Comprehensive presentation on Postoperative care including its phases as well as common complications after surgeries.

1. POSTOPERATIVE
CARE
DR. AZAN RID
HOUSE OFFICER
SURGICAL UNIT-II (GMMMC TEACHING HOSPITAL SUKKUR)

2. Introduction
 The aim of postoperative care is to provide the patient with as quick, painless and safe a
recovery from surgery as possible.
 Postoperative care is a critical phase due to the following reasons;
o Optimizing patient recovery
o Preventing complications
o Pain management
o Wound care
o Reducing hospital stay
o Improving patient outcomes
o Patient education
o Emotional support
o Rehabilitation
o Quality of life

4. Phases
POST-ANESTHETIC
Immediate
• PHASE I
HOSPITAL STAY
Intermediate
• PHASE II
AFTER DISCHARGE TO FULL RECOVERY
Convalescent

5. Immediate postoperative period
 All patients undergoing major surgery initially
monitored in the post anesthetic recovery room
under direct supervision of specially trained
personnel.

6. Care during this period
 Monitoring of the patient:
1. Basic noninvasive monitoring: Pulse, BP, temperature, R/R, oxygen saturation, urine output and ECG.
2. Additional invasive monitoring (in CCU):
• Central venous pressure (CVP)
• Arterial blood gas (ABG)
• Pulmonary artery wedge pressure (PAWP)
3. Fluid balance (monitoring):
• Record fluid loss
• NG suction
• Drain tube
• Catheter
• Stoma output
• Maintenance of input-output chart strictly

7. 4) Others: Depending on the nature of operation. E.g.,
Neurosurgery patients.
• Level of consciousness
• ICP should be monitored

8.  Positioning of the bed and mobilization
• Patient should be turned from side to side in every 30 minutes until conscious,
then hourly for 8-12 hours. To minimize atelectasis.
• Early ambulation and intermediate compression of calf by pneumatic device to
minimize DVT.
 Diet
Type of diet depends upon the type of operation.
 Drain tube
The drain tube should be examined frequently to assess the bleeding and
fistula.

9.  Respiratory care
• Patients who are not intubated- should be encouraged to take deep breath to
prevent atelectasis, supplementation of O2 by mask.
• Patients who are intubated- Give mechanical ventilation (if needed).
 Medications
• Adequate analgesia
• Appropriate antibiotics
• Sedatives
• H2 blockers
• Antipyretics etc.

10.  The patient can be discharged from postanesthetic care
unit when they fulfil the following criteria:
• Patient is fully conscious.
• Respiration and oxygenation are satisfactory.
• Patient is normothermic, not in pain and not nauseous.
• Cardiovascular parameters are stable.
• Oxygen, fluids and analgesics have been prescribed.
• There are no concerns related to the surgical procedure.

12. Classification of Postoperative
complications
 Based on time after surgery.
• Immediate (Within 6hr of procedure)
• Early (6-72hr)
• Late (>72hr)

13. General Postoperative Complications
 Bleeding
 Deep vein thrombosis
 Pulmonary embolus
 Fever
 Wound dehiscence
 Pressure sores

14. Bleeding
 Common in the immediate postoperative period.
 It may be arterial, venous or from any coagulopathy.
 If hemorrhage is suspected, blood samples should be taken for CBC,
coagulation profile and cross match.
 A large bore IV cannula should be sited, and fluid resuscitation
commenced.
 If the source of bleeding is in doubt and the patient is stable an U/S or CT
Scan is required.
 If the cardiovascular system is unstable patient should be taken back to OT
immediately.

15.  Treatment of hemorrhage is to stop the bleeding and supportive
management. Supportive management includes oxygen and fluid
resuscitation. It may require correction of coagulopathy.
 The decision about when to transfuse should be based on individual patient;
in general; however, the accepted transfusion trigger is 75 g/L except in the
presence of known or suspected coronary artery disease when a higher
trigger is acceptable.

16. Deep vein
thrombosis
 The symptoms and signs of DVT
include calf pain, swelling,
warmth, redness and engorged
veins.
 On palpation the muscle may
be tender and there may be a
positive Homans sign (calf pain
on dorsiflexion of foot), but this
test is neither sensitive nor
specific.

