dorsiflexion of the foot (Homans sign)
- 49. EVALUATION Pulmonary Embolism Patients complaint: Chest pain, shortness of breath Vitals – Tachypnea, Tachycardia
- 50. INVESTIGATIONS • Duplex scanning • Contrast venography ( if needed) • ECG • Chest xray
- 51. TREATMENT • DVT : Initially parenteral anticoagulation long term – Warfarin for prevention IVC filter to decrease the possibility of pulmonary embolism • Pulmonary Embolism :
- 52. DISCHARGE OF THE PATIENT • Discharge letter should include : Final diagnosis Treatment to be continued General advice for followup Indications for readmission
- 53. MULTIPLE CHOICE QUESTION • An otherwise healthy 65-year-old man is 16 hours postoperative from laparoscopic left colectomy for stage II colon adenocarcinoma. You are called by the nurse because over the last 3 hours his ueine output has been less than 15cc/hour.
- 54. • On evaluation, he reports feeling moderately anxious. His HR is 102 bpm and his BP is 120/80 mmofHg. His physical examination is unremarkable. The appropriate immediate next step(s) in the workup and treatment of the patient include :
- 55. A. Measure haematocrit B. Give 1 L fluid bolus C. Return to the operating room for reexploration D. A, B and C E. A and B
- 56. THANK YOU WE LOOK FORWARD TO ANSWERING YOUR QUERIES