2. Post-Operative Care
• Meaning: The management of a patient after surgery . This includes
care given during the immediate postoperative period , both in the
operating room and postanesthesia care unit , as well as during the
days following surgery .
• The goal of postoperative care :
1. to prevent, detect and manage complications during post-
operative period.
2. to promote healing of the operative site
3. to return the patient to a state of good health.
4. To treat pain during post-op period
4. Check list for 1st postoperative
assessment
• Instructions given to PACU Staff:
General info (name, age, surgery, etc)
Past medical History
Medications
Allergies
Intraoperative course and management
Intraoperative complications- anesthetic or surgical
Recommended Rx & prophylaxis ( e.g. fluids, nutrition, antibiotics , analgesia ,
anti-emetic , thromboprophylaxis)
The patient is transferred to PACU after the surgical procedure,
anesthesia reversal, and extubation (if it was necessary).
Mental status/ Level of consciousness: Patient conscious and normally
responsive? (AVPU: Alert, respond for Verbal & Painful stimuli,
unresponsive)
5. • Respiratory assessment status:
O2 saturation.
Effort of breathing
Respiratory rate
Trachea central or not.
Symmetry of inspiration and expiration.
Breath sounds.
Percussion.
Check list for 1st postoperative
assessment
Volume status assessment:
Hands-warm or cool; pink or pale.
Pulse- rate , volume and rhythm.
blood pressure.
Conjunctival pallor.
Jugular venous pressure.
Urine color & output .
Drainage from drains, wound & NG tube
6. Other assessment categories:
• surgical site (intact dressings with no signs of overt bleeding)
• patency (proper opening) of drainage tubes/drains
• body temperature (hypothermia/hyperthermia)
• rate of intravenous (IV) fluids
• circulation/sensation in extremities after vascular or orthopedic surgery
• level of sensation after regional anesthesia
• pain status
• nausea/vomiting
• RECORD any significant symptoms (e.g. chest pain, breathlessness, diaphoresis)
The amount of time the patient spends in the PACU depends on
• Length of surgery
• Type of surgery
• Status of regional anesthesia (e.g., spinal anesthesia)
• level of consciousness
7. • Acute pulmonary problems
• Cardio-vascular problems
• Fluid and Electrolyte derangements
Complications & Deaths in Immediate Post-op Period
Prevention is by Continuous Monitoring of Patient’s Vitals in Recovery
Room
Discharge from RR should be after complete stabilization of cardio-vascular,
pulmonary and neurological functions
(If not under special care in icu)
Prevention is by Continuous Monitoring of Patient’s Vitals in Recovery
Room
8. Post-operative orders
A) Monitoring
• Vitals (pulse, BP, RR, Temp) every
hourly.
• CVP
• ECG
• Fluid balance ( input and output)
• Urine.
• Other types of monitoring :
• Arterial pulses after vascular
surgery.
• Level of consciousness after
neurosurgery.
B) Respiratory Care:
• Tracheal suction.
• Chest physiotherapy.
C) Position in bed and
mobilization:
Turning in bed usually every
2 hours until full mobilization
to prevent pressure sores/ bed
sores.
DVT prevention mechanically
( intermittent calf
compression).
D) Diet:
NPO / Liquids / Soft diet /
Normal or special diet.
E) Administration of I.V. fluids:
Daily requirements.
Losses from GI and UT
Losses from stomas and
drains.
Insensible losses
10. Care of the wound
• Epithelialisation takes 48 hs.
• Dressing should be removed 3-4 days after operation.
• Soaked dressing changed earlier.
• Symptoms and signs of infection should be looked for, which if present; a few
stitches removed and daily dressing with swab for C/S.
• Tensile strength of wound minimal during first 5 days, then rapid between 5th
- 20th day then slowly again.
11. Management of drains
• To drain fluids accumulating after surgery, blood or pus.
• Should come out through separate incision to minimize risk of wound
infection.
