2. INTRODUCTION
Postoperative period is the period follows
surgery and after the recovery period. It
has a special care and many complications.
So, patient should be managed in this
period.
4. 1- Vital signs monitoring
Blood pressure, pulse, and respiration
should be recorded frequently until stable
and then regularly until the patient is
discharged from the recovery room.
5. 2- Respiratory care
It is simply measured by pulse oximetry.
Giving patient oxygen by mask corrects
moderate hypoxia but if oxygenation fails
(ABG) ANALYSIS should be performed and
in some conditions patient must be
intubated and ventilated.
6. 3- Medications
Pain control: oral analgesia is given in mild
to moderate pain.
Opiates are given IM, IV or Epidural to
control moderate to sever pain.
If patient is on TPN the analgesic is given
parenterally.
Antibiotics, sedatives, DVT prophylaxis,
antipyretics and laxatives.
7. 4- Drains
There are many types of drains.
There functions are according to process of
surgery, i.e.:
Drainage of fluids from cavities, pus from
abscesses, decreasing pressure.
For dirty procedure you can use open
system of drain.
8. 5- Catheters
Urethral catheter is put to prevent urinary
retention and is removed if patient is
conscious and mobile.
9. 6- Fluids and Electrolytes balance
Standard IV fluids for an adult is 35-70
ml/kg/day (1/3 normal saline +2/3 L
5%dextrose)
Fluids and electrolytes replacement is
depending on:
General circulation status of patient, urine
output and other measurements, urea and
electrolytes level
K replacement is not necessary within first
24 - 48 hours because body store is
sufficient.
10. K replacement (60-80mmol/day) can be
added to IV fluids.
If patient can take fluids orally, IV fluid
therapy is discontinued.
IV fluids: given for all patients general
anesthesia and it is not needed for local
anesthesia.
The more cutting in tissues, the more K will
be lost in blood.
11. 7- Blood transfusion
HB measurements will lead to the need for
postop blood transfusion.
CBC should be taken within 24 hours of
surgery and blood transfusion is applied if
HB is less than 8g/dl.
If patient HB is above this level, oral iron is
prescribed for patient unless the patient has:
cardiovascular instability, symptomatic
anemia and elective surgery done for
patient with Hb above 10.
12. 8- Position in bed and
mobilization
to prevent bed sores and thrombosis.
13. 9- Wound care
Keep the wounds clean and sterile.
Change dressing regularly.
15. 1. Fever
An elevation in body temperature postoperatively is so
common that many mistakenly consider it a normal
postoperative state
According to the society of critical care medicine
temperature elevation to 38.3˚ C is a trigger to initiate
an investigation
Evaluation should begin with a review of the
circumstances surrounding the patient, followed by
physical examination. Only after these two steps have
been taken should consideration be given to
diagnostic studies
16. Common causes of postoperative
fever:
At 0-48 hours:
Atelectasis
Wound infection
Leakage of bowel anastomosis
Aspiration pneumonia
Post blood transfusion
17. After postoperative day 3:
Urinary tract infection
Wound infections
Catheter infection
Intra-abdominal abscess
Phlebitis
Deep venous thrombosis
Pulmonary embolism
Drug fever
20. Wound infection
Incidence increases with long operation, abdominal
procedure, fluid collection, extremes of age,
diabetes, malnutrition, immunosuppression and
nasal carriage of staphylococcus aureus
Wound infections within 24-48 hours
postoperatively are frequently caused by clostridia
or group A streptococci
Most commonly occurs 3-7 days after surgery
mainly by staphylococci, streptococci and if a
hollow viscus has been entered gram negative
organisms
22. Superficial
Fascial
Factors that lead to wound dehiscence:
Local ischemia
Increased intra-abdominal pressure
Underlying illness
Poor surgical technique
Wound infection
Wound dehiscence
23. Typically 5-8 days postoperatively and preceded by
sudden drainage of pink, serosanguineous
peritoneal fluid
Treatment:
If evisceration occurs, cover the wound with sterile
saline soaked towels and arrange immediate
operative intervention and repair
Minor fascial separation without evisceration may
be treated expectantly with later repair of the
resultant hernia
24. Hematoma and seroma
A hematoma is a localized blood collection beneath
the wound
