PERI OPERATIVE CARE FOR SURGICAL PATIENTS

1. POST OPERATIVE CARE
By
Ismaila Adigun LAWAL, FWACS, FICS
Professor of Surgery & Former Head of Surgery/Head ,Division of Plastic
& Reconstructive Surgery
University of Ilorin/University Of Ilorin Teaching Hospital

2. General Management
• Post operative care provides the patient with a quick, painless and safe recovery
from surgery as possible
• Immediate post operative period
 Patient is nursed in a recovery room using one-to-one nursing and continuous
monitoring.
The nurse ensure - Patient is protecting their airway
- Breathing freely
- Perfusion adequate
- (A-airway, B-breathing, C-circulation)
The perioperative Nurse also Monitors;
- Patient’s pain as anaesthetic wears off
-Ensures no bleeding from the wound
-Loss of distal circulation
-BP, Pulse and Oxygen Saturation are monitored regularly
and result charted

3. General Management cont.
• Once patient is fully conscious and comfortable and with normal vital
signs, they are transferred to the General Ward
• Patient who are at risk may be transferred to a high dependency or
intensive care unit
• Managing Nursing staff must check the patient’s chart for:
• Temperature, Pulse and Respiration (TPR)
• Fluid balance
• Nutritional status in those patient who may be Negative Nitrogen Balance
• Review the drug chart

4. Specific Postoperative Complications
1. Respiratory Complication
• This complication may be reduced by using adequate analgesia including epidurals
• Administer oxygen using face mask or Nasal catheter
• Postponing surgery in patient with upper respiratory tract infection.
(a) Shortness of breath (Dyspnoea)
• The commonest cause of postoperative dyspnoea is alveolar collapse or atelectasis
• This can be diagnosed clinically and radiologically
• It responds to chest physiotherapy
• Other causes of acute postoperative shortness of breath are
 Pulmonary Embolism
 Myocardial infarction and Heart failure
 Chest infection
 Acute Respiratory Distress Syndrome

5. Specific Postoperative Complications Cont.
• Management of this condition is by starting Oxygen delivery immediately while taking history and
performing examination
• Intravenous access, blood taking for FBC
• Arterial blood gases analysis may be needed
• In chest infection:
Sputum is sent for m/c/s
CXR,
ECT may be needed
• Any foreign bodies in the mouth including dentures and vomitus are removed
• Neck shall be extended and jaw forwarded to allow tongue to come forward
• Oral airway should be maintained and protected by an airway such as oro-pharyngeal airway
• Neck wound may need to be opened to release the haematoma causing pressure on the airway

6. Specific Postoperative Complications Cont.
(b) Cyanosis
• Patient with clear airway who developed cyanosis may be having
problems with lungs or circulation
• Common problems in the lung may be acute bronchospasm as a
result of Asthmatic attack or pneumothorax
• Circulating problem include sudden blood loss= decreased venous
return.
• Massive pulmonary embolism

7. Specific Postoperative Complications Cont.
2. Cardiovascular Complication
a) Hypotension
Commonest cause of low blood pressure postoperatively is Hypovolaemia either by
bleeding or insufficient fluid replacement.
Other causes include :
 Myocardial Infarction
 Overdose of analgesic especially opioids
 Epidural anaesthesia as a result of vasodilatation
 Septic Shock
 The emergency treatment requires:
 Increase in the fluid input
 Administration of high flow oxygen
 Head tilted down to maintain cerebral blood perfusion
 A thorough examination should be performed to detect the cause

8. • (b) Hypertension
Most cause of hypertension relates to inadequate pain relief or anxiety
They are managed by appropriate analgesic.
• (C) Deep Vein Thrombosis (DVT)
 Most patients with DVT show no signs
 However, they may present with calf pain, swelling, warmness, redness and
engorged veins
 Homan’s sign may be positive
 Risk factor for DVT includes
 Age> 60 years
 Immobilization
 Trauma
 Surgery, like Pelvic & Lower limb e.g Total Knee and Hip replacement
 Oral contraceptive pills
 Venography is the standard diagnostic technique
 Duplex Doppler Ultrasonography to assess the flow and thrombosis

9. • If a significant DVT is found ( that is One that extends above the knee)
• Treatment is by giving intravenous heparin followed by long term
warfarin
• If untreated it can lead to pulmonary embolism
• Other prophylactics for DVT include; use of stockings, calf pumps and
some pharmacological agents such as Clexane (40-80mg dly)
• Prevention of DVT -Early mobilization
Use of compression stockings
Calf pump
Minimizing use of tourniquets
Prophylactic drugs such as clexane

10. Specific Postoperative Complications Cont
3. Gastrointestinal Complication
• Perioperative nausea and vomiting is a common problem that results in patients weakness and
demoralization
• It can result in complication such as wound dehiscence and pulmonary aspiration
• Prolonged nausea and vomiting results in increase pain levels and prolonged hospital stay
• Predisposing factor for nausea and vomiting post operatively
 Poorly controlled pain
 Use of opioids
 Surgery in GIT, ENT
 Acute gastric dilatation
• Management is by use of- Antiemetic e.g. Metochlopromide
-Nasogastric tube for adequate decompression
-Commence oral feeding slowly
-Avoid use of Opioids
-Maintain hydration and blood pressure

