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

Unstable/unsure

Daily
management plan

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

Unstable/unsure

Daily
management plan

Diagnosis required

Definitive Care
Medical
surgical
Radiological

Immediate management
Airway
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, 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

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 pts 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

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

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

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

Airway

Assessment of pain

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

Paracetamol
Should be given regularly, oral, rectal or IV

Epidural
analgesia

NSAIDs
Used as adjuncts, Increase efficacy and reduce opioid use
PCA
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)
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.