Treatment:
By percutaneous aspiration or may require opening
of the wound, evacuation and bleeding control in
case of expanding hematoma. Small, non-
expanding hematomas may be left alone but must
be watched for signs of infection
A seroma is a localized collection of serous fluid
often where skin flaps have been raised or where
lymphatics have been divided
Treatment:
Small areas may be left and may absorb
spontaneously. Large ones need drainage
25. Ischemic necrosis
Caused by disturbed arterial inflow or
venous outflow, or by tension at the site of
closure
Treatment:
by debridement
26. Insicional hernia
Incidence of Insicional hernia after surgery is 10%
Causes:
Factors that delay wound healing
Poor suture
Increased intra-abdominal pressure
Coughing/straining
Usually these hernias have a wide base and rarely lead to
strangulation
Treatment:
If the patient is unfit, a surgical belt may be worn. If
the patient is fit surgical repair should be carried out
27. Anastomotic breakdown
It is a major cause of morbidity and mortality after
abdominal surgery
Causes:
Poor surgical technique
Ischemia at the anastomosis
Preoperative sepsis
Distal obstruction
Residual inflammatory disease
General condition
May result in peritonitis, paracolic abscess, abscess
between loops of bowel and fistula formation
Treatment:
Surgical re-exploration with repair of the leak
28. 3. Pressure ulcers
Occurs in 10% of acutely hospitalized patients, and
results from pressure ischemia especially over bony
prominences (heal, sacrum and ischial tuberosities)
Patients at risk:
Neurologically impaired (chronic spinal cord injury)
Those with critical illness who are bedridden
Pressure ulcers can be prevented by frequent
turning and repositioning of patients at risk
Established pressure ulcers may need surgical
drainage to control infection and plastic
reconstruction to close the defect
30. 1- Paralytic ilieus
It is a functional abnormality where there is cessation
of GI motility, it usually starts immediately post
operatively and lasts for up to 48h.
causes could be:
1- abdominal surgery (laparatomy)
2- immobilization
3- medications(anticholinergics, narcotics, ganglion
blockers, etc)
4- localized inflammation adjacent to the peritoneal cavity
5- retroperitoneal Hmg
6- spinal or pelvic fractures
7- metabolic ( hypokalemia, ketoacidosis, uremia)
31. S & S: abdominal distension, vomiting,
constipation, tense tympanic abdomen, absent
bowel sounds
management:
1- NGT suction hourly
2- NPO until evidence of bowel motion
3- good hydration with urine output monitoring
4- correction of any electrolytes or acid-base imbalance
5- if persisted more than 3 days exclude mechanical
obstruction
Usually full recovery of bowel motion takes 3-5
days
32. 2- Mechanical intestinal obstruction:
it occurs usually after abdominal surgery up to 90% of
cases are caused by adhesions or internal herniation
classified as:
1-early: within 2wks post-operatively usually due to
fibrinous adhesions
2-late: after 2wks usually due to peritoneal healing with
fibrous band formation
same clinical picture & management as paralytic ilieus
may progress to strangulation where surgical
intervention is indicated
33. mechanical
obstruction
Paralytic ilieus
Persists for longer
time
Usually recovers in 3-
5 days
duration
Exaggerated & high-
pitched
absent
Bowel sounds
Colicky pain
painless
pain
Localized small bowel
distension while colon
& rectum are gas-free
Multiple air-fluid levels
involving both small &
large bowels
Abdominal XR
34. 3- Constipation
Causes:
1- dehydration
2- starvation
3- inactivity
4- medications (ex. opiates)
Management:
1- exclude fecal impaction by PR examination and
administer oil enema if confirmed
2- daily check up for bowel opening
3- give lactulose as soon as pt. is eating
4- glycerin suppositories
5- high fiber diet & bulking agents
35. 4- Acute gastric dilatation:
usually occurs in the early post-operative period, may be
associated with shock & it may cause vomiting and
aspiration
risk factors for this condition are:
1- abdominal surgery
2- gastric outlet obstruction
3- splenectomy
management:
1- NGT aspiration (several liters of dark-colored fluid with
altered blood)
2- fluid and electrolytes replacement
36. 5- Short Bowel Syndrome:
It usually follows extensive bowel resection (when less
than 120cm of bowel are left)
the pt. complains of diarrhea & malabsorption.