• types e.g Suction, sump, under water etc.
• Soft drains e.g. Penrose should not be left more than 40 days because they
form a tract and acts as a plug.
• Inspection of color, contents, amount, consistency and odour.
* Notify if there is excessive or abnormal drainage
• Should be removed as long as no function.
12. Post-op Pulmonary care
• Functional residual capacity (FRC) and VC decrease after major
intra-abdominal surgery down to 40% of the Pre-Op. Level.
• Post-anesthesia pulmonary oedema.
• Accentuated by obesity, heavy smoking or Pre-existing lung
diseases specially in elderly.
• Post-Op. atelectasis - enhanced by shallow breathing, pain,
obesity and abdominal distension (restriction of diaphragmatic
movements)
• Post-Op. Chest physiotherapy especially deep inspiration helps.
• Periodic hyperinflation using spirometer.
• Adequate management of fluids help to reduce pulmonary edema.
13. Post-op Fluid & Electrolytes
• Considerations:
• Maintenance requirements.
• Extra needs resulting from systemic factors e.g. fever, diarrhoea
and vomiting etc.
• Losses from drains and fistulas.
• Tissue oedema (3rd space losses)
• The daily maintenance requirements in adult for sensible and
insensible losses are 1500-2500mls. depending on age, sex, weight and
body surface area.
• Rough estimation of need is by body weight x 30/day. e.g. 60 KG x 30 =
1800ml/day.
• Requirement - fever and increased catabolic states.
• Estimation of electrolytes daily is only necessary in critical patients.
• 5% dextrose in normal saline or in lactated Ringer’s solution is suitable
for most patients.
14. Post-op Care Of GIT
• NPO until peristalsis returns.
• Ausculate for bowel sounds.
• Gradual return of oral feeding from liquids to normal diet.
• NGT is necessary after esophageal and gastric surgery.
• NGT is NOT necessary after cholecystectomy, pelvic operation or
colonic resections.
• RT Aspiration is important e.g. in GJ
• Gastrostomy and jejunostomy tube feeding can start on 2nd Post-Op.
day
• Early Ambulation and Repositioning helps in passage of flatus
• STOMA CARE: Look for color (Pink/ dusky), functionality,
Prolapse, Retraction, excoriation.
15. Post-operative Pain
• Factors affecting severity :
• Duration of surgery.
• Degree of Operative trauma (intra-thoracic, intra-abdominal or
superficial surgery).
• Type of incision.
• Magnitude of intra-operative retraction.
• Factors related to the patient : Anxiety, Fear, cultural
• Complications of Pain:
• Causes vasospasm -> Hypertension.
• Nausea/ vomiting
• May cause CVA, MI or bleeding.
• Management of Post-Op. pain:
• Physician – patient communication (reassurance).
• Analgesics (NSAIDS).
• Parenteral opioids.
• Anxiolytics potentiates action of opioids, anti-emetic effects.
• Suppositories e.g. Tylenol.
• Epidural analgesia
• Nerve block (Post-thoracotomy and hernia repair).
16. Urinary Assessment
• Urine examined for
• Note color, amount, consistency .
• Assess indwelling catheters for patency
• Urine output should be at least 0.5 ml/kg per hour or
30cc/hr.
17. Post-op Surgical Complications
• Age both extremes
• Obesity
• Chronic Smokers
• Co-morbid conditions
• Drug therapy e.g. steroids , immunosuppressant,
antibiotics and contraceptive pills
General Risk Factors :
18. Anaesthetic Complications
Depend on:
• The mode (General, Regional &Local)
• Type ofanesthetic (the anesthetic agent toxicity).
Local Anaesthesia:
Injection site: Pain, hematoma, Nerve trauma, infection
Vasoconstrictors:
( C.I in nose , fingers , penis , scrotum , ears , toes ) it may lead to ischemic necrosis
Systemic effects of LA agent: Allergic reactions, toxicity
SPINAL, EPIDURAL &CAUDAL ANESTHESIA:
Headache due to loss of CSF
Intrathecal bleeding
Permanent Nerve/ cord damage
Paraspinal infection
Severe hypotension
Urinary retention
General Anasthesia :
Direct trauma to mouth or pharynx.
