Post operative management in recovery Flashcards
4 phases of post-operative care
1) Transfer to recovery room
2) Handover of the anaesthetic and perioperative events to recovery staff
3) Communicating clear plan for airway mx, analgesia, fluid ad O2 therapy
4) Postoperative visit
AAGBI mandated required monitoring for patient transfer to recovery
ECG
NIBP
SpO2
Capnography if airway device in situ
Post op positioning of adult patients
Sat slightly head up once maintaining own airway and breathing
Post op positioning of paediatric patients
Left lateral common especially when risk of ‘airway soiling’ eg vomiting / ENT surgery
Initial priorities on arrival to recovery
Oxygen attached to wall supply
Apply monitoring
Re-assess airway, breathing, circulation to ensure patient stable
Handover of patients to recovery - information needed
Patient details
Relevant PMHx
Allergies + relevant DHx
Operation + estimated blood loss
Abx given
Any complications
Anaesthetic technique
Analgesia + antiemetics given
Fluids / blood products given
Cannulas and lines in situ
Oxygen and monitoring requirements
Analgesia, antiemetic and fluid regimes
Acceptable physiological parameters
Things to make sure are complete before anaesthetist leaves recovery
Document plan clearly
Anaesthetic chart and drug chart completed
Check patient is stable
Check recovery nurse is happy before leaving recovery
Approach to pain management - things to think about generally
Post operative pain is expected but need to exclude complication
Ensure patient is warm – may help reduce pain
Consider intraoperative analgesia given – inc regional, neuroaxial technique and LA wound infiltration
Initial pain management for acute post op pain
WHO analgesia ladder – paracetamol and NSAIDs if not CI
Opioids
Titration of morphine and fentanyl for severe acute post op pain
Morphine – 1 to 2 mg at 5 min intervals
Fentanyl – 20 to 25 micrograms at 5 min intervals up to 100 micrograms
Approach to pain management if patient requiring further rescue analgesia after receiving pain ladder / opioids
Contact seniors or pain team
Drugs which seniors or pain team may consider if ongoing need for rescue analgesia
Magnesium sulphate
Clonidine
Ketamine
Lidocaine (inc infusion but rarely used now)
Apfel risk score use
Risk score for post operative nausea and vomiting (PONV)
Apfel risk score for PONV - scoring system
1 point scored for each of:
- Female gender
- Non-smoker
- Post-op opiate use
- PMH of PONV / motion sickness
Interpretation of Apfel risk score
Points scored = Risk PONV %
1 = 20%
2 = 40%
3 = 60%
4 = 80%
Approach to PONV management
If higher risk consider preventative treatment
Easier to prevent than to treat PONV
Conservative options to reduce PONV
IV fluids
Patient warming
Pain control
Commonly used anti-emetic 4 classes
5HT3 antagonists
H1 antagonists
D2 antagonists (dopamine antagonists)
Glucocorticoids
5HT3 antagonist example
Ondansetron
H1 antagonist example
Cyclizine
D2 antagonist example
Prochlorperazine
(Also metoclopramide but not useful for PONV)
Glucocorticoid example for antiemetic
Dexamethasone
Signs of total airway obstruction
Silent patient
Signs of partial airway obstruction
Stridor
Sites of airway obstruction
Oropharynx
Larynx
Common causes of oropharyngeal obstruction
Decreased muscle tone
Secretions
Sleep apnoea
Rare causes of oropharyngeal obstruction
Foreign body
Oedema
Wound haematoma
Neuromuscular disease (inc Guillan-Barre)
Example of foreign body to oropharynx post op
Throat pack
Common causes of laryngeal obstruction
Laryngospasm
Secretions
Rare causes of laryngeal obstructions
Oedema
Bilateral recurrent laryngeal nerve palsy
Tracheal collapse
Example of tracheal collapse
Laryngomalacia (more common in paeds)
Central
Central causes
Lung tissue
Lung movement
Neuromuscular
Central causes for breathing complications
Sedation with opioids / benzos / volatiles
CVA
COPD
Lung tissue causes for breathing complications
Atelectasis
Oedema
Aspiration
Lung movement causes for breathing complications
Obesity
Splinting
Pain
Neuromuscular causes for breathing complications
Residual neuromuscular blockade
Reason why pre-op benzodiazepine pre-medication is generally avoided
Rarely takes effect prior to surgery
Long lasting effects and can effect breathing in post op period
Common causes of hypertension post op
Agitation
Pre-operative HTN
Pain
Inadequate ventilation (hypoxia, hypercapnia)
Rare causes of hypertension post op
Bladder distention
Drug related (cessation of antihypertensives)
Common causes of hypotension post op
Hypovolaemia
Vasodilation
Rare causes of hypotension post op
Myocardial depression from anaesthetic agents
Causes of hypovolaemia post op
Blood loss
Third space losses
Causes of vasodilation post op
Subarachnoid / extradural block
Residual effects of anaesthetic and analgesic agents
Re-warming
Sepsis
Location for post operative visit
On the ward after surgery
Aims of the post operative visit
Ensure they remain physiologically stable
Inform them of any issues related to anaesthetic eg difficult airway
Get feedback on anaesthetic / analgesic plan
Patients who should be informed that they have a difficult airway and should be added to ‘Difficult Airway Database’
Grade 3 or 4 laryngoscopy
Other causes of difficult airway
