1. PRE-OPERATIVE & POST-OPERATIVE CARE
Begashaw M (MD)

2. General consideration
General medical & surgical history
Complete P/E
Lab:
_Complete blood count
_Blood typing & Rh-factor, crossmach
_Urinalysis
_Chest x-ray

3. Assessment Cardiovascular System Pulmonary system Renal system
Hematologic system
Endocrine system

4. Cardiovascular System
Heart diseasehigh-risk
• chest pain, dyspnea, pretibial edema or orthopnea
• Recent history of CHF
• Recent MI
• Severe hypertension
• DVT

5. Pulmonary system High risk: • Upper airway infections
• Pulmonary infections
• Chronic obstructive pulmonary diseases chronic bronchitis, emphysema, asthma
Elective surgery should be postponed

6. Renal system Renal function test: -history of kidney disease
-diabetes mellitus
-hypertension
-over 60 years of age
-proteinuria, casts or red cells
creatinine clearance, blood urea nitrogen and electrolyte

7. Haematological system
Anemia
affects the oxygen carrying capacity of the blood
Iron deficiency
Megaloblastic
Hemolytic
Aplastic anemia
Patients with iron deficiency anemia respond to oral or parenteral iron therapy

8. Thrombocytopenia Normal platelet 150,000 to 450,000/ml
Manifestations:
• Petechia
• Epistaxis
• Menorhagia
• Uncontrolled bleeding
Treatment
-treat the underlying cause
-support with platelet transfusions & clotting factors

9. Diabetes mellitus
poorly controlled DM -susceptible to post-operative sepsis
In type - II patients-avoid hypoglycemia
not use longer acting oral hypoglycemic agents -2 days before operation
Insulin dependent diabetics with good control-sliding scale
Chronic cxs - Hypertension, myocardial ischemia which may be silent-proper workup & treatment

10. Thyroid disease
Elective surgery should be postponed when thyroid function is either excessive or inadequate
In Hyperthyroidism, the patient should be rendered euthyroid before surgerymay take up to 2 months with anti-thyroid medications

11. Post-operative care
is care given to patients after an operation in order to minimize postoperative complications
Early detection & treatment of post operative complications

12. Post-operative care
Aims: Comfortable, pain free recovery from operation
Immediaterecovery room
Intermediate  ward
Long term  home

13. Immediate care
a. Vital sign b. Chest auscultation c. Input and output monitoring d. Checking for bladder & abdominal distention e. Potent analgesics for pain relief

14. On subsequent post-operative days
a. Oral intake can be started b. Patients encouraged to ambulate

15. Post Op Complications General Immediate Primary hemorrhage
Reactive hemorrhage
Basal Atelectasis
Minor lung collapse
Shock
Blood loss
MI, Pulmonary Embolism
Low Urine Output

16. Cardiac complications
Abnormal ECG
Acute MI
Arrhythmia
Pulmonary embolus

17. Shock
Postoperative efficiency of circulation depends on blood volume, cardiac function, neurovascular tone
Shock:
Excessive blood loss
Third spacing
Marked peripheral vasodilatations
Sepsis
Pain or emotional stress

18. Treatment Arresting hemorrhage Restore fluid & electrolyte balance
Correct cardiac dysfunction
Establish adequate ventilation
Control pain & relief apprehension
Blood transfusion if required

19. Thrombophlebitis Superficial thrombophlebitis
-within the first few days after operation
Clinical features
A segment of superficial saphenous vein becomes inflamed manifested by:
Redness
Localized heat
Swelling
Tenderness

20. Treatment Warm moist packs Elevation of the extremity Analgesics
Anticoagulants

21. Thrombophlebitis of the deep veins
Occurs most often in the calf
Clinical features
asymptomatic
dull ache
tender & spasm
swelling of calf
Dorsiflexion of the foot may elicit pain in the calf Homan’s sign
pulmonary embolism

22. Treatment
Elevation
Application of full leg gradient pressure elastic hose
Anticoagulants
Prevention: Early ambulation

