1. Post anesthetic investigation and
medications
By:- preeti chaudhary
Final year (8749063)

2.  Hand washing with soap and water or with alcoholic
cleansing agents should be performed before and
after patient contact.
 Early identification and appropriate treatment of
sepsis improves outcome.
 Urine and blood cultures should be obtained
whenever there is reason to suspect systemic sepsis.
 If the cause of sepsis is unknown, treat with broad
spectrum antibiotics, guided by local protocols.
 Results from microbiological specimens should be
reviewed regularly and antibiotics changed as
necessary.
 A course of antimicrobial treatment should generally
be limited to 5-7 days. Fungi and atypical organisms
can contribute to sepsis syndrome, so take cultures
and prescribe appropriately VITAL SIGN within 2

3.  Optimal postoperative care requires:
 clinical assessment and monitoring
 respiratory management
 cardiovascular management
 fluid, electrolyte and renal management
 control of sepsis
 nutrition
 Only accept responsibility appropriate to
your training and experience. If in doubt ASK
FOR HELP

4.  Anaesthetic and surgical staff should record
the following items in the patient’s case
notes:
 § any anaesthetic, surgical or intraoperative
complications
 § any specific postoperative instruction
concerning possible problems
 § any specific treatment or prophylaxis
required (eg fluids, nutrition, antibiotics,
analgesia, anti-emetics,
thromboprophylaxis).

5.  A postoperative assessment should be carried out
when the patient returns from theatre.
 Patients at risk of deterioration require frequent
assessment.
 Patients with the following risk factors for
deterioration should be reassessed within two hours
of the first
 assessment postoperative :
 ASA grade ≥ 3
 emergency or high risk surgery
 operation out of hours
 The doctor completing the initial postoperative
assessment should consider the monitoring regimen
and appropriate level of care required for the next 24
hours in collaboration with the nursing team.

7. INTRA OPERATIVE HISTORY & POST
OPERATIVE INSTRUCTION RESPIRATORY STATUS ASSESMENT
 Past medical history *Oxygen saturation
 Medications  Effort of breathing/use
 Allergies of accessory muscles
 Intraoperative  Respiratory rate
complications  Trachea central or not?
 Postoperative  Symmetry of
instructions respiration/expansion
 Recommended  Breath sounds
treatment &  Percussion
prophylaxis���� note��������
�� ���

8. VOLUME STATUS ASSESMENT
 Hands - warm or cool, ����������
MENTAL STATUS ASSESMENT
pink or pale?
 Capillary return <2s or  Patient conscious and
not? normally responsive ?
 Pulse rate, volume and (AVPU; Alert, Verbal,
rhythm
Painful, Unresponsive)
 Blood pressure
 Conjunctival pallor
 If abnormal determine:
 Jugular venous pressure if confusion is present
 Urine colour and rate of (AMT) GCS, oxygen
production saturation and blood
 Drainage from drains,
wounds & NG tubes
glucose
������� ������

9.  Any significant symptoms eg chest pain,
 breathlessness
 Pain and adequacy of pain control
 Following specialist surgery it may be necessary to
assess additional factors.

11.  Patients requiring the frequent monitoring of
multiple variables should be considered for care
at level 2 or above.
 Trends in the physiological data, rather than
absolute numbers, should be reported to assist in
the detection of deteriorating patients before a
severe physiological compromise occurs.
 Postoperative monitoring should be continued on
a daily basis.
 The monitoring regimen should be reviewed
daily so as best to provide data for clinical
decision making.
 Any change in a monitoring regimen should
prompt reassessment of the level of care.

12.  Patients in whom there is a suspicion of postoperative pulmonary
complications should have an arterial blood gas analysis, a
sputum culture and ECG.
 Chest X-ray should be performed on suspicion of major
collapse, effusions, pneumothorax or haemothorax.
 Other investigations should be used only if there are specific
indications.
 Oxygen should be given to patients with hypoxaemia using a
device that is best tolerated to achieve the necessary SpO2.
In normally hydrated patients humidification is unnecessary.
 Failure to maintain an SpO2 >90% or PaO2 >8.0 kPa is an
indication to consider assisted ventilation.
 Patients developing respiratory failure should be referred to a
critical care specialist to be assessed for possible assisted
ventilation. The referral should be timely as hypoxia or
hypercapnia may lead rapidly to cardiorespiratory arrest.

13. *Any two of the following on two or more days:
 Pyrexia >38 C
 Positive sputum culture
 Positive clinical findings
 Abnormal chest X-ray –Atelectasis/infiltrates

14. Observe if :- Seek further advice if:
 Awake or easily * Drowsy or unrousable
rousable  Distressed
 Comfortable  Hypertensive
 Normal preoperative BP preoperatively
 Cold
 Warm
 Capillary ref ll > 2
 Well perfused (capillary seconds
ref ll <2 seconds)
 Heart rate >100 or <50
 Heart rate 50-100 bpm bpm
 Passing urine (>0.5  Oliguric (<0.5 ml/kg/hr)
ml/kg/hr)  Signs of bleeding (drains,
 No obvious bleeding wounds, haematoma)

15.  Postoperative blood pressure should always be reviewed with reference
to the preoperative and intraoperative assessments.
assessment is required for patients with:
- heart rate < 50 and > 100 bpm
-blood pressure <100 mm Hg systolic.
 Patients on regular antihypertensive medication should normally be
maintained on this medication perioperatively. If the patient becomes
hypotensive then it may be appropriate to discontinue some drugs.
 Beta blockers and IV nitrates may be used safely and effectively in
postoperative hypertension.
 Beta blockers should be continued perioperatively in patients previously
taking these drugs for coronary disease, congestive heart
failure, hypertension or arrhythmias.
 Be aware of clinical factors which increase risk to the patient and how
these interact with the risks imposed by the surgical procedure.
 Seek expert help early in the management of serious or potentially
serious arrhythmias.
 Search for the underlying causes of any supraventricular arrhythmias, eg
hypoxia, hypovolaemia, electrolyte abnormality, sepsis or drug toxicity.
 Where perioperative MI is diagnosed or suspected early specialist medical
advice should be sought.
 Maintain normothermia in the postoperative period.

