6. PREVENTIONPREVENTION
• 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 RECOVERYDISCHARGE FROM RECOVERY
SHOULD BE AFTER COMPLETESHOULD BE AFTER COMPLETE
STABILIZATION OF CARDIO-STABILIZATION OF CARDIO-
VASCULAR, PULMONARY ANDVASCULAR, PULMONARY AND
NEUROLOGICAL FUNCTIONSNEUROLOGICAL FUNCTIONS
WHICH USUALLY TAKES 2-4WHICH USUALLY TAKES 2-4
HOURS.HOURS.
IF NOT SPECIAL CARE INIF NOT SPECIAL CARE IN
ICU.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.
13. Care of the
wound• Epithelialisation 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.
• R.O.S. usually 5-7 days Post-Op.
• 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.
15. 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
16. • 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
17. 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.
18. • 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
19. 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.
20. • 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.
21. 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.
22. 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.
• Pain transmission:
• Splanchnic nerves to spinal cord.
• Brain stem due to alteration in ventilation, BP and
endocrine functions.
• Cortical response from voluntary movements and
emotions.
23. • 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 e.g. Tylenol.
• Epidural analgesia (for pelvic surgery).
• Nerve block (Post-thoracotomy and hernia repair).