23. Pulmonary embolism Pre-disposing factors -Pelvic surgery -Sepsis
-Obesity
-Malignancy
History of pulmonary embolism or deep vein thrombosis
7th to 10th post-operative day
cardiac or pulmonary symptoms occur abruptly

24. Clinical features
chest pain; severe dyspnea, cyanosis, tachycardia, hypotension or shock, restlessness and anxiety
pleuritic chest pain
blood-streaked sputum, and dry cough
pleural friction rub

25. Investigation
Chest X-ray=pulmonary opacity in the periphery-triangular in shape with the base on pleural surface, enlargement of pulmonary artery, small pleural effusion and elevated diaphragm
ECG
Treatment
Cardiopulmonary resuscitation measures
Treatment of acid-base abnormality
Treatment of shock
Immediate therapy with Heparin

26. Respiratory complications
Atelectasis
Aspiration pneumonitis/Pneumonia
Pulmonary edema
Pneumonia
Respiratory failure

27. Atelectasis early postoperative period-48 hrs
airway collapse distal to an occlusion
Predisposing factors
chronic bronchitis, asthma, smoking and respiratory infection
Inadequate immediate postoperative deep breathing and delayed ambulation

28. Clinical features Fever Increased pulse , respiratory rate Cyanosis
Shortness of breath
Dull with absent breath sounds

29. Investigation and Treatment
CXR - patchy opacity
- mediastinal shift
Prevention and treatment
stop smoking
Treat chronic lung diseases
Postpone elective surgery
encourage sitting, early ambulation
Adminster analgesics
Supplemental oxygen

30. Pneumonia and aspiration pneumonitis
Pneumonia -atelectasis or aspiration
Preexisting bronchitis
Clinical features
Fever
Respiratory difficulty
Cough becomes productive
pulmonary consolidation

31. Chest-x-ray _diffuse patchy infiltrates or lobar consolidation
Prevention and treatment
minimized by
- Fasting
- Naso-gastric tube decompression
Treatment
Deep breathing and coughing
Change position
Broad spectrum antibiotics

32. Paralytic Ileus
functional intestinal obstruction usually noted within the first hours
Clinical features
Abdominal distention
Absent bowel sounds
Generalized tympanicity on percussion
Investigation
Plain x-ray-generalized dilatation and gaseous distention of the bowel loops
Treatment
NGT decompression
Fluid and electrolyte balance

33. Post operative intestinal obstruction
Causes _Peritonitis,Peritoneal irritation, Fibrinous adhesion
Clinical features
between the 5th and 6th POD
vomiting
Crampy abdominal pain
Focal typmpanicity
Exaggerated bowel sounds
Investigation
Plain film _distension of small bowel with air fluid levels
Treatment
Hydration & electrolyte
keet NPO
NGT
After hours, reoperation

34. Urinary and renal complications
Urinary retention
Acute renal failure
Urinary tract infection

35. Urinary retention pelvic operations spinal anesthesia Pain Mx
encouraged to get out of bed
Bladder drainage _a urethral catheter

36. Urinary tract infection
Predisposing factor
contamination of the urinary tract
Catheterization
Clinical presentation
Fever
Suprapubic or flank tenderness
Nausea and vomiting
Investigation
Urine analysis
Treatment
Increase hydration
Encourage activity
appropriate antibiotic therapy

37. Wound infections Pre disposing factors Age General health
Nutritional status
hygiene
Malignancy
Poor surgical technique
Diagnosis: clinical
Fever during the 4th to 5th POD
Redness or induration

38. Treatment
Sutures _remove
wound exploration and culture
drainage
wound care
antibiotics if systemic manifestations like fever

39. Hematoma, Abscess and Seromas
may occur in the pelvis or under the fascia of abdominal rectus muscle
falling of hematocrit
low-grade fever
Small hematoma or seroma _resolve spontaneously
Ultrasonography
Drainage of infected hematoma