Post Operative Care of Patients

POST OPERATIVE CARE POST OPERATIVE CARE OF PATIENTSOF PATIENTS

A PRESENTATION BY A PRESENTATION BY

DR. FARRUKH R. MALIK DR. FARRUKH R. MALIK HOUSE OFFICERHOUSE OFFICERSURGICAL UNIT-IISURGICAL UNIT-II

CHANDKA MEDICAL COLLEGE HOSPITAL, CHANDKA MEDICAL COLLEGE HOSPITAL, LARKANA, PAKISTAN.LARKANA, PAKISTAN.

©Farrukh R. Malik MBBS ©Farrukh R. Malik MBBS 20062006

INTRODUCTIONINTRODUCTION

Post operative care of the patients is most important part of Post operative care of the patients is most important part of the management:the management:

It gives a complete outline of actions to be taken It gives a complete outline of actions to be taken immediately after surgery to discharge of patient and follow immediately after surgery to discharge of patient and follow up.up.

Plan laid and followed properly will optimize recovery and Plan laid and followed properly will optimize recovery and enable early detection of impending complications.enable early detection of impending complications.

Reference:Reference: Russell, RCG et al (2004) ,Bailey and Love’s short practice of surgery, 24Russell, RCG et al (2004) ,Bailey and Love’s short practice of surgery, 24 thth

edition, Arnold, London.edition, Arnold, London.Lavelle-Jones, Michael (2002), Master Medicine’s Surgery-I, 2Lavelle-Jones, Michael (2002), Master Medicine’s Surgery-I, 2ndnd edition, edition,

Churchill Livingstone, Edinburgh.Churchill Livingstone, Edinburgh.

POST OPERATIVE CARE OF PATIENT

SPECIFIC CONSIDERATIONSROUNTINE POSTOPERATIVE CARE

Reference:Reference:Klingensmith Mary E. et al (2005),The Washington Manual of surgery, 4th Klingensmith Mary E. et al (2005),The Washington Manual of surgery, 4th edition, Lippincott Williams & Wilkins,USA.edition, Lippincott Williams & Wilkins,USA.

ROUNTINE POST OPERATIVE ROUNTINE POST OPERATIVE CARECARE

INTRAVENOUS FLUIDSINTRAVENOUS FLUIDS MONITERINGMONITERING DEEP VENOUS THRMBOSIS PROPHYLAXISDEEP VENOUS THRMBOSIS PROPHYLAXIS WOUND CARE WOUND CARE MEDICATIONMEDICATION INVESTIGATIONSINVESTIGATIONS

Reference:Reference:Klingensmith Mary E. et al (2005),The Washington Manual of surgery, 4Klingensmith Mary E. et al (2005),The Washington Manual of surgery, 4thth edition, edition,

Lippincott Williams & Wilkins,USA.Lippincott Williams & Wilkins,USA.Lavelle-Jones, Michael (2002), Master Medicine’s Surgery-I, 2Lavelle-Jones, Michael (2002), Master Medicine’s Surgery-I, 2ndnd edition, Churchill edition, Churchill

Livingstone, EdinburghLivingstone, Edinburgh..

INTRAVENOUS FLUIDSINTRAVENOUS FLUIDS Insensible fluid loss and redistribution is Insensible fluid loss and redistribution is

responsible for intravascular volume responsible for intravascular volume depletion.depletion.

Surgical patients, as a general rule, are Surgical patients, as a general rule, are given intravenous infusion until and unless given intravenous infusion until and unless they are not able to take per oralthey are not able to take per oral

Reference:Reference:Klingensmith Mary E. et al (2005),The Washington Manual of surgery, Klingensmith Mary E. et al (2005),The Washington Manual of surgery,

44thth edition, Lippincott Williams & Wilkins,USA. edition, Lippincott Williams & Wilkins,USA.

INTRAVENOUS FLUIDS INTRAVENOUS FLUIDS (conti…)(conti…)

Courtesy: Bed no. 16, Male surgical unit-II, Chandka Medical college hospital, Larkana, Pakistan

INTRAVENOUS FLUIDS INTRAVENOUS FLUIDS (conti…)(conti…)

Courtesy: Bed no. 16, Male surgical unit-II, Chandka Medical college hospital, Larkana, Pakistan

MONITERINGMONITERING

•Temperature, Pulse, Blood Pressure and Respiratory Rate should be monitored.

