Postoperative care Postoperative period All anaesthetised patients should be recovered in a recovery room. All vital parameters should be monitored and documented. Treat pain and nausea/vomiting. Watch for complications.

The most common respiratory complications in the recovery room are hypoxaemia, hypercapnia and aspiration

Hypoxia in the postoperative period may occur due to a variety of reasons, for example: • Upper airway obstruction due to the residual effect of general anaesthesia, secretions or wound haematoma after neck surgery. • Laryngeal oedema from traumatic tracheal intubation, recurrent laryngeal nerve palsy and tracheal collapse after thyroid surgery. .

• Hypoventilation related to anaesthesia or surgery. • Atelectasis and pneumonia especially after upper abdominal and thoracic surgery . • Pulmonary oedema of cardiac origin or related to fluid overload

• Pulmonary embolism: this often presents with the sudden onset of chest pain and shortness of breath.

Cardiovascular complications Hypotension in the postoperative period can be multifactorial Arrhythmias can be prevented and corrected by treating hypotension and electrolyte imbalance Arrhythmias and myocardial ischaemia/infarction will need management with the help of cardiologists

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

Renal and urinary complications Postoperative renal failure is associated with high mortality. Prophylactic measures to prevent renal failure should be taken in high risk cases. Urinary retention and infection are a common problem postoperatively.

The main complications after abdominal surgery Paralytic ileus Bleeding or abscess Anastomotic leakage

The earliest sign is pain on passive stretching of muscles in Compartment syndrome Severe/greater than expected pain unresponsive to analgesia The earliest sign is pain on passive stretching of muscles in the affected compartment Paralysis, paraesthesia and pulselessness are very late signs

GENERAL POSTOPERATIVE PROBLEMS Pain Types of pain Nociceptive pain arises from inflammation and ischaemia Neuropathic pain arises from a dysfunction in the central nervous system Psychogenic pain is modified by the mental state of the patient

Pain control in benign disease Bring pain under control before amputation to avoid phantom pain Local anaesthetic and steroid injected around a nerve may reduce muscle spasm Transcutaneous nerve stimulators (TNS) modify pain by increasing endorphin production Trigeminal neuralgia responds to decompression of the nerve

Options for controlling severe pain in malignant disease Oral morphine using slow-release, enteric-coated tablets Slow infusion of opiates subcutaneously, by epidural, or intrathecally Neurolysis for patients with limited life expectancy Palliative hormone, radiotherapy, or steroids control pain from swelling

Postoperative bleeding All hospitals should have a major haemorrhage protocol in place Need to transfuse blood in the absence of continued bleeding in patients with Hb >8 g/dL should be weighed against the risks Minor bleeding in an airway can have a catastrophic effect.

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 haematoma. If immediate control of bleeding is essential, the patient may be taken back to the operating theatre

Consider problems in the lung, urine and wound Fever A very common problem postoperatively Consider problems in the lung, urine and wound

The causes of a raised temperature postoperatively include: • days 2–5: atelectasis of the lung; • days 3–5: superficial and deep wound infection; • day 5: chest infection, urinary tract infection and thrombophlebitis; • >5 days: wound infection, anastomotic leakage, intracavitary collections and abscesses; • DVTs, transfusion reactions, wound haematomas, atelectasis and drug reactions, may also cause pyrexia of non-infective origin.

Deep vein thrombosis Patients suffering postoperative deep vein thrombosis (DVT) may present with calf pain, swelling, warmth, redness and engorged veins

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

Preventing pressure sores Address nutritional status Recognise patients at risk Address nutritional status Keep patients mobile or regularly turned if bed-bound

Confusional state Acute confusional states can occur on recovery from anaesthesia (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

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

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