Download - By: Trajan Cuellar MB BCh MRCSI. General Surgery MIS BMS CRS PBS Vascular Plastics Transplant Trauma
Post-Operative Management of the Surgical Patient
by: Trajan Cuellar MB BCh MRCSI
Post Operative Patients
General Surgery MIS BMS CRS PBS Vascular Plastics Transplant Trauma
What is Post-Operative Management?
The management of the patient after surgery. This includes care given during the immediate post operative period, both in the operating room and the post anaesthesia care unit (PACU), as well as the days following surgery.
But hey I’m just a new intern…
Relish in your position Enjoy the fruits of your labour in
medical school Grow into the physician/surgeon role You will often stand alone with the
family in the room You are the last line of defense
Nobody will blame you, everyone will cheer you
Post Op Management starts with pre-operative considerations
Past Medical History
Past Surgical History
Social History
Family History
Post Op Management starts with pre-operative considerations
Past Medical History CNS – prior TIA, CVAs, mobility post op. CVS – CHF, prior MIs▪ Antiplatlet agents▪ IVF administration
Resp – COPD home O2, CPAP for OSA FEN/GI - Renal Failure – prescribe/dose all
medications appropriately (no Enoxaparin for renal impairment patients), dialysis days?
Endo – DM (no dextrose in IVF, ISS), Steroids – dose stress steroids appropriately
Post Op Management starts with pre-operative considerations
Past Surgical History Prior surgical intervention often makes
further surgical intervention more complex
Prior post operative issues are often relevant again
Post Op Management starts with pre-operative considerations
Social History Home support structure, if any EtOH▪ Delerium Tremens (not unique to VA system)
Post Op Management starts with pre-operative considerations
Family History Most common bleeding diathesis vWF
dysfuction Best way to determine if
Operating Theatre
If you did the case, you may be asked to… Write the brief operative note Talk to the family regarding the outcome of the
surgery Write post operative orders Dictate the case
Skin/Fascial closure, Final dressings, abdominal binder, transport the patient to PACU
Immediate Post Operative Care (1)
Day case surgery Final review Appropriate Discharge Paperwork Discharge Prescriptions Follow up Appointment
For Shands 352-265-0535 7:30am – 5pm, get an appointment
for every pt. Family questions
Immediate Post Operative Care (2)
PACU If called to the PACU attend immediately.
Face to face discussion with MDs or RNs and address their concerns directly
Perform a Post Operative Check Ordering appropriate investigations – ▪ Labs
▪ ABG, CBC, BMP, etc.,
▪ 12-lead EKG▪ Imaging
▪ CXR, CT brain
Report concern to the Operating Team Know what room they are in or where they can be found Come with an Assessment and a PLAN
Post Operative Check (1)
Post Operative Check – to be performed on EVERY patient, ABSOLUTELY NO EXCEPTIONS
Consists of Chart review▪ Surgical procedure (EBL, IVFs, intraoperative
events)▪ Pre-Operative medical/surgical conditions▪ Pre-Admission Medications▪ Current Post-Operative Medications
Post Operative Check (2)
Review of Vital Sign trends Pyrexia (Febrile) HR/BP/O2 Sats▪ Tachycardia▪ Tachypnoea
I/O, hourly urine outputs Analgesic Requirements RN notes – pt received resting soundly
vs. obtunded
Post Operative Check (3)
Finally go see the patient. Eyeball test – comes with experience Talk to the patient Examine the patient
HS 1-2, Lungs, Abdomen, Incision sites▪ Pulse check, Neurological exam
Don’t for get Drains Volume, colour, consistency, smell
Check Line sites, IVs, a-lines, CVLs, Urinary catheters, Chest tube sites.
Post Operative Check (4)
Go back to the computer Final chart review Check Labs (perhaps order them) Check Imaging (perhaps order CXR/KUB) Monitoring (perhaps add a continuous pulse ox
or telemetry)
DOCUMENT your findings with a PLAN
With experience this takes 10mins to perform
Overnight this is you, NIGHTFLOAT
Keep eye on vitals Certain Chiefs will want to be called
with information (i.e. post op checks, CT scan results), make sure you do this.
No major moves overnight, keep watch till morning
A change in condition of a patient, a transfusion, or change level of care mandates a prompt call to the primary team
PitFalls
Well its 4am they’ll be in a hour or two I’d rather the primary team handle it.
I’ll call the Chief when things settle down after intubation and transfer to the ICU.
I’ll call when I figure out exactly what’s going on. A plan doesn’t have to be exact.
I have to work on my animal research grant rather than check on patients overnight.
