prepoerative and post operative care

1. PREOPERATIVE PREPARATION
AND POSTOPERATIVE CARE

2. PREOPERATIVE PREPARATION
HAZMAN NORMAN 012013051891

3. OVERVIEW
• PATIENT ASSESSMENT
• RISK ASSESSMENT AND CONSENT
• ARRANGING THE THEATRE LIST

4. PATIENT ASSESSMENT
• Aims:
– look actively at risks
– proper management of risks
– enabling safe surgery
• Usually done by surgical team, nursing team and
anaesthetic team
• Standard history taking

5. • Proper physical examination
• Investigations needed (NICE guidelines)
• Airway assessment and evaluation

6. RISK ASSESSMENT AND CONSENT
• ASA classification
• Explain on the advantages, side effects and,
and prognosis
• Taking comprehensive valid consent – given
voluntarily by a competent and informed
person

8. ARRANGING THE THEATRE LIST
• Confirm it is the right date, time, and place of operation
• Personnel availability
• Appropriate equipment and instruments should be made
available
• Operating list should be distributed early
• Priorities to children, diabetic patients, cancer patients, and
life threatening patients

9. BEFORE THEATRE
• Must be seen by anaesthetist and operating surgeon
in charge
• Keep in view for specific requirement
• Arrange the theatre list appropriately

10. SURGICAL SAFETY CHECKLIST
Introduced by WHO in 2008, a guideline recommended practices
to reduce rate of preventable surgical complications and death
worldwide.
• Prelist briefing
• Sign in
• Antibiotic
• Monitoring
• Operating theatre
environment
• Diathermy
• Torniquets
• Time outs
• Temperature control
• Hair removal
• Glycaemic control
• Infection control

11. SCRUBBING UP
• Process of washing of hands and arms and putting on
gloves and gown
• 2 standard scrub solutions include
-2% chlorhexidine
-7.5% povidone-iodine
-alcohol

12. • Hat, mask and eye protection should be worn and
jewellery should be removed
• Nails and deep skin crease should be clean for 1-2 mins
using brush
• Hands and forearms wash systematically 3 times
• Hands and arms are dried from distal to proximal using
sterile towel
• Folded gown lifted away from trolley, allowed to unfold
• Arms inserted into armholes, hands remain inside gowns
until gloves are donned, secure the gown
• Gloves are put on, hands remain above waist level at all
times.

15. REFERENCES
• BAILEY AND LOVE’S 26TH EDITION
• OXFORD HANDBOOK OF CLINICAL MEDICINE
8TH EDITION

16. SPECIFIC PREOPERATIVE
PROBLEMS , REFERRALS
AND MANAGEMENT
SURENTHIRAN
012010090079

17. INTRODUCTION
OPreoperative problems – certain specific
medical conditions encountered during
preoperative assessment
OShould be corrected to the best possible level
to eliminate serious complications
OPatients with severe disease will need to be
referred to specialists and the referral letter
should include all the details
( history , examination and investigation
results ).

18. Preoperative management of patients with systemic
disease
 CAPACITY : baseline organ function capacity
should be assessed
 OPTIMISATION : Medication, lifestyle changes,
specialist referral will improve organ capacity
 ALTERNATIVE : Minimally impacting procedure ,
appropriate postoperative care will improve
outcomes
 THEATRE PREPARATIONS : Timing, teamwork ,
special instruments and equipment

19. OCARDIOVASCULAR DISEASE
OHYPERTENSION, IHD AND
STENTS
ODYSRHYTHMIAS
OVALVULAR HEART DISEASE
OANAEMIA AND BLOOD
TRANSFUSION
ORESPIRATORY DISEASE
OGASTROINTESTINAL DISEASE

20. CARDIOVASCULAR DISEASE
OIdentify patients who have a high
preoperative risk of MI and make
arrangements to reduce the risk
OInclude those who have suffered coronary
artery disease, CCF , arrhythmias , severe
peripheral vascular disease , CVD or renal
failure
OPatients with IHD – left ventricular status can
be evaluated using a stress test