11. 4. Urological Complication
a) Oliguria/Anuria
• Oliguria is defined as urine output less than the minimum obligatory volume
(0.5mls/kg/hr)
• Commonest cause of oliguria is reduced perfusion resulting in perioperative
hypotension or inadequate fluid replacement
• If untreated it may lead to acute renal failure
• To avoid this problem ensure fluid management is adequate
-Daily input/output chart should be monitored
-Hourly urine output to detect early change in renal function
-Urea/creatinine done daily until patient is fully recovered
• If hypovolemia is suspected;
• Give 500mls of IV fluid over 1 hour
• Monitor the urine output and measure JVP
• A central venous catheter can be used to monitor intravenous volume

12. (b) Urinary Retention
• Inability to void after surgery is common in patients with pelvic and
perineal operations or under procedures performed with spinal
anasthaesia
• Pain, fluid deficiencies as well as accessibilities of urinals and bed pans
• Urethral catheterization should be performed in surgical procedures
expected to last 3hours or longer or when large volume of fluid are
admitted.
(c) Urinary infection
• Patients who are at risk factors include
Immunocompromised or diabetic patients
Urinary retention
• Symptoms include; dysuria, mild pyrexia
• Diagnosis is by doing urine M/C/S
• Treatment include adequate hydration and proper bladder drainage

13. Complications Related to some Specific
Surgical Specialties
1. Abdominal Surgery
• The most important complications to look out for in a post operative abdominal surgical patients
are
 Anastomotic leakage
 Bleeding or abscess
 Paralytic ileus
(a) Localized infection
• This can be superficial or deep seated collection
• Swab is taken for m/c/s
• Ultrasonography or CT abdomen should identify suspicious collection
(b) Paralytic Ileus
• This may present with nausea, vomiting, refusal to eat, bowel distension, absence of flatus or
bowel movement
• Treatment is usually supportive with maintenance of adequate hydration and electrolyte level
• Passage of nasogastric tube to decompress the GIT

14. 2. Orthopaedic Surgery
• In patient having any limb surgery, including hip, knee arthroplasty
Distal neurovascular structures of the limb must be reviewed regularly
• In postoperative trauma case, evidence of compartment syndrome should be actively sought for
and treated by fasciotomy if suspected.
• Symptoms of compartment syndrome are- pain, pain, pain
• Pain is greater than expected and unresponsive to analgesia
• Paralysis , paresthesia and pulselessness are very late complication
• Patient who have undergone open reduction and internal fixation of fracture= the neurovascular
status of the limb must be checked every half an hour initially by the nurses in the recovery room.
• Patients who had tourniquets applied in the theatre should have the vascular supply to the limb
carefully monitored in the immediate post postoperative period

15. 3. Head and Neck Surgery
• Patient with neck surgery such as thyroid surgery must be observed for accumulation of
blood in the wound
• Need pre and post operative laryngoscopy for damage to recurrent laryngeal nerve
4. Plastic Surgery
• Viability of flaps is crucial and the perfusion of limbs to be monitored regularly
• Blood supply may be compromised by position, dressing or collection of fluid or blood
beneath the flap
5. Urologic Surgery
• Catheter patency must be ensured following urological surgeries
• Patients who have undergone transurethral resection of the prostate (TURP) must have
continuous bladder irrigation
• Care must be taken to prevent pulmonary embolism

16. General Complication
1. Fever
• About 40% of patients developed pyrexia after major surgeries
• In 80% of cases no particular cause is found
• Pyrexia does not necessarily implies sepsis: the inflammatory response to surgical
procedure may manifest as temperature
• A focus of infection must be sighted if a patient develops anything more than
slight pyrexia
• Patients with persistent pyrexia needs a thorough review
• Relevant investigations include; FBC, urine m/c/s, sputum microscopy, blood
culture, CXR, Abdominal USS.
2. Pressure Sores
• Affects pressure points of a recumbent patient
• Risk factors are poor nutritional status, dehydration , lack of mobility ,
unconscious patient
• 2 hourly turning of patient, use of air filter mattresses, early mobilization
• Others include Blood transfusion, wound care, Nutrition

17. Discharge of patient
• Following treatment in the hospital, patients are discharged home
where they will continue to recover
• Post operative orthopaedic patient may be transferred to a
rehabilitation centre
• Patient discharged home needs a discharge letter detailed the
postoperative plan for the patient. This is usually completed by the
house surgeons

18. Follow-up in the clinic
• Patients should be reviewed in the clinic when a key decision on the
management needs to be made
• Patient should be discharged from the clinic as soon as the GPs or
they themselves can manage their case

19. • Thanks for Listening