Courtesy: surgical unit-II, Chandka Medical college hospital, Larkana, Pakistan

DEEP VENOUS THRMBOSIS DEEP VENOUS THRMBOSIS PROPHYLAXISPROPHYLAXIS

In patients going through major procedures there are In patients going through major procedures there are chances of venous stasis and relative chances of venous stasis and relative hypercoagulability.hypercoagulability.

These patients are classified as low risk, low or These patients are classified as low risk, low or moderate risk, high risk and highest risk patients on moderate risk, high risk and highest risk patients on the basis of age and nature of procedure.the basis of age and nature of procedure.

Patients belonging to different risk groups are Patients belonging to different risk groups are provided with prophylaxis with different modalities provided with prophylaxis with different modalities (i.e. Mechanical prophylaxis, unfractionated heparin, (i.e. Mechanical prophylaxis, unfractionated heparin, Low molecular weight heparin, Warfarin). Low molecular weight heparin, Warfarin).

(Conti…..)(Conti…..)

DEEP VENOUS THRMBOSIS PROPHYLAXIS DEEP VENOUS THRMBOSIS PROPHYLAXIS (conti…)(conti…)

Low risk=Age less than 40 years+no risk factorLow risk=Age less than 40 years+no risk factor

Low or Moderate risk=Major surgery & age less Low or Moderate risk=Major surgery & age less than 40 years or minor surgery with risk factor or than 40 years or minor surgery with risk factor or age between 40 & 60 years.age between 40 & 60 years.

High risk=Major surgery+age over 40 years or High risk=Major surgery+age over 40 years or with risk factor or minor procedure with age over with risk factor or minor procedure with age over 60 years with risk factor.60 years with risk factor.

Highest risk=Age over 60 years with multiple risk Highest risk=Age over 60 years with multiple risk factors or with major procedurefactors or with major procedure

(Conti…..)(Conti…..)

DEEP VENOUS THRMBOSIS PROPHYLAXIS DEEP VENOUS THRMBOSIS PROPHYLAXIS (conti…)(conti…)

Patient Patient GroupGroup

Surgery Surgery TypeType

ProphylaxiProphylaxiss

Low riskLow risk MinorMinor NoneNone

Low or moderate riskLow or moderate risk MajorMajor GCS, SQH-12 or GCS, SQH-12 or IPCIPC

HighHigh MajorMajor SQH-8 or LMWHSQH-8 or LMWH

HighestHighest MajorMajor SQH-8/12 or SQH-8/12 or LMWH+IPCLMWH+IPC

Reference:Reference:Klingensmith Mary E. et al (2005),The Washington Manual of surgery, Klingensmith Mary E. et al (2005),The Washington Manual of surgery, 4th edition, Lippincott Williams & Wilkins,USA.4th edition, Lippincott Williams & Wilkins,USA.

WOUND CAREWOUND CARE

After surgery the wound care is one After surgery the wound care is one of the important considerations.of the important considerations.

In order to keep the wound clean, In order to keep the wound clean, dressing is being done in our wards dressing is being done in our wards with topical applications.with topical applications.

Reference:Reference: Russell, RCG et al (2004) ,Bailey and Love’s short practice of surgery, Russell, RCG et al (2004) ,Bailey and Love’s short practice of surgery, 24th edition, Arnold, London.24th edition, Arnold, London.

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WOUND CAREWOUND CARE (Conti…)(Conti…)


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WOUND CAREWOUND CARE (Conti…)(Conti…)


•Bed Sores maybe avoided in bed ridden patients by changing the position of patient time to time.

MEDICATIONMEDICATION


MEDICATIONMEDICATION (CONTI…)(CONTI…)

AntiemeticsAntiemetics Ulcer ProphylaxisUlcer Prophylaxis Pain controlPain control AntibioticsAntibiotics

Reference:Reference:Klingensmith Mary E. et al (2005),The Washington Manual of Klingensmith Mary E. et al (2005),The Washington Manual of

surgery, 4th edition, Lippincott Williams & Wilkins,USA.surgery, 4th edition, Lippincott Williams & Wilkins,USA.


Antiemetics are given as postoperative nausea is common after Antiemetics are given as postoperative nausea is common after general anesthesia.general anesthesia.