21. O Patients with symptomatic valvular heart disease
or poor left ventricular function – an echo should
be performed
(ejection fraction less than 30% - poor
outcomes)
O Referred to cardiologist if :
- murmur heard and patient is symptomatic
- poor left ventricular function or cardiomegaly
- ischaemic changes on ECG even if patient is
not
symptomatic (silent MI)
- abnormal rhythm on ECG , tachy/bradycardia
or
a heart block

22. HYPERTENSION , IHD AND
STENTS
OPrior to surgery blood pressure should be
controlled to 160/90 mmHg
OStabilisation period of 2 weeks if new
antihypertensive is introduced
OPatients with angina
– investigated further by a cardiologist if not
well controlled
- some may need thrombolysis , stents or
bypass surgery prior to non-cardiac surgery

23. OPatients who have had stents inserted for
IHD, should be asked for the effectiveness of
the treatment and concurrent antiplatelet
medication (clopidogrel and/or aspirin)
ORisk of stent thrombosis with consequences
of MI and death is reduced if elective surgery
is postponed until after dual antiplatelet
therapy is stopped
OIf cannot be postponed and risk of
perioperative bleeding is low – dual
antiplatelet therapy can be continued during
surgery

24. DYSRHYTHMIAS
OPatients with atrial fibrillation
-B-blockers, digoxin and CCB started
preoperatively
- warfarin stopped 5 days preoperatively
OImplanted pacemaker and cardiac
defibrillator checks and appropriate
reprogramming done
OSymptomatic heart blocks and asymptomatic
second and third degree heart blocks need
cardiology consultation

25. VALVULAR HEART DISEASE
O Patients with severe mitral and aortic stenosis
may benefit from valvuloplasty before elective
non-cardiac surgery
O Patients with mechanical heart valves-
- warfarin stopped 5 days prior to surgery and
infusion of unfractionated heparin ( INR <1.5)
- APTT kept at 1.5 times normal and stopped 2
hours before surgery
- Heparin and warfarin postoperatively and
heparin
stopped once full effect of warfarin realised

26. ANAEMIA AND BLOOD
TRANSFUSION
OAnaemic at preoperative assessment treated
with iron and vitamin supplements
OChronic anaemia well tolerated in the
perioperative period
O if major procedure, preoperative
transfusion if Hb below 8g/dL

27. RESPIRATORY DISEASE
OCurrent respiratory status should be compared
with their normal state
ORegular treatment, PEFR , steroids use ,
CPAP should be taken note of
OEncourage patients to be compliant with
medications, exercise , consume balanced diet
and stop smoking

28. REFER TO RESPIRATORY PHYSICIANS IF :
- Severe disease or significant deterioration from
usual condition
- Major surgery is planned in a patient with
significant respiratory comorbidities
- Right heart failure is present
- Patient is young with COPD

29. O Smoking : provide information regarding
perioperative risks associated with smoking
O Asthma : establish severity of asthma, PEFR ,
precipitating causes, frequency of steroid and
bronchodilator use and any previous intensive care
unit admission. Use regular inhalers until the start
of anaesthesia
O COPD : Patients with significant COPD who are
undergoing major surgery will need to be referred
to physicians to optimise their condition. ABG also
useful
O Infections : elective surgery postponed if chest
infection. Treated with antibiotics and operation
rescheduled after 4-6 weeks.

