3. Introduction
Care is given to the patient after an operation in order to minimize post
operation complications.
To provide the patient with quick, painless and safe recovery from
surgery
Early detection and treatment is possible if there is optimal care and
assessment
Requires appropriate skills and knowledge to manage medical as well
surgical post OP problems
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4. Phases of Post-operative Care
1. Immediate phase
2. Intermediate phase
3. Convalescent phase
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5. Immediate Phase
• ASA and AAGBI standards for procedures requiring GA and CNB
• Transfer to recovery room/PACU
• Staff trained
• Standards of equipment and discharge criteria
• post op observations
• Ensure airway, breathing & circulation are satisfactory
• Monitor pain
• Watch for complications (like bleeding from the wound)
• Monitor BP, pulse, oxygen saturation
• Temperature
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6. Con..
The patient can be discharged from the recovery room when they fulfill
the following criteria:
• Patient is fully conscious
• Respiration and oxygenation are satisfactory
• Patient is normothermic, not in pain nor nauseous
• Cardiovascular parameters are stable
• Oxygen, fluids and analgesics have been prescribed
• There are no concerns related to surgical procedure
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7. Intermediate Phase
• Starts with complete recovery from anesthesia & lasts for the rest of
hospital stay. It includes
Wound care,
Drains,
Nasogastric tube,
Urinary catheters,
Oxygen therapy
Fluid management and
Pain control
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8. 1. Wound Care
• Dressings should be applied and
removed correctly.
• Skin sutures should be removed at the
appropriate time and replaced by tape.
• Wound healing and wound problems.
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9. 2. Drains
• Drains & tubes are placed in
a wide variety of locations.
• To prevent accumulation of
air and to prevent
accumulation of fluids
(blood, pus, infected fluids)
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10. 3. Nasogastric tube
• Is specialized tube that
carries foods and
medicines to stomach
through nose.
• It is commonly placed
in GI operations for
treatment of ileus.
• Usually for drainage of
gastric secretions.
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11. 4. Urinary catheters
• Commonly placed after bladder
or GU surgery
• Used to empty bladder and
collect urine in drainage bag
• To provide accurate
measurement of volume output
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12. 5. Oxygen therapy
• Often necessary after a surgical
procedure.
• Indicators
• shallow breathing & pain
• atelectasis
• operative manipulation in the chest
cavity
• post-op impairment of breathing
mechanics
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13. 6. Fluid management
• To restore lost volume
7. Pain control
• To relieve the suffering and stress
• Through the use of analgesics
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14. Convalescent Phase
• Between the end of a disease and the patient’s restoration to complete
health.
• Transition period from the time of hospital discharge to full recovery.
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15. In summary
• All anaesthetized patients should be recovered in dedicated PACU
• All vital parameters should be monitored and documented acc.to the
local protocols
• Treat pain and nausea/vomiting
• Observe for complications
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18. • Immediate complications are complications that happen within 24hour
period of time. Like:
Fever
Primary hemorrhage
Low urinary output
Cardiovascular complications and
Respiratory complications
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19. Fever (Pyrexia)
• Pyrexia (fever) refers to a raised body temperature, typically greater
than 37.5c.
• Common in surgical patients, either normal immediate post-
operative response or as feature of a specific post-operative
complication.
• The most common cause of pyrexia in the post-operative patient is
infection.
• Drug interaction and transfusion reaction are less common causes.
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20. • The specific post-operative day on which the fever develops may
indicate the source of the infection:
• Day 1-2 – consider a respiratory source (or body’s routine response to
surgery)
• Day 3-5 – consider a respiratory or urinary tract source
• Day 5-7 – consider a surgical site infection or abscess/collection
formation
• Any day post-operatively – consider infected IV lines or central lines as
a source
21. Hemorrhage
• It is the most common complication.
• Can be due to
• coagulation or clotting factor defect, continuous bleeding from wound site,
• failed hemostasis, and
• associate injury which went unnoticed during surgery.
• The clinical manifestation will be according to the volume of blood
that is lost.
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22. Cont.
