Lecturer Wisam Khalid Abduljabbar FIBMS general surgery Post operative Care Lecturer Wisam Khalid Abduljabbar FIBMS general surgery

The aim of postoperative care is to provide the patient with as quick, painless and safe recovery from surgery as possible.

The immediate postoperative period: recovery room patient’s name, age, the surgical procedure, Existing medical problems, allergies, the anaesthetic and analgesics given, fluid replacement, blood loss, urine output, any surgical and anaesthetic problems encountered or expected vital parameters, consciousness, pain and hydration status are monitored in the recovery room

Criteria of discharging patient from recovery room • Patient is fully conscious. • Respiration and oxygenation are satisfactory. • Patient is normothermic, 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

SYSTEM-SPECIFIC POSTOPERATIVE COMPLICATIONS Respiratory complications: Early: hypoxemia, hypercapnia and aspiration Late: pneumonia and pulmonary embolism

Postoperative hypoxia oxygen saturation of less than 90 per cent. Obese, smokers and those with chronic lung conditions Causes: Upper airway obstruction Laryngeal oedema Hypoventilation Pulmonary oedema Atelectasis and pneumonia Pulmonary embolism

Management of postop. Hypoxia Urgent oxygen at 15 L/min, using a non-rebreathing mask Head tilt, chin lift or jaw thrust Suctioning of any blood or secretions and insertion of an oropharyngeal airway tracheal intubation and manual ventilation Neck wound haematoma evacuation(LA or GA) For pneumonia: antibiotics, chest physiotherapy and bronchodilators

Cardiovascular complications Hypotension: Causes:inadequate fluid replacement, vasodilatation from subarachnoid and epidural anaesthesia or rewarming of the patient surgical bleeding sepsis, arrhythmias, myocardial infarction, cardiac failure, tension pneumothorax, pulmonary embolism, pericardial tamponade and anaphylaxis S/S?

Myocardial ischaemia and infarction previous cardiac problems undergoing major surgery are at risk of developing an acute coronary syndrome retrosternal pain radiating into the neck, jaw or arms nausea, dyspnoea or syncope ST-elevation in two continuous leads on the ECG new left bundle branch block serum troponin is high Treatment : ?

Arrhythmias can be prevented and corrected by treating hypotension and electrolyte imbalance need management with the help of cardiologists Tachycardia (sinus or supraventricular) causes: anxiety, pain, MI, hypovolaemia, sepsis or hypoxia Rx :beta-blockers, amiodarone or cardioversion

Sinus bradycardia Normal in athletes hypoxia, preoperative beta-blockers, digoxin and increased intracranial pressure heart rate is 40 bpm or less, glycopyrrolate 0.2–0.4 mg or atropine 0.6 mg

Renal and urinary complications Acute renal failure: Postoperative renal failure is associated with high mortality urine output is less than 0.5 mL/kg per hour for 6 hours High risk group: chronic renal disease, diabetes, liver failure, peripheral vascular disease and cardiac failure sepsis, bleeding, hypovolaemia, rhabdomyolysis or abdominal compartmental syndrome

Common causes of acute renal failure Hypotension Hypovolaemia Renal Nephrotoxic drugs (gentamicin, diuretics, nonsteroidal anti-inflammatory agents) Surgery involving renal vessels Myoglobinuria Sepsis Postrenal Ureteric injury Blocked urethral catheter

Urinary retention pelvic and perineal operations or after procedures performed under spinal Anaesthesia Pain, fluid deficiency, problems in accessing urinals and bed pans, and lack of privacy on wards Catheterisation should be performed prophylactically when an operation is expected to last 3 hours or longer or when large volumes of fluid are administered.

Urinary tract infections most commonly acquired infections in the postoperative period dysuria and/or pyrexia Immunocompromised patients, diabetics Treatment:?

COMPLICATIONS RELATED TO SPECIFIC SURGICAL SPECIALTIES Abdominal surgery: Paralytic ileus Bleeding or abscess Anastomotic leakage Neck surgery: Hematoma RLN injury

GENERAL POSTOPERATIVE PROBLEMS AND MANAGEMENT Pain Fluid and nutrition Nausea and vomiting Bleeding Deep venous thrombosis Hypothermia and shivering Prophylaxis against infections Pressure sore Wound care Wound dehiscence Confusional status Drains

Nausea and vomiting Women, non-smokers, history of PONV, motion sickness , migraine, Use of volatile anaesthetic agents, opioids and nitrous oxide Duration and type of Surgery Rx:treatment of pain, anxiety, hypotension and Dehydration ondansetron Prochlorperazine Cyclizine Dexamethasone

Bleeding All hospitals should have a ‘major haemorrhage protocol’ in place. The consultant surgeon, anaesthetist and haematologist should all be informed early about unstable patients Lines of Mx: Oxygenation , fluid rescu., blood if Hb <8g/dl FFP ,cryoprecipitate and fibrinogen concentrates IF s.fibrinogen level <1 g/l or PT PTT >1.5

FEVER 40 % of patients develop pyrexia after surgery Day 0-2 ( reactionary to surgery and hematoma) Day 2-5(atelactasis, biliary leakage) Day 5 (chest infection ,UTI and thrombophlebitis) > Day 5 ( superficial and deep wound infection,anastmotic leakage, intracavitary collection and abscess) 2nd week (DVT and PE) Drugs : any day

Pressure sores Risk factors are poor nutritional status, dehydration , lack of mobility ,nerve block and anaesthesia Technique turn every 30 Minutes air filter mattress

Confusional state postoperative delirium POD 5–15 per cent elderly with hip fractures and is associated with increased morbidity and mortality pre-existing cognitive impairment (dementia), use of narcotics, benzodiazepines, alcohol (and withdrawal from it), severe illness, renal impairment and depression. Electrolyte disturbances Rx : underlying cause

Drains Uses : ??? Removal : < 25 ml/ day Wound care sterile dressings applied in theatre should not be removed Before48 hrs If the wound is healing satisfactorily, then the patient may be allowed to shower one week after surgery

Wound dehiscence Disruption of any or all of the layers in a wound. 3 %of abdominal Wounds From the 5th to the 8th postoperative day when the strength of the wound is at its weakest Serosanguinous discharge Popping sensation in the abdomen

Risk factors in wound dehiscence General Malnourishment Diabetes Obesity Renal failure Jaundice Sepsis Cancer Treatment with steroids

Risk factors in wound dehiscence Local Inadequate or poor closure of wound Poor local wound healing, e.g. because of infection, haematoma or seroma Increased intra-abdominal pressure, e.g. in postoperative patients suffering from chronic obstructive airway disease, during excessive coughing

Enhanced recovery Aims : Recovery , cost , hospital stay Strategies: Early planned physiotherapy and mobilisation Early oral hydration and nourishment Good pain control Discharge planning Telephone follow up

DISCHARGE OF PATIENTS Diagnosis Treatment Laboratory results Discharge letter Diagnosis Treatment Laboratory results Complications Discharge plan Support needed Follow up

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