Post-op management

Habari Daktari Mtarajiwa! Welcome to the Surgical Ward.

So, you've spent hours in the theatre, retracting, cutting sutures, and maybe even getting to close the skin. You feel the thrill as the consultant says, "Good job, team." But let me tell you a secret that every seasoned surgeon knows: the surgery is not over when the last stitch is placed. The most critical phase has just begun. Welcome to Post-Operative Management, where your vigilance, knowledge, and quick thinking can mean the difference between a smooth recovery and a life-threatening complication.

Think of yourself as the vigilant guardian, the "askari," for this patient who has just undergone immense physiological stress. Your job is to guide them safely through the vulnerable period that follows. Let's get started!

The Handover: Your First and Most Important Task

The patient is being wheeled out of the recovery room. The anesthetist or theatre nurse is giving you a report. Do not just nod! This is your moment to be a detective. You need to know:

• Patient Details: Name, age, hospital number. (Confirm the wristband!)
• The Surgery: What was the procedure? E.g., "Exploratory laparotomy for a perforated typhoid ileitis."
• Intra-op Events: Was it smooth? Were there any significant events? How much blood was lost? Was a blood transfusion given?
• Anesthesia: General or regional (e.g., spinal)? Any issues during induction or reversal?
• Immediate Post-op State: Are they stable? What were their last set of vitals?

A Word from the Wards: I once saw a junior clerk take over a patient post-appendectomy. The handover was rushed. He didn't ask about blood loss. Hours later, the patient was tachycardic and hypotensive. It turned out a vessel had started bleeding again. A clear, thorough handover could have raised suspicion earlier. Listen carefully. Ask questions.

The Systematic Approach: Your Post-Op ABCDEs

Just like in an emergency, a systematic approach is your best friend. Don't just rush to look at the wound. Go through the ABCDEs every single time you review your patient.

A - Airway: Is it patent? Can you hear clear breath sounds? Is the patient conscious enough to protect their own airway?

B - Breathing:

• Check the respiratory rate (RR).
• Check oxygen saturation (SpO2). Is it >94%?
• Is the patient on supplemental oxygen? How many litres/min via nasal prongs or face mask?
• Auscultate the chest. Are there crackles (suggesting fluid overload or pneumonia) or reduced breath sounds (atelectasis)?

C - Circulation: This is where you'll spend a lot of your time.

• Vitals: Blood Pressure (BP) and Heart Rate (HR). Are they stable? Tachycardia is often the *first* sign of trouble (like bleeding or sepsis)!
• IV Fluids: What fluids are running? At what rate? This is CRUCIAL.
• Urine Output: The window to the kidneys (and perfusion)! Is there a catheter? What is the hourly output? The target is 0.5 - 1 ml/kg/hour.

Let's talk about fluids. You will be prescribing these. You must know how to calculate maintenance fluids.

### Maintenance Fluid Calculation (The 4-2-1 Rule) ###

For an adult patient (we'll use a 70kg man as an example):

1.  **First 10 kg:** 4 ml/kg/hr  -> 10 kg * 4 ml = 40 ml/hr
2.  **Next 10 kg:**  2 ml/kg/hr  -> 10 kg * 2 ml = 20 ml/hr
3.  **Remaining kg:** 1 ml/kg/hr  -> 50 kg * 1 ml = 50 ml/hr

**Total Hourly Rate:** 40 + 20 + 50 = 110 ml/hr

**Total Daily Volume:** 110 ml/hr * 24 hrs = 2640 ml (approx 2.5 Litres)

This means you'd prescribe about 5 bags of 500ml fluids over 24 hours. A common prescription would be alternating Normal Saline with 5% Dextrose.

And what if you don't have an infusion pump, which is common? You must calculate the drip rate!

### IV Drip Rate Calculation ###

**Formula:** (Total Volume in ml * Drop Factor) / (Time in minutes) = drops/minute

*The drop factor is on the IV giving set package. Usually 20 gtts/ml for adults.*

**Example:** You need to give 1 Litre (1000ml) of Normal Saline over 8 hours.

1.  **Volume:** 1000 ml
2.  **Drop Factor:** 20 gtts/ml
3.  **Time:** 8 hours * 60 minutes/hr = 480 minutes

**Calculation:** (1000 * 20) / 480 = 20000 / 480 = 41.67

**Answer:** You will set the drip rate to approximately **42 drops per minute.**
Practice counting this out! One drop every 1.5 seconds.

D - Disability/Discomfort:

• Level of Consciousness: Are they alert, responding to voice, pain, or unresponsive (AVPU)? Check their GCS if there's any concern.
• PAIN: Surgery hurts! Uncontrolled pain leads to poor breathing (atelectasis), immobility (DVT), and immense distress. Ask the patient to score their pain from 0-10. Prescribe analgesia regularly (e.g., "Paracetamol 1g 6-hourly") and have PRN (as needed) options like Tramadol or Pethidine for breakthrough pain.

