Post op care

1. Post op care Precautions, wound mx, a/b, d/c

2. General Precaution • Fluids • TED • Mobilise early • Cough • Dressing check and change • IDC • Bowel • Fever – use time approach • Rehab

3. General Precaution • Fever (time approach is best.. with common sense) • hours: Malig hyperthermia, Bacteraemia >39 • Day 1: Common! Atelectasis – CXR, physio • 24- 48 hours: “?normal” -38-39 • Day 3: You missed atelectasis – now pneumonia • Day 3: No you didn’t miss atelectasis – search for UTI • Day 5: PE/DVT – if in doubt ultrasound! • SSI, deep/abscess – drain it and start a/b.

4. General Precaution • Patient not very oriented? • Hypoxia – infection cardio shock… • Don’t forget DT, try not giving alcohol • Electrolytes

5. General Precautions • Chest pain, as usual • MI • PE • pneumonia • Pneumothorax • ….dissection

6. General Precautions • Pressure sores • Note iceberg phenomenon, skin can withstand more necrosis • Regular turning, nutrition, relieve pressure (air fluidised beds), topical antimicrobial, VAC • Surg mx flap/graft

7. Specific Precautions • No hip flexion >90 degrees, adduction pass midline post THR • Remove deep sutures if dyspnoea post thyroidectomy. • Pt with hernias no sit-ups for 6 weeks after a herniorrhaphy • Weightbearing

8. Specific Precautions • Plastic: • flaps must survive! Failing factors 1) poor wound bed. 2) Sheer. 3) haematoma/seroma. 4) Infection • nicotine patches • Nutrition • VAC • Drain tubes – infection vs haematoma/seroma (which causes infection), ortho – 24 hour, breast/head and neck 30ml per day (soft evidence) • Photos are useful

9. Wound mx - general • Nutrition ?vit A for steroid dependent pt. Vit C (proline and lysine hydroxylation), Mg, Zn • Infection/dehiscence – always at back of mind • Rare - Evisceration – put pt back in bed and cover bowel with sterile dressing soaked with warm saline until OT • Surgical incisions usually epithelialise in 24 – 48 hours (not in elderly), can wash to decrease bact load. • Good scar – avoid sun and massage • Dressing • Usually use mesh with petroleum jelly – allows passage of discharge and reduce trauma when removing dressing. • When removing sutures – sutures should be pulled towards the new wound not away.

11. Wound mx - Vac • VAC (vacuum assisted closure) is indicated for • chronic open wounds, diabetic ulcers, stasis ulcers, acute and traumatic wounds, and dehisced wounds. • Especially stabilizing acute skin grafts fasciotomy. • The sponge must be changed every 2 to 3 days compared with traditional dressing, which must be changed daily at a minimum

12. Wound mx - Vac • Contraindications • Inadequate hemostasis – pt will run out of blood at some stage • The wounds must be surgically débridedprior to application of the sponge. • mechanism • tissue and cellular deformation creates a steady-state stress on the cell walls, which in turn stimulates growth factor pathways. The skin surrounding the treated wound may develop sensitivity and irritation from the sponge or overlying occlusive Precautions • Infections (esp when not adequately debrided) • pressure necrosis of the skin (placed tubing compressed too tightly against the skin) • Hematoma and hemorrhage may occur in wounds with inadequate hemostasis. • Toxic shock when the negative pressure was not maintained • Pain. Lowering the suction pressure will often alleviate the pain

13. antibiotics • 1st gen most commonly used, egcefazolin • Organise MCS early if infection suspected • Similar to other specialties, if in doubt IV  PO as per registrar

14. Discharge summaries • Delay is the most common problem • Concise but must inc • Reason for admission • haematemesis • Significant findings,  Dx admission • Bleeding esophagealvarices • Procedure • EGD with banding • Complications during stay, teams involved • Alcohol withdrawal • Pt discharge condition/health status • Plan: meds, orders, follow up • Meds – new, continued, discontinued • Appointments, tests, additional care,

15. Questions