1. Postoperative Care & postoperative complications

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

3. Postoperative Care Pain management Postoperative fever
Recognize postoperative complications

4. Immediate Postoperative Period:
Anesthesiologist in charge of cardiopulmonary functions

5. Immediate Postoperative Phase Recovery Room, ICU
ABCs of Immediate Recovery period airway breathing Consciousness Circulation system review

6. Discharge from the recovery room, ICU
Vital signs Controlled pain Awake Gag reflex returned Respirations and circulatory function normal

8. Surgeon responsible for all the rest

9. Surgeon’s Responsibilities Post 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

10. • Check pulses distal to op. site. • Measure and record 1st
• 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.

11. Position in bed Mobilization Medications Diet

12. Fluid balance, electrolytes Respiratory care

13. 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

14. Pain control. Comfort measures: reposition, oral care, hygiene
Pain control. Comfort measures: reposition, oral care, hygiene. Monitor dressing. Empty drainage tubes.

15. Turn, cough & deep breathing; incentive spirometry every hour
Turn, cough & deep breathing; incentive spirometry every hour. early ambulation. Monitor output – minimum of 30cc/hr; should void within 8 hours of surgery

16. NPO until ordered, start with clear liquids – full liquids – soft diet Monitor closely for signs of infection Administer medications as ordered-antibiotics.

18. Pain Management Essential part of postoperative management
Pain can increase risk of complications
Pain relief- Multimodal
E.g. PCA, IM pethidine, oral analgesics

19. 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.

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

21. About 7 days onwards
Abscess formation
Allergy to drug
Transfusion related fever
DVT/PE

23. Postop Complications General Specific
Complications do occur, but many are preventable!

24. General
Important examples: MI
pneumonia
DVT/Pulmonary embolism
CVA

25. Specific
Examples:
anastomotic leakage
abscess formation
wound infection
ileus
bleeding

26. Wound complications
Postoperative urinary retention
Respiratory complications
Postoperative parotitis
GIT complications

27. Wound complication Wound infection Wound hematoma Wound seroma
Wound dehiscence

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

29. Wound infection Clinical manifestation : pain swollen & edematous
redness & cellulitis
warm to touch

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

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

32. Wound infection Prevention : Skin preparation Bowel preparation
Prophylactic antibiotic
Meticulous technique
Appropriate drainage

33. Wound infection Management : Incision should be opened for drainage
Debridement if there is necrosis
Antibiotic if there is cellulitis

34. 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

35. 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

36. 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 .

37. 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

38. 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

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

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

41. 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

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

43. Respiratory complication
Atelectasis
Aspiration
Pulmonary edema
Pulmonary embolism

44. 1) Atelectasis : Collapse of alveoli
Anesthesia , postop. Incisional pain
Lung inflation in postop. period

45. 2) Aspiration : During induction of anesthesia
CXR show progression of local damage & infiltration
Prevention is only effective treatment

46. 3) Pulmonary edema :
Most common causes are fluid over load or myocardial insufficiency
Occur during :
* resuscitation
* postop. Period

47. 3) Pulmonary edema :
Simple therapy including O2 , digitalization & upright position

48. 4) Pulmonary embolism : 100’000 patients died in US per year
90 % originate from DVT of iliofemoral ves.

49. 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

50. 4) Pulmonary embolism : * direct or systematic thrombolysis.
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

51. 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

52. 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

53. 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

54. 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

55. GIT complications
Ileus
Anastomotic leaks
Fistulas
Stomal complication

56. 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

57. 1) Ileus : Blood in retroperitoneum often produces ileus
Hypokalemia , hypocalcemia , hyponatremia & hypomagnesemia prolong postop. Ileus
Treatment is purely supportive

58. 2) Anastomotic leaks : The etiology factors : 1) poor surgical tech.
2) distal obstruction
Risk increase with S.Albumin < 3.0 mg/dl

59. 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

60. 3) Fistulas : Abnormal communication between two epithelial surfaces
Common problem of GIT surgery
Can occur between :
( enterocutanous fistula ) , ( enteroenteric fistula )
( enterovesical fistula ) , ( enterovaginal fistula )

61. 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

62. 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

63. THANK YOU