Tutorial

Postoperative Care &postoperative complications

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

Postoperative Care

Pain management

Postoperative fever

Recognize postoperative complications

Immediate Postoperative Period:

Anesthesiologist in charge of cardiopulmonary functions

Immediate Postoperative Phase Recovery Room, ICU

ABCs of Immediate Recovery period
airway


breathing

Consciousness

Circulation

system review

Discharge from the recovery room, ICU
Vital signs

Controlled pain

Awake

Gag reflex returned

Respirations and circulatory function normal

Surgeon responsible for all the rest

Surgeon’s ResponsibilitiesPost Operative Checks
Note time of return, note level of consciousness, monitor vital sign

• Check dressings, location

• Check incision, report drainage, redness, edema

• Check IV site

• Report kinked tubing

• Check pulses distal to op. site.

• Measure and record 1st. Void, report flatulence.

• Learn type, purpose, location of all tubes, and how to empty.

• Report change in character of drainage, notify nurse of need for dressing change.


• Report changes in skin color.

• Equipment- report if disconnected or malfunctioning.

Position in bed

Mobilization

Medications

Diet

Fluid balance, electrolytes

Respiratory care

Postoperative Phase
Level of consciousness, movement, sensation

Skin color, temperature, nailbeds, oxygen saturation

Lungs sounds, pulses, heart rate.

Inspect abdomen for distention, monitor return of

bowel sounds, ask about flatus

Pain control.

Comfort measures: reposition, oral care, hygiene.

Monitor dressing.

Empty drainage tubes.

Turn, cough & deep breathing; incentive spirometry every hour.

early ambulation.

Monitor output – minimum of 30cc/hr;

should void within 8 hours of surgery

NPO until ordered, start with clear liquids – full liquids – soft diet

Monitor closely for signs of infection

Administer medications as ordered-antibiotics.

Pain Management

Essential part of postoperative management
Pain can increase risk of complications

Pain relief- Multimodal

E.g. PCA, IM pethidine, oral analgesics

Postop Fevers

An important sign of postoperative complications.

History

Examination
Investigations (to confirm the diagnosis)


Many possible DDX.

Time of onset may guide the management.

First 48hrs
• Atelectasis
• Transfusion rx
• Pre-existing infection
3-7 days: infections like:
• UTI, wound infection, Catheter related phlebitis , pneumonia, anastomotic leakage

About 7 days onwards

• Abscess formation
• Allergy to drug
• Transfusion related fever
• DVT/PE






Postop Complications
General

Specific

Complications do occur, but many are preventable!

General

• Important examples:
• MI
• pneumonia
• DVT/Pulmonary embolism
• CVA

• Specific

• Examples:
• anastomotic leakage
• abscess formation
• wound infection
• ileus
• bleeding




Wound complications


Postoperative urinary retention


Respiratory complications


Postoperative parotitis


GIT complications

Wound complication

Wound infection



Wound hematoma


Wound seroma


Wound dehiscence

Wound infection

Operative wound classification :
I clean 3.3-4 %
II clean-contaminated 8-10 %
III contaminated &
IV dirty (infected) 28 %

Wound infection

Clinical manifestation :
pain
swollen & edematous
redness & cellulitis
warm to touch


Wound infection
Wound infections are classified as :
Minor
( purlent material around skin suture sites)
Major
( discrete collection of pus within the wound )

Wound infection

Wound infections are classified as :
Superficial infection
( limited to skin & subcutanous tissue )
Deep infection
( involve area of the wound below the fascia )

Wound infection

• Skin preparation
• Bowel preparation
• Prophylactic antibiotic
• Meticulous technique
• Appropriate drainage


Wound infection
Management :


Incision should be opened for drainage


Debridement if there is necrosis


Antibiotic if there is cellulitis

Wound Hematoma

Caused by inadequate hemostasis


Good media for bacteria


Manifested by pain & swelling



Drain should be used


Must be evacuated in certain location


The wound should be opened in OR

Wound Seromas

Are lymph collections


Operation in which large areas of lymph-bearing tissues are transected


Closed-suction drain with pressure dressing


Repeated aspiration is indicated



Fertile ground for bacteria

Wound Dehiscence

Dehiscence
( is separation within the fascial layer , usually of abdomen )


Evisceration
(extrusion of peritoneal contents through the fascial separation)


Incidence : 0.5 – 3.0 % in all abdominal procedures .

