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PHASES
IMMEDIATE
PHASE (1)
( POST-ANAESTHETIC )
INTERMEDIATE
PHASE (2)
( HOSPITAL STAY )
CONVALESCENT
TO FULL RECOVERY )
( AFTER DISCHARGE
PREVENTION
RECOVERY ROOM :
FUNCTIONS.
ANAESTHETIST RESPONSIBILITIES TOWARDS CARDIO-PULMONARY
DISCHARGE FROM RECOVERY SHOULD BE AFTER COMPLETE STABILIZATION OF CARDIOVASCULAR, PULMONARY AND NEUROLOGICAL FUNCTIONS WHICH USUALLY TAKES 2-4 HOURS. IF NOT SPECIAL CARE IN ICU.
Post-Operative Orders
A) Monitoring
Vital sign (pulse, BP, R.R, Temp) every 15-30 min. C.V.P (? Swan gins for pulmonary artery wedge pressure) and arterial line for continuous BP measurement. ECG Fluid balance ( intake and output) ? Needs urinary catheter. Other types of monitoring :
Arterial pulses after vascular surgery. Level of consciousness after neurosurgery.
Post-Operative Orders
B) Respiratory Care:
O2 mask. Ventilator. Tracheal suction. Chest physiotherapy.
D) Diet:
NPO Liquids. Soft diet. Normal or special diet.
G) Medication:
Antibiotics. Pain killers. Sedatives. Pre-operative medication. Care of patients on Pre-Op. Steroids. H2 Blockers specially in ICU patients. Anti-Coagulants. Anti Diabetics. Anti Hypertensives.
Management of drains
To drain fluids accumulating after surgery, blood or pus. Open or closed system. Other types (Suction, sump, under water etc.) Should be removed as long as no function. Should come out throw separate incision to minimize risk of wound infection. Inspection of contents and its amount. Soft drains e.g. Penrose should not be left more than 40 days because they form a tract and acts as a plug.
Post-Op. atelectasis is enhanced by shallow breathing, pain, obesity and abdominal distension (restriction of diaphragmatic movements) Post-Op. physiotherapy especially deep inspiration helps to decrease atelectasis. Also O2 mask and periodic hyperinflation using spirometer.
Respiratory failure
Early :
Occurs minutes to 1-2 hs. Post-Op. No definite cause. Occurs suddenly. Occurs 48 hs. Post-Op. Due to pulmonary embolism, abdominal distension or opioid overdose.
Late :
Manifestation :
Tachypnea > 25-30/min. Low tidal volume < 4ml /kg High Pco2 > 45mmHg. Low Po2 < 60mmHg.
Treatment :
Immediate intubation and mechanical ventilation. Treatment of atelectasis, pneumonia or pneumothorax if any.
Prevention:
Physiotherapy (Pre. & Post-OP.) to prevent atelectasis. Treatment of any Pre-existing pulmonary diseases. Hydration of patient to avoid hypovolaemia and later on atelectasis and infection. May be hyperventilation to compensate for insufficiency of lungs. Use of epidural block or local analgesia in patients with COPD to relieve pain and permits effective respiratory muscle functions
The daily maintenance requirements in adult for sensible and insensible losses are 1500-2500mls. depending on age, sex, weight and body surface area. Rough estimation of need is by body weight x 30/day. e.g. 60 KG x 30 = 1800ml/day. Requirements is increased with fever, hyperventilation and increased catabolic states.
Post-Operative Pain
Factors affecting severity :
Duration of surgery. Degree of Operative trauma (intra-thoracic, intraabdominal or superficial surgery). Type of incision. Magnitude of intra-operative retraction. Factors related to the patient : Anxiety. Fear. Physical and cultural characteristics.
Pain transmission:
Splanchnic nerves to spinal cord. Brain stem due to alteration in ventilation, BP and endocrine functions. Cortical response from voluntary movements and emotions.
Complications of Pain:
Physician patient communication (reassurance). Parenteral opioids. Analgesics (NSAIDS). Anxiolytic agents (Hydroxyzine) potentiates action of opioids and has also an anti-emetic effects. Oral analgesics or suppositories e.g. Tylenol. Epidural analgesia (for pelvic surgery). Nerve block (Post-thoracotomy and hernia repair).