POST OPERATIVE CARE BY VAISHALI SYAL
► Post operative period is the most crucial and critical span of time after completion of surgery
► In this period numerous complications occur and if not treated on time can prove fatal hence increasing the mortality rate
POST OPERATIVE CARE
► The specialized care provided to the patient after completion of surgery till the patient is fully conscious
► This specialized care is provided in a specialized area called PACU
► This specialized care is provided according to the type of anaesthesia administered and nature of surgery done
LOCATION
► The PACU should be situated as close as possible to the operation theatre.
AREA AND CAPACITY
► The number of recovery beds should be 1.5-2 times the number of operating theatres
► Ideally the space allotted per bed should be at least 15-20 sq meters
► There should be enough space to allow unobstructed access for trolleys, equipments and staff
MHYPOXIA
Gradual decrease in oxygen saturation in blood
► Mechanical obstruction may be caused by the patients tongue, an incorrect held airway, secretions, blood and vomit .
► The airway should be cleared under direct vision using a laryngoscope, the patient turned on his or her side and supplement O2 given.
► If the patient develops hypoxia , the management is O2 by face mask ,after giving jaw thrust and chin lift
Diffusion hypoxia is caused when N2O diffuses out of the blood faster than oxygen from air is taken up such that alveolar PO2 is reduced. Supplementary postoperative oxygen is essential
► Blood pressure may be low in the immediate postoperative period because of hypovolemia or because of the continuing pharmacological effects of the anaesthetic techniques
► If the BP is low because of anaesthesia technique used, the head end of the bed may be tilted head down (although not immediately after spinal or epidural procedure as this might extend the block)
► Ephedrine diluted in 5 or 10 ml 0f NS and given in small boluses(5-10mg) up to 30 mg IV (especially after spinal or epidural anaesthesia).
► Severe hypotension must be treated. Oxygen and IV fluids should be given to combat hypovolaemia , Use vasopressors ( e,g diluted ephedrine)
► If the cause of hypotension is thought to be cardiac , a 12 lead ECG should be taken.
► An increased systolic BP is due to pain , extubation pressor response ,anxiety or fear and also could be due to full bladder.
► Increased diastolic BP is seen in treated or untreated hypertensive patients who may develop rebound hypertension .
A slow pulse may be normal in young , fit adults or may be caused by drugs , vagal stimulation , conduction block
Its treatment is necessary if the patients cardiac output is being compromised by the slow pulse
Glycopyrrolate (0.2 -0.4 mg IV) or if there is urgency in treatment atropine 0.6 mg IV should be administered
If the patient is receiving beta –adenoceptor blocking drugs it may be necessary to double the dose of atropine
► The cause of fast pulse is often pain , anxiety, hypercarbia , fever or inadequate neuromuscular reversal
► If the tachycardia is compromising the patients condition it should be treated by fluid administration and in some cases blood transfusion is needed
► Usually due to reversible causes like hypokalemia, hypoxemia, alkalosis and stress after the operation.
► Could be the 1st sign of a post-OP MI
► Usually asymptomatic but could present with chest pain, palpitations or dyspnea.
► Atrial flutter\fibrillation: -If the patient is stable, the heart rate could be controlled with β-blockers, digitalis or Ca channel blockers. -If the patient is unstable (eg. In shock) cardioversion is used.
-If hypokalemia is present, it should be corrected
► Body temperature below 35° C
► Causes : Trauma, exposure to cold enviornment and cold fluids – IV / Irrigation
► Mild: 32 – 35C
► Mod: 28 – 32C
► Severe: 25 – 28C
► Hypothermia could lead to
◦ Coagulopathy ◦ Platelet dysfunction ◦ Increased O2 consumption due to shivering
► Treatment with warmers like forced air devices and warm fluids.
► Meperidine (opioid analgesic) small doses can be used to stop the shivering.
► Patients may be hypovolaemic when they arrive in the recovery room due to inadequate pre-operative resuscitation and/or intra operative fluid replacement
► Blood loss should be replaced by blood only after 15 -20 % of the blood volume has been lost
► If significant hypovolemia is present ,a CVP line and urinary catheter should be inserted to monitor replacement of fluids
► Overzealous fluid replacement can result in hypervolaemia. In fit patients, the kidneys will deal with the overload, but in the paediatric ,elderly & sick, pulmonary oedema and cardiac failure may result.
► Diuretics e.g. Frusemide IV 5 – 10 mg will off load acute pulmonary oedema
► Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage .
o Assessment of pain
► The intensity of pain should be assessed , as for as possible, by the patient as long as they are able to communicate.
► 1. Verbal rating scale (VRS):
► The patient is asked to rate their pain on a five point scale as “ none, mild, moderate, severe, very severe
► 2. Numerical rating scale (NRS) :
► This consists of a simple 0 to 10 scale
► Zero indicates to no pain, while 10 indicates worst possible pain
uys
Simple description of pain intensity scale (SDPIS)
No pain
Mild pain
Moderate
pain
Severe pain
Very Worst severe possible pain pain
0-10 Numeric pain intensity scale (NPIS)
Htttttt 3 4 5 6 7 8 9
10
Visuat analog scale
No pain -
Pain as bad as it
could possibly be Fig. 39.1 : Pain Assessment Scales.
ANALGESICS
► Opioids Opioids may be administered by IM ,IV and by epidural route
► Paracetamol It is the most commonly used analgesic and antipyretic drug. It is a weak analgesic .It is only suitable for mild pain
► Nonsteroidal anti-inflammatory drugs(NSAIDs)
NSAIDs should not be given in asthmatics or to patients with a history of indigestion or peptic ulcer, hypovolaemia , renal dysfunction.
