POST OP ASSESSMENT INCLUDING POST OP ANALGESIA Ernest Lekgabe HMO Royal Melbourne Hospital

Objectives Immediately post op patients must be seen as unstable and must always be assessed systematically Recognise the critically ill who must undergo simultaneous examination and resuscitation when first seen

Full patient assessment Immediate Management ABCDE Full patient assessment Chart review History and examination Available results Decide and plan Stable patient Unstable/unsure Daily management plan Diagnosis required Definitive Care Medical surgical Radiological

Full patient assessment Immediate Management ABCDE Full patient assessment Chart review History and examination Available results Decide and plan Stable patient Unstable/unsure Daily management plan Diagnosis required Definitive Care Medical surgical Radiological

Immediate management Airway Breathing Circulation Look, Listen and feel Look for presence of central cyanosis, use of accessory muscles of respiration, tracheal tug, ACS, foreign bodies Listen for abnormal sounds e.g. grunting, snoring, gurgling, stridor Feel for airflow on inspiration and expiration Breathing Look for central cyanosis, signs of respiratory distress Feel for position of trachea, equality of chest expansion, percussion Auscultate for abnormal breadth sounds, heart sounds and rhythm Circulation Circulatory dysfunction in a surgical pt is due to hypovoleamia until proved otherwise, therefore haemorrhage must excluded. Look for reduced perfusion (pallor, coolness, collapsed or underfilled veins – BP may be normal in a shocked pt) Feel for pulses – assess for rate, quality, regularity and equality Dysfunction of the CNS Assess pupils and use the AVPU system or GCS Remember ACS may be due to others causes other than primary brain injury e.g. hypoxia and/or hypercapnia, decreased CPP due to shock. Exclude Hyploglycaemia. Exposure Allows for better assessment and access to patient for therapeutic manoeuvres but beware of pt getting cold and maintain dignity of the patient

Grades of hypovolaemic shock Grade 1 (15% BV, 750ml) Mild tachycardia Grade 2 (15-30% BV, 750-1500ml) Mod tachycardia, pulse pressure, cap return Grade 3 (30-40% BV, 1500-2000ml) BP, HR, U/O Grade 4 (40-50% BV, 2000-2500ml) Above plus profound hypotension

Question You visit Mr AB on the ward after his operation. You find that he is slightly drowsy, tachycardic and is cool peripherally. What is your immediate assessment and management.

Full patient assessment Immediate Management ABCDE Full patient assessment Chart review History and examination Available results Decide and plan Stable patient Unstable/unsure Daily management plan Diagnosis required Definitive Care Medical surgical Radiological

Full patient assessment Inspection of charts Respiratory (RR, FiO2, SpO2), Circulation (HR, BP, UO, CVP, fluid balance), Surgical (temperature, drainage) Check the drug chart to see what drugs have been given and which of the pt’s usual drugs might have been forgotten. History and examination Comorbidities Full physical examination Review of Results Biochemistry (U&Es, ABGs, BSLs) Haematology (FBE, clotting) Microbiology Radiology

Full patient assessment Immediate Management ABCDE Full patient assessment Chart review History and examination Available results Decide and plan Stable patient Unstable/unsure Daily management plan Diagnosis required Definitive Care Medical surgical Radiological

Decide and plan Decide wether patient is stable or unstable If not sure manage as unstable

Full patient assessment Immediate Management ABCDE Full patient assessment Chart review History and examination Available results Decide and plan Stable patient Unstable/unsure Daily management plan Diagnosis required Definitive Care Medical surgical Radiological

Stable patient – Daily plan Stable patients have normal signs and are progressing as expected. Most patients seen on the ward round are stable Daily plan Fluid balance Drugs and Analgesia – antibiotics, DVT prophylaxis Nutrition – route, how much Removal of drains/tubes Investigations (bloods, X-rays, referrals) Physiotherapy

Full patient assessment Immediate Management ABCDE Full patient assessment Chart review History and examination Available results Decide and plan Stable patient Unstable/unsure Daily management plan Diagnosis required Definitive Care Medical surgical Radiological

Unstable patient - Diagnosis required Resuscitation Investigations (bloods, CXR, ECG, cultures) Consider if patient needs urgent surgery Consider urgent specialist referrals, MET call Consider transferring to HDU or ICU

Post Op Analgesia Analgesia relieves suffering Inadequately controlled pain increases sympathetic outflow, leading to an increase HR, vasoconstriction and increased O2 demand, particularly in the myocardium and may contribute to MI. Pain (from e.g. abdominal and thoracic procedures) may impair Respiratory function leading to atelectasis/Pneumonia Good analgesia allows for rehabilitation

Assessment of pain Airway Breathing Circulation Disability Loss of airway from over sedation esp. in the elderly, patients with OSA, post cranial surgery. Breathing Assess depth of breathing, RR and ability to cough Inadequate analgesia can lead to poor respiratory function and a poor cough effort. This is a more common scenario than respiratory depression from opioid overdosage Circulation Inadequate analgesia can cause persistent tachycardia or hypertension, this in turn contribute to MI esp. in a pt who is already hypoxaemic Epidural analgesia may lead to hypotension (sympathetic blockade - vasodilatation) Disability Opioid toxicity Assessment of pain

Pain scoring systems Verbal rating scale Is your pain 0 – absent, 1- mild, 2 – discomforting, 3- distressing, 4 – excruciating Numerical rating scale On a scale from 1 – 10 how do you rate your pain Visual analogue scale No pain Worst imaginable Functional assessment Can you sit up? Can you cough?

Techniques available for Mx of Acute pain Analgesic ladder - Single agent to epidural Paracetamol Should be given regularly, oral, rectal or IV NSAIDs Used as adjuncts, Increase efficacy and reduce opioid use Can affect haemostasis and renal function, gastric ulceration Opioids Gold standard in severe pain Codeine (weak analgesis, contipating), Tramadol (opoid-like, less respiratory depression effect, less tendency to produce dependence but marked emetic effect) Oxycodone, oral, S/C or IV Morphine (bolus or infusion) Side effects – Respiratory depression (reduce sensitivity of the respiratory centres in the brain stem), Sedation (may cause loss of airway), Nausea and vomiting (direct stimulation of CTZ in the medulla and by reduced gastric emptying) Epidural analgesia PCA Multimodal therapy Single-agent analgesia

Techniques available for Mx of Acute pain PCA self administered boluses of morphine with “patient lockout time”. Epidural Most effective way of producing profound analgesia, blocks afferent pain pathways. Lumbar or thoracic approach Usually a combination of drugs e.g. a local anaesthetic like bupivacaine and an opioid like fentanyl. Aim is to get good pain relief with minimal sympathetic effects and no motor block.