Managed by:
1- NPO &TPN for short duration
2-perminant multiple small-meals diet as soon as pt. can eat
37. 6- Pancreatitis:
causes are:
pancreas manipulation during surgery
decreased pancreatic blood flow (ex. Cardiopulmonary
bypass)
gallstones disease
hypocalcemia due to any cause
side effect of medications
idiopathic
managed as any other case of acute pancreatitis
39. 3-Extra-hepatic biliary obstruction
Gallstones
Ascending cholangitis
Pancreatitis
Common bile duct injury
Management:
1- of the cause
2- usually self-limited
42. 1- Pulmonary collapse
(atelactasis)
Definition:
collapse of part or all of a lung d.t a blockage of the air
passages (bronchus or bronchioles) or by pressure on
the lung.
Causes:
- Anesthetic agent - Tumors
- Abd.pain or distention - COPD or smoking
45. 2- Aspiration Pneumonia
Definition :
spillage of gastric content into the bronchial tree leading
to direct injury to the airways .
Causes :
- Anesthesia .
- Paralytic ileus .
47. 3- ARDS .
Definition :
inflammation of the lung parenchyma leading to
impaired gas exchange ending with hypoxemia and
multiple organ failure.
Causes :
septicemia vomit inhalation DIC
blood transfusion fat embolism analgesia
48. Presentation :
SOB
Exams & Tests :
CXR
ABG
Management :
Treat the cause
Treat lung problems
49. 4- Pneumothorax :
- Central venous line .
- Emphysematous bulla rupture .
5- Hemothorax :
- Chest surgery .
6- Pulmonary edema :
- IV fluid .
- Elderly with cardiac or renal
dis .
50. 7- Acute respiratory failure
Causes :
- general anesthesia or
major surgery .
- systemic sepsis .
Management :
- clearing airway .
- Oxygen by mask .
- relieving underlying cause .
- cardio-pulmonary support .
52. The risk of anesthesia & surgery are increased in
patient suffering from cardiovascular disease
Classifications of cardiac complications:
Immediate: - operative MI
- Hypotension
- Arrhythmias
- Acute heart failure
Late: heart failure
Cardiac Complications
53. Predisposing factors:
Major surgery + any risk of IHD: - DM
- HTN
- dyslipidemia
- smoking
- obesity
Hypovolumic episodes in IHD
Hypovolumic episodes in elderly
Cardiac surgery it self
IHD in non cardiac surgery
1- Operative myocardial infarction
54. 5-20 %
Presentation of MI in surgical patient may be more
subtle
The majority of episodes of post op. MI are silent
Evaluation:
Immediate ECG
Serum troponin levels
ECHO to asses the cardiac function
55. Management:
High flow O2
Transfer to ICU & early involvement of the
Cardiologist
B blockers, aspirin, heparin
In most cases thrombolytic therapy is
contraindicated in the post op. period
Diuretics & antiarrhythmic should be considered
Constant ECG is required
Angiography in nonresponding patient
56. 2- Hypotension
Causes are:
Hypovolemia due to:
Inadequate blood replacement
Third-space loss
Postoperative hemorrhage
Preexisting ventricular dysfunction
57. Management:
Fluid or blood resuscitation
Pharmacologic support with a pressor may
become necessary
Monitoring of the volume status
58. HTN is a serious problem that can cause
complications in the pre, intra & postoperative
period.
25% of patients with a prior history of HTN will
develop postoperative HTN
Postoperatively HTN can be caused by:
Pain & excitement
Fluid overload
Failure to administer hypertensive medications
3- Postoperative Hypertension
59. HTN should be detected during the routine
preoperative work-up.
