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1. Post-operative care
Dr. Yonas G.(MD)

2. OR Set Up

3. Post-operative care
• Aims: Comfortable, pain free recovery from operation
with an emphasis on early rehabilitation and expedition
of discharge.
1. Immediate/ post-anesthetic recovery sites/ICU
2. Intermediate recovery / regular wards
3. Long term recovery / home
.

4. Care in the PACU
What should be included in the following
assessments?
1. Respiratory Assessment
2. Cardiovascular Assessment
3. Neurological Assessment

5. Role of the physician
1. Monitoring
– Vital signs (Pulse, BP, Temperature, Respiratory Rate)
– Urine Output
– Level of consciousness
2. Analgesia
– Improve sleep and psychological well being- faster
recovery
– Decrease psychological and physiological stress
– Reduce hospital stay and costs incurred
– Promotes easy wound healing

6. Role of the physician
3. Fluid Balance
– Effects of fluid balance monitored with regular FBC,
U&Es
– Remember activation of Vasopressin/ ADH axis during
surgery
4. Awareness of Complications
5. Mobilization
– In association with physiotherapists and nursing staff
6. Respiratory Measures

7. Sample Post-operative Orders
1. Diet (NPO, sips/chips, soft).
2. Activity (Respiratory therapy, physiotherapy,
occupational therapy).
3. Vitals (frequency, alerts, treatment of extremes).
4. Investigations (labs/frequency, imaging, ECG,
alerts).
5. Drugs (IV, antibiotics, heparin, pain control,
maintenance meds and substitutes).

8. Sample Post-operative Orders
6. Drains (foley, NG, surgical drains, volumes)
7. Dressings (wounds, drain sites, dressing
changes, frequency)
8. Disposition (ward, high-care, high-dependency
wards, ICU)

9. Post Op Complications
General Immediate:
1. Primary hemorrhage
2. Reactive hemorrhage:
3. Basal Atelectasis
4. Minor lung collapse
5. Shock
6. Blood loss
7. MI, Pulmonary Embolism
8. Low Urine Output

10. Post-op complications: General Early
1. Acute confusion
2. Nausea and vomiting
3. Analgesia or anaesthetic related
4. Pyrexia
5. Secondary Hemorrhage
6. Pneumonia
7. Wound or Anastomosis Dehiscence

11. Complications: General Early
8) DVT
9) Acute Urinary Retention
10) Urinary Tract Infection
11) Postoperative Wound Infection
12) Bowel Obstruction: due to
fibrinous adhesions
13) Paralytic Ileus

12. Complications: General Late
• Obstruction: due to fibrous adhesions
• Incisional Hernia
• Persistent Sinus
• Recurrence of Malignancy

13. Days 0 to 2
• Mild fever (T<38) (Common)
– Tissue damage and necrosis at operation site
– Hematoma
• Persistent Fever (T> 38)
– Atelectasis:
– Specific infections related to the surgery
– Biliary infection post biliary surgery
– UTI post urological surgery
– Blood Transfusion/ Drug Reaction:

14. Days 3-5
• Bronchopneumonia
• Sepsis
• Wound infection
• Drip site infection/ phlebitis
• Abscess formation (e.g. subphrenic or
pelvic)

15. Days 5-7
• DVT
• Specific complications related to surgery
– bowel anastomosis breakdown
– fistula formation
• After the first week (less likely related to the
specific operation)
– Wound infection
– Distant sites of sepsis
– DVT

16. • Wound: examined daily:
Seroma
Hematoma
Infection
Non-healing
Dehiscence
Post Op Complications

17. Urinary and renal complications
• Urinary retention
• Acute renal failure
• Urinary tract infection

18. Respiratory complications
1. Atelectasis
2. Aspiration pneumonitis/Pneumonia
3. Pulmonary edema
4. Pneumonia
5. Respiratory failure

