1 Post-Op Management Kempf 2024.pdf

Post-Op Management Allen J Kempf, DPM, MS, AACFAS, DABPM Assistant Professor College of Podiatric Medicine and Surgery Des Moines University Objectives Demonstrate knowledge on the various types of post-operative dressings, splints, cast, boots, and post-op shoes Demonstrate knowledge of discharging...

Post-Op Management Allen J Kempf, DPM, MS, AACFAS, DABPM Assistant Professor College of Podiatric Medicine and Surgery Des Moines University Objectives Demonstrate knowledge on the various types of post-operative dressings, splints, cast, boots, and post-op shoes Demonstrate knowledge of discharging and admitting of the postoperative patient Recognize and treatment of acute post-operative complications and patient concerns Outline: Post-Operative Dressings and Splints Dressings Materials and Indications Incisional wound vac Jones compressive dressing Posterior splint Sugar tong splint Cast CAM boot Flat surgical shoe Post-Operative Dressing Materials: Incision Site his choice Non-adhesives for incisions: ↳ Xeroform- fine mesh material impregnated with petrolatum and Bismuth Tribromophenate Inhibits bacterial growth Prevents adhesion to incision Adaptic- knitted cellulose acetate impregnated with petrolatum Prevents dressing from adhering to incision Cover with gauze and remainder of indicated/desired dressing May only be gauze and ACE bandage May be full splint/cast https://www.exmed.net/What-is-Xeroform-Sterile-Petrolatum-Gauze-Dressing https://medicalmonks.com/product/adaptic-non-adhering-dressing/ Incisional Wound Vacs Multiple models available Apply wound vac directly to incision site Draws moisture away from incisions Uses negative pressure to hold incision site flaps together Removes infectious materials from drainage in incisions if present https://thewoundvaccompany.com/blog/2019/6/7/negative-pressure-wound-therapy-for-closed-surgical-incisions Post-Operative Compression Jones Compressive Dressing: Multi-layer compressive wrap Alternating layers of cast padding and ACE bandages Used to help control edema in postoperative or trauma patients “Soft cast” Can apply elastic bandage Useful in immobilized patients Not used in patients with arterial insufficiency https://www.researchgate.net/figure/A-Two-layers-of-multipurpose-underpadding-bandage-are-placed-over-the-tubular-gauze_fig3_262071982 Posterior Splint Main goal is to immobilize the foot and ankle following injury or surgery Primary indications: High-grade ankle sprain Ankle fracture Ankle dislocation (following reduction) Post-operative stabilization Foot fracture https://readysplints.com/products/ankle-splint-kit Posterior-Splint Application & Management Commonly used over soft dressing such as Jones compressive dressing or surgical dressing Ensure that prominent areas are padded well Malleoli Metatarsal heads Calcaneus Fibular head/neck (common peroneal N.) Splint should extend from metatarsal heads to fibular head/neck Check digits for possible rubbing Secure splint with ACE bandages Check neurovascular status after application Ankle should be at 90 degrees Patient should remain non-weight bearing in the splint Keep pillow under lower leg to keep the heel off the bed Monitor for pressure ulcerations Sugar-Tong Splint (Stirrup/U-Splint) U-shaped splint Rigid splint which maintains stability and immobilization of the ankle Usually has posterior splint as well Indications: Ankle sprain Ankle fractures Ankle dislocations (reduced) Posterior heel surgery (w/wo posterior splint) https://www.ebay.com/itm/143767350822 Post-Operative Cast Allow for complete immobilization following injury or surgery Patient unable to remove them Can uni- or bi-valve them to relieve compression and allow for swelling Many modifications exist depending on needs of the cast Do have to be changed if become wet or if significant incision/wound drainage DVT risk Ulcer risk Post-Operative Cast 2 main materials options: Fiberglass Lighter Dry quickly Allow for weight bearing sooner Easier to radiograph More expensive Plaster Heavier Slower to dry Can be molded in more custom fashion Less clear radiographs Less expensive https://www.pixelsquid.com/png/blue-fiberglass-leg-cast-1226885963746121502 https://jamesmazurdpm.com/blog/item/440-possible-treatments-options-for-a-broken-ankle.html Controlled Ankle Motion (CAM) Boot Removable boot used to control foot and ankle motion Tall and short options Contralateral hip and knee concerns Indications: Stress fractures Post-operative immobilization Ankle sprains Traumatic foot injuries (fractures/ dislocations) Tendonous/ligamentous injuries (tendon tear, Lisfranc) Stable ankle fractures https://www.shhc.com.au/cam-boots Post-Operative Shoe Used to stabilize structures of the foot following injury or surgery Stiff soled shoed that prevents excessive motion of the foot Does not provide control of the ankle or lower leg muscles Can lead to contralateral hip and knee pain, should wear supportive shoe on contralateral foot when ambulating Allows for increased range of motion of the ankle https://www.amazon.com/ProCare-Squared-Post-Op-Shoe-Medium/dp/B006IUU95W Post-Operative Admission Checklist of post-operative admission: ADC VANDILMAX Admit: H & P, admission order Diagnosis: Reason for admission Condition: Stable/unstable Vitals: How often? Activity: WBAT, non-weight bearing, bed rest? Nursing: Dressing changes, drain management, etc Diet: Regular, Diabetic I/O: IV, foley, drains Labs: CBC, BMP, how often? Medications: Antibiotics, pain, etc. Ancillary: Consults X-ray: Baseline, post-op Post-Operative Discharge (Inpatient) Discharge order Discharge summary Brief description of why the patient was in the hospital, overview of their care including procedure and lab/imaging results as well as pending results and follow up appointments Prescriptions Pain Antibiotics Home medications Home Health Durable Medical Equipment (DME) Referrals Follow up appointments Discharge instructions Post-Operative Discharge (Outpatient) Discharge order Prescriptions Pain Antibiotics Home medications Durable Medical Equipment (DME) Referrals Follow up appointments Discharge instructions No DC summary Discharge Instructions Should include very specific details on what you wish the patient to do post-operatively Medication management Pain management Follow up appointments What to do if bleeding through dressing occurs Signs and symptoms of infection (and what to do if these occur) Signs and symptoms of DVT (and what to do if these occur) Outline: Post-Operative Complications Dressings Bleeding Drainage Pain Infection Hardware https://www.pinterest.com/pin/205195326759178572/ Post-Operative Dressings Bleeding in dressing (“strike-through”) Common reason to hear about/from patient How much blood? Reinforce dressing if minimal bleeding Ideally, want to keep surgical dressing intact for 1-7 days post-operative If necessary, take dressing down in clean environment Check for arterial bleed if significant blood volume Address as needed Post-Operative Dressings Drainage What type? How much? Color? Odor? Saturation Rain Bathing May be able to reinforce, may have to remove and re-apply https://stock.adobe.com/search?k=%22trauma+shears%22 Post-Operative Pain How much pain? What does it feel like? Loosen dressings R.I.C.E Opioids NSAIDs Neurological agents Acetaminophen Rule out: Surgical Infection DVT Compartment syndrome Post-Operative Infection Identify infection Labs Imaging Clinical findings PO antibiotics Local wound care Admission with IV antibiotics Incision and Drainage Amputation https://www.hmpgloballearningnetwork.com/site/podiatry/article/2787 Post-Operative Hardware Concerns Pain Hardware backing out Breakage Loosening Removal Revision https://www.huffingtonpost.co.uk/2015/08/10/man-with-screw-coming-out-of-foot_n_7964576.html https://eor.bioscientifica.com/view/journals/eor/7/1/EOR-21-0025.xml Questions?