Wound Dehiscence

Related factors :
Imperfect technical closure
Increased intra-abdominal pressure from bowel distention, ascites, coughing, vomiting, or straining
Hematoma with or without infection
Infection
Metabolic diseases such as
diabetes mellitus,
uremia,
Malignant disease,
Radiation


Wound Dehiscence


Detected by the classical appearance of salmon colored fluid draining from wound occurs in about 85 % of cases about fourth or fifth postoperative days



Present late as an incisional hernia

Wound Dehiscence

Complete repair , the skin and subcutaneous tissue, facial layers closed.

Urinary retention

Incidence :
major abd. Surgery : 4 – 5 %
Anorectal surgery : > 50 %

Urinary retention

Stress ,pain ,spinal anesthesia & anorectal reflexes lead to increased Alpha-adrenergic stimulation , which prevent release of musculature around the bladder neck


Urgency ,discomfort , fullness ,enlarged bladder


Catheterization to relive retention

Respiratory complication

5 – 35 % of postop. Deaths
Predisposing factors :
smoking , age ,
obesity , COPD ,
cardiac disease


Respiratory complication
• Atelectasis
• Aspiration
• Pulmonary edema
• Pulmonary embolism

• Collapse of alveoli

Anesthesia , postop. Incisional pain


Lung inflation in postop. period

2) Aspiration :

During induction of anesthesia


CXR show progression of local damage & infiltration



Prevention is only effective treatment

3) Pulmonary edema :

Most common causes are fluid over load or myocardial insufficiency


Occur during :
* resuscitation
* postop. Period

3) Pulmonary edema :

Simple therapy including O2 , digitalization & upright position

4) Pulmonary embolism :

100’000 patients died in US per year



90 % originate from DVT of iliofemoral ves.

4) Pulmonary embolism :

Mild tachypnea to sudden cardiopulmonary arrest


Diagnosis require combination of :
- ABG
- CXR
- ECG
- Doppler studies for lower extremities
- Radionucleotide ventilation – perfusion scan

4) Pulmonary embolism :

Management options :
* intensive supportive measures & resuscitation.
* direct or systematic thrombolysis.
* surgical pulmonary ebolectomy.
* IVC filter.



Prevention of PE by using mechanical devices or pharmacologic inhibition of coagulation

Postoperative Parotitis

Serious complication


High mortality rate


Rt. & Lt. equally involved


Bilaterally 10 – 15 % of cases


75 % of patients are 70 year or older


Poor oral hygiene , dehydration , use of anticholinergic drugs


Postoperative Parotitis


Majority of infections are from staphylococi


Lack of oral intake to stimulate parotid secretions predisposes to bacterial invasion of Stensen’s duct


Interval between operation & the onset varies from hours to many weeks

Postoperative Parotitis

Present with :
pain in the parotid region
swelling & tenderness
cellulitis on face & neck
temperature & leukocyte high


Prophylaxis includes adequate hydration & good oral hygiene


Postoperative Parotitis


Antibiotic should be started against staphylococi


Surgical drainage
( by incision made ant. to ear extending to mandible angle )


In 80 % of patient treated with incision & drainage the parotitis was palliated or cured

GIT complications

• Ileus
• Anastomotic leaks
• Fistulas
• Stomal complication

1) Ileus :

Non-mechanical obstruction that prevents normal postop. Bowel function



Arise from neural inhibition of bowel motor activity & effective peristalsis


Increased with manipulation ,inflammation , peritonitis & blood left in peritoneal cavity

1) Ileus :

Blood in retroperitoneum often produces ileus


Hypokalemia , hypocalcemia , hyponatremia & hypomagnesemia prolong postop. Ileus


Treatment is purely supportive

2) Anastomotic leaks :

The etiology factors :
1) poor surgical tech.
2) distal obstruction




Risk increase with S.Albumin < 3.0 mg/dl

2) Anastomotic leaks :

Three technical factors play roles in a proper anastomosis :
1- both end of bowel should have adequate blood supply
2- anastomosis should lie in tension-free manner
3- adequate hemostasis

3) Fistulas :

Abnormal communication between two epithelial surfaces


Common problem of GIT surgery


Can occur between :
( enterocutanous fistula ) , ( enteroenteric fistula )
( enterovesical fistula ) , ( enterovaginal fistula )


3) Fistulas :


Most common cause is anastomotic leakage


Persistence secondary to ( FRIEND )
( F.B. , Radiation , Infection , Epithiallization , Neoplasm , Distal obstruction )


Spontaneous closure usually occurs within 5 weeks with adequate nutrition


If persist >5 weeks operation is indicated

4) Stomal complications :

Stomal necrosis & retraction
( inadequate blood supply lead to ischemia )



Stomal stricture
( late complication , caused by development of serositis )


Peristomal hernia & prolapse
( resecting the stomal prolapse & fixing it again in place )


Skin complication

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