post op

1. POST-OPERATIVE
CARE
AFFAN | AUDI | HUSNA

2. INTRODUCTION
The aim of post-operative care is to
provide the patient with as quick,
painless and safe recovery from
surgery as possible

3. PHASES
IMMEDIATE
INTERMEDIATE
CONVALESCENT
POST-ANESTHETIC // PHASE I
HOSPITAL STAY // PHASE II
AFTER DISCHARGE TO FULL RECOVERY

4. SUMMARY OF MOST COMMON
CAUSES OF POST-OP FEVER WHEN
STARTING ON
 1st Day
 2nd Day
 3rd Day
 4th Day
 5th Day
 7th Day
: Reactive to drugs or surgical tissue trauma
: Atelectasis
: IV line infection (STP)
: Pneumonia, DVT, UTI
: Wound infection (still pneumonia, DVT, UTI)
: Abscess somewhere
 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
MONITOR
 Vital signs
 ECG
 Fluid balance
 Other types of monitoring (arterial pulses after vascular surgery,
level of consciousness after neurosurgery)
RESPIRATORY CARE
 Oxygen mask
 Ventilator
 Tracheal suction
 Chest physiotherapy

8. 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

9. POST-OPERATIVE ORDERS
ADMINISTRATION OF IV FLUIDS
 Daily requirements
 Losses from GIT & UT
 Losses from stomas & drains
 Insensible losses
 Care of renal patients
 Care of drainage tubes
MEDICATION
 Antibiotics
 Pain killers
 Sedatives
 Pre-operative medication
 Care of patients on pre-op
steroids
 H2 blockers (esp. ICU)
 Anti coagulants
 Anti diabetics
 Anti hypertensives

10. POST-OPERATIVE ORDERS
LABORATORY TESTS & IMAGING
To detect or exclude post-operative complications

11. POST-OPERATIVE
PULMONARY CARE
 Functional residual capacity (FRC) and vital capacity (VC)
decrease after major intra-abdominal surgery down to 40% of
pre-operative level
 They go up slowly to 60-70% by 6th – 7th day and to normal pre-
operative level after that
 FRC, VC and post-operative pulmonary edema (post
anesthesia). Contribute to the changes in pulmonary functions
post-operative
 The above changes are accentuated by obesity, heavy smoking
or pre-existing lung diseases especially in elderly

12. 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

13. 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

14. 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

15. PAIN
 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.

16. 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.

17. 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.

18. 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.

19. DEEP VEIN THROMBOSIS
 Patients suffering postoperative deep vein thrombosis (DVT)
may present with calf pain, swelling, warmth, redness
and engorged veins.
 However, most will show no physical signs.
 On palpation, the muscle may be tender and there is a positive
Homans’ sign (calf pain on dorsiflexion of the foot)
 Venography or duplex Doppler ultrasound is used to assess
flow and the presence of thromboses.

20. DEEP VEIN THROMBOSIS
MANAGEMENT
 Initially starts with intravenous heparin followed by longer-
term warfarin, should be started.
 In some patients with a large DVT
, a caval filter may be
required to decrease the possibility of pulmonary embolism.
 Most hospitals have a DVT prophylaxis protocol.
i. use of stockings
ii. calf pumps
iii. pharmacological agents, such as low molecular weight
heparin

21. DEEP VEIN THROMBOSIS
RISK OF DVT

22. 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.

24. SUMMARY OF MOST COMMON
CAUSES OF POST-OP FEVER WHEN
STARTING ON
 1st Day
 2nd Day
 3rd Day
 4th Day
 5th Day
 7th Day
: Reactive to drugs or surgical tissue trauma
: Atelectasis
: IV line infection (STP)
: Pneumonia, DVT, UTI
: Wound infection (still pneumonia, DVT, UTI)
: Abscess somewhere
 After first week : allergy to drugs, transfusion-related-fever,
septic pelvic vein thrombosis and intraabdominal abscesses

25. 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.

