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Post-operative Care Ishaa AhmedThanks to our partners!Learning Objectives • Understand the perioperative procedures and protocols in emergency cases • Understand and describe the measures taken to enhance patient recovery • Describe the importance of analgesia post operative and recall the different types available • Understand the significance of postoperative nausea and vomiting and recall the medications used to counteract this intra- and post operatively • Understand the use of catheters intraoperatively and describe trial without catheter postoperatively • the nutritional need of an individualtional support available postoperatively as well as how to calculate • Understand common postoperative complications, • Recall re-starting drug regimes post operatively, paying attention to corticosteroids and diabetes medications.Enhanced Recovery Principles of enhanced recovery (elective surgery) • Good preparation for surgery • Minimally invasive surgery • Adequate analgesia • Good nutritional support around surgery • Early return to oral diet and fluid intake • Early mobilisation • Avoiding drains + NG tubes • Early catheter removal • Early dischargeP ost-operative analgesia 1. Non-Opioid Analgesics: 1. Paracetamol and non-steroidal anti- inflammatory drugs (NSAIDs) are Aims for analgesia: recommended as first-line for mild to moderate pain. •Encourage the patient to •Mobilise 2. Opioid Analgesics: •Ventilate their lungs fully (reducing the risk of 1. Limit opioid use to the lowest effective dose for the shortest duration.s and atelectasis) 2. Use opioids in c•Have an adequate oral intake opioid analgesics for severe pain. 3. Patient-Controlled Analgesia (PCA): 1. Consider PCA for opioid administration, allowing patients to self-administer within preset limits.P ost-operative analgesia Paracetamol • Inhibits prostaglandin synthesis • Metabolised in the liver • Toxicity: acute liver injury due to formation of NAPQI metabolite • Mx: activated charcoal (1hr), N-acetylcysteine (within first 8 hours) NSAIDs • COX-2 inhibitor in prostaglandin synthesis • Analgesic + anti-inflammatory • Increase the risk of peptic ulcer – must co-prescribe PPI • Contraindicated in asthma, renal impairment, CHD Neuropathic Pain • Amitriptyline, duloxetine, gabapentin, pregabalinP ost-operative analgesia Codeine • Gets converted to morphine in the body (lower dose) • Poor metabolisers: inactive copies of CYP2D6, cannot metabolise codeine into morphine. Morphine • medium half-life and poor bioavailability • Short half life = fentanyl/alfentanyl • Metabolised in the liver, toxicity is managed with naloxone Signs of opioid toxicity: Itch, myoclonic jerks, pinpoint pupils, confusion, decreased GCS, • S/E: N+V, constipation, respiratory depression respiratory depression, N+V • Can develop tolerance PCA Anaesthetics • IV infusion of strong opiate attached to patient-controlled pump Local Anaesthetics • Administer bolus of short acting opiate • Requires careful monitoring • Bupivacaine (long-acting) • Rapid access to naloxone • Provides analgesia for several hours Epidural Anaesthetics • Can be used as a nerve block for selective analgesia • Gold standard for abdominal or bilateral lower limb surgery • Useful when a sympathetic block is • If block ascends above t4 there is needed to improve post-operative associated hypotension, stop infusion for blood supply 30 mins and restart at a lower rate • Or use vasopressor • Monitor block via Bromage Score • Risks: haematoma, post-dural puncture headache, failureP ost-operative urinary retention Decrease in the normal volume of urine, output < 0.5 mL/kg/hour Inability to pass urine despite Investigation + Diagnosis accumulating in the bladder • Ix: bladder scan • Measure urine output • Urinalysis Causes: medications, obstructions • U&E’s Can lead to AKI • Unknown cause : USS KUB Management Removal of catheter = TWOC • Correct fluid and electrolyte Catheter might need to be reinserted imbalances 2 X TWOC -> long-term catheter • Manage underlying cause • Urinary catheterisationP ost-operative nausea and vomiting Nausea and vomiting in the 24 hrs after operation Prophylaxis Causes • Ondansetron • Surgical procedure • 5HT3 receptor antagonist • Anaesthetic • Avoid in prolonged QT • Pain • Dexamethasone • Opiates • Corticosteriods • Caution with DM or immunocompromised Risk factors • Cyclizine • Female • H1 receptor antagonist • History of PONV or motion sickness • Caution with HF and elderly • Non-smokers Rescue antiemetics • Use of post-op opiates • Ondansetron • Young age • Cyclizine • Volatile anaesthetics • ProchlorperazineNutritional Support post-op Why? Important for healthy wound healing and overall recovery • Encourage eating if possible -> via GI tract (enteral feeding) • NG tube, PEG -> percutaneous endoscopic gastrostomy TPN – IV infusion of solution of carbs, fats, proteins, vitamins, minerals • S/E : thrombophlebitis => central line rather than peripheralPost-operative complicationsP yrexia Management Causes: • Antibiotics Wind – pneumonia + atelectasis • Anticoagulants • Modification/cessation of drug Water – UTI • Further surgical intervention Wound – Infection Wonder drugs – anaesthesia *only if malignant hyperpyrexia* Walking – DVT Causes if infective until proven otherwise P ost-op Anaemia Main body Post-op FBC used to measure haemoglobin Treatment is dependent on haemoglobin • Hb < 100g/L : start oral iron • Hb < 70-80 g/L : blood transfusion + oral iron • Symptomatic or underlying CV/resp disease : more severe transfusionAtelectasis Basal alveolar collapse -> respiratory difficulty -> failure Signs: dyspnoea + hypoxaemia (72 hrs post- op), fine crackles Prevention : encourage deep breathing post- surgery, adequate pain management Management: position patient upright, chest physiotherapyBleeding • Reactive bleeding occurs 24 hours or less post operatively. • Often slipped ligature/missed vessel – due to interoperative hypotension and vasoconstriction • Identified using NEWS score • Revision surgery or activation of major haemorrhage protocol if neededHaemorrhage Main bodyHaemorrhage • Loss of 50% of blood in 3 hours • Loss of 1 blood volume in 24 hours • 7% of total adult body weight • 8-9% of total child body weight Transfusion complications • Hypothermia – impairs homeostasis • Hypocalcaemia • Hyperkalaemia • Delayed transfusion reactions • TRALI – transfusion related lung injury • coagulopathyDVTPE Sx: pleuritic chest pain, dyspnoea, haemoptysis Ix: ECG = S1Q3T3 sign, sinus tachycardia. 2-level PE Wells score Invesigations PE unlikely : arrange a D-Dimer test, if positive : CTPA (if delay give anticoagulation) PE likely : CTPA (interim anticoagulation) • If CTPA is positive – manage PE • If CTPA is negative – proximal leg vein USS if DVT suspected Management : • ABCDE – supportive therapy, subsequent anticoagulation • DOAC • If haemodynamically unstable : thrombolysis Haemorrhagic Shock • Can be due to: • Trauma Septic • Tension pneumothorax • High mortality rate • Spinal cord injury •MaiSIRS – fever, high HR, high RR, • Myocardial contusion high/low WBC • Cardiac tamponade • Septic shock = sepsis with refractory • Control bleeding hypotension • Normalise circulating volume • Excessive inflammation, coagulation, fibrinolytic Cardiogenic suppression • Ischaemic heart disease, trauma, contusion • Mx: supportive + TT echo Neurogenic • Following spinal cord transection Anaphylactic • Decreased sympathetic tone • Type 1 hypersensitivity • Increased parasympathetic tone • Compromise to airways • Vasodilation=decreasedinperipheral • Mx: adrenaline 500 mg IM resistance=decreasedcardiacoutput • Anterolateral part middle 1/3 of thighW ound Dehiscence Separation of a surgical wound, (one week) commonly after abdominal surgery 0.5-3% of all surgeries Increased risk : diabetes/obesity, surgical techniques, post-op care Signs • Sharp pain at the wound site • Serous discharge • Fever • Increased abdominal girth • Internal organs are visible Management • Cover wound with saline soaked gauze • Return to theatre – re-suture, wound vacuum • Optimise patient healthInfection Signs Risk Factors • Contaminated operations • Mild : erythema, tenderness, no systemic response • Prolonged procedures • Severe: purulent discharge, fever, • Diabetes/Obesity abscess formation, systemic signs • Smoking • Immunosuppression Management • Swabs + Sepsis 6 • Analgesia • Regular wound care • Oral/IV antibiotics • Drainage + debridement • Wound to heal by secondary intentionInfection Sepsis 6 protocol • Decreased blood flow to the vital organs due to systemic vasodilation • Sepsis: dyregulated host response to infection • qSOFA scoreAnastomotic Leak Leak of luminal contents from a surgical join (3-5 days post op) • Serious complication of bowel resection surgery • Can lead to sepsis and death All patients who deteriorate or don’t progress : assume anastomotic leak Sx: inflammation and infection Mx: NBM,Abx, IV fluids, urinary catheter • Minor – conservative management • Pain, tachycardia, fever, tachypnoea, ileus • Endoluminal vacuum therapy • Surgical intervention -> stoma formation Dx: CT scan with contrastIleus Paralytic small bowel – stopping of peristalsis Causes Signs + symptoms • Injury to bowel • Green bilious vomiting • Handling of bowel during surgery • Distension • Inflammation or infection • Diffuse abdominal pain in/nearby bowel • Absolute constipation + lack of • Electrolyte imbalance flatulence • Absent bowel sounds Management • NBM • NG tube or TPN • IV fluids • MobilisationDelirium Management • Treat underlying cause • Modify the environment Causes: • Haloperidol 0.5mg • Olanzapine Drugs • In PD : quetiapine + Electrolyte imbalances/epilepsy clozapine Liver failure Infections Retention Intracranial Ureamia Metabolic 1. Acute Cognitive Impairment 2. Fluctuation in consciousness 3. Inattention 4. Disordered thinkingDiabetic Medications • AVOIDING RISK OF HYPOGLYCAEMIA • SGLT2 inhibitors (eg, canagliflozin, dapagliflozin, and empagliflozin) • omitted on the day of surgery and not restarted until the patient is eating and drinking. • Risk euglycaemicketoacidosis.Check ketones as well as BMs!! • Sulfonylurea (eg, gliclazide) - hypoglycaemiarisk, • should always be omitted on the day of surgery until the patient is eating and drinking again • Insulin – follow local guides and BNF. • Dependent elective/emergency and glycaemic control • Metformin – • Miss one meal = safe to continue. • Miss more than one meal = risk lacticacidosisand AKI, stop metformin once fast begins.Steroids • Patients with adrenal atrophy resulting from long-term corticosteroid use may suffer a precipitous fall in blood pressure • Also related to patients with primary adrenal insufficiency (Addisons) • Corticosteroid cover should be provided during anaesthesia and in the immediate postoperative period . • Replacement regimes are dependent on procedure and guidelinesReferences https://zerotofinals.com/surgery/general/ https://app.quesmed.com/dashboard https://www.passmedicine.com/v7/menu.php?@supta_uk @SUPTAUK www.supta.uk