E - Exposure/Everything Else:

• Temperature: Check for fever or hypothermia.
• The Wound: Is the dressing clean and dry? Is there any ooze? Don't be shy to look, but use an aseptic technique if you need to change a soaked dressing.
• Drains: Are there any surgical drains? What colour is the fluid? How much has come out? This is a direct message from the surgical site!
• Lines and Catheters: Check IV cannula sites for signs of phlebitis. Ensure the urinary catheter is not kinked.

Image Suggestion: An illustration showing a medical student systematically assessing a post-operative patient in a hospital bed in a Kenyan ward setting. The student is pointing to different parts of the body corresponding to ABCDE: pointing to the patient's chest (A/B), the IV line (C), asking the patient about pain (D), and looking at the abdominal dressing (E). The style should be clear, educational, and realistic.

The "Big Five" Post-Op Gremlins to Watch For

There are common complications that you must always have at the back of your mind. A helpful mnemonic is the 5 W's for post-op fever.

        Timeline of Post-Op Fever (The 5 W's)
        
    Day 1-2      Day 3-5      Day 5-7      Day 7+      Anytime
      |            |            |            |            |
      |            |            |            |            |
   ---O------------O------------O------------O------------O---
      |            |            |            |            |
    **Wind**      **Water**     **Wound**    **Walking**   **Wonder**
 (Atelectasis)     (UTI)      (Infection)     (DVT/PE)      (Drugs)

1. Wind (Lungs): Atelectasis (collapse of the small airways) is very common in the first 48 hours. Encourage deep breathing exercises and coughing. This is the job of the physio, but you must reinforce it!
2. Water (Urine): Urinary tract infections (UTIs) are common, especially with a catheter. Look for fever and cloudy, smelly urine.
3. Wound: A wound infection typically shows up after Day 5. Look for redness, swelling, warmth, and purulent discharge.
4. Walking (Veins): Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) are serious risks. Is the calf swollen or tender? Has the patient suddenly become breathless and tachycardic? Encourage early mobilization! Get them out of bed!
5. Wonder Drugs: Has the patient started a new drug that could be causing a fever?

Image Suggestion: A clear, medical-style diagram of Virchow's Triad (Stasis, Hypercoagulability, Endothelial Injury). Each component should have small icons representing risk factors relevant to a post-op patient (e.g., a person lying in bed for Stasis, surgical tools for Endothelial Injury, and blood cells clumping for Hypercoagulability).

Writing Your Post-Op Orders: Be Clear, Be Safe

When the surgeon asks you to "write the post-op orders," they are trusting you to be thorough. A good structure is key. Think of the mnemonic "VIPS".

• V - Vitals: How often? E.g., "Monitor vitals (BP, HR, RR, SpO2, Temp) half-hourly for 4 hours, then hourly for 4 hours, then 4-hourly if stable."
• I - IV Fluids & Intake/Output: What fluid, what rate? E.g., "IV Normal Saline 1L over 8 hours." Specify diet: "Nil Per Oral (NPO)," "Sips of water," or "Diet As Tolerated." Always add "Strict Intake/Output charting."
• P - Prescriptions (Pharmacology): This is your medication list.
  • Analgesia: "IV Paracetamol 1g 6-hourly." AND "IM Pethidine 50mg 8-hourly PRN for severe pain."
  • Antibiotics: "IV Ceftriaxone 1g 12-hourly."
  • DVT Prophylaxis: "Subcutaneous Enoxaparin 40mg daily."
  • Regular Meds: Don't forget to restart the patient's essential medications for hypertension or diabetes!
• S - Specifics & Investigations:
  • Position: "Nurse patient in Fowler's position (head up at 45 degrees)."
  • Mobilization: "Encourage deep breathing exercises." "Mobilize out of bed in the morning with physiotherapy."
  • Wound/Drain Care: "Observe wound for ooze." "Monitor drain output 8-hourly."
  • Labs: "Check Full Haemogram (FBC) and Urea/Electrolytes/Creatinine (U/E/Cs) in the morning."

Conclusion: Your Role is Monumental

As a junior clerk, you are the eyes and ears on the ward. The consultant sees the patient for a few minutes on ward rounds, but you are there for hours. You are the one who will first notice the subtle drop in blood pressure, the slight increase in heart rate, or the patient's complaint of a sore calf. Never underestimate your role.

Remember the Kenyan proverb, "Haraka haraka haina baraka" – hurry, hurry has no blessings. Take your time with your post-op patients. Be systematic. Be vigilant. And never, ever be afraid to ask your senior, the registrar or consultant, for help. We were all in your shoes once. Now go, make us proud, daktari!