30. GASTROINTESTINAL
DISEASE
Nil by mouth and regular medications
- Not to take solids within 6 hours and fluids
within 2 hours before anaesthetic
- Infants allowed a clear drink up to 2 hours ,
mother’s milk up to 3 hours and cow or
formula milk up to 6 hours before anaes
- If surgery delayed, oral (until 2 hours of
surgery) or IV fluids started in the vulnerable
group of patients

31. Regurgitation risk
- High risk of pulmonary aspiration if patients with
hiatus hernia, obesity, pregnancy and diabetes
- Antacids, H2-receptor blockers or PPI given
Liver disease
- Cause of the disease , clotting problems, renal
involvement and encephalopathy should be
known
- LFT, coagulation , blood glucose, urea and
electrolyte levels
- Ascitis, hypoalbuminaemia, sodium and water
retention should be noted

32. THANK
YOU…..
(but to be continue…)

33. SPECIFIC
PREOPERATIVE
PROBLEMS ,
REFERRALS AND
MANAGEMENT (2)
BY :
M.Krishnavaathi
012011100086

34. Genitourinary disease
1) Renal disease
- Diabetes mellitus, hypertension and ischemia heart disease
should be stabilised
( leading to chronic renal failure )
- Apporiate measures to treat acidosis, hypocalcemia and
hyperkalemia > 6mmol/L
- Continue peritoneal or hemodialysis until a few hours before
surgery
- Blood sample sent for FBC and U & E ( after final dialysis before
surgery )
- Chronic renal failure patients often suffer chronic microcytic
anemia that is well tolerated
- Acute renal failure can present with acute surgical problems ; eg
bowel obstruction needing emergency surgery ( simultaneous
medical , surgery treatments and critical care unit )

35. 2) Urinary tract infection
- Uncomplicated urinary infections are common in female
- Outflow uropathy with chronically infected urine is common in
men
- For elective surgery * infection should be treated because it
carries dire consequences eg joint replacements
- For emergency surgery * give antibiotics, ensure good urine
output before, during and after surgery

36. Endocrine and metabolic disorders
1 ) Malnutrition
- BMI < 18.5 kg/m2 ( nutritional impairment )
- BMI < 15 kg/m2 ( significant hospital mortality )
- Nutritional support for 2 weeks before surgery
2) Obesity
- Advice on healthy eating and taking regular exercise
- Use CPAP device for obstructive sleep apnea and cholesterol
reducing agents
- If possible, delay surgery until patients more active and lost
weight.
- Preventative measures for acid aspiration , DVT and associated
risks explained prior to surgery

37. 3) Diabetes mellitus
- Check HbA1c level
- Start lipid lowering medication in high risk group of
cardiovascular complications of diabetes
- Morning operation { advice to omit morning dose medication
and breakfast, tight control of blood sugar not needed }, check
blood sugar for every 2 hrs
- Afternoon operation { breakfast + half regular dose of insulin or
full dose of oral anti – diabetics, check blood sugar for every 2
hrs
- Intravenous insulin sliding for insulin dependent diabetes
mellitus undergoing major surgery or if blood sugar difficult to
control for other reason
4 ) Adrenocortical suppression
- Ask oral adrenocortical steroid dose and duration to avoid
Addisonian crisis

38. Coagulation disorders
1) Thrombophilia
- Thrombophylaxis needed if present of risk factors
Risk factors for thrombosis
- Increasing age
- Significant medical comorbidities (particularly malignancy)
- Trauma or surgery (especially of the abdomen, pelvis and lower
limbs)
- Pregnancy/puerperium
- Immobility (including a lower limb plaster)
- Obesity
- Family/personal history of thrombosis
- Drugs (e.g. oestrogen, smoking)

39. - Hormone replacement therapy ( HRT ) should be stopped 6 weeks
prior to surgery
- Low risk patients can be given thromboembolism deterrent stockings
- Give warfarin for patients with high risk patients with history of
recurrent DVT, pulmonary embolism and arterial thrombosis
- Stop warfarin before surgery and replaced with low molecular weight
heparin or factor Xa inhibitor
Neurological and psychiatry disorders
- History of stroke, pre existing neurological deficit patients may be on
antiplatelet or anticoagulants.
- Low risk of cardiovascular thrombosis, antiplatelet withdrawn ( 7days
for aspirin, 10 days for clopidogrel )
- High risk patients, use aspirin alone
- Anticonvulsant and antiparkinson continued to help early mobilization
- Stop lithium 24 hours prior to surgery, measure blood level to avoid
toxicity
- Inform anaesthetist if psychiatric medications such tricyclic
antidepressants or monoamine oxidase inhibitors to avoid drug
interactions.

