This document provides information on post-operative care, including common complications, their prevention and treatment. It discusses care of patients in the post-anesthesia care unit and criteria for discharge. Some immediate complications discussed are respiratory and cardiovascular issues. Long term complications include infections, DVT and wound healing problems. The importance of early mobilization and physiotherapy to aid recovery is also covered.
3. LEARNING OBJECTIVES:
• Need of immediate post-op care
• Common post-operative problems
• Anticipation & prevention of common complications
• Identification & Treatment
• Enhancement of recovery
• Systematic discharge
6. POST- ANESTHESIA CARE
• Patient is handed over to a dedicated PACU working under observation of trained
staff, along with complete patient information & nature of surgical intervention.
PACU management involves:
• Resuscitation
• Difficult airway management
• Scheduled vitals monitoring
• Drugs
• Discharge criteria out of PACU
7. PACU DISCHARGE CRITERIA
• Conscious
• Maintaining SPO2
• Normothermic
• Vitally stable & Pain free
• Proper medications prescribed
• No concern related to surgical procedure
9. IMMEDIATE RESPIRATORY COMPLICATIONS
• Upper airway obstruction
Causes
Vocal
Cord
dysfunctio
n
Laryngo
-spasm
Persistent
relaxation
of Airway
Muscles
Soft
tissue
edema
Hematom
a
Foreign
body
10. CONTINUED…
• Impaired adequacy of ventilation (NM blockade, Anesthetic agents, Opioids)
• Supplemental O2
• Hypoxemia (Ac. Pulmonary Edema, bronchospasm, pneumothorax, Aspiration, PE)
• If spontaneously breathing, supplemental oxygen 15L/min using a non re-breathing mask
• If not breathing spontaneously, Endotracheal tube insertion or other invasive intervention
• Surgery specific (Vocal cord Palsy, Neck hematoma, bleeding)
11. EARLY AND LATE RESP. COMPLICATIONS
• Fever
• Malignant Hyperthermia 104˚due to Halothane or Succinylcholine( IV Dantrolene,
100% Oxygen, correct Acidosis, Cooling blankets)
• Bacteremia 30-45 mins (Blood Culture and Empiric Antibiotics)
• Atelectasis 1st POD (Auscultation, Chest X-ray, Improve ventilation, Bronchoscopy)
• Pneumonia 3rd POD (Sputum culture, Antibiotics)
• UTI 3rd POD (UCE, Antibiotics)
• DVT 5th POD (Doppler USG, Anti-coagulation therapy)
• Wound infection 7th POD
• Deep Abscesses 10-15th POD (USG guided drainage or Surgery)
17. CONTINUED…
• Urinary retention
• Catheterization should be done if when an operation is expected to last 3 hours or
more, or when large volumes of fluids are administered.
• UTI
• Low Urine Output (less than 0.5 ml/kg/hour)
1. Fluid deficit (Urinary Na < 10-20 mEq/L)
2. Acute renal failure (Urinary Na > 40 mEq/L)
18. CENTRAL NERVOUS SYSTEM
• Post operative disorientation/coma may result from various causes:
• Hypoxia
• May be secondary to sepsis
• Blood gas analysis and Respiratory support
• ARDS
• B/L pulmonary infiltrates, hypoxia with no evidence of CCF
• Positive end expiratory pressure therapy
• Correct sepsis
19.
20. CENTRAL NERVOUS SYSTEM
• Delirium Tremens
• Alcoholics
• Hallucinations and combative behavior
• Intravenous Benzodiazepines
• Hyponatremia
• May occur after surgery due to combination of large volumes of sodium free fluids (like
DW) and elevated ADH levels in response to trauma/surgery.
• Confusion, convulsions, coma and death
• Include Na in IV fluids
• Osmotic diuretics might help
21. CENTRAL NERVOUS SYSTEM
• Hypernatremia
• Induced by large unreplaced water loss
• Confusion, lethargy, coma
• Do rapid fluid replacement with half DW or DS soln.