• Presentation
• low blood pressure,
• rapid pulse, paleness,
• hematoma formation,
• bruising at the site of surgery,
• Continuously soaking wound dressing
• Rx:
• adequate resuscitation,
• reopen the wound to secure hemostasis,
• Tx of blood or blood products such as platelets or fresh frozen plasma
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23. Acute Kidney Injury/Oliguria
• Oliguria, or low urine output, is common in the postoperative patient and
is often the first presenting sign of acute kidney injury (AKI) or acute
renal failure (ARF).
• While oliguria can occur in any patient, patients with preexisting chronic
kidney disease (CKD) are at higher risk.
• Other risk factors include advanced age, heart failure, hypertension,
peripheral vascular disease, diabetes,
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24. Respiratory system Complications
o Atelectasis
o Pneumonia
o Aspiration pneumonitis
o Pulmonary edema
o ARDS
o Pulmonary embolism
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25. 1. Atelectasis
• A condition characterized by areas of airway collapse distal to an
occlusion.
• Most common post operative pulmonary complication.
• Often a precursor or contributor to other important, and often more severe,
post-operative pulmonary complications such as pneumonia.
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26. Predisposing factors
• The main risk factors for developing atelectasis in the surgical patient
include:
1. Smoking
2. Pulmonary problem(bronchitis, asthma etc)
3. Depressed cough reflex
4. NGT
5. Congestion of bronchial wall
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27. Clinical Features
• The most common clinical
features are increased
respiratory rate and
reduced oxygen saturations.
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28. Cardiac complications
• Individuals with cardiovascular conditions are at an increased risk for
postoperative complications.
• For this reason, underlying vascular conditions, such as hypertension,
should be corrected as much as possible before the procedure.
• Most common cardiac complications are
• Myocardial Infarction
• Heart Failure
• Arrythmia
• Stroke
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30. Myocardial Infarction
• The most common cardiac complication.
• Diagnosis:
• ECG: characteristic abnormalities depending on the location/type of MI
• Troponin levels: elevated
• Echocardiography : can help predict survival and look for complications of MI
• Coronary angiography: gold standard test
• Management:
• Varies according to hemodynamic stability
• MONA therapy: morphine, oxygen, nitroglycerin , and aspirin Statins to reduce
in-hospital mortality
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32. Early complications
• Acute confusional state
• DVT and PTE
• Acute urinary retention, UTI
• Surgical site infection
• Pressure sores
• Wound complications
• Pneumonia ,Pneumothorax, Atelectasis
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33. Confusional State
• Develops in 10% of patients especially elderly
• High morbidity and mortality
• Anxiety, incoherent speech, cloudy consciousness, destructive
behavior, sleep deprivation…
• Various causes
• Renal
• Respiratory
• Cardiovascular
• Drugs
• Idiopathic
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34. Deep Vein Thrombosis
• It presents with calf pain, swelling,
warmth, tenderness, engorged veins and
Homan’s sign.
• Risk factors include
• Age > 60
• Recent surgery
• Immobilization
• Trauma
• OCP
• Obesity
• Heart Failure
• Cancer
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35. Cont…
Treatment
• IV heparin initially, then long-term warfarin
• Untreated DVT results in chronic venous insufficiency and pulmonary
embolism.
• Preventive measures include
o Early ambulation
o Hydration
o Compression stockings
o LMWH as prophylaxis
oMinimal use of tourniquets
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36. Urinary infection
• Urinary infection is one of the most commonly acquired infections in
the postoperative period.
• Patients may present with dysuria and/or pyrexia.
• Immunocompromised patients, diabetics and those patients with a
history of urinary retention are known to be at higher risk.
• Treatment involves adequate hydration, proper bladder drainage and
antibiotics depending on the sensitivity of the microorganisms.
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37. Urinary Retention
• Inability to void after surgery is common with pelvic and perineal
operations, or after procedures performed under spinal anesthesia.
• Pain, hypovolemia, problems with access to urinals and bed pans and a
lack of privacy on wards may contribute to the problem of urine
retention.
• The diagnosis of retention may be confirmed by clinical examination
and by using ultrasound imaging.
