MISC - Post op care Flashcards
How would you examine a post op pt?
- Vital signs - ABCD
- Fluid balance – including urine output
• Output for any drains
–content and volume
–Can they be removed?
• Examine operative site
– are these findings expected?
• Examine anywhere else of concern – related to operation?
What drugs do you normally expect to see in a post op pt?
• VTE prophylaxis
• Does patient still need these medications?
–Antibiotics
–Analgesia
• Are other medications needed? –Analgesia –Aperients –Antiemetics –Regular medications
How (4) can you treat the inadequate intake of nutrition post op?
- multivitamins
- High-calorie and protein drinks
- Nasogastric feeding
- Total Parenteral Nutrition
How can you examine fluid balance of a patient?
• Urine Output
– measure of tissue perfusion
– maintain UO >30mL/hr or >0.5mL/kg/hr
– beware in CCF and renal impairment
• What fluids are running?
– Replacement vs maintenance fluids (typically 12/24-8/24)
- Critical for major abdominal surgery, especially GI
- Consider total daily balance – does not count insensible losses
What other than urine output can you rely on for fluid balance?
– Consider HR, BP, JVP
• Difficult assessments: use daily weight, compare with preoperative weight
• Be wary of frusemide use
Why should you not give excessive fluids post op day 1?
• Day 1: increased ADH, do not give excessive fluids
What do you anticipate for fluid balance in post op day 2?
• Day 2: mobilisation often shifts fluid from interstitium back into intravascular space
– Decrease IV fluid rate in anticipation
Low urine output
- signs
- Rx
• If anuria, check for blocked IDC • Assess patient for hypovolaemia • Ensure patient is not bleeding • Give fluid challenge –500mL to 1L stat crystalloid
(4) What are the complications of immobilisation due to pain post op etc?
- pneumonia
- DVT/PE
- atrophy
- pressure sores
How would you adequately give analgesia for post op pt?
- WHO analgesia ladder
- Patient-Controlled Analgesia
- Regional
- Spinal
- Epidural
- Acute Pain Service
How can you prevent Cx post op in general?
- Mobilisation: aim for out of bed and walking by day 2
- Chest physiotherapy
- VTE prophylaxis: mechanical and chemical
- Adequate analgesia
- Adequate nutrition and fluids
Give DDx for post op fever causes depending on the days post op.
- Day 1: usually drug fever
- Day 3: lungs (pneumonia)
- Day 5+: infection: urinary tract, surgical site; leaks; DVT/PE
What should you check in a post op fever pt?
– Symptoms
– Vitals – any tachycardia or hypotension?
– lungs, surgical site, all lines, calves, urine dipstick
– inflammatory markers
•Septic Screen: CXR, MSU, Blood cultures
How (3) do you do a septic screen?
CXR, MSU, Blood cultures
How do you treat a wound infection (over closed staples)?
Consider opening suture line over infected area
–Drain underlying abscess
–Swab for MCS
–Heal by secondary intent
–Antibiotics
How do you treat a superficial wound dehiscence?
- May occur if skin poorly apposed
- Suture/staples may have cut through
- Heal by secondary intention
How do you treat a deep wound dehiscence?
• Burst abdomen
• Due to dehiscence of fascial layer
–Sutures pulled through/slipped knot/poor tension
- Excessive haemoserous discharge from suture line or bowel on view
- Usually return to theatre – consider tension sutures
What are the risks to poor wound healing?
poor nutrition, obesity, smoking, steroids, DM, uraemia, jaundice, malignancy, tissue ischaemia, infection
- 50y male 4 days ago had an incisional hernia repair with findings of an obstructed loop of small bowel.
- Now vomiting ++
- What (5) are possible causes??
Mx?
Causes of vomiting: • Post operative ileus • Small bowel obstruction • Ischaemic or infarcted segment bowel • Gastric dilatation • Drugs (narcotics)
Mx:
• Give antiemetic (maxolon, stemetil, ondansetron)
• Place NG tube: free drainage and aspirate
• Give IV fluids- check fluid balance
• Order AXR- S&E
- 80y woman, 2 days after open cholecystectomy is confused.
* What (5) are possible causes??
