4. SUMMARY OF MOST COMMON
CAUSES OF POST-OP FEVER WHEN
STARTING ON
• : Reactive to drugs or surgical tissue trauma
• : Atelectasis
• : IV line infection (STP)
• : Pneumonia, DVT, UTI
• : Wound infection (still pneumonia, DVT, UTI)
• : Abscess somewhere
1st Day
2nd Day
3rd Day
4th Day
5th Day
7th Day
After first week : allergy to drugs, transfusion-related-fever,
septic pelvic vein thrombosis and intraabdominal abscesses
5. AIM OF PHASE I & II
Homeostasis
Treatment of pain
Prevention & early detection of
complications
6. IMMEDIATE PHASE
DISCHARGE FROM RECOVERY SHOULD
BE AFTER COMPLETE STABILIZATION OF
CARDIO-VASCULAR, PULMONARY AND
NEUROLOGICAL FUNCTIONS WHICH
USUALLY TAKES 2 – 4 HOURS
IF NOT SPECIAL CARE IN ICU
7. POST-OPERATIVE ORDERS
POSITION IN BED AND MOBILIZATION
Turning in bed usually every 30 minutes until full mobilization
Special position required sometimes
DVT prevention mechanically (intermittent calf compression)
DIET
NPO
Liquids
Soft diet
Normal or special diet
8. POST-OPERATIVE PULMONARY
CARE
Post-operative atelectasis is enhanced by shallow breathing,
pain, obesity and abdominal distension (restriction of
diaphragmatic movements)
Post-operative physiotherapy especially deep inspiration helps
to decrease atelectasis. Also oxygen mask and periodic
hyperinflation using spirometry
Early mobilization helps a lot
Antibiotics and treatment of heart failure post-operative by
adequate management of fluids will help to reduce pulmonary
edema
9. WHEN CAN PATIENT LEAVE RECOVERY ROOM?
Patient is fully conscious
Respiration and oxygenation are adequate
Patient is normotensive
Not in pain nor nauseous
Cardiovascular parameters are stable
Oxygen, fluids and analgesics have been
prescribed
There are no concerns related to the
surgical procedure
10. GENERAL POST-OPERATIVE PROBLEMS
Pain
IV nutrition
Nausea & vomiting
Bleeding
Deep vein thrombosis
Hypothermia / shivering
Fever
Prophylaxis against
infection
Pressure sores
Confusional states
Drains
Wound care
Wound dehiscence
Enhanced recovery
Discharge of patients
Follow-up in clinic
11. P
AIN
Nociceptive pain arises from inflammation and ischemia
Neuropathic pain arises from a dysfunction in the central
nervous system
Psychogenic pain is modified by the mental state of the patient
Surgical patients may have persistent pain from a variety of
disorders including chronic inflammatory disease, recurrent
infection, degenerative bone or joint disease, nerve injury and
sympathetic dystrophy.
Effective analgesia is an essential part
Important injectable drugs for pain are opiate analgesics.
NSAIDS such a diclofenac, ibuprofen and paracetamol can also
be given orally.
Commonly inexpensive opiates are pethidine and morphine.
12. FLUID AND NUTRITION
Fluid therapy and nutritional support are fundamental to
good surgical practice.
This requires knowledge of the consequences of surgical
intervention and, in particular, intestinal resection.
Malnutrition is common in hospital.
All patients who have sustained or who are likely to sustain 7
days of inadequate oral intake should be considered for
nutritional support.
The success or otherwise of nutritional support should be
determined by tolerance to nutrients provided and nutritional
end points, such as weight.
13. NAUSEA & VOMITING
Nausea and vomiting occur when there is
of vomiting centre by multiple
stimulation
factors.
Adequate treatment of pain, anxiety,
hypotension and dehydration will minimize the
risk of the patient developing PONV.
Mx : Administer antiemetics that work at
different sites, such as :
i. HT3 receptor antagonists (e.g.
ondansetron)
Steroids (e.G. Dexamethasone)
Phenothiazines (e.G. Prochlorperazine)
Antihistamines (e.G. Cyclizine)
ii.
iii.
iv.
14. BLEEDING
The patient’s blood pressure, pulse, urine output, dressings and drains
should be checked regularly in the first 24 hours after surgery.
If bleeding is more than expected for a given procedure, then pressure
should be applied to the site and blood samples should be sent for
blood count, coagulation profile and crossmatch.
Fluid resuscitation should also be started.
Ultrasound or CT scan may need to be arranged to determine the size
and extent of the hematoma.
If immediate control of bleeding is essential, the patient may be taken
back to the operating theatre.
If surgical hemostasis is not successful using conventional methods,
hemostatic dressings or surgical glue may be tried.
The radiological embolization of bleeding vessels can also prove useful.
15. HYPOTHERMIA / SHIVERING
Anesthesia induces loss of thermoregulatory control
Hypothermia is due to exposure of skin and organs to:
i. A cold operating environment
ii. Volatile skin preparation (which cool by
evaporation)
iii. The infusion of cold IV Fluids
This, in turn, leads to increased :
i. Cardiac morbidity
ii. Hypo coagulable state
iii. Shivering with imbalance of
demand
oxygen supply and
iv. Immune function impairment with the possibility
of wound infection
Active warming devices should be used to treat
hypothermia as appropriate.
