Post-Operative Management of the Surgical Patient

1. by: Trajan Cuellar MB BCh MRCSI June 2012 Post-Operative Management of the Surgical Patient

2. Post Operative Patients • General Surgery • MIS • BMS • CRS • PBS • Vascular • Plastics • Transplant • Trauma • Paediatric

3. 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.

4. 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 last line of defense • Nobody will blame you, everyone will cheer you …at least if everything goes ok

5. Post Op Management starts with pre-operative considerations • Past Medical History • Past Surgical History • Social History • Family History

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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.

16. 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

17. 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.

18. 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

19. Overnight this is you, NIGHTFLOAT (Raza) • 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

20. 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

21. 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

22. First 24hr Post Operative ICU patients • Plans by System • Neurological • CVS • Respiratory • FEN/GI • Endo • ID • Haematological • Communication with ICU service

23. 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

24. 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

25. 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

26. 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

27. Good signs… • Look better/feels better • No fever, normal VS, normal WCC, stable HCT/plt count, normal electrolytes • Mobilisationof fluid • Spontaneously negative I/O fluid balance • Patient crosses legs in bed and starts to complain about hospital food

28. 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

29. Ugly signs… • Arrest • Sudden change in mental status • Sudden respiratory compromise • Sudden cardiovascular embarrassment • Audible Bleeding

30. 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

31. 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

32. 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

33. 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)

34. 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…

35. Danger Zones • PACU • During Transfer • CT scanner • Interventional Radiology

36. 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?

37. 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.

38. 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

39. 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

40. 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)