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

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

3. 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

4. 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

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

6. 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

9. 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

10. 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?

14. 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 : ?

15. 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

16. 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

17. 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

18. 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

19. 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.

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

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

22. 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

23. 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

24. 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

25. 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

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

27. 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

28. 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

29. 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

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

31. 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

32. 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

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

34. THANK YOU