Hypothermia due to long operations with
extensive cold fluids replacement.
19. Complications due to surgery :
•Immediate (0-24hrs)
Primary hemorrhage
Basal atelectasis
Shock
•Early (2nd day- 3weeks)
•Mental state change
•Fever
•2ndry hemorrhage
•Wound infecton
•Paralytic ileus
Late (Weeks –months)
Bowel obstruction
Incisional hernia
Hemorrhage
Wound Infection
Cardiovascular
Respiratory
Gastrointestinal
Urinary tract
Cerebral
Septicemia
20. HEMORRHAGE
Primary Hemorrhage :
• Inadequate hemostasis.
• Unrecognized damage to blood vessels.
• Defective vascular anastamoses.
• Clotting factor deficiency.
• Intra-operative anticoagulants
Early recognition & management
Surgical re-exploration is usually required
Secondary hemorrhage:
Usually Related to infection.
21. WOUND COMPLICATIONS
Infection:
Classification
1. Superficial (skin and SC tissue)
2. Deep (fascia and muscle )
3. Space (anatomical space and organ)
Symptoms & signs: Local rise in temp, redness , pain, Swelling + Fever, chills
Treatment
1. Superficial >> incision and drainage with or without systemic antibiotic
2. Deep >>> surgical debridement with systemic antibiotic
3. Space >>> CT scan guided percutaneous drainage & may need open drainage
Etiology : It based on the site of
operation
Staph: In thoracic , neuro ,
vascular, breast
G –negative for GIT and urologic
operation
Strept. Head and neck
22. Hematoma : Localized collection of blood.
Seroma : Localized collection of serous fluid.
Common sites : breast and abdominal surgery
Treatment
Small hematoma/ seroma : spontaneously absorbed
Large hematoma/ seroma : may required drainage
Wound dehiscence
Evisceration – wound edges separate so that the intestine protrudes through gap. –
Emergency; in cases of increased Straining.
Incisional hernia
Risk Factors: chronic cough, Increased abdominal pressure like lifting Heavy object etc
Treatment :
Herniorrhaphy
Hernioplasty ( with mesh)
23. HYPOTHERMIA
• Body temperature below 35° C.
• Causes : Trauma, Exposure to Cool Fluids – IV / Irrigation
• Hypothermia can lead to:
• Increased O2 consumption due to shivering
• Coagulopathy
• Platelet dysfunction
• Mild: 32 – 35 ° C
• Mod: 28 – 32 ° C
• Severe: 25 – 28 ° C
• Treatment with warmers like forced air devices and warm
fluids.
• Meperidine (opioid analgesic) in small doses can be used to
stop the shivering.
24. • Within 48 Hours
- Usually Atelectasis
• After 48 Hours
- UTI
- Catheter related phlebitis
- Pneumonia
• After the 5th PO day
- Wound infection
- Anastomotic breakdown
- Intra-Abdominal abscess
• After the 7th PO day
- Deep vein thrombosis
- Pulmonary embolism
•Regular work up includes:
• CBC
• Blood cultures
• Urine analysis and urine
cultures
• CXR
• Sputum cultures
POSTOPERATIVE FEVER
Body temperature > 38.5° C
40% of patients after a major surgery.
In most patients it resolves without specific
treatment, however a patient must be evaluated
for:
•Pneumonia / Atelectasis
•Wound Infections/ Abscess
•UTI
•Deep vein thrombosisPulmonary embolism
•Medications
25. Myocardial Infarction
• Risk factors:
-Previous history/ Angina / Advanced age/
Lifestyle
• Investigations:
-ECG/ Troponin I CKMB
• Presentation:
-Often asymptomatic; Symptoms include:
breathlessness, new onset dysrhythmia,
hypotension, chest pain, tachycardia...