Patients with or without peptic ulcer disease on prolonged Patients with or without peptic ulcer disease on prolonged ventilator support are prescribed with acid-reducing agents or ventilator support are prescribed with acid-reducing agents or cytoprotective agents like sucralfate.cytoprotective agents like sucralfate.

Pain control is necessary for early mobility and healing as well as Pain control is necessary for early mobility and healing as well as prevention of cardiac complications.prevention of cardiac complications.

Antibiotics are needed to prevent nosocomial infections.Antibiotics are needed to prevent nosocomial infections.


4th edition, Lippincott Williams & Wilkins,USA.4th edition, Lippincott Williams & Wilkins,USA.



INVESTIGATIONSINVESTIGATIONS

COURTESY: Pathology laboratory, Chandka Medical College Larkana, Pakistan

INVESTIGATIONS INVESTIGATIONS (conti…)(conti…)

• As a routine practice it is required that blood cp, serum electrolytes, blood urea, creatinine and coagulation studies should be done.



X-ray is required, particularly of chest, in X-ray is required, particularly of chest, in procedures in which the thoracic cavity is procedures in which the thoracic cavity is entered or when central venous access is entered or when central venous access is attempted.attempted.

In certain cases like that of inflamed In certain cases like that of inflamed appendix or peritoneal collection, ultrasound appendix or peritoneal collection, ultrasound is required to ensure the presence of is required to ensure the presence of pathological state.pathological state.

Reference:Reference:Klingensmith Mary E. et al (2005),The Washington Manual of surgery, 4th edition, Klingensmith Mary E. et al (2005),The Washington Manual of surgery, 4th edition,

Lippincott Williams & Wilkins,USA.Lippincott Williams & Wilkins,USA.


Courtesy: Department of Radiology, Chandka Medical College hospital, Larkana, Pakistan

POST OPERATIVE CARE OF PATIENT

SPECIFIC CONSIDERATIONSROUNTINE POSTOPERATIVE CARE


SPECIFIC SPECIFIC CONSIDERATIONCONSIDERATION

SEIZURE DISORDERS SEIZURE DISORDERS CARDIOVASCULAR DISEASESCARDIOVASCULAR DISEASES RENAL DISEASESRENAL DISEASES DIABETESDIABETES


44thth edition, Lippincott Williams & Wilkins,USA. edition, Lippincott Williams & Wilkins,USA.Lavelle-Jones, Michael (2002), Master Medicine’s Surgery-I, 2Lavelle-Jones, Michael (2002), Master Medicine’s Surgery-I, 2ndnd

edition, Churchill Livingstone, Edinburgh.edition, Churchill Livingstone, Edinburgh.

SEIZURE DISORDERSSEIZURE DISORDERS Management of patients with known seizure disorders be Management of patients with known seizure disorders be

directed by keeping in view the type of seizure (i.e. general directed by keeping in view the type of seizure (i.e. general versus partial, simple partial versus complex partial), versus partial, simple partial versus complex partial), frequency and degree of control of disorder.frequency and degree of control of disorder.

Well controlled disorders pose little risk.Well controlled disorders pose little risk.

Standard precaution may be taken including medication.Standard precaution may be taken including medication.

Phenytoin and Phenobarbital are available in parenteral Phenytoin and Phenobarbital are available in parenteral form.form.

Carbamazepine,ethosuximide and valproic acid are not Carbamazepine,ethosuximide and valproic acid are not available in parenteral form.available in parenteral form.


CARDIOVASCULAR CARDIOVASCULAR DISEASESDISEASES

In case of coronary artery disease In case of coronary artery disease the control of precipitants is the control of precipitants is required.required.

Stresses that exacerbate the Stresses that exacerbate the ischemia are required to be avoided.ischemia are required to be avoided.


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CARDIOVASCULAR DISEASES CARDIOVASCULAR DISEASES (Conti…)(Conti…)

Acute hypertension must be Acute hypertension must be controlled as it increases the oxygen controlled as it increases the oxygen requirement and exacerbates requirement and exacerbates ischemia.ischemia.

Reference:Reference:Klingensmith Mary E. et al (2005),The Washington Manual of surgery, 4th Klingensmith Mary E. et al (2005),The Washington Manual of surgery, 4th edition, Lippincott Williams & Wilkins,USA.edition, Lippincott Williams & Wilkins,USA.Lavelle-Jones, Michael (2002), Master Medicine’s Surgery-I, 2nd edition, Lavelle-Jones, Michael (2002), Master Medicine’s Surgery-I, 2nd edition, Churchill Livingstone, Edinburgh. Churchill Livingstone, Edinburgh.

