POST OPERATIVE CARE & MANAGEMENT

Postoperative care is the management of a patient after surgery. This includes care given during the immediate postoperative period, both in the operating room and post- anesthesia care unit (PACU), as well as during the days following surgery. Purpose The goal of postoperative care is to prevent complications such as infection, to promote healing of the surgical incision, and to return the patient to a state of health. Description Postoperative care involves assessment, diagnosis, planning, intervention, and outcome evaluation. The extent of postoperative care required depends on the individual's pre-surgical health status, type of surgery, and whether the surgery was performed in a day-surgery setting or in the hospital. Patients who have procedures done in a day-surgery center usually require only a few hours of care by health care professionals before they are discharged to go home. If post anesthesia or postoperative complications occur within these hours, the patient must be admitted to the hospital. Patients who are admitted to the hospital may require days or weeks of postoperative care by hospital staff before they are discharged. Recovery Room Post-operative recovery starts in the post-anesthesia care unit (PACU). This unit is dedicated to meet the patient s needs, thereby minimizing post-operative complications. Anesthesia and Waking Up Although it may only have taken moments to surrender to general anesthesia, recovery from anesthesia takes time. Throughout surgery, the anesthesiologist helps you maintain deep sleep. During this time, muscles and fat absorb some of the anesthesia, which helped to maintain levels of anesthesia in the brain and blood. It takes time for anesthesia to be eliminated from the body s tissues. Many factors affect the amount of time a patient may spend in the PACU. These factors include the pre-operative medication, the type of anesthetic, and the length of time an anesthetic was administered during surgery. Hearing is the first sense to return following general anesthesia. This is why the PACU staff speaks in a reassuring tone while letting the patient know what they are doing. Assessing Patient Needs and Vital Signs In the PACU, you may need to wear certain devices to automatically monitor your vital signs. These devices include a blood pressure cuff, oximeter (records pulse), and EKG leads (monitors the heart). The IV remains in place to deliver medication and fluids intravenously. A urinary catheter collects urine to help the nurse monitor kidney function and hydration after many spine surgical procedures. Every few minutes, a nurse assesses your overall condition. This helps to minimize post-operative complications. In addition, the nurse will place warm blankets around your body. It is common for patients to feel cold following surgery.

Pain Management The effects of anesthesia linger following surgery, providing extended relief from pain. Other forms of pain management are used to augment the diminished effects of anesthesia. Patient-controlled analgesia (PCA) is used post-operatively for pain control. This device allows you to self-dose pain relieving medication at the push of a button. PCA is a computerized pump programmed to dispense small doses of pain medication through an intravenous (IV) line. Your physician will set the parameters so you will only get the appropriate dose. Pain relief is sustained to provide more consistent and better pain relief. Later, oral pain medications will replace PCA. Notify your nurse or doctor immediately if pain is not sufficiently relieved. Proper Breathing Lying flat for long periods of time can cause fluid to accumulate in the lungs. A nurse can helps you sit up to breath deeply and cough. This loosens secretions for elimination and helps to prevent pneumonia. Deep breathing increases circulation and promotes elimination of anesthesia. Some patients are instructed to breath into a spirometer. A spirometer is a device used to measure how deeply a patient is able to breath (eg, lung capacity) and acts as an incentive so you will see just how deeply you are breathing. Regardless of what type of surgery you had, the most important advice is to always follow your doctor's specific instructions. If you do that, you're well on your way to achieving a successful recovery from spine surgery. During this time nutritional needs are met through IV fluids. Patients then progress toward a regular wellbalanced diet. Circulation and Ambulation Changing position in bed, walking and prescribed exercise promotes circulation. Good blood flow discourages the formation of blood clots and enhances healing. You may have compression devices placed on your legs to prevent blood clot formation. The most important thing to prevent blood clots is early ambulation. Most patients sit up in bed and walk with assistance the day following surgery. If an assisted device is needed (e.g. walker, cane) a physical therapist will teach the patient how to safely walk, climb stairs and maintain balance. Each day the patient is encouraged to increase physical activity and to be as independent as possible. This includes person hygiene, getting in and out of bed without assistance and walking. Surgical Incisions Patients should expect pain in the area of the incision. Pain will subside as healing progresses. Unusual incision pain, swelling, redness, discharge, numbness or flu-like symptoms (e.g. fever/chills) should be reported immediately.

