Post operative care Flashcards
post op care
Immediately after the operation, the patient will go to the recovery room to be monitored closely whilst they regain consciousness. Once they are conscious and stable, they can return to the ward. Patients may be transferred to HDU or ICU depending on their condition and the monitoring requirements post-operatively.
enhanced recovery
aims to get a patient back to their pre operative condition asap
- encourage independence
- early mobility
- appropriate diet
- increased nutritional requirements after physiological stress of surgery (calories)
- discharge asap
what are the principles of enhanced recovery
Good preparation for surgery (e.g., healthy diet and exercise)
Minimally invasive surgery (keyhole or local anaesthetic where possible)
Adequate analgesia
Good nutritional support around surgery
Early return to oral diet and fluid intake
Early mobilisation
Avoiding drains and NG tubes where possible, early catheter removal
Early discharge
post operative analgesia
Adequate analgesia in the post-operative period is important to encourage the patient to:
Mobilise
Ventilate their lungs fully (reducing the risk of chest infections and atelectasis)
Have an adequate oral intake
analgesia in theatre
starts with the anaesthetists: regular paracetemol, NSAIDs, opiates e.g g., regular modified-release oxycodone with immediate-release oxycodone as required for breakthrough pain)
the surgeon may put local anaesthetic into the wound to help with the initial pain after the procedure. Analgesia should be reduced and stopped as symptoms improve. There is more detail on analgesia in the anaesthetics section.
NSAIDS
ibuprofen, naproxen and diclofenac
may be inappropriate or contraindicated in patients with: Asthma
Renal impairment
Heart disease
Stomach ulcers
PCA
Patient-controlled analgesia (PCA) involves an intravenous infusion of a strong opiate (e.g., morphine, oxycodone or fentanyl) attached to a patient-controlled pump. This involves the patient pressing a button as pain starts to develop, for example during a contraction in labour, to administer a bolus of this short-acting opiate medication. The button will stop responding for a set time after administering a bolus to prevent over-use. Only the patient should press the button (not a nurse or doctor).
Patient-controlled analgesia requires careful monitoring. There needs to be input from an anaesthetist, and facilities in place if adverse events occur. This includes access to naloxone for respiratory depression, antiemetics for nausea, and atropine for bradycardia. The anaesthetist may prescribe background opiates (e.g., patches) in addition to a PCA, but avoid other “as required” opiates whilst a PCA is in use. The machine is locked to prevent tampering.
Post op nausea and vomiting
Nausea and vomiting are common in the 24 hours after an operation and is called post-operative nausea and vomiting (PONV). There are many causes, including the surgical procedure, anaesthetic, pain and opiates.
Risk factors for post-operative nausea and vomiting are:
Female History of motion sickness or previous PONV Non-smoker Use of postoperative opiates Younger age Use of volatile anaesthetics
prophylactic antiemetic- given at the end of the procedure to prevent POVN from occuring:
Ondansetron (5HT3 receptor antagonist) – avoided in patients at risk of prolonged QT interval
Dexamethasone (corticosteroid) – used with caution in diabetic or immunocompromised patients
Cyclizine (histamine (H1) receptor antagonist) – caution with heart failure and elderly patient
Examples of “rescue” antiemetics used in the post-operative period if nausea or vomiting occur are:
Ondansetron (5HT3 receptor antagonist) – avoid in patients at risk of prolonged QT interval
Prochlorperazine (dopamine (D2) receptor antagonist) – avoid in patients with Parkinson’s disease
Cyclizine (histamine (H1) receptor antagonist) – caution with heart failure and elderly patients
Some local guidelines also refer to the P6 acupuncture point on the inner wrist. There is evidence that pressure to this area can reduce nausea.
tubes post operatively
- catheter
- drains
- NG tubes
drains removed once they are draining mininmal/no blood/fluid
NG tube removed when pt no longer required for intake or drainage of gas or fluid
catheter removed when the pt can mobilise to the toilet
removal of catheter TWOC
It is called this as there is a risk the patient will find it difficult to pass urine normally and go into urinary retention, and the catheter may need to be reinserted for a period before removal can be tried again. This is quite common, more so in male patients.
NG support
Where possible, patients should get their nutrition via their gastrointestinal tract. Having nutrition via the gastrointestinal tract is called enteral feeding. This could be by:
Mouth
NG tube
Percutaneous endoscopic gastrostomy (PEG) – a tube from the surface of the abdomen to the stomach
Total parenteral nutrition (TPN) involves meeting the full ongoing nutritional requirements of the patient using an intravenous infusion of a solution of carbohydrates, fats, proteins, vitamins and minerals. This is used where it is not possible to use the gastrointestinal tract for nutrition. It is prescribed under the guidance of a dietician. TPN is very irritant to veins and can cause thrombophlebitis, so is normally given through a central line rather than a peripheral cannula.
post op complications
Anaemia
Atelectasis is where a portion of the lung collapses due to under-ventilation
Infections (e.g., chest, urinary tract or wound site)
Wound dehiscence is where there is separation of the surgical wound, particularly after abdominal surgery
Ileus is where peristalsis in the bowel is reduced (typically after abdominal surgery)
Haemorrhage with bleeding into a drain, inside the body creating a haematoma or from the wound
Deep vein thrombosis and pulmonary embolism
Shock due to hypovolaemia (blood loss), sepsis or heart failure
Arrhythmias (e.g., atrial fibrillation)
Acute coronary syndrome (myocardial infarction) and cerebrovascular accident (stroke)
Acute kidney injury
Urinary retention requiring catheterisation
Delirium refers to fluctuating confusion and is more common in elderly and frail patients
anaemia post operatively
A post-op full blood count is used to measure the haemoglobin.
Treatment of anaemia is based on individual factors and preferences alongside local guidelines. As a rough guide (local policies will vary):
Hb under 100 g/l – start oral iron (e.g., ferrous sulphate 200mg three times daily for three months)
Hb under 70-80 g/l – blood transfusion in addition to oral iron
Patients with symptoms of anaemia or underlying cardiovascular or respiratory disease may need a transfusion with higher haemoglobin levels.
It is worth noting that Jehovah’s Witnesses may refuse blood transfusions. They often have a written advanced directive to state that even in an emergency scenario where they lose capacity, blood transfusions are prohibited. Provided they have capacity and are making an informed decision, they have the right to autonomy. Measures are taken before surgery to optimise any anaemia, and careful steps are taken during surgery to minimise blood loss.