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•Pain is required to be controlled with analgesics as it can cause tachycardia and hypertension.Reference:Reference:Lavelle-Jones, Michael (2002), Master Medicine’s Surgery-I, 2nd Lavelle-Jones, Michael (2002), Master Medicine’s Surgery-I, 2nd edition, Churchill Livingstone, Edinburgh. edition, Churchill Livingstone, Edinburgh.

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•Oxygen is required to be given continuously in postoperative patients to increase the oxygen content of the blood.

(Conti…)



•Anemia should be avoided as it decreases the oxygen carrying capacity of the patients. Transfusion should be considered when hemoglobin falls below 9.0 (Conti…

)


Role of medication in postoperative Role of medication in postoperative care of patients having cardiovascular care of patients having cardiovascular disease is very important.disease is very important.

Patient receiving beta-adrenergic Patient receiving beta-adrenergic antagonists, nitrate therapy and/or antagonists, nitrate therapy and/or calcium channel blocker should be calcium channel blocker should be continued same.continued same.


RENAL DISEASESRENAL DISEASES Fluid replacement in postoperative patients having chronic Fluid replacement in postoperative patients having chronic

renal disease should be done as in normal individual.renal disease should be done as in normal individual.

Care must be taken to avoid excessive fluid replacement.Care must be taken to avoid excessive fluid replacement.

Maintenance fluids should not contain potassium.Maintenance fluids should not contain potassium.

Serum electrolytes should be measured time to time.Serum electrolytes should be measured time to time.

Early dialysis may be necessary in case of hyperkalemia or Early dialysis may be necessary in case of hyperkalemia or intravascular volume overload.intravascular volume overload.

Reference:Reference: Russell, RCG et al (2004) ,Bailey and Love’s short practice of surgery, Russell, RCG et al (2004) ,Bailey and Love’s short practice of surgery, 24th edition, Arnold, London.24th edition, Arnold, London.Lavelle-Jones, Michael (2002), Master Medicine’s Surgery-I, 2nd Lavelle-Jones, Michael (2002), Master Medicine’s Surgery-I, 2nd edition, Churchill Livingstone, Edinburgh. edition, Churchill Livingstone, Edinburgh.

(Conti…)

RENAL DISEASES RENAL DISEASES (conti…)(conti…)


•Patient should be catheterized to monitor the urine output.

(Conti…)

RENAL DISEASES RENAL DISEASES (conti…)(conti…)

In patients having renal insufficiency In patients having renal insufficiency and decreased creatinine clearance and decreased creatinine clearance the dosages of the drugs should be the dosages of the drugs should be adjusted.adjusted.

Some medications such as Some medications such as meperidine are contraindicated. meperidine are contraindicated.


DIABETESDIABETES


•Postoperative management of diabetic surgical patient centers on maintenance of euglycemia and management of chronic complications.

•The blood glucose levels should be measured time to time.

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DIABETES DIABETES (conti…)(conti…) Diet controlled diabetic patients infrequently need glucose or Diet controlled diabetic patients infrequently need glucose or

insulin therapy after minor surgeries.insulin therapy after minor surgeries.

Diabetic patients who are receiving oral hypoglycemic agents Diabetic patients who are receiving oral hypoglycemic agents frequently need insulin postoperatively.frequently need insulin postoperatively.

Patients who are taking insulin preoperatively usually require Patients who are taking insulin preoperatively usually require insulin postoperatively to achieve adequate control of serum insulin postoperatively to achieve adequate control of serum glucose levels. glucose levels.

Intermittent dosing of subcutaneous insulin can be given as Intermittent dosing of subcutaneous insulin can be given as intermediate acting insulin twice a day, with hyperglycemia intermediate acting insulin twice a day, with hyperglycemia managed by supplemental dosing of regular insulin.managed by supplemental dosing of regular insulin.

Continuous intravenous insulin infusion in a monitored setting is Continuous intravenous insulin infusion in a monitored setting is indicated in patients with hyperglycemia that is not controlled by indicated in patients with hyperglycemia that is not controlled by intermittent subcutaneous dosing. intermittent subcutaneous dosing.


THANKSTHANKS

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Post Operative Care of Patients