40. Musculoskeletal and other disorders
- Rheumoid arthritis , flexion and extension lateral cervical spine x ray
should be taken. ( lead to unstable cervical spine with spinal cord
injurt during intubation )
- Rheumatologist will advice on steroids and disease modifying drugs so
as to balance immunosuppression against need to stabilise disease
preoperatively
- In ankylosing spondylitis, technique of spinal or epidural anaesthesia
often challenging
- Patients with systemic lupus erthematosis may exhibit
hypercoagulable state along with airway difficult
Airway assessment
Samsoon and Young modified Mallampati test
Fauces, pillars, soft palate and uvula seen Grade 1
Fauces, soft palate with some part of uvula seen Grade 2
Soft palate seen Grade 3
Hard palate only seen Grade 4

41. - Patient’s mouth open and tongue protruding
- Higher the grade, higher the risk in obtaining and securing
airways
- Look for loose teeth, obvious tumors, scars, infections,
obesity, thickness of neck which will indicate difficulty in
obtaining airway
- Modified Mallampati class
- Jaw protrusion, neck movement and thyromental distance

42. Preoperative assessment in emergency surgery
- Start similar principle to that for elective surgery
- Constraints : time, facilities available
- Consent : may be not be possible in life saving emergencies
- Organisational efforts : for example, local/ national algorithms
for treatment of multi-trauma patients

44. GENERAL MANAGEMENT
AND
SYSTEM SPECIFIC
POST-OPE
COMPLICATION
SABRINA TAMILMANY

45. 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.

46. GENERAL
MANAGEMENT

47. WHAT IS NEEDED?
 the immediate recovery and requires to detect
early signs of complication.
 Receive a complete patient record from the
operating room which to plan post operative
care. Patient’s name
•Age
•Surgical procedure
•Existing medical problem
•Allergies
•Aneasthetic & analgesics given
•Fluid replacement
•Blood loss
•Urine output
•Any surgical/ anaesthetic problems
encountered

48. Assessing the patient
 Monitor vitals-pulse volume
and regularity, depth and
nature of respiration.
 Assessment of patient’s O2
saturation.

49. KEEP MONITORING VITALS

50. • Check the level of consciousness.
Ability to respond to commands.

51. MAINTAIN INTAKE AND OUTPUT

52. PROTECT
AIRWAY
 By proper positioning of
patient’s head.
 By clearing airway.
 Oxygen therapy.

53. Maintaining IV Stability
Hypovolemic shock: can be avoided
by timely administration of IV Fluids,
blood and blood products and
medication.
 Replacement of fluids.[colloids and
crystalloids]
 Keep the patient warm.
 Monitor intake and output balance.
 Monitor the vitals continuously with
the patient condition.

54. ASSESSMENT OF THE SURGICAL SITE
 Haemorrhage
It is a serious complication
of surgery that resulting
death.
 It can occur in immediate
post operatively or upto
several days after surgery.
 If left untreated,cardiac
output decreases and blood
pressure and Hb level will
fall rapidly.

55. • Blood transfusion if necessary.
• The surgical site+incision
should always be inspected.
• If bleeding,pressure dressing
are placed.
• If the bleeding is
concealed,the patient is taken
in OR for emergency
exploration of concealed
haemorrhage in body cavity.

56. RELIEVING PAIN +ANXIETY
 Administer opioid analgesia as
per Doctor’s order.
 Epidural analgesia.
 NSAIDS.
 Psychological support to
relieve fear+To give support.