17.  Duplex doppler ultrasound and
venography can be used to assess flow
and the presence of a thrombosis.
 If a significant DVT is found (one that
extends above the knee), treatment with
parenteral anticoagulation initially,
followed by long-term warfarin or new
anticoagulant. In some patients with large
DVT, a caval filter may be required to
decrease the possibility of pulmonary
embolism.

18. Pulmonary embolism
 PE typically occurs on PO day 7 in elderly or immobilized patients.
 Thrombus can arise from DVT in the legs/pelvis, venae cava or right
atrium.
 Pain is pleuritic, of sudden onset and is accompanied by SOB. The patient
is anxious, diaphoretic and tachycardia with prominent distended veins in
the neck and forehead.
 The gold standard pulmonary angiogram is rarely done, spiral CT, often
with help of IV contrast is the standard diagnostic test.
 After confirming the diagnosis, start treatment with heparinization.

19. Fever
 40% patients develop fever after major surgery.
 Malignant hyperthermia develops shortly after the onset of anesthetic
(halothane or succinylcholine. Temperature exceeds 104 F with metabolic
acidosis and hypercalcemia. Treat with IV dantrolene, 100% oxygen,
correction of acidosis and cooling blankets.
 The causes of raised temperature postoperatively include:
o Day 2-5: Atelectasis of lungs.
o Day 3-5: Superficial and deep wound infection.
o Day 5: Chest infection, UTI, thrombophlebitis.
o >5 days: Wound infection, anastomic leakage, abscess.

20. Wound dehiscence
 Wound dehiscence is disruption of any or all the layers in a wound.
 Most commonly occurs from the fifth to eighth postoperative day when
the strength of the wound is at its weakest.
 Evisceration is a catastrophic complication of wound dehiscence, where
the skin itself opens and the abdominal contents rush out. It happens
when patient coughs, strains or get out of bed. The patient must be kept in
bed, and the bowel covered with large sterile dressings soaked with warm
saline. Emergency abdominal closure is required.

22. Management
 Ensure there is IV access
 Give IV antibiotics
 Superficial
o Continue regular wound lavage and dressing.
o For large defects consider vacuum assisted lavage.
 Full thickness:
o Resuturing the defect in theatre may be appropriate.
o In some cases (e.g., presence of infection) the wound should be allowed to
form a chronic wound and close by secondary intention.

23. Pressure sores
 Pressure sores occur because of friction or
persisting pressure on soft tissues.
 Risk factors are poor nutritional status,
dehydration and lack of mobility and nerve
block anesthesia technique.
 Early mobilization prevents pressure sores.
 High risk patients may be nursed on an air
mattress, which automatically relives the
pressure areas.
 Surgical management: Exploration, debridement
of devitalized and scarred soft tissue.
 Vacuum assisted closure.

24. Staging
 Stage 1: Non-blanchable erythema, without breach in the epidermis.
 Stage 2: Partial thickness skin loss involving epidermis and dermis.
 Stage 3: Full thickness skin loss extending into subcutaneous tissue but not
through underlying fascia.
 Stage 4: Full thickness skin loss through fascia with extensive tissue
destruction, may be involving muscle, bone, joint or tendon.

25. System-specific Postoperative
complications
 Respiratory system
- Atelectasis
- Pneumonia
- Pleural effusion
- Pneumothorax

26.  Cardiovascular system
• Immediate cardiovascular complications
- Hypotension
- Hypertension
- Myocardial ischemia
- Arrhythmias
- Stroke
• Early and late cardiovascular complications
- MI
- CHF
- Arrhythmias
- Stroke
 Renal and Urinary System
• Acute Kidney Injury
• Urinary retention
• Urinary infection

27. Central nervous system
 Postoperative delirium
 Stroke
 Seizures

28. Surgery-specific complications
 Abdominal surgery
Paralytic ileus
• Expected in first few days after abdominal surgery.
• Presents with nausea, vomiting, loss of appetite, bowel distension and absence
of flatus or bowel movements but there is no pain.
• Bowel sounds are absent.
• Paralytic ileus is prolonged by hypokalemia.
• Treatment: Supportive with maintenance of adequate hydration and electrolyte
levels.
• Return of function of the intestine occurs in the following order: small bowel,
large bowel and then stomach.