As a rule, keep incisions dry. Avoid tub baths, swimming and the Jacuzzi until the physician grants permission. Surgical dressings that cover the incision may be removed prior to discharge from the hospital. Dissolving stitches, sutures or staples are used to close incisions. Be sure to make an appointment to have sutures or staples removed according to the physician s written instructions. Some incisions are held closed with Steri-Strips. These are small pieces of paper tape made to peel and fall off as the incision heals. It may take one to two weeks for all of the Steri-Strips to fall off. Follow your surgeon or nurses instructions for when any remaining Steri-Strips should be removed. Physical Therapy and Rehab Physical therapy (PT) may begin as early as the day following surgery! PT is an important part of recovery because it helps the patient build strength, flexibility and endurance. Many patients are given a home exercise program to continue their progress for life. Occupational therapy (OT) is helpful in identifying special needs following your surgery such as assistive devices to help put shoes on or pick up something that has fallen to the floor. Some OT programs help the patient to problem-solve mechanical deficiency (e.g. dressing). Other aspects of OT would be identifying barriers to returning to the work environment. The OT would help simulate the work environment to help the patient resume work and their life. Hospital Discharge Some patients will require home care or assistance. These services may be provided by a visiting nurse, physical therapist or home health aid. Prior to discharge patient needs are assessed and arrangements are made for needed services. Some patients may be discharged to a rehabilitation facility. Prior to discharge, patients are given written instructions and necessary prescriptions or medications. The instructions provide reminders for various aspects of home care. Patients returning home should pre-arrange for someone responsible to drive them home and stay with them the first day or two. To make the ride home more comfortable, have the driver bring pillows and a blanket. Ride in an upright position with seatbelt fastened. You may need to stop for a break to stand up if your ride is longer than 1 hour.

POST OPERATIVE COMPLICATIONS & MANAGEMENT

Post operative complications can range from minor, self limiting problems to major life threatening ones depending on the nature of the surgery and the organ operated upon. Complication can be due to anesthesia or surgery or a reaction to the stress of surgery itself. Some complications are general and apply to all procedures and some are specific that apply to only that procedure. Common complications include fever, chest infection, pneumonia, wound infection, bleeding or deep vein thrombosis. Most of the complications manifests after the first few days of surgery usually 1 to 3 days Post operative complications can range from minor, self limiting problems to major life threatening ones depending on the nature of the surgery and the organ operated upon. Complication can be due to anesthesia or surgery or a reaction to the stress of surgery itself. Some complications are general and apply to all procedures and some are specific that apply to only that procedure. Common complications include fever, chest infection, pneumonia, wound infection, bleeding or deep vein thrombosis. Most of the complications manifests after the first few days of surgery usually 1 to 3 days. Immediate or delayed complication: Some of the complications may be evident soon after the operation while some may take a couple of days to show up, they may be called immediate or delayed according to the time of manifestation. There are also complications that may manifest only after the patient has been discharged from the hospital. Associate Conditions that may Increase morbidity of Surgery: By and large it can be said that a healthy young individual undergoing a minor surgery for conditions such as piles or squint surgery will have a smooth recovery, devoid of any complications in the post-operative period. Whereas a person with other medical problems like high blood pressure, diabetes, asthma or heart or kidney disease runs a greater risk of experiencing post-op complications due to the illness he suffers from. The possibility of having complications is increased if the above illnesses are untreated or not under control. Thus it is very important to inform the surgeon as well as the anesthetist of the existence of any illness or allergy and so on. Previous instances of specific complications or problems during any surgery in the past will also guide the doctors in preventing and being prepared to tackle any complications. Avoiding Complication: Recent statistics indicate that worldwide almost 234 million major surgical procedures are performed each year. This translates into 1 for every 25 people in the world. Majority of the patients who undergo the procedure get well and go home however major complications ranges from 3% to 16%, and rates of permanent disability or death range from 0.4% to 0.8%. Co-operation from patients can help in preventing some of the complications. If planning prolonged surgery under general anaesthesia of the lungs or the upper abdomen, it is always wise to ask the patient to learn and practise breathing exercises for a few days prior to surgery. This not only helps to open up areas that maybe functioning sub-optimally but most importantly helps the patient resume normal breathing during the postoperative period and also helps overcome some of the sedative effects of anesthesia on the lungs. In most studies patients who undertook breathing exercises prior to surgery had less chances of lung infection and post-operative fever and had better surgical outcomes. Similarly people who smoke should give up smoking at least a month prior to surgery.

