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Postoperative management

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Abstract

The goals of the immediate postoperative period are to: Recover the patient from anaesthesia; Prevent and manage postoperative complications; Provide ongoing treatment for pre-existing disease; Identify new problems rapidly and treat them appropriately; Support the patient's physiology effectively, promoting rapid recovery; Ensure patient welfare. To achieve these goals, close patient monitoring and regular assessment are required to alert the clinician to changing patient needs and permit timely intervention. The completion of a surgical procedure never constitutes the conclusion of a patient's veterinary care. The following are addressed: Repeated physical examination; Monitoring; Postoperative use of clinical pathology; Management of drains, tubes and catheters; Respiratory care; and Care of the recumbent patient.

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Figures

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13.1 A detailed complete intensive care unit sheet from a patient’s medical record. Note the extensive problem list, list of therapeutic procedures with scheduled administration times and the use of clinician notification parameters towards the bottom of the sheet. The sheet should also facilitate recording of all ‘ins and outs’, i.e. urine output, faecal production and drain effusion volumes.
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13.2 A normal pulse profile. Pulse profiles in hypovolaemia. In early shock, physical examination findings are characterized by tachycardia, tall and narrow pulses and a brisk capillary refill time. With clinical deterioration, inappropriate bradycardia may occur accompanied by short and narrow pulses, pale or grey mucous membranes and a sluggish capillary refill time.
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13.3 A cat in severe respiratory distress demonstrating characteristic open-mouth breathing and anxiety. The patient is in a paediatric incubator being monitored with telemetric ECG. Oxygen is being supplemented via tubing visible in the background. (Courtesy of H Wilson)
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13.4 Monitoring the post-surgical patient with a bedside ECG monitor. The multiparameter monitor is also displaying a direct arterial blood pressure tracing. A telemetric ECG monitoring screen mounted within the intensive care unit nurses station.
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13.5 A blood pressure recording being taken by Doppler sphygmomanometry from the plantar metatarsal artery in a cat following thoracotomy. Oscillometric blood pressure reading from a dog using a multiparameter monitor.
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13.6 Direct arterial blood pressure monitoring in a postoperative patient. Simultaneous paper tracings of ECG, direct arterial blood pressure and central venous pressure from a patient following cardiopulmonary bypass surgery.
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13.7 Frank–Starling law of the heart, demonstrating the curvilinear relationship between ventricular preload and cardiac output. A hypovolaemic patient, represented by A, is likely to be volume-responsive, i.e. a small increase in ventricular preload leads to a large increase in cardiac output. In contrast, a patient with high filling pressures consistent with heart failure, represented by B, is not likely to be volume-responsive, i.e. a large increase in ventricular preload produces a minimal increase in cardiac output.
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13.10 In-house cytology of abdominal fluid from a patient with septic peritonitis. Multiple rod-shaped bacterial organisms are visible and there are a large number of degenerate neutrophils. Erythrocytes are also visible in the background. (X 400 original magnification, rapid Romanowsky staining). Blood gas, electrolyte and metabolite analyses performed on the fluid demonstrated a very low pH, low O and low glucose concentration with high CO and high lactate concentration.
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13.13 A finger-trap suture securing an oesophagostomy tube in a dog.
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13.14 A dressing incorporating a jugular catheter and an oesophagostomy tube in a post-surgical feline patient.
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13.17 All adaptors should be inserted firmly with at least three ridges of the connector within the chest drain or encircled with cerclage wire for additionally security. A minimum of two forms of tube security should be fitted. Typically this includes a clamp and a three-way tap with injection port bungs securing the openings.
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13.20 Calculation of the A–a gradient.
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