Hypertensive patient with diastolic BP >110 mmHg
Management:
Beta blockers
Alpha2 agonists
ACE inhibitors
Intravenous vasodilators
60. Possible causes are:
Electrolytes imbalance
Fever and shivering
Medications
Stress
Underlying cardiac disease
Tachycardia increases myocardial O2 consumption
& decreases coronary arteries perfusion which my
lead to myocardial ischemia & infarction
* Initial approach:
Correction of any underlying medical conditions.
4- Cardiac Arrhythmias
61. Supraventricular tachycardia (SVT) including A.fib
- Most common after cardiac surgery
- 20-30 %
- Usually preceded by multiple PACs
Ventricular ectopy (more common in non cardiac
surgery)
- for frequent >6-10/min or premature ventricular
complexes
- Treatment: with lidocaine 1mg/kg followed by at drip
2-4 mg/min
- Cardioversion when symptomatic V.tach or V.fib
Nodal or junctional rhythm
- If asymptomatic or normotensive no treatment
62. Atrial ECG using atrial pacing leads in
distinguishing fibrillation from flutter during rapid
rates
Adenosin can be used as diagnostic & therapeutic
intervention
Diltiazem if adenosin fails to convert
Atrial fibrillation Digoxin to control rate
Atrial flutter - rapid atrial pacing >400 b/min
- Digitalis
- B blocker
- verapamil
Calcium channel blockers must be given as wide
complex SVT can mimic V.tach
63. Predisposing factors:
Anesthetic medication
Hypotensive episodes
Fluid disturbance mismanagement
Weak EF going for major surgery
Low cardiac output syndrome (cardiac index < 2.0
L/min/m2) CI= CO/BSA = SV x HR / BSA
Signs: decreased urine output, acidosis and hypothermia
Assessment: heart rate & rhythm, pre & afterload states &
measurement of CO
5- Acute Heart Failure
64. Treatment:
Stabilize rate & rhythm
Volume status & systemic vascular resistance
Correct acidosis & hypothermia
Ionotropic agents
If persists intra-aortic balloon pump
Heart Failure as a late complication it could be due to:
1. Failure of the heart it self (cardiac disease) EF
2. Failure of the procedure: 1. repair
2. infective endocarditis
3. failure of anastomosis
67. 1- Deep vein Thrombosis (DVT)
There is risk of DVT after all the most minor
operation but the risk reflect several factor:
Increase of age
Obesity
Extend and type of operation
Period of post operative bed rest
Present of malignant disease
Use of OCP
Cardiac failure
Pregnancy
Past history of DVT or pulmonary embolism
68. Precaution measure against
thromboembolism:
Avoidance of prolonged vein compression
Using compression stocking
LMWH
Subcutaneous heparin:5000 U given S.C injection starting 2hour
before operation and continue 8-12 until the patient ambulant
Intravenous heparin by low dose infusion in those at special risk
Investigations:
Duplex ultrasound
Ascending venograph (iliofemoral thrombosis)
Radio labeled fibrinogen (screening)
69. 2- Pulmonary Embolism
It is an emergency case if patient develops pulmonary
embolism
Massive embolus:
-patient will be pale,shoked, need immediate (CPR) &
hepranization.
-the embolus will be detected by CT pulmonary
angiography
Management
Fibrinolytics e.g. streptokinase or urokinase can be
infuse intravenously to encourage clot lysis if the
patient is at least 6days post surgical intervention
In extreme case, the clot is removed by open
pulmonary embolectomy under cardiopulmonary by
pass (TRENDELENBURG OPERATION)
70. In small embolus:
Patient complain of chest pain with or without tachypnea, hemoptysis
and plural rub and effusion
The radioisotope ventilation perfusion lung scan (V/Q scan) is the
investigation of choice
CXR & ECG are advisable, mainly to rule out other possible cause of
pain and collapse.
Management:
- If V/Q scan reveals lobar or segmental perfusion defect(s) the
patient is heparinized and monitored carefully .