• Treatment:
-Nitrates, Aspirin, Oxygen, Pain control,
Heparin and ICU monitoring
Reversible causes like hypokalemia,
hypoxemia, alkalosis and stress after the
operation.
Could be the 1st sign of a post-OP MI.
Atrial flutterfibrillation:
-If the patient is stable, the heart rate could
be controlled with β-blockers, digitalis or Ca
channel blockers.
-If the patient is unstable (eg. In shock)
cardioversion is used.
Premature Ventricular contractions (PVC) :
Oxygen, sedation, analgesia
Ventricular Tachycardia: Can lead to the life
threatening ventricular fibrillation.
Rx: Lidocaine
Complete Heart Block: Insertion of a
pacemaker is necessary.
correction of fluidelectrolyte
disturbances
Arrhythmia
26. DVT
• Risk Factors:
• Advanced age, Obesity, Hormonal therapy , Immobilization, Smoking, DMHTN
• Symptoms: Can be asymptomatic; Pulmonary embolism, lower limb pain, tenderness
and swelling
• Homan’s sign: Calf pain with dorsiflexion of the foot
• Moses sign: Calf pain on squeezing.
• Investigation: Duplex US.
• DVT prophylaxis
• Leg exercise (10-12/Q 1-2 hr)
• Elastic stockings
• Sequential compression devices
• Anticoagulants (Heparin, LMWH)
• Early ambulation
27. • Early :
• Occurs minutes to 1-2 hours. Post-Op.
• Occurs suddenly.
• Late :
• Occurs 48 hs. Post-Op.
• Due to pulmonary embolism, abdominal distension or opioid overdose.
Manifestation :
• Tachypnea > 30/min.
• Low tidal volume < 4ml /kg
• High Pco2 > 45mmHg.
• Low Po2 < 60mmHg.
• Treatment :
• Immediate intubation and mechanical ventilation if required.
• Treatment of underlying lung disease.
• Prevention:
• Physiotherapy (Pre. & Post-OP.) to prevent atelectasis.
• Treatment of any Pre-existing pulmonary diseases.
• Hydration of patient to avoid hypovolemia and later on atelectasis and
infection.
Respiratory
failure
28. Pulmonary embolism
• Symptoms: Dyspnea, fever, tachypnea and
hemoptysis.
• Investigations: ABG, CT angiogram,
Pulmonary angiogram [Gold Standard].
• Treatment:
-Stable Patient: Low molecular weight heparin
or a green field filter.
-Unstable Patient: Thrombolytic therapy,
pulmonary artery embolectomy or catheter
suction embolectomy.
• Prophylactic measures for DVTPE:
• Preoperative heparin.
• Elastic stockings.
• Early ambulation.
Risk Factors:
Prolonged ventilation support,
peritoneal infection, atelectasis and
aspiration.
SignsSymptoms:
Fever, tachypnea, increased
secretions and signs of pulmonary
consolidation.
Investigations:
Sputum culture and CXR showing
consolidation.
Treatment:
Antibiotics and clearing the airway of
secretions.
Post-Op Pneumonia
29. ATELECTASIS
Collapse of the alveoli.
Occurs within the first 48 hours post op.
Affects 25% of patients who have abdominal surgery.
Risk Factors:
Thoracicabdominal surgery, COPD, smoking
poor pain control and poor ventilation during
surgery.
Signs:
Fever, decreased breath sounds, tachypnea,
tachycardia
and increased density on CXR.
Treatment:
Incentive spirometry, deep breathing, coughing,
early ambulation and chest physical therapy.
Prophylaxis
Smoke cessation and good pain control.
30. Urinary Retention:
• Enlarged bladder from spinal
anesthesia or medication.
• SymptomsSigns: Palpable
bladder and inability to void.
• Treatment:
K-90 / Foley catheter.