57. CONTROLLING NAUSEA+VOMITTING
These are common
problem in post
operative period.
Medication can be
administered as per
doctor’s order.
Example:
Inj Metaclopramide
Inj Ondansetron
( Emeset )

58. WHEN TO BE DISCHARGED
FROM RR?
• When patient fulfill following criterias,
 Fully concious
Respiration and oxygenation are satisfactory
Not in pain or nausea
CVS parameters are stable
Oxygen, fluids and analgesics prescribed
No conceren related to surgical procedure

59. SYSTEM SPECIFIC
COMPLICATION

60. RESPIRATORY COMPLICATION

61. • most common are
 hypoxaemia
 hypercapnia
 aspiration
• late complication
 Pneumonia
 pulmonary embolism

62. POSTOPERATIVE HYPOXIA
• Present as shortness of breath, or agitated due
to upper airway obstruction
• Signs
 Absence of air movements
 Seesaw movement of chest
 Suprasternal recession
 cyanosis

63. Causes of
hypoxia
Upper airway
obstruction due
to residual
effect of
anaesthesia
Laryngeal
edema due to
tracheal
intubation or
palsy
hypoventillatio
n
Atelectasis or
pneuomia
Pulmonary
edema of cardiac
origin
Pulmonary
embolism with
sudden chest pain

64. TREATMENT
• Should be treated urgently
• Administer oxygen at 15L/min using a non-
rebreathing mask + head tilt, chin lift and jaw
thrust
• Suctioning of any blood or secretions
• Tracheal intubation and manual ventillation
• If pneumonia : antibiotics, chest physiotherapy
and bronchodillators
• If pulmonary edema : start on diuretics and
cardiology opinion sought

65. CARDIOVASCULAR
COMPLICATION

66. • Hypotension is common due to inadequate
fluid replacement, vasodilatation from
anesthesia
• Other causes
 Surgical bleeding
 Sepsis
 Arrythmias
 Myocardial infarction
 Cardiac failure
 Tension pneumothorax
 Pulmonary embolism

67. • Signs
 Cold clammy extremities
 Tachycardia
 Low urine output ( < 0.5 ml/kg )
 Low CVP

68. MYOCARDIAL ISCHEMIA /
INFARCTION
• Patient with previous cardiac problems are at
risk of ACS
• Present with retrosternal pain radiating to jaw,
neck or arms, may have nausea, dyspnoea or
syncope
• ST elevation seen in 2 continous leads on ECG
and serum troponin level will be high in both
conditions

69. TREATMENT
• Start with oxygen, glyceryl trinitrate, morphine
and aspirin
• Beta blockers or calcium antagonist may be
started
• Cardiologist should be involved.

70. ARRYTHMIA
• Cause hypotension and ischemia
• Need continuous monitoring
• Treated according to Resuscitation Council
peri-arrest guideline,
Correct the cause including acid-base and
electrolyte imbalance, hypoxia, and
hypercapnia

71. RENALAND URINARY
COMPLICATIONS

72. ACUTE RENAL FAILURE
• Any perioperative events like sepsis, bleeding,
hypovolaemia, rhabdomyolysis and abdominal
compartment syndrome precipitates
• Treatment,
 If urine output < 0.5ml/kg for 6 hrs, check the catheter if its
blocked
 Correct hypovolaemia, metabolic and electrolyte disturbance
and stop nephrotoxic dugs

73. URINARY RETENTION
• Common in pelvic and perineal operations
• Catheterisation should be performed if an ope
expected to last more than 3 hours or longer or
when large volumes are administered

74. URINARY INFECTION
• Patient present with dysuria or pyrexia
• Immunocompromised, diabetis and patient
with h/o urinary retention are at higher risk
• Treatments
Adequate hydration
Proper bladder drainage
antibiotics

76. Complicatons Related
to Specific Surgical
Specialities
Anna Alisha Mathew Simon

77. Abdominal Surgery
• The abdomen should be examined for
distension, tenderness, drainage
• Sites/wounds :
– Paralytic illeus
• following surgery, bowel movements may
reduce temporarily
• adequate hydration and electrolytes
– Localised infection
– Anastomotic leakage