26. PRESSURE SORES
 These occur as a result of friction or persisting pressure on soft
tissues
 They particularly affect the pressure points of a recumbent
patient, including the sacrum, greater trochanter and heels
 Risk factors are :
i. Poor nutritional status
ii. Dehydration and lack of mobility
iii. Use of a nerve block anesthesia technique
 Early mobilization prevents pressure sores, while those who
are unable to turn in bed should be turned every 30 minutes to
prevent pressure sores from developing
 High-risk patients may be nursed on an air lter mattress, which
automatically relieves the pressure areas

27. CONFUSIONAL STATE
 Acute confusional states can occur on recovery from anesthesia
(postoperative delirium (POD)) or a few days after surgery.
 The overall incidence of POD is 5–15 per cent, but is higher in the elderly
with hip fractures and is associated with increased morbidity and mortality
 Confusion may present as :
i. Anxiety
ii. Incoherent speech
iii. Clouding of consciousness or destructive behavior, e.G. Pulling out of
cannula
 Risk factors for POD include :
i. Pre-existing cognitive impairment (dementia)
ii. Use of narcotics
iii. Benzodiazepines
iv. Alcohol (and withdrawal from it)
v. Severe illness
vi. Renal impairment
vii. Depression

28. 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.

29. 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

30. 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

31. 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

32. RESPIRATORY
COMPLICATIONS

33. RESPIRATORY
COMPLICATIONS
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

34. POST-OPERATIVE
HYPOXEMIA
 Defined as an oxygen
saturation of less than
90%
 Presentations are ;
i. Shortness of breath
ii.Agitation
iii. Upper
obstruction
airway
(absence
of air movement,
seesaw motion of
suprasternal
chest,
recession)
iv. Cyanosis
v. Combination of any of
the above
 Upper
residual
WHY DOES IT OCCUR?
airway obstruction due to the
effect of general anesthesia,
secretions or wound hematoma after
neck surgery.
 Laryngeal edema from traumatic tracheal
intubation, recurrent laryngeal nerve
palsy and tracheal collapse after thyroid
surgery.
 Hypoventilation related to anesthesia or
surgery.
after upper abdominal and
 Atelectasis and pneumonia especially
thoracic
surgery.
 Pulmonary edema of cardiac origin or
related to fluid overload.
 Pulmonary Embolism

35. PULMONARY ASPIRATION
 GERD patients, food in the stomach, or position of the
patient
 Intestinal obstruction, pregnancy  increased intra-
abdominal pressure and decreased gastric motility
are also risk of aspiration.
 60% of cases of aspiration follow thoracic or
abdominal surgery
 50% result in pneumonia mostly on right side.
 Mortality from subsequent pneumonia is about 50%.
 Minor amounts of aspiration are frequent during
surgery and are apparently well tolerated

36. 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.

37. POST-OPERATIVE
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

38. 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%

39. ATELECTASIS
 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.)

41. ATELECTASIS
SYMPTOMS
Fever (pathogenesis unknown), tachypnoea, and tachycardia
SIGNS
Scattered rales, and decreased breath sounds
TREATMENT
Early mobilization, frequent changes in position, encourage to cough,
and use of an incentive spirometer

42. SUMMARY OF RESPIRATORY
COMPLICATIONS
 Can occur either immediately or a few days later on
the ward
 Obese, smokers
conditions are
and those with chronic lung
more likely to have respiratory
complications
 Early intervention and multidisciplinary involvement
can prevent life threatening respiratory complications

43. CARDIOVASCULAR
COMPLICATIONS

44. CARDIOVASCULAR
COMPLICATIONS
Life threatening, but incidence is reduced by
appropriate preoperative preparation
Regional anesthesia is safer than GA, as GA drugs and
gases may cause dysrhythmia and hypotension.
1. Postoperative Dysrhythmias
2. Postoperative Myocardial Infarction
3. Postoperative Cardiac Failure
4. Severe hypertension
NB: non-cardiac complications ( hypoxia, sepsis ) increase incidence of cardiac
complications.

45. POST-OPERATIVE
DYSRHYTHMIAS
 Mostly appear during the operation or within the first 3
postoperative days.
 More in or after thoracic than abdominal procedures.
 Generally causes are reversible: Hypokalemia, hypoxemia,
hypercapnia, alkalosis, digoxin toxicity, stress during recovery,
mostly asymptomatic
 It can be 1st sign of myocardiac ischemia, especially when
associated with chest pain, sweating, palpitation, dyspnea
 SVT less dangerous than ventricular dysrhythmias.
 Treatment according to type, but all associated abnormalities
should be corrected.
 Complete heart block is usually due to serious cardiac disease
and calls for the immediate insertion of a pacemaker

46. MYOCARDIAC INFARCTION
 Precipitated by hypotension or hypoxemia.
 Over 50% asymptomatic silent MI ( GA, or analgesia )
 S&S: chest pain, hypotension, dysrhythmia.
 Diagnosis: ECG changes, elevated CPK MB, Troponin I.
 Management: ICU, oxygenation and precise fluid and
electrolyte replacement. Anticoagulation, though not always
feasible after major surgery, prevents the development of
mural thrombosis and arterial embolism after myocardial
infarction.
 CHF treated with digitalis, diuretics, and vasodilators as
needed.

