Transcript Post-Operative Management

by: Trajan Cuellar MB BCh MRCSI
June 2012
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General Surgery
MIS
BMS
CRS
PBS
Vascular
Plastics
Transplant
Trauma
Paediatric
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.
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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
…at least if everything goes ok
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Past Medical History
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Past Surgical History
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Social History
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Family History
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Past Medical History
 CNS – prior TIA, CVAs, mobility post op.
 CVS – CHF, prior MIs
▪ Antiplatelet 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, dialysis access?
 Endo – DM (no dextrose in IVF, Insulin Sliding Scale),
Steroids – dose stress steroids appropriately
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Past Surgical History
 Prior surgical intervention often makes further
surgical intervention more complex
 Prior post operative issues are often relevant
again
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Social History
 Home support structure, if any
 EtOH
▪ Delirium Tremens (not unique to VA system)
 Smoking
▪ Pulmonary toliet, O2 requirements
 Drugs
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Family History
 Familial Medical Conditions
▪ DM, CAD, amongst many others
 Commonest bleeding disorder in the USA is von
Willebrands Disease
▪ Best way to determine its presence is a sound history
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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
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Skin/Fascial closure, Final dressings,
abdominal binder, transport the patient to
PACU
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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
Admitting Team/Attending
Diagnosis
Condition
Specify Vital Sign monitoring (Neuro exams?)
New Medications/Home Medications
Diet order, Mobility orders, Elevate HOB
Wound care, IVF, Analgesia, DVT prophylaxis,
Abx
 NG, Foley Catheter, Drain orders
 Post Op Labs and/or Imaging Ordered
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ENSURE THE PATIENT IS ON THE LIST
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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
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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
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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
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Don’t forget Drains
 Volume, colour, consistency, smell
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Check Line sites, IVs, a-lines, CVLs, Urinary
catheters, Chest tube sites.
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Go back to the computer
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Final chart review
Check Labs (perhaps order them)
Check Imaging (perhaps order CXR/KUB)
Monitoring (perhaps add a continuous pulse ox or
telemetry)
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DOCUMENT your findings with a PLAN
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With experience this takes 10mins to perform
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Well its 3pm they’ll be out of the OR in a hour
or two I’ll tell the Chief Resident then.
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.
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PACU
 If called to the PACU attend immediately.
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Face to face discussion with MDs or RNs and address their
concerns directly
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Perform a Post Operative Check
 Ordering appropriate investigations –
▪ Labs
▪ ABG, CBC, BMP, etc.,
▪ 12-lead EKG
▪ Imaging
▪ CXR, CT brain
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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
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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
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Early post operative period
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Mobilization
Incentive Spirometers
Analgesia Plan
Diet/Nutrition Plan
Wound Care Plan
Antibiotics Plan
Urinary Catheter Plan
Drain Plan
Medication review
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Surgery Specific Management
 MIS - Swallow studies
 BMS - Drain care, Physical Therapy
 CRS - NG management, Ostomy volume consistency
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management
PBS - Drains for amylase, nutrition plan (TPN)
Vascular - Wound care, dialysis
Transplant - Immunosuppressive therapy, dialysis
Trauma - Follow up consult service…Disposition
Paediatric - Dose medications by pt. weight
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Plans by System
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Neurological
CVS
Respiratory
FEN/GI
Endo
ID
Haematological
Communication with ICU service
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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
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You may be asked to ‘run the list’ and list out
your jobs with the patients
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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?
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Daily contact with consulting Services
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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
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Gradual return to preoperative state
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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
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Look better/feels better
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No fever, normal VS, normal WCC, stable
HCT/plt count, normal electrolytes
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Mobilisation of fluid
 Spontaneously negative I/O fluid balance
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Patient crosses legs in bed and starts to
complain about hospital food
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Fever
Rising WCC
Drop in HCT, Hb
Electrolyte imbalance
Drain output change
Reduced Urine Output
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Pt has little to say for him/herself
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Surgery Specific Concerns
 POD 5 Colorectal pt with fever, elevated WCC
 Salmon coloured fluid escaping from a previously dry
abdominal wound
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Arrest
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Sudden change in mental status
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Sudden respiratory compromise
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Sudden cardiovascular embarrassment
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Audible Bleeding
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Bleeding, bleeding, bleeding
 Surgical bed
 GI tract
 Anticoagulation
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Sepsis (UTIs, RTI, Intraabdominal Abscesses)
Myocardial Infarction
Cerebrovascular Accident
Acute Urinary Retention
Confusion
Atelectasis
Mucus plug
Pneumothorax
DVT
Surgery specific complications…
 MIS – Anastomotic leak
 BMS – Haematoma
 Colorectal – Anastomotic leak
 PBS – Bleeding, Sepsis
 Transplant – Organ rejection
 Vascular – Bypass occlusion,
pseudoaneurysms
 Trauma – DTs, withdrawal
 Paediatric – Necrotizing enterocolitis
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Know your surgical procedures and their
expected post operative courses
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Attention to detail
 Check vitals carefully looking for clues
▪ Tachycardia (gradually developing)
▪ Tachypnoea (gradually developing)
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Dare to think
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Eyeball
 Distressed, obtunded, tachypnoeic, tachycardic
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Vital Signs
IV access?
 Lines working
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Finger stick glucose
Labs
Imaging
Monitoring (continuous pulse ox, telemetry)
Level of care (floor, IMC, ICU)
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Contact senior resident early with concerns
and Plan
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Communication continues until resolution of
the concern (may occur over days)
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Follow through on plan – CT scan etc…
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PACU
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During Transfer
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CT scanner
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Interventional Radiology
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Date/Time/Venue on all notes
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Time of incident to time of initiation of legal
action averages 18 months, how good is your
memory?
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Call your covering chief with information
regarding –
 Current state of patient
 Your working diagnosis
 Your plan of action
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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.
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Tertiary Level University Teaching and
Academic Center
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We take the cases that local and sometimes
distant hospitals refer to us for ‘Complexity of
Care’
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Level 1 Trauma care for the local population
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Standards are high
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Expectations are high
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You are all here for a reason
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Everyone here is capable of performing the
tasks required
‘I have given my name and day clothes to the
nurses and my history to the anaesthetist and my
body to surgeons.’
Excerpt from ‘Tulips’ by Sylvia Plath 1961
QUESTIONS?
Trajan A. Cuellar MB BCh MRCSI
352-413-0313 (pager)
352-642-2704 (mobile)