Post-Operative Care Flashcards
Management of chest drain for pneumothorax
- Put the drain on low pressure, high volume wall suction (–3–5kPa) initially (not the high pressure wall suction used for tracheal toilet).
- Request and review CXRs daily.
- Bubbling in the underwater seal, either continuously or only when the patient coughs, indicates an air leak and implies that the lung parenchyma has not healed. Principles of surgery You can only remove the drain when there is no air leak; otherwise a pneumothorax will rapidly re-form.
- When the air leak stops, take the drain off suction for 12h and repeat the CXR: if the lung is fully up, the drain can be removed.
- Get a CXR after drain removal to check for a pneumothorax.
Indications for clamping a chest drain
Clamping drains when transferring patients stems from the days of TB treatment with caustic solutions and was aimed to prevent drain effluent draining back into the chest.
In modern practice, the only indications to clamp a drain are:
(1) in the trauma setting if the patient is exsanguinating through it;
(2) under specialist supervision in patients with chronic air leaks or pneumonectomy.
If you connect the drain to wall suction, but do not put the wall suction on, this is effectively clamping the drain; if you and the nurses do not know what you are doing, ask for help
Indication for platelets
Platelets <50 x 109/L or <100 x 109/L with active bleeding (lower threshold if patient was on aspirin or clopidogrel within 5 days and is actively bleeding).
Indications for Cryoprecipitate
Patient’s circulating blood volume replaced or fibrinogen <1g/L with active bleeding.
One bag of ‘cryo’ contains 150–250mg fibrinogen and factors VII and VIII.
• If cryopreciptate is unavailable, 5U of FFP contain the same amount of fibrinogen as 10U of cryoprecipitate.
Indications fro FFP
Patient’s circulating blood volume replaced or activated partial thromboplastin time ratio (APTR) >1.5 with active bleeding.
Post-Op Haemorrhage
- Primary haemorrhage. Occurs immediately after surgery or as a continuation of intraoperative bleeding. Usually due to unsecured blood vessels (e.g. liver bleeding following trauma).
- Reactionary haemorrhage. Occurs within the first 24h. Usually due to venous bleeding and is commonly thought to be due to improved post-operative circulation and fluid volume, exposing unsecured vessels that bleed (e.g. delayed splenic bleeding following minor trauma at laparotomy).
- Secondary haemorrhage. Occurs up to 10 days post-operatively. Usually due to infection of operative wounds or raw surfaces, causing clot disintegration and bleeding from exposed tissue.
Primary haemorrhage.
Occurs immediately after surgery or as a continuation of intraoperative bleeding. Usually due to unsecured blood vessels (e.g. liver bleeding following trauma).
Reactionary haemorrhage
Occurs within the first 24h. Usually due to venous bleeding and is commonly thought to be due to improved post-operative circulation and fluid volume, exposing unsecured vessels that bleed (e.g. delayed splenic bleeding following minor trauma at laparotomy).
Secondary haemorrhage
Occurs up to 10 days post-operatively. Usually due to infection of operative wounds or raw surfaces, causing clot disintegration and bleeding from exposed tissue.
Post-Op Haematoma
If this occurs after vascular surgery, flap surgery, or procedures on the limbs or neck, get senior help as urgent surgical exploration and evacuation may be indicated to avoid ischaemia, compartment syndromes, airway obstruction, flap failure, or ongoing haemorrhage.
- Apply firm pressure followed by a pressure dressing.
- Check clotting and FBC and treat appropriately (see Principles of surgery [link]).
- Withhold heparin.
- Surgical management is the same as for haemorrhage.
Surgical antbibiotics
Cefuroxime 1.5g IV + 500mg IV tds.
AND
Metronidazole 500mg IV + 500mg IV tds
Causes of wound dehiscence
Most wound dehiscences are secondary to wound infection.
Pre-operative factors
- immunosuppression
- malnutrition
- steroid use
- previous surgery or procedures
- anaemia
- jaundice
- diabetes
- increased BMI
- smoking
Peri-operative factors:
- not following Jenkins rule
- excessive bowel handling leading to bowel oedema
- poor anastomosis leading to leaks
Post-operative factors
- chronic cough
- constipation
Occasionally, the dehiscence is due to intracavity pathology causing wound breakdown from within (e.g. anastomotic leakage causing enteric fistulation).
Management of wound dehiscence
Emergency management
Resuscitation
• Ensure there is IV access
• Calm the patient, particularly if there is any degree of evisceration.
Early treatment
• If there are exposed viscera, cover these with saline soaked dressings.
-Do not reduce the bowel as risk of damaged it surrounded by guarded abdomen
• Give IV antibiotics if there features of wound infection
• If the dehiscence is superficial, ensure the wound is open and any pus is fully drained. Lightly pack the wound with absorbent dressing (e.g. Sorbsan®).
Definitive management
Superficial
• Continue regular wound lavage and dressings.
• For large defects, consider vacuum-assisted closure.
Full thickness
• Resuturing/closure of the defect in theatre may be appropriate using interrupted sutures
• For some deep defects, re-closure may be inappropriate (e.g. the presence of infection, intestinal contents/fistulas, severe immunocompromise, physiologically unstable, intracavity pathology causing the dehiscence). In these cases, the wound should be allowed to form a chronic wound and close by secondary intention (e.g. called a laparostomy in the abdomen). This may be assisted by vacuum closure devices.
Jenkin’s Rue
Suture length should be 4x the length of the incision
Bites should be 1cm from the wound edge and 1cm apart
Kisselbach’s plexus
Little’s area
-Common bleeding point in anterior inferior nasal septum
- Anastomosis of 4 arteries
1) Anterior ethmoidal artery (branch of the ophthalmic artery)
2) Sphenopalatine artery (terminal branch of the maxillary artery)
3) Greater palatine artery (from the maxillary artery)
4) Septal branch of the superior labial artery (from the facial artery)
