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Surgery - Anesthesiology

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Common Causes of Post-Op Fever - the “5 W's” Mnemonic.

Wind: Atelectasis (first 24-48 hrs)
Water: UTI (after POD #3)
Wound: Infection (usually after POD #5, Grp A Strep→POD 1)
Walking: DVT (after POD #7-10)
Wonder drugs: Drug fevers (anytime)

Morning Presentation

Example: “This is Mr. X who is post op day _ from a _. He complains of _. His vitals are _. His physical exam shows _. His diet is _. His meds are _. His iv fluids are _ and his urine output is _. His activity level is _. His active issues are _. The plan for Mr. X is _."

Tips:

Streamlined and concise--not as much focus on FHx/SHx, only relevant PMH/PE
Include post-op day and type of surgery (POD#0= day of surgery, POD#1=day after surgery)

Progress Note

ID – 73M POD 3 from R Hemicolectomy

Subjective - Past 12 hr events – (MI, transfusion, confusion, chest pain), Bowel fxn

flatus, BM?Tolerating diet – clears, soft – n/v?Ambulating?Pain control (on IV or PO meds? If on PCA, then note usage in past 24 hours)

Objective

Tmax, Tcur, HR, BP, RR, SpO2I/O - IVF type and rateUrine Output past 8 hrsDrains – volume/quality (bilious, serous, serosanginous)

PE Gen*

Heart*Lung*AbdWoundExt*

*may not necessarily have to present if focused rounds

(Labs, imaging and pathology presented in PM rounds)

A/P (Assessment and Plan): POD 3, doing well

IV Fluids, Blood products if applicablePain controlAntibioticsDiet? Advancement of diet - NPO→Sips/Chips→Clears→Soft→RegularDrains/tubes/catheters – JP to suction, Chest tube to suction/seal, Foley to gravity. NG Tube to low, intermittent suction. Daily checks of amount (in cc’s) and appearance of drainage fluid. Normal appearance is “serosanguinous.” Can drain out come out?? Can foley come out and can patient have trial of voiding?DVT prophylaxis – Heparin 5000u SQ, Enoxaparin, SCDs, early ambulationGI prophylaxis?Incentive spirometry – 10 inspirations/hr, hold inspiration for 1-2 seconds.Activity – Ambulation – as tolerated (consider out of bed to chair), Phys Therapy?Weight bearing status – of extremity (if applicable, check with Ortho)Neuro/vascular checks – if applicableStool softeners (if on opioids)Disposition

Op Note

DatePre-op dxPost-op dxProcedureSurgeonsAnesthesia i.e., general with ET tubeEBL (Estimated Blood Loss)IV fluids received – amt. and typeAntibiotics10 Findings & complications & specimens sentDrainsCondition/Disposition

Sample Post-Op Orders

Admit to recovery roomProcedure and anesthesiaCondition:Vital signs q15 minutes until stable, then qlh x 4 then q2h x 4, Then as per routine.Notify H.O. if: (e.g. BP 90/60, P 120, T 100.6, or if pt. has not voided by 8 hours post-op).Activity – bed rest today, OOB with assistance in AM.Turn, cough and deep breathe q2h while awake or incentive spirometry q4h while awake. Teds stockings/ anticoagulationDiet – NPOMeds: (note: if including pain medications, explain prn dosing)Labs: Specify

Post-Op Check

Vital signsState of consciousnessPhysical exam (check condition of dressings & drains)Volume of drainage from various tubesVoidingLabsA/P

Pre-Operative Anesthetic Evaluation

Age / Sex / Indications and Procedure

Preoperative Assessment

Past medical historyPast surgical historyPast anesthetic historyMedicationsAllergiesSocial history

Physical Exam

Vital Signs: BP HR RR Wgt. Hgt.Airway assessmentCardiacPulmonary

ASA Physical Classification 1-5
ASA 1 Patient with no systemic disease
ASA 2 Patient with mild systemic disease
ASA 3 Patient with severe systemic disease that limits activity
ASA 4 Patient with incapacitating disease that is a constant threat to life
ASA 5 Patient that is moribund and not expected to survive 24 hours
In the event of emergency surgery the letter E is added to the classification

Anesthetic Management Plan

General anesthesia vs. Regional anesthesia vs. MAC

Regional anesthesia - Can be a central neuraxial block such as a spinal or epidural or a peripheral nerve block, such as an interscalene blockMAC - Monitored anesthesia care, typically local anesthesia with monitoring and sedationGeneral anesthesia

Components

Amnesia, Analgesia, Unconsciousness, Immobility, Hemodynamic Stability

Induction agents

Propofol, Etomidate, Ketamine, Inhalational agents

Maintenance agents

Inhalational agents, narcotics, muscle relaxants

Emergent

Fluid management

Deficit, Maintenance, Ongoing losses, Blood lossEstimation of blood volume and allowable blood lossIntraoperative interventions and results

Postoperative/PACU course

Continued monitoring of patient’s vital signs

Pain management

Intravenous, Patient-controlled analgesia (PCA), Regional block