1.               POSTOPERATIVE PAIN RELIEF

Postoperative pain is associated with all surgical procedures. This varies according to the surgical procedure. Severe pain can prolong gastrointestinal ileus, urinary retention, impair respiratory movements producing atelectasis and predisposes to deep vein thrombosis due to immobilization. Various methods to alleviate postoperative pain are NSAIDs, opioids (intramuscular, transdermal or transmucosal), patient-controlled analgesia, local infiltration of anaesthetic drugs, epidural analgesia and intrapleural analgesia. The method used depends upon the site and the magnitude of surgery done, severity of pain, whether the patient is allowed orally, facilities and expertise available. It is necessary to give analgesics by intramuscular or intravenous route in the immediate postoperative period and till the patient is able to accept orally. Commonly used agents are:

lnj. Diclofenac sodium 75 mg 8 hourly or

Inj. Pentazocine (30 mg/ml) 30-60 mg IM/IV repeated 3-4 hourly or lnj. Tramadol (50 mg/ml) IM/1V4-6 hourly or

lnj. Morphine (15 mg/ml) 4-15 mg, can be repeated 4-6 times.

In tertiary care centres, epidural analgesia, intravenous patient- controlled analgesia, intrapleural analgesia can be used under expert care.

When patient is able to accept orally-

Tab. Paracetamol 500 mg 3-4 times a day or Tab. Ibuprofen 400-600 mg 8 hourly or Tab. Diclofenac 50 mg three times in a day.

Tab. Aceclofenac 100mg + Paracetamol 325mg, BD, 12 hourly

2.  POSTOPERATIVE NAUSEA AND VOMITING

Postoperative nausea and vomiting leads to significant morbidity and prolonged hospitalization. It has an incidence of 20-30% after abdominal surgery. Predisposing factors are diabetes mellitus, pregnancy, dehydration, electrolyte imbalance, gastroesophageal reflux, use of certain anaesthetic drugs and opioids. Treatment- Bowel obstruction (mechanical or paralytic ileus) should be ruled out as a cause of vomiting by proper examination and investigations if it is associated with abdominal distension, fever and occurs beyond 3rd postoperative day. Nausea and vomiting are managed with intravenous fluids, analgesics to relieve postoperative pain, nasogastric decompression.

lnj. Metoclopramide (5 mg/mi) 10mg l/M or slow I/V 1-3 times daily or lnj. Ondansetron (2 mg/ml) 4 mg slow IV or IM.

In children: 100 mcg/kg (max 4mg/day) by slow IV or IM. Or inj. Promethazine (25 mg/ml) 2 ml I/V slowly

3.  POSTOPERATIVE PNEUMONIA

Pulmonary disorders remain the most frequent post-operative problem and (10-15 percent) of patients are considered to have clinically significant chest complication after surgery under general anaesthesia.

Factors predisposing to increased chest complications are smoking, obesity, chronic restrictive obstructive lung disease, prolonged general anaesthesia and presence of nasogastric tube.

Postoperative pneumonia is caused by pathogens such as Pseudomonas, Serratia, Proteus and streptococcus.

Salient features

•               Fever, productive cough, dyspnoea, Chest pain.

•               Bronchial breathing and presence of rales.

•               Chest X- ray shows areas of consolidation.

Treatment

1.      Antibiotics: depending upon sputum culture and sensitivity. Initial treatment can be started with aminoglycoside and antipseudomonas Cephalosporins.

2.      lnj. Ketorolac 30 mg every 6-8 hours lV or lM/lnj. Diclofenac 75 mg 1M every 6-8 hours.

3.      Chest physiotherapy

4.      Nebulization with bronchodilators may be used if bronchospasm is present.

4.  HANDLING OF MEDICO-LEGAL CASES

First aid has to be provided in all cases who report in an emergency state. After stabilizing the patient, patient should be properly guided and helped in shifting to the appropriate centre. In case that we decide to treat, we must:

•    Send information, in duplicate, to the police.

•    Prepare a medico legal report.

•       Preserve and seal clothes etc. preserve fluid and stain samples where

indicated.

•    Respond to information sought by the police.

•    Arrange to take dying declaration, where indicated.

•    Preserve all X-rays and patient records.

•Respond to court summons.

•    In case of death, hand over the body to the police.

•    In case of discharge/referral, police need to be informed.

•       All medico-legal work should be carried out as per the existing state guidelines.

5.  CARE DURING TRANSFER

This would depend on a number of factors like nature, patient's condition, referral, readiness of the referral centre to accept the patient and whether the transfer or elective.

Emergency transfer

•               Identify the degree of emergency.

•               Resuscitative   measures    to    be    adopted    in                            serious        patients with management etc.

•               Transfer in a well-equipped ambulance.

•               Transfer to a referral center with prior intimation and confirmation of the referral centre.

•               Doctor (if required) or paramedical staff to accompany the sick patient.

Referral slip Should contain information on:

•               Condition of the patient when first seen.

•               Diagnosis and resuscitative measures taken.

•               Reasons for referral.

•               Where referred.

•               Precautions advised during transportation.

•               Any other information (e.g. any staff or equipment sent along with, any referral centre or specialist concerned).

6.  ACUTE WOUND CARE

Irrigate gently with copious quantities of water or normal saline. If it is incised primary suturing is done. In lacerated wound margins are freshened, devitalized tissue is primary suturing is done. In crushed or devitalized wound there will be edema and t wound, after excising all the devitalized tissues the edema is allowed to subside for 2-61 delayed primary suturing is done. Wound debridement involves excision of all the devitalized regular intervals. If the wounds are fresh and less than 12 hours old, they can be closed with sutures staples. Any wound which is more than 24 hours old should be suspected to be contaminated and not closed completely. Only the deeper tissues can be approximated and the skin should be Left open.

•               Primary suturing means suturing the wound immediately within 6 hours. It is done incised wounds. Delayed primary suturing involves suturing the wound in 48 hours to 10 days. It is done in lacerated wounds. This time is allowed for edema to subside.

•               Secondary suturing implies suturing the wound in 10-14 days or later. It is done wounds. After control of infection, secondary suturing is done.

Associated injuries to deeper structures like vessels, nerves, tendons should be looked for before closure of the wounds. Any foreign body in the wound should be removed. Antibiotics and analgesics are required. Sutures are removed after seven days