Introduction Postoperative complications are the most important factors in determining outcome in the first 72 hours following surgery It is critical to monitor basic physiological parameters such as renal, cardiovascular and respiratory functions

Postoperative orders Vital signs Diet: NPO until bowel sounds present Intravenous fluids Care of drains Input and output chart Pain medication: dose and route of administration Antibiotics

Postoperative orders Venous thrombosis prophylaxis Other medications

Postoperative vascular complications Venous thromboembolism (VTE) includes DVT and PE and are a major but preventable cause of morbidity and mortality

Pulmonary embolism Has few definite symptoms But onset of respiratory distress with hypotension, chest pain and cardiac arrhythmias may be harbingers of impending death Can convert a successful operation into a postoperative fatality

Prevention of VTE Unfractionated heparin LMWH Graduated compression stockings Intermittent pneumatic compression stockings

Risk factors of postop thrombosis Virchow’s triad: hypercoagulability, stasis, trauma to vessels

Diagnosis of VTE Venography Impedence plethysmography Doppler ultrasound MRI/MRI Venography

Treatment of VTE UFH LMWH

Postoperative pulmonary complications Atelectasis Pneumonia Respiratory failure Pulmonary thromboembolic disease

Risk factors for PPCs Age > 60 years Cancer Congestive cardiac failure Smoking (within 8 weeks of surgery) Upper abdominal incision Vertical incision Incision length > 20cm

Atelectasis Definition not uniform in clinical studies Generally accepted criteria include: impaired oxygenation in a clinical setting where atelectasis is likely Unexplained fever > 38 o C CXR evidence of volume loss or new airspace opacity

Risk factors for atelectasis Advanced age Obesity Intraperitoneal atelectasis Prolonged anaesthesia time NG tube placement Smoking

Prevention of atelectasis Cessation of smoking (6-8 weeks before surgery) Laporoscopic procedure Deep breathing exercises Mobilization Adequate analgesia (epidural or PCA preferred) Selective gastric decompression

Postoperative pneumonia Hospital-acquired pneumonia (HAP) is pneumonia that develops 48 hours or more after hospital admission because of an organism that was not incubating at the time of hospitalization HAP after abdominal surgery increases mortality, hospital stay and hospital charges Caused by a wide range of bacteria. Also by viruses and fungi in immunosuppressed patients

Pathogens causing early onset (<4 days) HAP Strep pneumonia MS Staph aureus H influenza E coli K pneumonia Enterobacter spp. Proteus spp. Serratia marcescens

Pathogens causing late onset (>5 days) HAP Pseudomonas aeruginosa MDR K pneumonia Acinetobacter spp

HAP: clinical definition New opacity on CXR( PA and lat views preferred) plus 2 of the following: Fever >38 o C Leukocytosis or leukopenia Purulent respiratory secretions Diagnosis should be supported by sample of lower resp tract secretions-bronchoscopy

HAP treatment Initial therapy should be given IV Combination therapy for those at risk of MDR pathogens Monotherapy for those at low risk of MDR

Respiratory failure Def: inability to maintain normal tissue oxygen transport or the normal excretion of carbon dioxide Arterial PO 2 45 mmHg generally indicate significant respiratory compromise Generally managed in ICU including endotracheal intubation

Postoperative care of the urinary bladder Most common postop problem of female bladder is atony caused by overdistension and reluctance of the patient to initiate the voluntary phase of voiding Urethral or suprapubic catheter is used 7-10 days postop postvoid residuals are evaluated If >100ml catheterization duration is extended Once residuals are less than 100ml on 2 successive voidings of >200ml catheters can be removed

Postoperative GIT managenent Advancing of diets should be individualized Patients with uncomplicated surgery may be given a regular diet on the 1 st POD if bowel sounds are present, if abdominal exam reveals no distention and patient is not nauseated from anaesthesia Seriously ill patients may reuire TPN