- Searching for the source of embolus , if phlebography reveals
thrombus in the iliofemoral junction , then a filter can be inserted in
to the inferior vena cava to prevent further pulmonary emboli .
- Warfarin therapy is recommended in all patients who have
sustained pulmonary embolism , and therapy is normally continued
for 3 - 6 months .
71. 3- Bleeding:
Classification:
Primary (reactive): within 24 – 36 hours.
Secondary: start after day 7 post operation .
Causes of PRIMARY Bleeding:
- Slipped ligature .
- Dislodgment of diathermy coagulum as the blood
pressure recovers from the operation and the patient
vomits and coughs .
- Blood vessels damage .
- Defective vascular anastmosis .
- Massive blood transfusion without adequate clotting
factors.
72. Management :
Check clotting screen .
Local pressure, if bleeding does not stop , re-
exploration of the wound is required .
73. Causes of SECONDARY bleeding :
Deep seated infection
Management :
Surgical re-exploration after correction of
hypovolemic shock .
75. 1- Acute retention of urine
Acute retention of urine typically occurs in elderly males with pre-
existing prostatism, especially after groin operations (e.g. hernia
repair) or perineal operations (e.g. haemorrhoidectomy).
The mechanism is unclear, but appears to be related to:
1- pain inhibiting normal contraction of the abdominal muscles and
relaxation of the bladder neck.
2- IV fluid administration
3- embarrassment and transient neurological effects of general or spinal
anesthesia may also play a role.
The patient will be unable to pass urine, and lower abdominal pain is
common. On examination the bladder can be felt as a midline mass
arising out of the pelvis which is dull to percussion and usually tender.
It should be managed at first conservatively be ensuring adequate
analgesics & stand the patient up. If this fail, pass a urinary catheter
76. 2- Urinary tract infection
Postoperative urinary tract infection is common,
particularly in women. Especially after urological &
gynecological operations.
The presence of a urinary catheter is the most likely cause,
but reduced urine output, inadequate bladder emptying in
the supine position and bacteraemia induced by surgery
are other possible reasons.
The patient is often asymptomatic and pyrexia may be the
only sign. After removal of the catheter, dysuria, frequency,
dribbling & smelly urine may be experienced.
It should be managed by adequate hydration, bladder
drainage & proper antibiotics
77. 3- Acute renal failure
Acute renal failure can be classified as:
Pre-renal: This results from hypovolaemia or reduced
cardiac output (e.g. haemorrhagic shock, septicaemia,
cardiogenic shock) and is the commonest form of
postoperative oliguria.
Renal: This may be caused by pre-existing renal disease
such as diabetes, hypertension or glomerulonephritis.
Nephrotoxic drugs such as gentamicin may be to blame,
and myoglobinuria (from crush injuries) or haemoglobinuria
(from haemolysis) can be implicated.
Post-renal: This is due to obstruction of the urinary tract
e.g. ureteric damage, blocked urinary catheter.
78. You should manage it by:
restoring adequate circulating blood volume without
over hydration.
Diuretics, e.g. frusemide or mannitol, in early stages to
provoke the secretion of urine.
Low dose dopamine may increase renal blood flow
Correct any electrolyte disturbances.
80. 1- Neuropsychiatric disturbances
The most common disorder is delirium (mental
confusion with agitation, restlessness & disorientation).
It is most commonly seen in elderly patients, particularly
at night. There is, however, often an underlying cause
such as:
hypoxia
sepsis
oversedation
electrolyte imbalance
hyper or hypoglycaemia
alcohol or benzodiazepine withdrawal
cerebrovascular accident (stroke).
The patient is disorientated, both in time and space.
Hallucinations may occur.
81. 2- Stroke
A postoperative cerebrovascular event (bleed or ischaemic
episode) is more common in patients with a previous
history of similar events. Hypotension during surgery may
be important, particularly in the patient with carotid artery
disease or hypertension & it is seen more after cardiac or
carotid surgeries.
The clinical features will depend on the underlying
neurological damage, but range from a minor transient
ischaemic attack (TIA) to a dense, completed stroke.