47. POST-OPERATIVE CARDIAC
FAILURE
 LVF and pulmonary edema occur in 4% after age 40
 Fluid overload, limited cardiac reserve are main causes,
trauma, transfusions, sepsis are other causes
 Manifestations: progressive dyspnea, hypoxemia with normal
CO2 tension, and diffuse congestion on chest x-ray.
 Shock require transfer to ICU, placement of a pulmonary artery
line, monitoring of filling pressures, and immediate preload and
afterload reduction.
 Preload reduction with diuretics (and nitroglycerin if needed)
 Afterload reduction: by administration of sodium nitroprusside.
 Patients not in shock may instead be digitalized rapidly IV with
careful monitoring of the serum potassium level)
 Fluid restriction, and diuretics may be enough in milder cases.
 Respiratory insufficiency calls for endotracheal intubation and a
mechanical respirator.

48. RENAL AND
URINARY
COMPLICATIONS

49. ACUTE RENAL FAILURE
25% of cases of hospital-acquired renal failure occur in
the perioperative period and are associated with high
mortality
especially after cardiac and major vascular surgery
 Patients with chronic renal disease, diabetes, liver
failure, peripheral vascular disease and cardiac failure
are at high risk.
 Perioperative events such as sepsis, bleeding,
hypovolaemia, rhabdomyolysis or abdominal
compartmental syndrome can all precipitate acute
renal failure.

50. ACUTE RENAL FAILURE
 ARF is characterized by a sudden reduction in renal
output that results in the systemic accumulation of
nitrogenous waste.
 Diagnostic criteria :
i. Increase in serum creatinine level > 1.5x baseline
ii. Decrease urine output <500 ml/day (20ml/hr)
 Causes :
i. Pre renal
ii. Renal
iii. Post renal

51. ACUTE RENAL FAILURE
MANAGEMENT
 Ascertain cause of ARF
 If urine output decrease;
i. Checked Catheter Is Not Blocked
ii. Correct Hypovolaemia And Hypotension
iii. Correct Metabolic And Electrolyte Imbalance
 Treat the cause
 Stop nephrotoxic drugs
 Hemodialysis

52. URINARY RETENTION
 Common with pelvic and perineal operation.
 Causes :
i. Pain
ii. Fluid deficiency
iii. Problems with access urinals and bed pans
iv. Lack of privacy in the ward

53. URINARY INFECTION
 Most common due to acquired infection.
 Patient can come with dysuria and/ or pyrexia.
 Treatment :
i. Adequate hydration
ii. Proper bladder drainage
iii. Antibiotic

54. COMPLICATION IN
SPECIFIC
SURGICAL
SPECIALITIES

55. COMPLICATION IN SPECIFIC
SURGICAL SPECIALITIES
 Abdominal
 Urology
 Neck
 Neurosurgery
 Thoracic surgery

56. ABDOMINAL
COMPLICATIONS
 Paralytic Ileus: signaled by nausea, vomiting, loss of
appetite, bowel distension, and absence of flatus /
bowel movement.
 Bleed
 Abscess: may present with abdominal pain, focal
tenderness & spiking fever
 Anastomotic leak

57. UROLOGY
COMPLICATIONS
 Pulmonary Edema: continuous bladder irrigation may
be used after transurethral resection of prostate
(TURP)
 Pulmonary edema is developed if a large amount of
irrigation fluid is absorbed.

58. NECK
COMPLICATIONS
 Thyroid surgery: Accumulation of blood in the
wound. Can cause rapid asphyxia
 Damage of recurrent laryngeal nerve

59. NEUROSURGERY
COMPLICATIONS
 Increased intracranial pressure: signaled by
deteriorating state of consciousness / appearance of
new neurological sign

60. THORACIC
COMPLICATIONS
 Susceptible to fluid overload; patient undergoing
lobectomy / pneumonectomy should have fluid
restriction as they are susceptible to overload in the
first 24-48 hours

61. ENHANCED RECOVERY
It is an approach designed to speed clinical recovery of
patient, and reduce the cost and the length of stay of
the patient in the hospital
 Achieved by optimizing the health of patient before surgery
 Postoperatively achieved by:
i. Early planned physiotherapy & mobilization
ii. Early oral hydration and nourishment
iii.Good pain control
iv. Discharge planning: Includes plan for follow up,
physiotherapy, and other support needed.

62. REFERENCES
Bailey & Love Short Practice of surgery, Chapter 21,
Postoperative care.