UTI
Risk Factors:
Urinary retention, preexisting
contamination of urine and
instrumentation.
SymptomsSigns:
Cystitis: Dysuria and mild fever.
Pyelonephritis: High fever, flank
tenderness and ileus.
Diagnosis:
Urine examination and cultures.
Treatment:
Hydration, proper drainage of the
bladder and antibiotics.
31. POSTOPERATIVE ILEUS
It is an obstruction due to paralysis of the
bowel.
• Risk factors:
Hypokalemia, narcotics and GI surgery.
• Symptoms and signs:
Constipation, abdominal pain,
absent bowel sounds and bowel
distention with gases on CXR.
• Treatment: Supportive until motility
returns (usually within 3-5 days).
32. Neurologic
• Drug Induced
• ICU Psychosis
• Neuropsychiatric Complications
• Operative Nerve Injuries
Late Complications
Wound: Hypertrophic scar, keloid, wound sinus, implantation dermoids,
incisional hernia
Adhesions: Intestinal obstruction, strangulation
Short gut syndrome, postgastric surgery syndromes, etc.
Susceptibility to other diseases, Tuberculosis, etc.
Enterocutaneous Fistula from GI tract to the skin.
Causes: Anastomotic leak, traumainjury, infection , etc.
Investigations: CT, fistulagram.
Treatment:
NPO, total parenteral nutrition, half will resolve spontaneously, but the other half will requir
resection of the involved bowel segment.
33. 1. Education ( + family) : Encourage early
mobilization: Deep breathing and coughing,
2. Active daily exercise, Joint range of motion,
Muscular strengthening , Make walking aids
available
3. Ensure adequate nutrition
4. Prevent skin breakdown and pressure sores:
Turn the patient frequently o Keep urine and
faeces off skin
5. Provide adequate pain control
6. Prescriptions
7. Follow up
Hinweis der Redaktion
medication for nausea or vomiting, as well as pain.
Patients with a patient-controlled analgesia pump may need to be reminded how to use it. If the patient is too sedated immediately after the surgery, the nurse may push the button to deliver pain medication. The patient should be asked to rate his or her pain level on a pain scale in order to determine his or her acceptable level of pain. Controlling pain is crucial so that the patient may perform coughing, deep breathing exercises, and may be able to turn in bed, sit up, and, eventually, walk.
Respiratory exercises (coughing, deep breathing, and incentive spirometry) should be done every two hours. The patient should be turned every two hours to prevent pressure sores
must perform respiratory exercises to prevent pneumonia; and that movement is imperative for preventing blood clots, encouraging circulation to the extremities, and keeping the lungs clear
NOTIFY to the operating surgeon
K causes increased aldosterone activity
Paralytic ileus usually takes about 24hs.
Normal frequency :
absorption from small bowel is not affected by laparotomy.
Enteral feeding is better than parenteral feeding.
Pain transmission:
Splanchnic nerves to spinal cord.
Brain stem- alteration in ventilation, BP and endocrine functions.
Cortical response from voluntary movements and emotions.
Malignant hyperthermia is disease passed down through families that causes a fast rise in body temperature (fever) and severe muscle contractions when the affected person gets general anesthesia
symptoms :
High temperature, Tachycardia, Tachypnea, increased carbon dioxide production, increased oxygen consumption, acidosis, rigid muscle & rhabdomyolysis
Treatment :
Discontinue the anesthesia, wrapping the patient in a cooling blanket Benzodiazepine >>>((dantrolene))
Seroma is common in excessive fatty tissuesIncsional hernia They occur more commonly among adults than among children
Cardiovascular Complications are life threatening.
Emboli get trapped in pulmnonary arteries; obstruct blood flow
Most common Respi complication
Pseudomembranous Colitis - antibiotic associated diarrhea usually caused by Clindamycin
C.difficile toxin in stool, fecal WBCs and mucus membranes in the lumen of the colon
Metronidazole orally or IV.