• Catheterization should be performed prophylactically when an
operation is expected to last 3 hours or longer, or when large volumes
of fluid are administered.
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38. Paralytic Ileus
• Paralytic ileus describes a deceleration or arrest in
intestinal motility following surgery.
• It is classified as a functional bowel obstruction and
is very common, particularly after abdominal surgery
or pelvic orthopaedic surgery.
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39. Clinical Features
• Common presenting features therefore are:
• Failure to pass flatus or feces
• Loss of appetite,
• Sensation of bloating and distention
• Nausea and vomiting
• On examination, there will be abdominal distention and absent bowel
sounds (whereas in mechanical obstruction there are classically
‘tinkling’ bowel sounds present).
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40. Risk Factors
• Patient Factors
• Increased age
• Electrolyte derangement (e.g. Na+, K+ and Ca2+ derangement)
• Use of anti-cholinergic medication
• Surgical Factors
• Use of opioid medication
• Pelvic surgery
• Peritoneal contamination (by free pus or faeces)
• Intestinal resection
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41. Management
• Treatment is usually supportive, with maintenance of adequate
hydration and electrolyte levels.
• Any established postoperative ileus should be initially managed
with:
• Nil-by-mouth (NBM), ensuring adequate maintenance intravenous fluids
• Correct any electrolyte abnormalities
• Encourage mobilization as tolerated
• Reduce opiate analgesia and any other bowel mobility reducing medication
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42. Pressure sores
• Are injuries to skin and
underlying tissue
primarily caused by
prolonged pressure on the
skin
• Mainly occur in sacrum,
greater trochanter and
heels.
• Poor nutritional status,
dehydration, lack of
mobility
• Careful positioning and
padding
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43. Pulmonary embolus
• The blockage of
pulmonary arteries in the
lungs by blood clot.
• Signs and symptoms
• Diagnosis by history and
physical examination
• Investigation
• management
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45. Clinical Features
• Adhesions themselves are generally
asymptomatic. Rather, it is the effect of the adhesions
that present with clinical features .
Investigations and Management
• The patient should be kept nil-by-
mouth, prescribed intravenous fluids, and provided with
adequate analgesia.
• Surgical intervention in adhesional bowel obstruction is
warranted in any patient with clinical features of ischemia
or perforation.
• For those warranting surgical management, adhesiolysis
can be performed laparoscopically or via an open
approach.
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46. Incisional hernia
• An incisional hernia is the protrusion of the contents
of a cavity through a previously made incision in
the compartment’s wall.
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47. Clinical Features
• The characteristic clinical feature of an incisional hernia is a reducible,
soft and non-tender swelling at or near the site of a previous surgical
wound. If the hernia is incarcerated, it can become painful, tender, and
erythematous.
• On examination, a mass is palpable at or near the site of the surgical
incision, which may be reducible into the abdominal cavity.
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48. Investigations
• In most cases of incisional hernia, the diagnosis is made on a
clinical basis. However, often radiological imaging can be used to
confirm the diagnosis, most commonly CT imaging.
Management
• surgical intervention.
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49. Prevention of Complications
• To avoid surgical complications, there are standard
preventive mechanisms including:
• Preoperative “huddles” and/or “time-outs”: a time when
the entire team meets to review plans and address any
potential safety concerns prior to the case
• Policies regarding antibiotic, catheter, and drain use
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50. Cont….
• Prophylaxis measures against some of the most common
complications, based on individual risk factors:
• Anticoagulation and early ambulation to prevent DVT /PE
• Holding anticoagulation to prevent hemorrhage
• β-blockers to prevent MI
• Preoperative antibiotics and surgical preparations to prevent SSI
• Incentive spirometry to prevent atelectasis
• Discontinuing catheters, drains, and lines as soon as possible to prevent
infection
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51. References
• Williams, N. S., K., B. C. J., O'Connell, P. R., Bailey, H., & McNeill, L. R. J.
(2018). Bailey & Love's short practice of surgery. CRC Press.
• Brunicardi, F. C., & Schwartz, S. I. (2005). Schwartz's principles of surgery. New
York: McGraw-Hill, Health Pub.
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