• Ammonium intoxication
• Occurs in cirrhotic undergoing a portocaval shunt procedure
22. ABDOMINAL SURGERY COMPLICATIONS
• Paralytic ileus
• Nausea, Vomiting, Anorexia, mild bowel distension with no pain, absence of flatus
and bowel movements
• Adequate hydration and maintain electrolyte levels
• Return of intestinal function occurs as Small bowel > Larger bowel > Stomach
• Local infection / Anastomotic leakage
• Persistent abdominal pain, focal tenderness and fever spike (masked if deep seated
abscess)
• USG or CT for collection along with guided drainage
23. CONTINUED…
• Early mechanical bowel obstruction
• Paralytic ileus not resolving after 5-7 days after surgery
• X-ray: dilated gut loops and air fluid levels
• CT scan Abdomen helps
• Surgical intervention is required
• Ogilvie Syndrome
• Paralytic ileus of colon
• Seen in elderly sedentary patients ( Alzheimer’s, Nursing homes) who become further
immobile due to surgery
• Larger abdominal distension (Tense but no pain), x-ray : massively dilated colon
• Iv Neostigmine and long rectal tube
26. COMPLICATIONS OF ORTHOPEDIC SURGERY
• Damage to the neurovascular supply of the extremity
• Compartment Syndrome
• Increased pressure in Osseo-fascial compartments that hinder adequate tissue
perfusion
• Pain, pallor, pulselessness, paralysis, paresthesia
• Treatment:
• Circumferential cast split and dressings cut down to skin
• Limb elevation
• Fasciotomy
30. UROLOGY
• Loss of urinary catheter patency
• Transurethral resection syndrome
• Problems related to continued bladder irrigation
31. GENERAL POST-OP PROBLEMS
• Hemorrhage
• Primary -- At the time of surgery
• Reactionary -- within 24 hours of surgery
• Secondary -- Several days after surgery
32. CONTINUED…
• PONV
• Risk Factors:
• Female gender (1)
• Non-smoker (1)
• History of motion sickness or PONV (1)
• Post-op opioid treatment (1)
• Apfel Scoring for probability of PONV
• 0 =10 %
• 1= 21 %
• 2= 29 %
• 3= 61 %
• 4= 78 %
33. CONTINUED…
• Treatment of PONV
• Relieve Pain & Anxiety
• Maintain BP
• Proper hydration
• Combination of various drugs may help:
• HT3 receptor antagonists (Ondansetron)
• Steroids
• Phenothiazines
• Anti-histamines
34. CONTINUED…
• Hypothermia & Shivering
• Causes
• Loss of thermo regulatory control due to anesthesia
• Exposure of patient during surgery
• Evaporation of ani-septic
• Treatment:
• Temperature monitoring intraoperatively
• Active warming devices
35. CONTINUED…
• Deep Venous thrombosis
• Thrombosis of one or more deep veins usually of the lower limb
• Calf pain, swelling, erythema, warm limb and engorged veins
• Investigations
• Duplex Doppler Ultrasound
• Venography
• Prevention
• Non-Pharmacologic: Compression stockings and Calf pump
• Pharmacologic: Parenteral anticoagulation initially followed by longer term warfarin or new
anticoagulants
• Surgical: Caval filter to avoid PE
36. STRATIFICATION OF THE SURGICAL PROCEDURE
AND ASSOCIATED RISK OF DVT
• Low
• Maxillofacial surgery
• Neurosurgery
• Cardiothoracic surgery
• Medium
• Inguinal hernia repair
• Abdominal surgery
• Gynecological surgery
• Urological surgery
• High
• Pelvic Surgery
• Total knee and hip replacement
37.
38. DRAINS
• Placed to avoid collection of blood, serosanguinous purulent fluid
• Quantity and character of fluid drained may allow early intervention
• Complications:
• Damage to surrounding tissues
• Infection
• Removal:
• As soon as possible
• When the drainage has stopped or became less than 25 ml/day
39. WOUND
• Wound dehiscence
• Disruption of any or all layers in a wound
• Around 5-8th POD after laparotomy
• Wound looks intact but the dressing is soaked with “Salmon Pink” colored fluid
• May need wound washout and re-suturing
• In some wound may be left open and treated with dressings or VAC pumps
• Evisceration is a catastrophic complication and may need emergency re-closure
• Re-operation for possible ventral hernia may be required but is not an emergency
40. CONTINUED…
• Fistula of GI tract
• Bowel contents leak out of a wound site or through drain site
• Fistulas not draining freely but leaking after a collection develops cause sepsis &
peritoneal irritation and require complete drainage
• Fistulas draining freely won’t cause peritoneal irritation or fever
• Potential problems due to fistula
• Fluid & electrolyte loss
• Nutritional depletion
• Digestion of abdominal wall
41. CONTINUED…
• Types of fistulas
• Low GI fistula (in distal colon) – up to 200-300 ml/day
• High GI fistula (in stomach, duodenum, upper jejunum – several liters per day
• Management
• Fluid & electrolyte replacement
• Nutritional support
• Protection of abdominal wall though suction tubes and ostomy bags
• Avoid the risk factors that prevent healing
• Keep the patient alive until the nature heals the fistula
42. CONTINUED…
• Pressure Sores
• Friction or persistent pressure on soft tissues in patients undergoing surgery for
prolonged periods of time
• Pressure points: Sacrum, Greater trochanter and Heels
• Prevention & Treatment
• Early mobilization and posture changes
• Air mattress for high risk patients
• W/W and W/D
43. WOUND CARE
• Within hours of surgical wound closure the dead space fills with inflammatory exudate
• Within 48 hours epidermal cell in wound edge bridge the gap
• Only inspect the wound if there is concern about its condition or the dressing needs
changing
• Infected wound or hematoma may require drainage and packing
• Send pus for culture & sensitivity (before giving antibiotics)
• Skin sutures or clips can be removed 6-10 days later or may be left longer in sutures
applied under tension
• Exclude factors that prevent healing
44. RECOVERY
• Factors that enhance recovery are
• Early physiotherapy and mobilization
• Earl oral intake
• Opioid sparing analgesia
• Support of nursing staff and community care providers
45. DISCHARGE LETTER
• Final diagnosis
• Treatment given
• Laboratory results
• Complications that might have occurred
• Discharge plan comprising of further care and management of complications,
physiotherapy and referrals for comorbidities
• Support needed by community care providers
• Follow-Up plan
• Prognosis (if appropriate)