Post-op nausea

Question 1

You are asked by the nursing staff on the surgical ward to review a 68 year old woman with persistent nausea. She underwent a laparotomy for a perforated peptic ulcer two days earlier. What are the differential diagnoses and appropriate treatment?

Answer 1

Impression
This patient has prolonged post-op nausea, as most typically subsides after 24 hrs. There are a number of potential causes; ulcer and non-ulcer related.

Ddx

• surgery related: post-op ileum, anastomotic leak from repeat, remaining intra-abdominal collection from perf, SBO (unlikely)
• non-surgical: uncontrolled pain, analgesia reaction

Goals

• ensure HD stability, assess using targeted Hx/Ex/Ix for any red flag sx of perf/infection, anastomotic leak, ileus
• inform treating team of any indication of surgical complication
• Chart appropriate anti-emetics, for symptomatic relief, initiate appropriate mx according to underlying aetiology

Question 2

Post-op nausea - Assessment

Answer 2

Assessment
- Take A to E approach to assess for HD instability, use emergent management and stabilisation, assess for red flags of intra-abdominal complications post-operatively.

Question 3

Post-op nausea - History

Answer 3

History

• review op notes, current management and existing meds that are prescribed
• sx: abdo pain (SOCRATES), assoc sx N/V/D, opened bowels/wind? Sx of infection, systemic illness, urinary changes/resp changes
• Nausea: when started, how long for, constant or in waves, any vomiting, how has oral intake been (fluids, solids)

Question 4

Post-op nausea - Examination

Answer 4

Examination

• Appearance + vitals
• Abdominal exam: tenderness, peritonitis, assess wounds for signs of infection, any drains in-situ,
• systems review for evidence of systemic signs
• hydration status assessment, ?dehydrated if vomiting

Question 5

Post-op nausea - Investigations

Answer 5

Investigations
Will depend on clinical suspicion of underlying pathology
Bedside: UA,
- Bloods: will already have bloods ordered for that day, consider adding cultures if febrile
- imaging: upright AXR if concerned about air under diaphragm

Question 6

Post-op nausea - Management

Answer 6

Management
Definitive
- if underlying pathology, either surg or non-surg treat accordingly.
- anti-emetics: administer early and prevent vomiting;
o Ondansetron
o Droperidol
o Dexamethasone

Supportive

• fluids (IV) +/- electrolyte replacement
• consider non-opioid analgesia if tolerable
• Positioning: upright and avoid movement
• medication review
• NG tube if risk of aspiration, and can provide relief