16.  Accurate assessment of fluid and electrolyte status can be
difficult and the treatment of a particular patient must be
individualised and reviewed frequently in the light of the
response to treatment.
 Volume depletion should be avoided as this can lead to poor
perfusion and problems such as anastomotic breakdown, cerebral
damage, renal failure and multiple organ failure.
 Diuretics should not be used to treat oliguria and should be
reserved for fluid overload.
 Hyponatraemia is more commonly due to excess water than
sodium deficiency – assess volume status.
 Hypernatraemia most commonly indicates a total body deficiency
of water and is an indication for prompt assessment and
intervention, especially when levels exceed 155 mmol/L.
 Hypokalaemia can delay postoperative recovery - magnesium
supplementation may also be required.
 Hyperkalaemia is a medical emergency – obtain senior help.
 Metabolic acidosis is usually due to poor tissue perfusion but can
also be caused by excessive administration of saline.

17. Composition of replacement
fluids

18. FLUID Na K GLUCOSE( Osm pH
(mEq/l) (mEq/l) g/l)
Whole 168-156 3.9-21.0 7.20-6.84
blood in
CPD
PRBC, AS- 117 ?-49 552 6.6
1
PRBC, CPD 169-111 ?-95 6.6
PRBC,CPD 15.4 5.1-78.5 7.55-6.71
A-1
FFP 130-160
5%ALBUMI 130-160 <2.5 0 330 7.4
N
2.5%ALBU 130-160 <2.0 0 330
MIN
PLASMA 0 <2.0 7.4
NATE
10%DETRA 154 0 50 255 4.0
N

19. Hetastarch 154 0 0 310 5.9
0.9%NaCl 154 0 0 308 6.0
Lactated 130 4.0 0 273 6.5
Ringer’s
solution
5% dextrose 0 0 50 252 4.5
D5LR 130 4.0 50 525 5.0
D50.45% 77 0 50 406 4.0
NORMOSOL 140 5.0 100 555 7.4
Normosol - 40 13 50 363 5.6
M
Normosol-R 140 5.0 0 295 7.4
Ph 7.4
Normosol-R 140 5.0 0 295 6.6
D5 140 5.0 0 547 5.2
Normosol-R

20.  Hand washing with soap and water or with alcoholic
cleansing agents should be performed before and
after patient contact.
 Early identification and appropriate treatment of
sepsis improves outcome.
 Urine and blood cultures should be obtained
whenever there is reason to suspect systemic sepsis.
 If the cause of sepsis is unknown, treat with broad
spectrum antibiotics, guided by local protocols.
 Results from microbiological specimens should be
reviewed regularly and antibiotics changed as
necessary.
 A course of antimicrobial treatment should generally
be limited to 5-7 days. Fungi and atypical organisms
can contribute to sepsis syndrome, so take cultures
and prescribe appropriately

21.  Systemic inflammatory response syndrome
(SIRS) is defined as the presence of 2 or more
of the following:
 § temperature >38 C or <36 C
 § heart rate >90 bpm
 § respiratory rate >20 breaths/min or PaCO2
<4.3kPa
 § white cell count >12,000 cells/mm3 ,
<4,000 cells/mm3 or >10% immature
forms.
 When SIRS is present an infective cause
should be sought first.

22.  Oral intake should be commenced as soon as
possible after surgery.
 Nutritional replacement should be discussed
with a dietician and tailored to the patient's
requirements.
 Entenral nutrition is the preferred method of
postoperative nutritional support and should
be used if possible.
 Nutritional and metabolic status should be
assessed regularly and the nutritional
prescription modified as necessary.

23.  Giventhe lack of a strong evidence base of
effective practice for postoperative
management this guideline has been
developed using a combination of evidenced
based and consensus techniques. Initial
systematic searches identified any relevant
evidence. The critically appraised
evidence, together with the clinical
experience of the guideline development
group, informed the formal consensus
methods that were used to develop
recommendations. These are presented in
the form of “consensus statements”.

24. CATEGORY DRUG DOSAGE INDICATION
Antihistamine Benadryl 10 -50 mg Mild allergic
chlorotrimetron 10 mg reaction
barbiturates nembutal 50 – 100mg toxic overdose
seconal 100 mg (local
anesthetic)
steroids Solu-cortef 100 mg severe allergic
decadron reaction
vasopressors Methedrine 10-20 mg hypotension
vasoxyl 10-20 mg
branchodilators Isuprel Nebulizer(0.2 mg) allergic or
asthmatic
Aminophylline 0.25-0.5 gm condition
epinephrine o.2- Anaphylactic
nitrogycerine 0.5ml(1:1000) shock or allergic
1/150-1/200 gr reactions
Atropine sulfate linually Angina pectoris
succinylcholine 0.4-0.6 mg
40-60 mg Bradycardia
laryngospasm