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Postoperative carePostoperative 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.

COMPLICATIONS

Respiratory 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

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

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

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