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
Immediate Management
ABCDE
Full patient assessment
Chart review
History and examination
Available results
Decide and plan
Stable patient
Daily management
plan
Unstable/unsure
Diagnosis required
Definitive Care
Medical
surgical
Radiological
Immediate Management
ABCDE
Full patient assessment
Chart review
History and examination
Available results
Decide and plan
Stable patient
Daily management
plan
Unstable/unsure
Diagnosis required
Definitive Care
Medical
surgical
Radiological
Immediate management
Airway


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
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


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Look, Listen and feel
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.
Immediate Management
ABCDE
Full patient assessment
Chart review
History and examination
Available results
Decide and plan
Stable patient
Daily management
plan
Unstable/unsure
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
Immediate Management
ABCDE
Full patient assessment
Chart review
History and examination
Available results
Decide and plan
Stable patient
Daily management
plan
Unstable/unsure
Diagnosis required
Definitive Care
Medical
surgical
Radiological
Decide and plan
 Decide wether patient is stable or unstable
 If not sure manage as unstable
Immediate Management
ABCDE
Full patient assessment
Chart review
History and examination
Available results
Decide and plan
Stable patient
Daily management
plan
Unstable/unsure
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
Immediate Management
ABCDE
Full patient assessment
Chart review
History and examination
Available results
Decide and plan
Stable patient
Daily management
plan
Unstable/unsure
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

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
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
 Functional assessment
Can you sit up? Can you cough?
Worst imaginable
Techniques available for Mx of Acute pain
 Analgesic ladder
- Single agent to epidural
Epidural analgesia
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
PCA
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)
Single-agent
analgesia
Multimodal
therapy
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.