Post-operative care

Question 1

Aims of enhanced recovery

Answer 1

Aims to get patients back to their pre-operative condition as quickly as possible –> independence, early mobility and appropriate diet.
- increased nutritional requirements after surgery, so sufficient calories are very important.
- The aim is to discharge as soon as possible. => better outcomes for the patient.

Question 2

Principles of enhanced recovery

Answer 2

1. Good preparation for surgery (e.g., healthy diet and exercise)
2. Minimally invasive surgery (keyhole or local anaesthetic where possible)
3. Adequate analgesia
4. Good nutritional support around surgery
5. Early return to oral diet and fluid intake
6. Early mobilisation
7. Avoiding drains and NG tubes where possible, early catheter removal
8. Early discharge

Question 3

Post-Operative Nausea and Vomiting

Answer 3

• common in the 24 hours after an operation
• many causes, including the surgical procedure, anaesthetic, pain and opiates.

Question 4

Risk factors of PONV (FUNHYU)

Answer 4

Female
Use of postoperative opiates
Non-smoker
History of motion sickness or previous PONV
Younger age
Use of volatile anaesthetics

Question 5

Prophylactic antiemetics for PONV

Answer 5

1. Ondansetron (5HT3 receptor antagonist) – avoided in patients at risk of prolonged QT interval
2. Dexamethasone (corticosteroid) – used with caution in diabetic or immunocompromised patients
3. Cyclizine (histamine (H1) receptor antagonist) – caution with heart failure and elderly patient

Question 6

Management of PONV

Answer 6

1. Ondansetron (5HT3 receptor antagonist) – avoid in patients at risk of prolonged QT interval
2. Prochlorperazine (dopamine (D2) receptor antagonist) – avoid in patients with Parkinson’s disease
3. Cyclizine (histamine (H1) receptor antagonist) – caution with heart failure and elderly patients

Question 7

Tubes

Answer 7

E.g. catheter, drains or nasogastric tube

Drains - usually removed once they are draining minimal or no blood or fluid

NGT - removed when they are no longer required for intake or drainage of gas or fluid

Catheters - removed when the patient can mobilise to the toilet

Question 8

Define TWOC

Answer 8

Trial without catheter

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.

Question 9

What is the ideal route of feeding post-surgery?
i. Define it

Answer 9

Enteral feeding
i. Feeding through the GI tract

Question 10

Define TPC (total parenteral nutrition)

Answer 10

meeting the full ongoing nutritional requirements of the patient using an intravenous infusion of a solution of carbohydrates, fats, proteins, vitamins and minerals.

Question 11

General post-op complications

Answer 11

• Anaemia
• Atelectasis
• Infections
• Wound dehiscence
• Ileus
• Haemorrhage
• VTE
• Shock
• Arrhythmias (e.g., atrial fibrillation)
• MI/Stroke
  -AKI
• Urinary retention requiring catheterisation
• Delirium refers to fluctuating confusion and is more common in elderly and frail patients

Question 12

Common causes of post-op delirium

Answer 12

hypoxia, infection, drug-induced, dehydration, pain, constipation, or urinary retention