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POST_-OP CARE 2013

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11 views32 pages

POST_-OP CARE 2013

Uploaded by

olivermugambim
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
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 Recovery from anaesthesia a time of

great physiological stress


 Level of postoperative care:
 determined by
 the degree of underlying illness;
 the duration and complexity of anesthesia
and surgery
 risk of postop complications
 May be: ambulatory, general wards,
HDU or ICU.
Principles of Post-op
management

 Clinical assessment and monitoring


 Respiratory management
 Cardiovascular management
 Fluid, electrolyte and renal management
 Control of sepsis
 Nutrition
 Management of underlying co-morbidities
Post-anaesthesia care unit
(PACU)

An open ward design./ recovery room

Basic intra-operative level monitors

 Oxygen delivery points

 Suction apparatus

 Resuscitation trolley
Postanaesthesia care unit
(PACU)
Staffing:
 Anaesthesiologist (s)
Nurses trained in:
the care of patients emerging from
anesthesia,
airway management and ACLS
problems commonly encountered in
surgical patients.
First Postop Assessment

 Intraop history
 Past medical history
 Medications
 Allergies
 Intraop complications
 Post instructions
 Recommended Rx & prophylaxis
Respiratory status
assessment
 Oxygen saturation

 Effort of breathing/use of accessory

muscles
 Respiratory rate

 Symmetry of respiration/expansion

 Breath sounds, percussion note


Perfusion status

 Hands: warm or cool, pink or pale

 Capillary refill

 Pulse rate, volume & rhythm

 Blood pressure

 Conjunctival pallor
Volume and fluid balance

 Urine colour and rate of production

 Drains & wound soiling

 Jugular venous pressure


Mentation

 Level of consciousness

 Responsiveness
Principles of
Monitoring
 Trends rather than absolute numbers
 Continuous with individualized
frequency.
 Parameters
 Temperature
 Pulse rate
 Blood pressure
 Respiratory rate
 Pain assessment (resting & moving)
 Urine output
Criteria for transfer to
the ward
 Independently maintains a secure airway
with intact airway reflexes
 Spontaneously breathing with adequate
oxygen saturations
 Haemodynamically stable
 Awake
 Normothermic
 Pain free
Common Post-op
Complications
 General or specific to the type of surgery
undertaken,
 Highest incidence: 1 - 3 days postop
 Distinct temporal patterns of
occurrence:
 immediate
 early
 several days after the operation,
 throughout the post-operative period
 late 1
General post-op
complications
Immediate:
Airway obstruction, hypoventilation,
hypoxaemia
Primary haemorrhage
Hypothermia
Delayed emergence from anaesthesia
Postop nausea and vomiting
Immediate complications

 Shock: blood loss, acute myocardial


infarction pulmonary embolism or
sepsis.

 Low urine output: inadequate fluid


replacement intra- and post-operatively.

 Electrolyte imbalances, hypoglycaemia,


hyperglycaemia
Early complications

 Acute confusion: exclude dehydration


and sepsis
 Nausea and vomiting: analgesia or
anaesthetic-related; paralytic ileus
 Fever.
 Secondary haemorrhage: often as a
result of infection
 Pneumonia
Interval complications

 Wound or anastomotic dehiscence


 Deep vein thrombosis
 Acute urinary retention
 Urinary tract infection
 Wound infection
 Paralytic ileus
Late complications

 Bowel obstruction due to fibrous adhesions

 Incisional hernia

 Persistent sinus

 Recurrence of reason for surgery, e.g.


malignancy
Respiratory
complications
 Airway obstruction—
 Causes:
 laryngospasm
 soft tissue swelling around the
pharynx
 foreign bodies (loose teeth)
 hypotonia of pharyngeal muscles
 viscous fluids (blood)
Respiratory
complications
 Airway obstruction
 Signs
 Stridor
 Tachypnoea (sometimes with tachycardia)
 Tracheal tug
 Use of accessory muscles
 Intercostal & supraclavicular muscle
recession
 Reduced oxygen saturations and
hypoxaemia (late signs)
Airway Security

Patent airway must be achieved


immediately

 head tilt / chin lift


 clear the airway
 airways adjuncts
 Endotracheal instrumentation
Hypoventillation

 opioid drugs,
 hypothermia
 parenchymal lung disease
 muscle weakness
 residual effects of relaxants
 pain
 obesity
Hypoxaemia

 A reduced inspired oxygen fraction,


N2O

 Hypoventilation

 Ventilation or perfusion mismatch


 lung collapse or atelectasis,
 bronchospasm,
 Pulmonary oedema,
 Pneumothorax
 pulmonary embolism.
Delayed emergence

 Poor reversal

 Failure to regain consciousness 30–60


min after general anaesthesia
Delayed emergence

 Residual anaesthetic
 Sedative & analgesic drug effect
 Perioperative stroke.
 Hypothermia
 Marked metabolic disturbances
 Comorbidity - especially relating to the
hepatorenal system -
Postoperative pain

Consequences of undertreated pain


Respiratory: depression/ Hypo-ventilation
CVS tachycardia,
Hypertension , O2consumption, DVT
Endocrine / Immunologic defects
Autonomic dysfunction
Anxiety/psychiatric consequences
Delayed wound healing, Urine retention
Modalities of
management
 Parenteral : opioids, NSAIDs,

paracetamol
 Regional anaesthetic techniques:

epidural block, spinal block, nerve


blocks, local infiltration
 Patient-controlled analgesia

 Oral: NSAIDs, opioids, paracetamol


Fluid management

Fluid replacement

1. Maintenance requirement

2. Replacement of deficits

3. Ongoing losses
Fluid management

Maintenance requirement
Formulae
4/2/1: requirements /Kg/hr
100/50/20: requirements/kg/day
Usually 2.5 – 3L/24hrs in adults
Crystalloids
RL, N/S
Dextrose containing infusions
added
Fluid management

 Replacement of deficits
 Deficit calculated, degree of dehydration
 Replacement: volume for volume,
 Crystalloids: N/S, RL
 Ongoing losses – drains, vomiting,
 Replacement: volume for volume
 Crystalloids: RL, N/S
Fluid management

 Guided by:
 Physical examination
 Vital observations trends
 Urine output
 Invasive monitors – invasive arterial BP,
CVP,
 NB: some labs e.g. pH, PCV/Hb may
be of some benefit.
Summary

 Respiratory and cardiovascular status


most important consideration
‘postanaesthetically’
 Airway complications demand
immediate attention.
 Pain must be adequately controlled.
 Fluid management entails maintenance
requirements, replacement deficits and
ongoing losses.

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