29. Localized infection
• Presents with persistent abdominal pain, focal tenderness and a spiking fever.
• Prolonged ileus.
• CBC may show neutrophilic leukocytosis with positive blood cultures.
• Investigations: CBC, U/S abdomen or CT scan of abdomen.

30.  Orthopedic surgery
Compartment syndrome
Raised pressure in an osteofascial compartment can prevent adequate tissue
perfusion and present after surgery.
• Presents with pain out of proportion.
• Paralysis and paresthesia.
• Pallor and pulselessness.
Management: Circumferential casts split, dressing cut down to skin and limb
elevated.

31.  Neck surgery
• Accumulation of blood in the wound, which may cause rapid asphyxia.
• Damage to the recurrent laryngeal nerve, which can produce voice change.
 Thoracic surgery
• Susceptible to fluid overload in the first 24-48hr postoperatively.
• Chest drains require regular review.
• If the fluid in a chest drain swings, then the drain has been correctly inserted
into the pleural cavity.
• If the chest drain continues to bubble, then a bronchopleural fistula probably
exists
• Hemothorax is prolonged loss of blood.
• Pleural effusion is prolonged loss of fluid.
• Cardiac patients require continuous ECG monitoring postoperatively.

32.  Neurosurgery
• Rise in intracranial pressure may be signaled by a deterioration in the state of
consciousness as well as neurological signs.
 Vascular surgery
• The patency of grafts and anastomosis needs to be checked by regular
clinical assessment of the limbs and by doppler ultrasound.
 Plastic surgery
• The viability of flaps is crucial, and the perfusion needs to be monitored
regularly.
 Urology
• Catheter patency must be checked regularly following urological surgery.

33. General Postoperative Problems and
their management
 Nausea and Vomiting
 Hypothermia and shivering
 Drains
 Wound care

34. Nausea and Vomiting
 Postoperative nausea and vomiting (PONV) can delay recovery
and prolong length of stay.
 They can lead to serious complications including aspiration
pneumonia, precipitation of bleeding and dehiscence of
wounds.
 Risk factors: Female gender, non-smoking, and a history of
PONV, motions sickness or migraine and use of volatile
anesthetic agents.
 Treatment:
o Treatment of pain, anxiety, hypotension and dehydration.
o Antiemetics prophylactically and for treatment.

35. Hypothermia and Shivering
 Anesthesia induces loss of thermoregulatory control. Exposure of skin and
organs to a cold operating environment, antiseptic skin preparation (that
cools by evaporation), and infusion of cold IV fluids all lead to
hypothermia and shivering.
 Active warming device should be used to treat hypothermia.

36. Drains
 Drains are used to prevent accumulations of blood, serosanguinous or
purulent fluid or to allow the early diagnosis of a leaking surgical
anastomosis.
 The complications of drains include trauma to surrounding tissues and
infection.
 The quantity and character of drain fluid can be used to identify an
abdominal complication such as fluid leakage (e.g., bile or pancreatic fluid)
or bleeding.
 Drains should be removed as soon as possible and certainly once drainage
has stopped or become less than 25mL/day.

37. Wound care
 Within hours of the wound being closed, the dead space fills up with
inflammatory exudate. Within 48 hours of closure a layer of epidermal cells
from wound edge bridges the gap. Consequently, sterile dressing applied
in the operation theatre should not be removed before this time.
 If the wound is inflamed, a wound swab can be taken and sent for
microbiological examination.
 Skin sutures or clips are usually removed between 6 and 10 days after
surgery.
 Wound healing is delayed in patients who are malnourished or have
vitamin A and C deficiency. Steroids also inhibit wound healing. Poorly
controlled diabetes delays wound healing and increases risk of surgical site
infection.

38. Discharge of patients