19. Cardiac complications
1.Abnormal ECG
2.Acute MI
3.Arrhythmia
4.Pulmonary embolus

20. Others
1.Paralytic ileus
2.Post-op delirium
3.Intra abdominal abscess
4.Sleep deprivation

21. Post operative check list
• Post-operative day number 1:
– Assess the patient’s level of pain, lungs, cardiac
status, flatulence and bowel movement.
– Examine the distention, tenderness, bowel sounds,
wound discharge, bleeding from incision.
– Discontinue IV infusion when taking adequate PO
fluids. Discontinue Foley catheter.
– Ambulate as tolerated, incentive spirometry,
hematocrit.
– Post operative pain control

22. Post operative check list
• Post-operative day number 2
–If passing gas or if bowel movement,
advance to regular diet unless bowel
resection
–Milder analgesia
–Remove drains if dry

23. Post operative check list
• Post-operative day number 3-7
–Check pathology result
–Remove stitches
–Consider discharge home with
appropriate medication
–Write discharge note

24. Surgical Nutrition

25. Impact on Outcome
• For well nourished or mildly malnourished general surgery
patients, peri-operative nutritional support did not improve
outcome and actually is associated with increased septic
complications after surgery both pulmonary and intra-
abdominal.
• For severely malnourished patients before a major surgical
procedure, peri-operative nutritional support reduced
postoperative complications (wound complications, wound
failure, prolonged hospital stay, ICU days, use of hospital
resources) by about 10%, without significant increase in
infectious complications.

26. Who will need it?
• Well nourished and mildly malnourished patients who cannot
take oral food for more than one week post operatively to
avoid prolonged starvation.
• Severely malnourished patients undergoing general surgery
procedures.
• All critically ill patients (Sepsis patients, Multiple Injury
patients Burn patients, etc).
• Patients whom you predict cannot use their gut for prolonged
period of time (Short gut syndrome, EC fistula, etc).

27. When to Start?
• Preoperatively in severely malnourished patient undergoing a
major surgical operation.
• Immediately postoperatively in severely malnourished
patients.
• Immediately after major trauma, sepsis, major burns.
• Normal or mildly malnourished patient who is unable to eat
on his own by 7 days after surgery.

28. Assessment of Nutritional Status
• Weight loss is a significant indicator
• More than 10% unintentional loss in 6 month period.
• 5% loss in 1 month.
• Anorexia, persistent nausea, vomiting, diarrhea, malaise.
• Loss of subcutaneous fat, muscle wasting, edema, ascites.

29. Assessment
• Signs of specific nutritional deficiencies.
• Skin rash
• Pallor
• Glossitis
• Gingival lesions, hepatomegaly,
neuropathy, dementia.

30. Evaluation of Body Composition
• Ideal body weight (IBW)
• Men 106lb+ 6lb for each inch over 5 feet
• Women 100lb + 5lb for each inch over 5 ft.
• IBW depends on patient age, body habitus.
• Other measurements include triceps skin fold,
arm circumference.

31. Body Composition
• BMI characterizes degree of obesity.
• BMI = weight(kg)/total body surface area.
• BMI over 40 or over 35 with co-morbid
conditions are considered candidates for
surgical treatment.
• Severe obesity is associated with
significant increase in morbidity and
mortality.

32. Laboratory Markers
• Serum proteins
• Albumin half life 20 days
• Transferrin half life 8.5 days
• Prealbumin half life 1.3 days
• Severe hypoalbuminemia <2 poor
outcomes

33. Nutritional Requirements
• Total energy requirements.
• Total protein requirements.
• The relative distribution of calories between
carbohydrates, fats, and protein.

34. Energy Requirements
• Harris-Benedict equation estimates BEE at rest.
(BEE = basic energy expenditure).
• Men= 66 + (13.7x weight) + (5x height) –(6.8 x age).
• Women= 65+(9.6 x weight)+(1.7 x height)–(4.7 x age)
• Most require 25-35 kcal/kg/day.
• Stress increases these values.