78. Orthopeadic Surgery
• Neurovascular status of limbs must be checked
regularly
• External fixator-pin site should be checked
• Compartment syndrome-remove circumferential
dressings-fasciotomy

79. Neck Surgery
• Accumulation of blood = asphyxia
• Recurrent laryngeal nerve damage-pre
and post op

80. Thoracic Surgery
• Regular review of chest drain
• Continous ECG monitoring
• Bronchopleural fistula
• Heamothorax
• Pleural effusion

81. Neurosurgery
• Raised intracranial pressure-monitored
closely
Vascular Surgery
• Regular clinical assessment and Doppler
ultrasound post op

82. Plastic Surgery
• Viability of flaps and perfusion needs to be
monitored regularly
Urology
• Catheter patency must be check regularly
• TURP-continous bladder irrigation-
pulmonary oedema

83. GENERAL POSTOPERATIVE
PROBLEMS AND MANAGEMENT
NUR NABILAH ISZA BT ISMAIL JA’FAR

84. • Pain
• Nausea and vomiting
• Bleeding
• Deep vein thrombosis
• Hypothermia and shivering
• Fever
• Prophylaxis against infection
• Confusional state
• Drains
• Wound care
• Wound dehiscence
• Enhanced recovery

85. Pain
• Most feared problem among patients
• More than 80% of patients experience post operative
pain

86. Nausea & Vomiting
• Postoperative nausea and vomiting (PONV) can precipitate bleeding and
dehiscence of wounds by dislodging the clots and bursting suture lines.
• In neurosurgical patients  raised intracranial pressure
• Risk factors:
– Women
– Non smoker
– Past h/o PONV, motion sickness, migraine
– Use of volatile anesthetic agents, opioids & NO
– Duration and type of surgery
• Management
– Adequate treatment for pain, anxiety, hypotension & dehydration
– Antiemetic (eg. Ondansetron, dexamethasone)

87. Bleeding
• Primary hemorrhage:
– either starting during surgery or following
postoperative increase in blood pressure - replace
blood loss and may require return to theatre to re-
explore the wound
• Secondary hemorrhage:
– often as a result of infection.

88. Deep Vein Thrombosis
• Presentation:
– Calf pain
– Swelling
– Warmth
– Redness
– Engorged veins
• Venography or duplex Doppler ultrasound is used to assess
flow and the presence of thromboses
• Management :
– Use of stockings, calf pumps
– Low molecular weight warfarin

89. Stratification of risk of DVT
Low Medium High
Maxillofacial surgery Inguinal hernia repair Pelvic elective and
trauma surgery
Neurosurgery Abdominal surgery Total knee and hip
replacement
Cardiothoracic surgery Gynecological surgery
Urological surgery

90. Hypothermia and shivering
• Anesthesia induces loss of thermoregulatory control.
• Exposure of skin and organs to a cold operating
environment, volatile skin preparation, infusion of
cold IV fluids
• Leads to increased cardiac morbidity, a
hypocoagulable state, shivering with imbalance of O2
supply and demand, immune function impairment
with possibility of wound infection.
• Management  active warming devices

91. Fever
• Causes of a raised temperature postopertively
include:
– Day 2-5 : atelectesis of lung
– Day 3-5 : superficial & deep wound infection
– Day 5 : chest infection, UTI and thrombophlebitis
– > 5 days : wound infection, anastomotic leakage,
abscess
• Management : treat possible causes

92. Prophylaxis against infection
• Patients who had foreign material insertion :
– Hip or knee prosthesis
– Aortic valve
• Bacteria can be incorporated into the biofilm that
forms on the surface of the implant.
• Management :
– Prophylactic antibiotic should be administered,
usually one dose 30 mins before ‘knife to skin’ and
two postoperatively.

