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ASFAR ZAMAN

Post Operative Care

• The post operative period begins from the time the patient leaves the operating room and ends with the follow up visit by the surgeon.

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Purposes

• To enable a successful and faster recovery of the patient post operatively.• To reduce post operative mortality rate.• To reduce the length of hospital stay of the patient.• To provide quality care service.• To reduce hospital and patient cost during post operative

period.

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Complications• Complications 5-40%• Mortality <2%• Complications are more frequent in emergency situations,

severely ill patients and young ones.

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1.Constant Supervision• For bleeding, displacement, blocking of tubes, removing

secretions• Pt given 100 % oxygen. Deflate the tube cuff.

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2.Suction• Suction catheter with negative suction pressure (10 -15

mmHg) used.• Catheter diameter should be < 1/3rd of internal diameter of

tracheostomy tube • Catheter length introduced just enough to go beyond inner

tube (10 cm)

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3.Tracheostomy tube care• Inner tube is removed & cleaned when blocked• Outer tube never removed before 72 hrs to allow formation of

tracheo-cutaneous tract• Cuff of Portex tube deflated for 10 minutes every 2 hours to

prevent pressure necrosis & dilatation of trachea

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4. Others• Chest auscultated for confirmation of adequate suctioning. Re-

inflate cuff to a pressure of 25 mmHg. Patient oxygenated again.

• Tracheostomy wound dressing done BID • Steam inhalation TID. Moist gauze piece placed over

tracheostomy tube opening. Regular chest physiotherapy, expectorants & mucolytics given.

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5.Prevention of crusting and tracheitis

• Proper humidification using humidifier or keeping boiling kettle in room.

• Using a few drops of ringer lactate or normal saline or hypotonic saline

• Every 2-3 hrs

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Complications of tracheostomy

i. Immediate Complications (During tracheostomy)ii. Intermediate Complications (Few hours or days later)iii. Late Complications (Due to prolonged use of tube for

weeks-months)

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Immediate complications• Haemorrhage• Aspiration of blood• Injury to recurrent laryngeal nerve• Injury to apical pleura (Pneumothorax)• Injury to oesophagus (May cause tracheoesophageal fistula)• Apnoea (Due to Carbondioxide wash out)

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Intermediate Complications• Haemorrhage• Displacement of tube (Due to use of improper size tube)• Blocking of tube (Due to excessive crusting/poor

humidification)• Subcutaneous emphysema• Tracheitis/Tracheobronchitis with crusting in trachea• Pulmonary infections (Due to compromised airway defense

mechanism)• Wound infection & granulation

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Late Complications• Haemorrhage (Due to erosion of major vessels esp

innominate/bracheocephalic art)• Laryngeal stenosis (Due to perichondritis of cricoid cartilage)• Tracheal stenosis (Due to tracheal ulceration & infection)• Tracheoesophageal fistula (Due to erosion of trachea by tip of

the tube)• Persistent tracheocutaneous fistula• Difficult decannulation

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Indications for changing

Elective:• Facilitate weaning/speech production• To increase patient comfort• To allow non-routine cleaning and dressing of a tracheostomy

wound• To allow treatment of granulation tissue at stoma site and/or

fenestrationEmergency:• Blocked tube• Misplaced or displaced tube• Cuff failure Faulty tube • Resuscitation

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Care• A healthy stoma should be clean and dry with pink edges,

though in the early postoperative period it is normal to see dried blood around the stoma.

• Any redness, swelling, or pus is abnormal. • A small amount of blood should be expected with each

tracheostomy tube change especially when a cuffed tube is inserted or removed.

• The constant exposure of the stoma to secretions can be very irritating to the skin so the stoma must be cleansed regularly and kept dry.

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Key points of dressing change are:

• Remove old dressing and tapes.• Clean the stoma and surrounding area with saline and gauze.• Dry the peri-stoma area.• Apply keyhole dressing around the stoma/under flange of

tracheostomy tube.• Apply transparent film dressing if required.• Inspect dressing frequently.• Change dressing when exudate visible

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Frequency of suctioning• It is commonly held that suctioning should be done only as

needed,• In order to prevent obstruction of the tube and the

accumulation of secretions.• In the early postoperative period the patient will require

frequent suction to clear secretions.• This need will gradually settle as the trachea becomes

accustomed to the presence of the tracheostomy tube and the patient learns to clear the secretions by coughing

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Humidification• Mucous membranes often require added moisture because

the tracheostomy tube bypasses the upper airway. • Humidification can be provided by a tracheostomy collar, or

atomized saline. • Lack of adequate humidification can cause the trachea to

develop squamous metaplasia, desiccation of the tracheal mucosa, and impaired ciliary function.

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The properties of an ideal humidifier

• Provision of adequate levels of humidification• Maintenance of body temperature• Safety• Lack of microbiological risk to the patient• Suitable physical properties• Convenience• Economy

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Conclusions• The most common indications for tracheostomy is mechanical

ventilation with prolonged tracheal intubation.• Tracheostomy: emergency and elective, improve quality of life.• Meticulous surgical technique.• Appropriate postoperative tracheostomy care to reduce

complications.

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