35. Carbohydrate (30-60% of Total)
• Each gram releases 4 kcal.
• Also important in membranes as
glycoproteins, glycolipids, carbon backbone
of essential amino acids.
• CHO are stored as glycogen in liver (40%),
muscle (60%), cardiac muscle.
• Stores depleted in 48hrs (starve), 24 hrs
(stress).

36. Protein
• Essential components of all living cells,
involved in virtually all bodily functions.
• Total protein in a healthy male is 15-18%
of body weight.
• 2.5% of total body protein is broken
down and re-synthesized every 24hrs.
• Protein yields 4 kcal per gram.

37. Protein Requirements
• Most healthy individuals require 0.8-1.0 g
protein/kg/day.
• Mild stress = 1-1.2 g/kg/day.
• Moderate stress = 1.3-1.5 g/kg/day.
• Severe stress = 1.5-2.5 g/kg/day.
• Renal failure (more)
• Hepatic encephalopathy (less)

38. Nitrogen Balance
• A crude measurement of protein
consumption.
• Difference between net nitrogen intake and
excretion.
• Positive balance indicates more protein
ingested than excreted.
• Negative balance is catabolism.
• Protein excretion in urine = nitrogen x 6.25g.

39. Lipids
• Provide 25-40% of total calories.
• Fatty acids a major source of fuel for heart,
liver, skeletal muscle.
• Liver oxidation of fatty acids yields ketones
which are used by the heart, brain, muscle
during starvation.
• During the fed state, insulin stimulates
lipogenesis and fat storage, inhibits lipolysis
in adipocytes.

40. Vitamins
• Deficiencies can occur in severely
malnourished patients, chronic nutritional
support.
• Impaired wound healing can be a direct result
of deficiencies in Vitamin A, C, and zinc.

41. Deficiencies
• Vitamin A- Wound healing
• Vitamin D- Rickets, osteomalacia
• Vitamin E- Anemia, ataxia, nystagmus, edema,
myopathy.
• Vitamin C- Wound healing
• Thiamine- Encephalopathy
• Vit -B6 - Neuropathy

42. Stress
• The same events as starvation.
• Much more accentuated tissue protein breakdown in
order to:
– Supply increased demands of energy
– Supply building blocks for acute phase reactant proteins by
the liver.
• This accentuated protein breakdown is stimulated by
– Increased steroid production
– Cytokines associated with acute stress response
• Nitrogen loss:
– 5-8 gm/d normally
– 2-4 gm/d after several days of unstressed starvation
– 30-50 gm/d under severe stress (multiple trauma, sepsis,
burns)

43. Critical Illness
• Metabolic rate is increased
• While patients are in negative nitrogen
balance, protein synthesis is active centrally
• Fat not as available as energetic substrate
– Cortisol and catecholamines block lipolysis and
oxidation of fatty acids to ketone bodies

44. Protein Synthesis in Critical Illness
Reprioritization
Albumin
Retinol binding protein
Transferrin
Acute phase proteins
Immune proteins

45. Nutritional Supplementation
• Benefits high risk patients such as severely
malnourished, critically ill, burns, severe trauma.
• Delayed oral intake 7-10 days.
• Enteral route is indicated in all patients with an
intact, functioning GI tract.
• Prevents intestinal atrophy, gut immune function,
inhibition of stress induced increase in intestinal
permeability.

46. Nutritional Supplementation
• Oro-enteric, naso-enteric, gastrostomy,
jejunostomy.
• Small bore NG tubes can be use for short
period of time.
• Gastrostomy and jejunostomy for long term.
• Complications in placement, organ injury,
aspiration, malfunction, leaks, sinusitis,
erosion.

47. Parenteral Feeds
• TPN- indicated when GI tract is unavailable or
nonfunctional.
• Via Central catheter due to hyperosmolarity
of the solutions.
• Complications related to catheters frequent.
• Severe metabolic complications can occur.
• Hyperglycemia, hypoNatremia, hypoKalemia,
hypoMagnesemia, hypoPhosphatemia.

48. ….
Thank you!