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)