Auto-transfusion: Patients who may require blood transfusion for an elective surgery should think of donating one unit of their own blood to prevent blood transfusion relate problems. This kind of donation has to be done a week or ten days prior to surgery. Sometimes despite all the precautions a patient may develop a complication like deep vein thrombosis after surgery. However this is rare, if all necessary precautions are taken. The best way to avoid complications is to anticipate them. Types of post-operative complications: Post- operative complications generally fall in one or more of the three broad categories 1. Anesthesia related complications 2. Complications common to any procedure 3. Complications common to specific procedure Depending on the severity of the complications they can again be broadly categorized as Major or Minor. Minor Complications -Dryness of the mouth and throat, sore throat, drowsiness, shivering, vomiting, dizziness, and giddiness are common side effects of the medicines used during anesthesia. They are selflimiting and do not persist beyond an hour or two. Fatigue, feeling weak, headache are also common and could be attributed to the fasting that is often required before and after a surgery. Under normal circumstances these symptoms vanish in a day or two. Some people also experience bloated feeling, constipation and urine retention following an operation and these resolve spontaneously. Fever can occur as a reaction to the intravenous fluid transfused during an operation. Major Complications - These complications can be serious and sometimes even life-threatening. They prolong the recovery period and stay in the hospital. The complications may happen during surgery or in the postoperative period. Some of these include 1.Pulmonary thromboembolism - Clots formed in the deep veins of the legs or thigh can get detached from the leg veins and travel to the lungs and get stuck in the major artery supplying the lungs causing a fatal collapse. These clots are formed in the leg veins when a patient is in prolonged immobilization following a surgery. 2. Aspiration of stomach contents into the lung - This can happen during the initiation of anesthesia if a patient has eaten a meal before the surgery. The food and acidic contents of the stomach can be inhaled into the lungs setting up a severe near-fatal pneumonia of the lung. 3. Anaphylaxis - is a severe allergic reaction to either the anesthetic agents or antibiotics or certain substances used during the operation (e.g-cement used during a joint replacement surgery)

