Post-Op _1 Flashcards
What’s the minimum monitoring immediately post-operatively?
- obs (BP, HR, sats, RR)
- ECG
*sometimes GCS
What should all patients receive post-op and how long for?
All pt should receive post-op oxygen for at least 4 hours
(3) important factors to review regularly post -op
- vital signs -> is patient shocked?
- pain relief/management -> is there more bleeding than expected?
- wounds/drains
What’s staff to patient ratio on:
- surgical ward
- HDU
- ITU
Surgical ward 4:1
HDU 2:1
ITU 1:1
What are the components of an analgesic pain ladder?
- Non-opiates (start with) e.g. paracetamol/ NSAIDs
- Weak opiate (e.g *Co-codmol*) +/-non-opiate**
- Strong opiates (Morphine) +/- non - opiate
NSAIDs
- what are they good for?
- contraindications
NSAIDs
Good for: orthopaedic pain -> given either orally, IM or as a suppository
Containdications: asthma, renal impairment, peptic ulcers
Examples of specific weak-opiates
Paracetamol + codeine phosphate -> Co-codamol
Dihydrocodeine -> Co-dydramol
- When do we think of use of weak opiates (such as Co-codamol, Co-dydramol)?
- What are their side effects?
- We think of starting weak opiates when Paracetamol on its own is ineffective
- Side effect: constipation
Morphine
- class
- main use
- forms that can be administrated
- site effects
Morphine
Class: strong opiates
Forms: oral, enteral, IM, SC, IV, continous infusion (patient-controlled analgesia)
Side effects: respiratory depression (careful in trauma and elderly patients), hypotension, nausea and constipation
Whare epidural analgesia is injected into?
The injection is usually made in the lumbar region at the L2/3 or L3/4 space
What’s epidural analgesia?
Epidural analgesia is an injection of local anaesthetic alone, or more commonly in combination with pain.
- may be used for pain relief intraoperatively (instead of using general anaesthetic for that purpose)
- often used in combination with GA -> to provide intra and post operative pain relief
What is the drug often used in epidural analgesia?
What is it usually combined with?
Bupivacine - a local anaesthetic
It is commonly used with diamorphine
*this combination is to enhance analgesia
Contraindication for epidural
Contraindications for an epidural:
- clotting disorders
- warfarin, heparin use and INR >1.5
*these are risk fo epidural haematoma -> paraplegia
What are possible risks (complications) for use of epidural haematoma?
- epidural haematoma leading to paraplegia -> if clotting disorders, warfarin/heparin use
- hypotension
- urinary retention
- small risk of infection -> epidural abscess
In what cases can we consider epidural in patient on Warfarin?
If the benefits outweigh risks, e.g. in patients with major abdominal or thoracic surgery -> epidural will reduce pain so the patient would be able to mobilise early and cough effectively -> reduced risks of pneumonia
What to do if e decide to give epidural to a patient on warfarin?
Heparin infusion (as warfarin would have been stopped earlier) would be switched on 4 hours pre op and INR rechecked
If INR <1.5 we can go ahead with epidural
How does patient-controlled analgesia work?
The patient presses the bottom that delivers a bolus of morphine IV -> normally every 5 min 1 mg
- maximum 12 mg / hr can be delivered -> so no risk of overdose
(1) advantage of patient-controlled analgesia
(1) disadvantage of patient controlled analgesia
Advantage: patient feels in control of their pain relief
Disadvantage: the patient must have physical ability to press the bottom -> may not be suitable for patient with severe RA or dementia
Why do we provide post-op pain care? (3)
- part of compassionate care
- to reduce complications e.g. pneumonia - if the patient would not be able to breathe deeply (e.g. due to pain) -> predisposed to pneumonia
- to mobilise early -> reduce risk of DVT
Differential diagnosis for post-op pain
- true post-op pain -> pain related to the disease process for which the procedure was undertaken OR/AND tissue damage sustained by the operation itself
- post- op complication -> additional attention is required
- pain arises from completly separate pathology from the one that the procedure was carried out for (least likely but still possible0
What’s the most important distinguishing sign between SIRS and pain in terms of vital signs? (2)
BP
- in SIRS/ sepsis -> it may be low
- in pain -> may be high
Cap refill
- expected to be normal in pain
- would be increased in SIRS/sepsis
*other vital signs may be similar in both
What to prescribe together with opioids? (2)
- Anti-emetic PRN
- Laxative PRN
Examples of intraoperative complications
- haemorrhage -> hypovolemic shock
- dehydration and decreased organ perfusion
- MI
- faecal contamination -> becomes apparent 1-4 days post-op
Early (<24) post-op
- haemorrhage
- respiratory: pneumothorax, adult respiratory distress syndrome
- poor urine output
- dehydration
Post-op complications seen in days 1-4
- urinary retention (also can occur in first 24 hours)
- pneumonia
- DVT, PE
- paralytic ileus
- operative sepsis (e.g. faecal contamination) shows up
- sepsis due to different causes (e.g. resp infection via ventilation, UTI via catheter)
Wound complications (post-op) that may occur before discharge
- anastomotic breakdown
- faecal fistula
- wound dehiscence -> may result in an incisional hernia
Post-op complications that may show up weeks later (2)
- incisional hernia
- obstruction due to adhesions
What organisms usually cause cellulitis (3)
- Clostridium perfringens
- staphylococci
- Beta- haemolytic streptococci
Types of gangrene (3)
- wet
- dry
- gas
Describe dry gangrene
Dry gangrene
Cause: a gradual reduction in blood supply e.g. atherosclerosis
Appearance: tissue becomes dry, wrinkled and black (from the disintegration of haemoglobin)
Wet gangrene description
Wet gangrene
Cause: death and decay of the tissue due to bacterial infection
Appearance: moist and infected areas
Gas gangrene description
- cause
- pathological process
- risk factors
- prognosis
- management
Gas gangrene
Cause: infections of the deep wounds or abdominal cavity (e.g. bowel) with Clostridium Performans or other gas-forming organisms (e.g. anaerobes)
Pathology: involves tissue enzymes (proteases, collagenase, hyaluronidase) and alpha toxin
Risk factors: DM, immunosuppression, malignancy, AKI
Prognosis: poor
Management: aggressive Rx with Penicillin and repeated debridement
What’s Fournier’s gangrene?
Fournier’s gangrene
Spreading cellulitis of perineum and scrotum (may involve tights and abdominal wall) -> can result in necrotising fascitis
*may be fatal if systemic spread
Management: broad-spectrum antibiotics and debridement
