HEGAZY SURGERY

2. Presented By
Prof. Dr. Ibrahim El Ghazawy
2012

3. Immediate postoperative period:
Patient is nursed in recovery area.
Nurse: one to one.
Watch:
 Airway.
 Breathing.
 Circulation.
Chart: BLP, pulse, O2 saturation.
Look for Early problems: (bleeding, distal, pulses).
Monitor: pain.
General Management

4.  Stable, Low-risk: to general ward.
 High risk: to ICU.
SOAP:
 S = subjective: Ask the patient about:
(Nausea, pain, mobility, anxiety, change in behavior)
 Airway.
 Breathing.
 Circulation.
 O = objective: Chart:
Temperature
TPR Pulse
Respiration
 Check the wound.
 Check pressure areas.
 Specific physical signs
 Bowel sounds.
 Distal neuro-vascular function
 Review investigations.
 Review fluid charts.
 Review all drugs given to patient.
Transfer of patients after recovery

5. (SOAP)  Cotin ….
A = Assessment:
(“after review of “S” & “O”, List the “problems”
that patient is facing.
 P = Plan:
 Plan of further management is documented,
explain to patient.
 Home management is explained.

6. 1. Air embolism:
>15 mls. of air introduced during insertion of v. catheter.
Signs: ↓ B.P.
↑ pulse rate
Distension of jug. V.P.
Prevention:
 Head-down position.
 Run fluids in the tubing system.
2. Phlebitis: Inspect IV. Cannulas:
 Postoperative pyrexia.
 Induration.
 Edema.
 Tenderness.
Complications in postoperative period

7. 3. Finger necrosis:
 Arterial cannulas (radial A).
 Prevention: Do before:
 Allen’s test.
 Doppler.
Complications in postoperative period

8. Prevention
 Adequate analgesia.
 O2 by mask/ nasal prongs.
 Physiotherapy.
 Treat infections first.
Specific postoperative complications
Respiratory

9. Commonest causes:
 Atelectasis.
 Splinted diaphragm after abdominal wounds.
Sudden onset of shortness of breath:
 Pulmonary embolism.
 MI.
 Acute heart F.
 Pneumothorax.
 Pneumonia, bronchopneumonia.
 ARDS (e.g. severe pancreatitis, multitrauma, sepsis).
 Acute bronchospasm, (COAD).
Shortness of breath

10. Action:
 O2 administration.
 IV access.
 Withdraw blood for CBC, electrolytes, ABGS,
cardiac enzymes.
 Chest XR, - sputum for bacteriology.
 Chest physioth.
 ECG.
 Remove dentures.
 Support airway.
Shortness of breath (Contin…)

11. Hypotension:
Causes:
 Hypovolemia (commonest) (bleeding/
inadequate fluids).
 MI.
 Epidural anesthesia.
 Septic shock.
 Too much morphine.
Cardiovascular complications

12. Emergency therapy: (for hypotension)
 Head-down.
 IV fluids.
 High-flow O2.
 Thorough exam. Of patient.
Qs:
 Is the patient dehydrated?
 Is the patient bleeding?
 Is the patient on much morphine?
 Has the patient had epidural anesthesia?
 Has the patient had MI?

13. Risk factors for DVT:
 Age > 60.
 Pelvic, L.L. surgery.
 Immobilization.
 Trauma.
 Oral contraceptive pills.
Prevention of DVT:
 Early mobilization.
 Hydration.
 Stockings.
 Low-Molec. Wt. heparin.
 Calf pumps.
 Minimize use of tourniquets.
Deep Vein thrombosis: DVT

14. Postoperative nausea & vomiting:
Predisposing Fs:
 Poor control of pain.
 Excess opioids.
 GIT, orthoped., ENT., surgery.
 Motion sickness, migraine.
 Female sex.
Gastrointestinal

15. Treatment of postoperative nausea & vomiting:
 Antiemetics.
 Pain control.
 NG-tube.
 Avoid opiates.
 Start slow oral feeding.
 Maintain hydration & BP.
Drugs:
 Dopamine-receptor antagonist:
 Prochlorperazine
 Metochlopramide.
 H1-receptor antagonist:
 Cyclizine
 5HT-receptor antagonist:
 Ondansetron.

