Post Op Assessment Surgery

8/18/2019 Post Op Assessment Surgery

1/20

POST OP ASSESSMENTINCLUDING POST OP ANALGESIA

Ernest Lekgabe

HMO

Royal Melbourne Hosptal


2/20

Ob!e"t#es

I$$e%ately post op patents $ust be seen asunstable an% $ust al&ays be assesse%

syste$at"allyRe"ognse t'e "rt"ally ll &'o $ust un%ergo

s$ultaneous e(a$naton an% resus"taton &'en)rst seen


3/20

Full patient assessmentC'art re#e&

Hstory an% e(a$natonA#alable results

ImmediateManagement

A*CDE

Decide and plan

Dailymanagement plan Diagnosis required

Defnitive CareMe%"alsurg"al

Ra%olog"al

Unstable+unsureStable patent


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ImmediateManagement

A*CDE

Decide and plan

Dailymanagement plan Diagnosis required


Ra%olog"al



5/20

I$$e%ate $anage$ent

Airway Look, Lsten an% -eel

Look -or presen"e o- "entral "yanoss, use o- a""essory $us"les o- respraton, tra"'eal tug, ACS, -oregn

bo%es

Lsten -or abnor$al soun%s e.g. gruntng, snorng, gurglng, str%or /eel -or ar0o& on nspraton an% e(praton

Breathing Look, Lsten an% -eel

Look -or "entral "yanoss, sgns o- respratory %stress

/eel -or poston o- tra"'ea, e1ualty o- "'est e(panson, per"usson

Aus"ultate -or abnor$al brea%t' soun%s, 'eart soun%s an% r'yt'$

Circulation Cr"ulatory %ys-un"ton n a surg"al pt s %ue to 'ypo#olea$a untl pro#e% ot'er&se, t'ere-ore

'ae$orr'age $ust e("lu%e%.

Look -or re%u"e% per-uson 2pallor, "oolness, "ollapse% or un%er)lle% #ens 3 *P $ay be nor$al n as'o"ke% pt4

/eel -or pulses 3 assess -or rate, 1ualty, regularty an% e1ualty

Dysunction o the CN Assess pupls an% use t'e A5PU syste$ or GCS

Re$e$ber ACS $ay be %ue to ot'ers "auses ot'er t'an pr$ary bran n!ury e.g. 'ypo(a an%+or

'yper"apna, %e"rease% CPP %ue to s'o"k. E("lu%e Hyplogly"ae$a.

!"posure

Allo&s -or better assess$ent an% a""ess to patent -or t'erapeut" $anoeu#res but be&are o- pt gettng"ol% an% $antan %gnty o- t'e patent


6/20

s'o"k

Grade 1 #$%& B'( )%*ml+Mild tachycardia

Grade 2 #$%,-*& B'( )%*,$%**ml+

Mod tachycardia(

pulse pressure(

capreturn

Grade 3 #-*,.*& B'( $%**,/***ml+B0(12( 345

Grade 4 #.*,%*& B'( /***,/%**ml+A6ove plus proound hypotension


7/20

6ueston 7ou #st Mr A* on t'e &ar% a-ter 's operaton. 7ou )n% t'at 'e s

slg'tly %ro&sy, ta"'y"ar%" an% s "ool perp'erally.

8'at s your $$e%ate assess$ent an% $anage$ent.


8/20



ImmediateManagement

A*CDE

Decide and plan

Daily

management plan Diagnosis required


Ra%olog"al



9/20

Full patient assessment

Inspe"ton o- "'arts Respratory 2RR, /O9, SpO94, Cr"ulaton 2HR, *P, UO, C5P, 0u% balan"e4, Surg"al

2te$perature, %ranage4

C'e"k t'e %rug "'art to see &'at %rugs 'a#e been g#en an% &'"' o- t'e pt:s usual %rugs$g't 'a#e been -orgotten.