Causes of post operative confusion
• Hypoxia: atelectasis, chest infection, over sedation (narcotics), CCF, MI, PE
• Sepsis: chest, urine, wound, intraabdominal (bile leak)
• Medication: opiates, sedatives
• DTs (Delirium tremens; withdrawal from alcohol)
• Metabolic: uraemia, hyponatraemia, hypo or hyperglycaemia
what can be the contributing factors to confusion in a post op elderly pt?
- Stroke
- Pain
- Anaemia
- Hypotension
- Dementia
- Sleep deprivation
- Change of environment
How do you manage confusion?
- Get history from nursing staff or family
- Turn on lights
- Check history for pre-op state, alcohol, drugs, diabetes
- Check obs
- Look at patient. Give Oxygen
- Ix: ABG, RBG, U&E, FBE, Blood cultures, MSU, CXR, ECG
- 78y man returned to the ward after abdomino-perineal resection 6 hours ago.
- Lost 2L blood in theatre. Given 1500ml gelofusine and 2 units packed red cells.
- BP in recovery 120/70.
- Epidural infusion in situ- no pain.
- IV running at 100ml/h
- BP now 85/50
• What (3) are possible causes??
- Hypovolaemia: bowel prep and fasted, long operation, behind in fluid replacement, bleeding, 3rd space loss, sepsis
- Epidural causing peripheral vasodilatation
- Myocardial infarct or CCF
How do you treat hypotension in a post op pt?
• Decrease rate or stop epidural infusion
• Check FBE, U&E, ECG
• Give more IV fluid +/- blood.
–Start with Nsaline 1L over 30 min then review
–May need gelofusine 500ml stat if does not respond
If Gram –ve sepsis possible give IV antibiotic (3rd gen. cephalosporin or stat gentamicin)
- A 70 year old man had an anterior resection 5 days ago and now has a fever of 38.5C.
- What (6) are the possible causes?
- Wound infection
- Pelvic abscess
- UTI
- Pneumonia
- DVT/PE
- Drip site infection
What could be the cause of fever in first 48 hours of post op when the pt commonly looks well?
–basal atelectasis
–metabolic response to injury
what could be the cause of fever at post op day 5-10?
Abscesses
How do you manage post op fever?
- Identify site of infection
- Obtain pus-swab or aspirate Blood cultures
- MSU
- FBE
- Imaging – CXR, EGG, U/S, Duplex Doppler, CT
How often should you change the IV cannula?
Every 3 days to avoid thrombosis and infection
What is a PICC line?
- indications
- site of insertion
- period of use
- risks
- PICC line- placed by radiology under U/S control into basilic vein in upper arm (sterile technique)
- Can use for TPN or other infusions
- Almost equivalent to CVC
- Risk of venous thrombosis of basilic vein
- Can be used for weeks
What is a central venous catheter?
- indications
- site of insertion
- period of use
- risks
- good for TPN or other infusions
- Place into IJV or subclavian vein with tip in SVC (can use femoral V.)
- Usually insert in theatre or recovery (clean and ECG monitored)
- Can leave in for 5-21 days (antibiotic impregnated)
- Risk of pneumothorax, arterial puncture, haematoma (immediate)
- Risk of thrombosis, stenosis, sepsis (later)
What is a vascath?
- indications
- site of insertion
- period of use
- risks
- temporary catheter used for haemodialysis
- Local anaesthetic
- Use IJV or femoral vein (NOT subclavian)
- Leave in maximum 5 days
- Ultrasound control to insert is optimal
What is a permcath?
- indications
- site of insertion
- period of use
- risks
- long term catheter for haemodialysis
- with dual lumen
- general anaesthetic
- Place in IJV or EJV
- Tunnelled cuffed catheter to prevent infection and displacement
- Risk of infection and blockage
- Can replace
What is a infusaport/Portocath?
- indications
- site of insertion
- period of use
- risks
buried port on chest wall with line into SVC
- GA
- Used for long term central access for chemotherapy, IV drugs, blood taking
- Less risk of infection
What is a Hickman catheter?
- indications
- risks
single or dual lumen catheter
- GA
- Tunnelled with cuff to prevent infection
- Use for chemotherapy, bone marrow infusion, blood transfusions, long term TPN