16. INFECTION
Prophylactic antibiotics should be administered, in patients
who have had foreign material inserted during the operation,
including a hip or knee prosthesis in orthopedic surgery or
aortic valves in cardiovascular surgery, up to three dose.
Usually one dose 30 minutes before ‘knife to skin’ and two
postoperatively.
Bacteria can be incorporated into the biofillm that forms on
the surface of the implant, where they are protected from
antibiotics and from the natural defenses of the body
Prophylactic antibiotics appear to reduce the risk of any
contamination developing into infection by destroying bacteria
before they are incorporated into the biofilm.
17. DRAINS
Drains are used to prevent accumulation of blood, serosanguinous
or purulent fluid or to allow the early diagnosis of a leaking surgical
anastomosis.
The complications are trauma to surrounding tissues, and act as a
conduit for infection.
The quantity and character of drain fluid can be used to identify any
abdominal complication, such as fluid leakage (e.g. bile or
pancreatic uid) or bleeding.
This lost fluid should be replaced with additional intravenous fluids
with the same electrolyte contents.
Continued loss of blood through the drain should be investigated
for the source.
Drains should be removed as soon as possible and certainly once
the drainage has stopped or become less than 25 mL/day.
18. WOUND CARE
Epithelialization takes 48 hours
Dressing can be removed 3-4 days after operation
Wet dressing should be removed earlier and changed
Symptoms and signs of infection should be looked for,
which if present compression, removal of few stitches
and daily dressing with swab for C & S
Tensile strength of wound minimal during first 5 days,
then rapid between 5th to 20th day then slowly again
(full strength takes 1-2 years)
Good nutrition
19. WOUND DEHISCENCE
Wound dehiscence is disruption of any or all of the layers in a
wound.
Dehiscence may occur in up to 3 per cent of abdominal
wounds and is very distressing to the patient.
Wound dehiscence most commonly occurs from the 5th to the
8th postoperative day when the strength of the wound is at its
weakest.
It may herald an underlying abscess and usually presents with
a serosanguinous discharge.
The patient may have felt a popping sensation during straining
or coughing.
Most patients will need to return to the operating theatre for
resuturing.
In some patients, it may be appropriate to leave the wound
open and treat with dressings or vacuum-assisted closure
(VAC) pumps
20. WOUND DEHISCENCE
RISK FACTORS
GENERAL
Malnourishment
Diabetes
Obesity
Renal failure
Jaundice
Sepsis
Cancer
Treatment with steroids
LOCAL
Inadequate or poor closure of
wound
Poor local wound healing
i. Because of infection,
haematoma or seroma
Increased intra-abdominal
pressure
i. In postoperative patients
suffering from chronic
obstructive airway disease,
during excessive coughing
21. RESPIRATORY
COMPLICA
TIONS
The most common respiratory complications in the
recovery room are:
Hypoxemia
Hypercapnia
Aspiration (occurs when unconscious)
Pneumonia (later)
Pulmonary embolism may occur later in the post-
operative period
22. PULMONARY ASPIRATION
PREVENTION & TREATMENT OF ASPIRATION
i. Preoperative fasting
ii. Proper positioning of patient
iii. Careful intubation.
iv. A single dose of H2-blocker or PPI before induction.
v. Treatment is by re-establishing patency of the airway and
preventing further damage to the lung.
vi. Endotracheal suction immediately, stimulates coughing,
which helps to clear the airway.
vii. Bronchoscopy may be required to remove solid matter.
viii. Fluid resuscitation should be undertaken concomitantly.
ix. Antibiotics if aspirate is heavily contaminated.
23. POST-OPERA
TIVE
PNEUMONIA
Tend to appear later in the post operative period.
Atelectasis, aspiration, and copious secretions are
important predisposing factors
Pathogens Gm-ve, or mixed bacteria from aspiration
Pseudomonas aeruginosa and klebsiella can survive in the
moist reservoirs of the machines ( ventilators, suctions )
TREATMENT : Clear secretions, antibiotics, specific
identification of the infecting organism, supportive
measures
24. PULMONARY EMBOLISM
Sudden onset of chest pain and shortness of breath.
In large embolism, there will be systemic
hypotension, pulmonary hypertension and an
elevated central venous pressure (CVP).
PATIENTS WITH HYPOXIA , URGENT
ACTIONS
If breathing spontaneously give O2 at 15 L/min,
by non-rebreathing mask.
A head tilt, chin lift or jaw thrust should relieve
obstruction related to reduced muscle tone.
Suctioning of any blood or secretions and
insertion of an oropharyngeal airway
Call the anaesthetist as tracheal intubation and
manual ventilation may be needed.
Quick ANTI-COAGULATION reduce mortality from 30 to 3%
25. A
TELECT
ASIS
Affects 25% of patients with abdominal surgery.
More common in elderly or overweight and smokers or with
symptoms of respiratory disease. (loss of elastic recoil of
the lung)
Most frequently in the first 48 h after operation.
Responsible for 90% of febrile episodes during that period.
Most cases are self-limited and recovery is uneventful.
Pathogenesis involves obstructive and nonobstructive
factors. (Secretions resulting from chronic obstructive
pulmonary disease, intubation, or anesthetic agents.
Occasional cases may be due to blood clots or malposition
of the endotracheal tube.)