)Epidural analgesia
► It is effective in preventing dynamic pain
► It also reduces the endocrine –metabolic stress response to surgery & thus reduce post op complications (b)peripheral nerve blocks & plexus blocks
Postoperative Nausea and
Vomiting
► Incidence of post operative nausea and vomiting PONV is 25 – 30 %.It may be central,peripheral,vestibular in origin
Factors influencing PONV: 1.Patients factor:- Post operative nausea and vomiting is more in
following patients. Patient factor:
► Women,
► young,
► positive history of PONV
2.ANAESTHETIC FACTOR:- Certain anaesthetic agents and techniques
increase the incidence of PONV:
► Opioids
► Inhalational agents specially N2O
► Neostigmine
► Hypoxia 3.SURGICAL FACTOR:-
► Gynaecological surgeries
► Ophthalmic
► ENT
► Neurosurgeries
► Use of regional technique when possible
► Use of propofol rather than sodium thiopentone as an inducing agent
► Perioperative oxygen supplementation
o TREATMENT
► Inj metoclopromide
► Inj ondensetron
► Inj Dexamethasone
► Utmost care should be taken while transportation of patient
► Bleeding should be observed by checking soaked dressings/drain for amount, colour, odour
► Encourage the patient for deep breathing & coughing to prevent collapse of lung alveoli
► Remove secretions by suctioning
► Pain management should be done according to instructions
► Change position of the patient frequently and do mobilization to prevent venous stasis
► In case of intubated patients check ET tube for blockage tube cuff should not be over or under inflated
► I.V fluids, blood transfusion are administered & reactions are managed in event of occurrence
► An unconscious/semi-concious patient should not be left alone
► Oxygen therapy should be given as appropriate
► The recovery room should be equipped by following equipments:-
► Equipment required for airway management and oxygen therpy i.e oxygen outlets, face masks, ET tubes, oxygen tubing, humidifier, breathing system , difficult airway devices,suction machine with suction catheter
► Defibillator, laryngscope with all blades, resuscitation trolley
Crash cart
Defibrillator
Do
racheal
Breathing equipment/ / air supplies
✓ Emergency drugs
IV supplies and tubing
POLYMED NELATON CATHETER
► Paediatric equipment trolley containing face masks,airways ET tubes and connectors of various sizes
► Monitoring equipments e.g, NIBP monitor, pulse oximeter, capnography,ECG recording,
► Drugs for resuscitation (Emergency drug tray), airway management, pain relief, intravenous fluids,anti emetics
► In gynecological, laparoscopic, gastrointestinal surgeries and female gender are at the greater risk of having post operative nausea and vomiting . These patients require additional anti emetics
Mod Cart
"ONDANSETRON
PHENYLEPH
TETHE CHAINE
► NIBP
► SPO2
► ECG
► Urine output
► Temperature
► Respiratory monitoring
► Temperature should be monitored especially in long operations. Hypothermia can lead to a number of problems e.g. delayed recovery, impaired coagulation, shivering or even arrhythmias
► It can be treated by body surface warming,blankets and warm I.V fluids
► Tramadol 1mg/kg body weight can be used to treat shivering
► Fluid management reduces adverse outcomes and improves patients comfort and satisfaction
► Certain procedures involving significant loss of blood or fluids may require additional fluid management
► Urine output is a good indicator of adequate perfusion and should be monitored in all post op patients
► In addition to this loss of body fluids through vomitus, naso gastric tube drainage and wound drainage should be recorded
► The intake of fluid and output should be carefully matched
► Excess blood in the wound drainage tube indicate bleeding inside the wound .In this situation surgeon must be informed
► Many times blood is transfused in the immediate post operative period . The recovery room staff must match the patients details with those given on the blood bag to prevent mismatched transfusion
► They must monitor the patient throughout the blood transfusion to recognize and treat the blood transfusion reaction at the earliest
► Any kinking or pulling out of catheters and drainage tubes should be prevented and their patency and their proper function should be maintained
► The side rails of the bed should be kept raised to prevent patient from falling down
► If the patient vomits the head end of the bed should be lowered the vomitus and secretions should be removed immediately by suctioning to prevent aspiration
► Always wash hands before and after working with all patient to prevent transmission of infection from one patient to another
► If the patient is alert encourage him for deep breaths to improve lung function and to prevent accumulation of secretions
► The patients level of consciousness should be assessed and documented. It is done by talking to the patient and then looking for orientation and the response of the patient to stimuli.
► The following criteria can be used for level of consciousness
►Comatose: unconscious, unresponsive to stumuli
►Stupor: lethargic and unresponsive; unaware of surroundings
►Drowsy: half asleep; sluggish; respond to touch and sounds
►Alert: able to give appropriate response to stimuli
Aldrete Post Anesthesia Recovery Score (PARS)
• Numerical scoring system to eval PACU patients
• Based on activity, Respirations, Circulation,
Consciousness, O2 Sats
• Ranges from o to 10, 10 is the best
• Score when arrives in PACU, every 30 min until
8 or higher is achieved
• Score also done at discharge
Aldrete Score
Activity
Respiration
Circulation
Consciousness
Oxygen Saturation
2:Fully awake
2: Moves all extremities voluntarily/ on command
2:Breaths deeply and coughs freely.
2: BP + 20 mm of preanesthetic level
2: Spo2 > 92% on room air
1: Moves 2 extremities
1: Dyspneic, 1: BP + 20-50 shallow or limited mm of breathing
preanesthetic level
1: Arousable on calling
1.Supplemental O2 required to maintain Spo2
>90%
0: Apneic
0: Not responding
0: Unable to move extremities
0: BP + 50 mm of preanestheic level
0: Spo2 <92% with 02 supplementation
THANK YOU |
| POST OPERATIVE CARE BY VAISHALI SYAL |
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