16. Oliguria: (< 0.5 ml/kg/h)
Aetiology of acute renal failure:
Prerenal:
 Hypotension.  Hypovolenia.
Renal:
 Nephrotoxic drugs.  Gentamicin.
 Steroids.  Sepsis.
Postrenal:
 Uretric injury (bilat.)
 Blocked urethral cath.
Urinary Complications

17. Prevention of postoperative renal failure
1. Monitor renal function:
 U. Output.
 S. urea, s. creatinine, electrolytes.
2. Monitor:
 Pre renal:
 Pulse, BP.
 CVP.
 Input/ output chart.
 PAWP.
3. Monitor cardiac function:
 C.O.
 Inotropic support.

18. Prevention of postoperative failure (Contin…)
4. Exclude urinary tract obstruction:
 U.S. Abdomen (ureteric, obst. Hydronephrosis).
 Catheter obst.
 Surgical correction.
5. Avoid nephrotoxins:
 Treat sepsis (drain abscess).
 Avoid aminoglycosides.
6. Consider diuretics:
 Mannitol.
 Furosemide.
7. Nephrology consultation:

19. 1) Abdominal surgery:
Problems expected:
 Anastomotic leak.
 Bleeding.
 Sepsis, abscess.
 Ileus (slow recovery).
 Gastric dilatation.
 Pancreatitis.
Specific surgical specialities

20. Look for:
Compartment Syndrome:
 Symptoms:
 Pain + + +
 Not responsive to ordinary analgesia.
 Pain on passive strech.
 Late signs 
 Paralysis
 Paraesthesia.
 Pulselessness
 Be sure tourniquets are removed.
 Examine periph. Neuro-Vasc. bundle.
 Examine for tight plaster casts.
Orthopedic surgery

21.  Observe breathing.
 Check for accumulating hematoma.
 Check for Rec. L.N. injury.
Treatment:
 Re-intubation & reassessment for Rec. L.N.
injury. (consider tracheostomy).
 Emergency evacuation of neck hematoma,
inspection of thyroidectomy bed.
Thyroid/ neck surgery

22.  Continuous ECG monitoring.
 Observe chest drains.
 Caution: Susceptibility to fluid overload after
pneumonectomy.
 Check for:
 Haemothorax.
 Pleural effusion.
 Pneumothorax.
 (? Mediastinal shift).
Cardiothoracic surgery

23.  1st on operating list (avoid starvation).
 Start on glucose-insulin infusion.
 Avoid hypoglycemia.
 Avoid excessive hyperglycemia.
 Rate of insulin infusion 1.5 u/h. in 5%
Dextrose.
Diabetic patients

24. Causes:
 Days 2 – 5 Lung atelectasis.
 Days 3 – 5 Wound infection.
 Day 5 Chest infection.
U.T. infection.
Thrombophlebitis.
 > 5 days Wound infection.
Anastomotic leak.
Abscess formation.
DVT
Infected I.V. catheters.
 Others: Wound hematoma.
Transfusion reaction.
DVT.
Drug reaction.
Postoperative Fever

25. S & S:
 Sleep deprivation.
 Anxiety.
 Impaired memory.
 Disturbed emotions.
 Incoherent speech.
 Destructive behavior.
Postoperative confusion

26. Causes of postoperative confusion:
 Renal:
 Renal failure.
 Hyponatremia.
 UTI.
 U. retention.
 Respiratory:
 Hypoxia.
 Chest infection, actelectasis.
 Pulm. embolism.
 Cardiac vascular:
 Arrhythmia.
 MI.
 Dehydration.
 Sepsis, septic shock.

27. Causes of postoperative confusion: (cont.)
 Drugs:
 Opiates.
 Cocaine, heroin.
 Alcohol withdrawal.
 Neurological:
 Epilepsy.
 Cerebro-vasc. Accident.
 Head injury.
 Endocrine:
 Hypothyroidism, hyperthyroidism.
 Addison’s disease.

28. Wound dehiscence:
Risk factors:
General:
 Malnutrition.
 Diabetes.
 Obesity.
 Renal F.
 Jaundice.
 Cancer.
 Steroids.
Local:
 Poor wound closure.
 Wound hematoma, infection, seroma.
 Raised intraabdominal pressure.
 Chronic cough.
 COAD.
 Ileus.
Wound problems