93. Confusional state
• Acute confusional states occur on recovery from
anesth or few days after surgery.
• Higher in elderly with hip fractures & is
associated with increased morbidity and
mortality.
• Present as :
– Anxiety
– Incoherent speech
– Clouding of consciousness
– Destructive behavior (eg. pulling off cannula)

94. Cause
Renal  Renal failure
 Hyponatraemia
 UTI
 Urinary retention
Respiratory  Hypoxia
 Atelectesis
Cardiocvascular  Pulmonary embolism
 Dehydration
 Septic shock
 Myocardial infarction
 Chronic heart failure
 Arrhythmia
Drugs  Opiates
 Hypnotics
 Cocaine
 Alcohol withdrawal
 Hypoglycemia

95. Neurological  Epilepsy
 Encephalopathy
 Head injury
 Cerebrovascular accident
Idiopathic (rare)  Hypothyroidism
 Hyperthyroidism
 Addison’s disease

96. • Risk factors:
– Pre-existing
cognitive
impairment
– Use of narcotics,
benzodiazepines,
alcohol
– Renal impairment
– Depression
• Precipitating factors
– Physical restraints
– Addition of new
medications
– Electrolyte & fluid
abnormalities
– Intraoperative
blood loss
– Admission to ICU
• Management
– Treat underlying
medical problems
– Involve relative,
friends
– Pain control

97. Drains
• Used to prevent
– Accumulation of blood, serosanguinous or
purulent fluid
– To allow the early diagnosis of a leaking surgical
anastomosis
• Quantity & character of drain fluid can be used to
identify any abdominal complication such as fluid
leakage (eg. bile or pancreatic fluid) or bleeding
– Additional IV fluids with same electrolyte contents
• Removed if drainage stopped or become less than 25
ml/day

98. Wound care
• Within hours, dead space cells fills up with an inflammatory exudate.
• Within 48 hours, a layer of epidermal cells from wound edge bridges the
gap.
• Inspect wound only if there is any concern or the dressing needs changing
(under sterile condition)
• Inflamed wound  swab and sent for Gram staining & culture
• Infected wound & hematoma  treat with antibiotics
• Contaminated/nonviable tissue remains  packed & return to theater
every 24-48 hours for cleaning
• Skin sutures/clips are usually removed between 6-10 days after surgery.
• Delayed wound healing  patients who are malnourished, or have
vitamin A & C deficiency
• Causes of inhibition of wound healing :
– Steroids
– Diabetes (uncontrolled)

99. Wound dehiscence
• Is a disruption of any or all of the layers in a wound
• Commonly occurred from 5th to the 8th postoperative
day when the strength of the wound is at the weakest.
• It may herald an underlying abscess & usually presents
with serosanguinous discharge.
• Management
 Return to theater & resuturing
 Leave wound open & treat with dressings or vacuum
assisted closure (VAC) pumps

100. Risk factors
General Local
Malnourishment Inadequate or poor closure of wound
Diabetes Poor local wound healing
Obesity Increased intra-abdominal pressure
Renal failure
Jaundice
Sepsis

101. Enhanced recovery
• An approach to the perioperative care of patients undergoing
surgery.
• Designed to speed clinical recovery of patient, reduce the cost
and length of stay in the hospital.
• Strategies include :
– Early planned physiotherapy & mobilisation (reduce risks
of DVT, urinary retention, pressure sores)
– Early oral hydration & nourishment
– Good pain control NSAIDs
– Discharge planning (support from stoma care nurses,
physiotherapists)

102. DISCHARGE OF PATIENTS

103. Discharge Letter
• Do include:
– Diagnosis
– Treatment
– Laboratory results
– Complications
– Discharge plan
– Support needed (eg: physiotherapy)
– Follow up

104. Follow Up in Clinic
• Reviewed in clinic when a key decision on
management needs to be made
• Letter to patient’s GP:
– Care plan agreed with patient
– Advise on recognizing the onset of complications
• Discharge patient from clinic