Hstory an% e(a$naton Co$orb%tes

/ull p'ys"al e(a$naton

Re#e& o- Results *o"'e$stry 2U;Es, A*Gs, *SLs4 Hae$atology 2/*E, "lottng4

M"robology

Ra%ology


10/20



ImmediateManagement

A*CDE

Decide and plan

Daily



Ra%olog"al



11/20

Decide and plan

De"%e &et'er patent s stable or unstable

I- not sure $anage as unstable


12/20



ImmediateManagement

A*CDE

Decide and plan

Daily



Ra%olog"al



13/20


14/20



ImmediateManagement

A*CDE

Decide and plan

Daily



Ra%olog"al



15/20

3nsta6le patient , Diagnosis required

Resus"taton

In#estgatons 2bloo%s, C


16/20

Post Op Analgesa

Analgesa rele#es su>erng

Ina%e1uately "ontrolle% pan n"reasessy$pat'et" out0o&, lea%ng to an n"reaseHR, #aso"onstr"ton an% n"rease% O9%e$an%, part"ularly n t'e $yo"ar%u$ an%$ay "ontrbute to MI.

Pan 2-ro$ e.g. ab%o$nal an% t'ora""pro"e%ures4 $ay $par Respratory -un"tonlea%ng to atele"tass+Pneu$ona

Goo% analgesa allo&s -or re'abltaton


17/20

Assess$ent o- panAr&ay Loss o- ar&ay -ro$ o#er se%aton esp. n t'e el%erly, patents &t' OSA, post "ranal surgery.

*reat'ng Assess %ept' o- breat'ng, RR an% ablty to "oug'

Ina%e1uate analgesa "an lea% to poor respratory -un"ton an% a poor "oug' e>ort.

T's s a $ore "o$$on s"enaro t'an respratory %epresson -ro$ opo% o#er%osage

Cr"ulaton

Ina%e1uate analgesa "an "ause persstent ta"'y"ar%a or 'ypertenson, t's n turn"ontrbute to MI esp. n a pt &'o s alrea%y 'ypo(ae$"

Ep%ural analgesa $ay lea% to 'ypotenson 2sy$pat'et" blo"ka%e = #aso%lataton4

Dsablty Opo% to("ty


18/20

0ain scoring systems

5erbal ratng s"ale

Is your pan ? 3 absent, @= $l%, 9 3 %s"o$-ortng, = %stressng, B 3e("ru"atng

Nu$er"al ratng s"ale

On a s"ale -ro$ @ 3 @? 'o& %o you rate your pan

5sual analogue s"ale

No pan 8orst $agnable

/un"tonal assess$ent

Can you st up Can you "oug'


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8echniques availa6le or M" o Acute pain

Analges" la%%er = Sngle agent to ep%ural

Para"eta$ol S'oul% be g#en regularly, oral, re"tal or I5

NSAIDs

Use% as a%!un"ts, In"rease e"a"y an% re%u"e opo% use

Can a>e"t 'ae$ostass an% renal -un"ton, gastr" ul"eraton

Opo%s Gol% stan%ar% n se#ere pan

Co%ene 2&eak analgess, "ontpatng4,

Tra$a%ol 2opo%=lke, less respratory %epresson e>e"t, less ten%en"y

to pro%u"e %epen%en"e but $arke% e$et" e>e"t4

O(y"o%one, oral, S+C or I5 Morp'ne 2bolus or n-uson4

S%e e>e"ts 3 Respratory %epresson 2re%u"e senst#ty o- t'erespratory "entres n t'e bran ste$4, Se%aton 2$ay "ause loss o- ar&ay4,

Nausea an% #o$tng 2%re"t st$ulaton o- CT n t'e $e%ulla an% by

re%u"e% gastr" e$ptyng4

Ep%uralanalgesa

PCA

Mult$o%alt'erapy

Sngle=agentanalgesa


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8echniques availa6le or M" o Acute pain

PCA

sel- a%$nstere% boluses o- $orp'ne &t' Fpatent lo"kout t$e.

Ep%ural

Most e>e"t#e &ay o- pro%u"ng pro-oun% analgesa, blo"ks a>erentpan pat'&ays.

Lu$bar or t'ora"" approa"'

Usually a "o$bnaton o- %rugs e.g. a lo"al anaest'et" lkebup#a"ane an% an opo% lke -entanyl.

A$ s to get goo% pan rele- &t' $n$al sy$pat'et" e>e"ts an%no $otor blo"k.

Post Op Assessment Surgery

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