First 24hrs Post Operative Care, Floor Patients
Early post operative period Mobilization Incentive Spirometers Anaglesia Plan Diet/Nutrition Plan Wound Care Plan Antibiotics Plan Urinary Catheter Plan Drain Plan
First 24hrs by Service (not a complete list)
Surgery Specific Management MIS - Swallow studies BMS - Drain care, Physical Therapy CRS - NG management, Ostomy volume
consistency management PBS - Drains for amylase, nutrition plan (TPN) Vascular - Wound care, dialysis Transplant - Immunosuppressive therapy,
dialysis Trauma - Disposition
First 24hr Post Operative ICU patients
Plans by System Neurological CVS Respiratory FEN/GI Endo ID Haematological
Communication with ICU service
Always - LISTEN CAREFULLY
Write everything down on your list Have tick boxes or equivalents to
help you manage your patient related tasks
Do not move on to the next patient until your questions are answered Plans may change during rounds with
the Attending Surgeon You may be asked to ‘run the list’
and list out your jobs with the patients
Intern Role in Daily Housekeeping
Daily notes to be written on all in-patients no exceptions
Daily notes on consults Laboratory investigations
AM labs ordered? AM CXR ordered? Electrolytes replaced?
Daily contact with consulting Services
Prioritization
Identify with your team your ‘sickest’ patients and ensure their tasks are performed first
Put in all orders on all patients at once
Call consults early (UF Surgery is not like certain services that drop the 5:30pm bombshell)
Half fill in boxes of tasks that have follow up CT scan order and reviewed
POD 2,3,4,5….
Gradual return to preoperative state Improved mobility and mood Reduction in IVF, toleration of PO intake Return to home medication regiment Return of Bowel Activity (flatus then BMs) Reduced Analgesia requirements and
transition to oral pain medications. Wound healing Disposition and home environment
Good signs…
Look better/feels better
No fever, normal VS, normal WCC, stable HCT/plt count, normal electrolytes
Mobilisation of fluid Spontaneously negative I/O fluid balance
Patient crosses legs in bed and starts to complain about hospital food
Bad signs - Failure to progress is a surgical regression
Fever Rising WCC Drop in HCT, Hb Electrolyte imbalance Drain output change Reduced Urine Output
Pt has little to say for him/herself
Surgery Specific Concerns POD 5 Colorectal pt with fever, elevated WCC Salmon coloured fluid escaping from a previously dry
abdominal wound
Ugly signs…
Arrest
Sudden change in mental status
Sudden respiratory compromise
Sudden cardiovascular embarrassment
Audible Bleeding
What can happen…
Bleeding, bleeding, bleeding Surgical bed GI tract Anticoagulation
Sepsis Myocardial Infarction Cerebrovascular Accident Acute Urinary Retention Confusion Atelectasis Pneumothorax Mucus plug
Is there anything else?
Surgery specific complications… MIS – anastomotic leak BMS – haematoma Colorectal – anastomotic leak PBS – Bleeding, Sepsis Transplant – Organ rejection Vascular – bypass occlusion,
pseudoaneurysms Trauma – DTs, withdrawal
How am I supposed to catch it all?
Know your surgical procedures and their expected post operative courses
Attention to detail Check vitals carefully looking for clues▪ Tachycardia (gradually developing)▪ Tachypnoea (gradually developing)
Dare to think
Bedside Assessment (your weapon in the war against unwellness)
Eyeball Distressed, obtunded, tachypnoeic, tachycardic
Vital Signs IV access?
Lines working Finger stick glucose Labs Imaging Monitoring (continuous pulse ox, telemetry) Level of care (floor, IMC, ICU)
Communication
Contact senior resident early with concerns and Plan
Communication continues until resolution of the concern (may occur over days)
Follow through on plan – CT scan etc…
Danger Zones
PACU
During Transfer
CT scanner
Interventional Radiology
Document document document
Date/Time/Venue on all notes
Time of incident to time of initiation of trial averages 18 months, how good is your memory?
I’m still worried…What now? Call your covering chief with information
regarding – Current state of patient Your working diagnosis Your plan of action
You will receive gentle guidance Calling is what you are expected to do As your experience level increases you
will feel more confident and identify routine calls from serious pathology.
University of Florida, Shands
Tertiary Level University Teaching and Academic Center
We take the cases that local hospitals refer to us for ‘Complexity of Care’
Level 1 Trauma care for local population
University of Florida, Shands
Standards are high
Expectations are high
You are all here for a reason
Everyone here is capable of performing the tasks required
Good Luck
QUESTIONS?
Trajan A. Cuéllar MB BCh MRCSI352-413-0313 (pager)352-642-2704 (mobile)