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P0ST-OPERATIVE CARE. PHASES. IMMEDIATE ( POST-ANAESTHETIC ) PHASE (1) INTERMEDIATE ( HOSPITAL STAY ) PHASE (2) CONVALESCENT ( AFTER DISCHARGE TO FULL RECOVERY ). AIM OF PHASES 1 & 2. HOMEOSTASIS TREATMENT OF PAIN PREVENTION & EARLY DETECTION OF COMPLICATIONS.

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phases
PHASES
  • IMMEDIATE ( POST-ANAESTHETIC ) PHASE (1)
  • INTERMEDIATE ( HOSPITAL STAY ) PHASE (2)
  • CONVALESCENT ( AFTER DISCHARGE TO FULL RECOVERY )
aim of phases 1 2
AIM OF PHASES 1 & 2
  • HOMEOSTASIS
  • TREATMENT OF PAIN
  • PREVENTION & EARLY DETECTION OF COMPLICATIONS
causes of complications death
CAUSES OF COMPLICATIONS & DEATH
  • ACUTE PULMONARY PROBLEMS
  • CARDIO-VASCULAR PROBLEMS
  • FLUID DERANGEMENTS
prevention
PREVENTION
  • 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.)
slide7
DISCHARGE FROM RECOVERY SHOULD BE AFTER COMPLETE STABILIZATION OF CARDIO-VASCULAR, PULMONARY AND NEUROLOGICAL FUNCTIONS WHICH USUALLY TAKES 2-4 HOURS.

IF NOT SPECIAL CARE IN ICU.

post operative orders
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.
post operative orders1
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).
slide10
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.
slide11
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.
the intermediate post operative period
The Intermediate Post-Operative period

Starts with complete recovery from anaesthesia and lasts for the rest of the hospital stay.

care of the wound
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.
management of drains
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.
post operative pulmonary care
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 diseases specially in elderly.
slide16
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 reduce pulmonary oedema.
respiratory failure
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.
slide18
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
post operative fluid electrolytes management
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.
slide20
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.
post operative care of git
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.
post operative pain
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.
  • Paintransmission:
    • Splanchnic nerves to spinal cord.
    • Brain stem due to alteration in ventilation, BP and endocrine functions.
    • Cortical response from voluntary movements and emotions.
slide23
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).