4. Cardiac arrest - is possible as an end result of any of the above events. Prompt cardio-pulmonary resuscitation can help revive the person. Other possible complications may occur and be related to pre-existing medical illness A person who suffers from ischemic heart disease, diabetes, high blood pressure, asthma, kidney disease, liver disease, epilepsy, psychosis can expect an exacerbation of these problems in the post-operative period. Therefore such a patient may develop a heart attack, stroke, high blood sugar, severe asthma, liver or kidney failure following the surgery. The likelihood of these eventualities is more if any of the above mentioned conditions are not under control and the patient is not under regular medication. A thorough pre-operative evaluation of the risk factors is essential when dealing with patients who have these co-morbid condition. Diabetes and hypertension is not uncommon in the middle and older age group patients. Control of sugar and cardiac evaluation prior to surgery is mandatory in such situations. Steps to Avoid Complication: Pre-operative Steps to Avoid Complications: Before a patient is subjected to any surgery it is essential that a thorough check up is done and a risk evaluation is undertaken. If there are certain unavoidable risks and the operation is mandatory these risks should be explained to the relatives. A proper informed consent is essential before proceeding for surgery. Certain surgeries like heart surgery have the inherent problem of blood loss hence enough blood should be cross-matched and kept ready. Similarly in some situations the chances of infections are high and this can lead to sepsis in this situation prophylactic antibiotic should be used. General guidelines to avoid complications: 1. History- certain problems like allergy can be avoided if prior knowledge of these complications is informed to the anesthetists and surgeons. 2. Proper medication-Regular treatment of illnesses like diabetes, high blood pressure should be undertaken 3. Follow instructions regarding fasting, discontinuing some medications as advised faithfully to prevent complications 4. Prevent contamination of wound (operated site) by maintaining general hygiene and asepsis while changing dressings Remain calm- A relaxed mind will go a long way in making the ordeal of surgery a pleasant experience Post-operative complications Surgical Checklist: Over half and sometimes almost 100% of the surgical complications can be prevented by following simple rules. The release of WHO Surgical Safety Checklist has for the first time provided universally applicable surgical safety standards and aims to improve surgical safety, especially in underserved areas.

To provide high standrard of surgical care audit of 1000 patients from 8 pilot sites were undertaken. It was concluded that by using the checklist the chances of surgical complications can be halved. The checklist covers 3 phases of a surgical procedure: Before anesthesia is induced or "Sign In" Before skin incision or "Time Out" Before the patient leaves the operating room or Sign Out" Before anesthesia - use mnemonic "Sign In" Check to see if the patient has (1) Any known allergy e.g. antibiotics - If so, document it (2) If anticipating an anatomically difficult airway to intubate or aspiration risk get additional equipment and assistance should be available. (3) If there is a risk of losing more than more than 500-mL of blood in adults or 7 mL/kg in children that there is adequate intravenous access and fluids or reserve blood . Before induction of anesthesia, key components of the checklist or "Sign In," are as follows: 1. Patient s identity - Check that the patient has confirmed their identity, the surgical site, and the procedure to be done and that the patient has given informed consent. 2. Surgical site should be marked, if applicable. 3. Do Anesthesia Safety Checks should be completed. 4. Place a Pulse oximeter on the patient and ensure it is functioning. Before Incision or the checklist use the mnemonic "Time Out" Introduction, familiarity with roles during surgery and anticipating critical events are the key components: 1. Ensure all team members have introduced themselves both by name and by their role on the surgical team. 2. The surgeon, anesthesia professional, and nurse should verbally confirm the patient's identity, surgical site, and procedure to be performed. 3. Anticipated critical events to be reviewed by the surgeon are any critical or unexpected steps, estimated operative duration, and anticipated blood loss. 4. Anticipated critical events to be reviewed by the anesthesia team are whether there are any patient-specific concerns. ensure

5. Anticipated critical events to be reviewed by the nursing team are confirmation of sterility of the tools, supplies, and field (including indicator results); a. documentation and discussion of any equipment issues or concerns; b. whether antibiotic prophylaxis has been given within the last 60 minutes - if applicable c. and whether essential imaging is displayed - if applicable. Before Patient Leaves Operating Room uses the mnemonic "Sign Out" Check for the following components -1. The nurse verbally confirms with the team the name of the procedure to be recorded 2. The nurse verifies instrument, sponge, and needle counts - if applicable 3. Labeling for the surgical specimen, including patient name 4. Whether there are any equipment problems to be addressed 5. The surgeon, anesthesia professional and nurse should review the key concerns regarding recovery and management of the specific patient

References: http://www.medindia.net/surgicalprocedures/post-operative-complications_print.htm http://www.surgeryencyclopedia.com/Pa-St/Postoperative-Care.html#b http://www.spineuniverse.com/treatments/surgery/what-post-operative-care