1. Postoperative Assessment, Management And Complications
Supervised By : prof. S.Al-Salamah
Khaled Al-Qarni
Mansour Al-Harthi
Yazeed Al-Dalilah
NOTE: The prof said that 50% of the questions will be from this presentation and the other 50% will be from the reference

2. Overview This tutorial composed of two topics : Post operative Care
Post-op care
Post-op surgical complications
Post operative Care
Objective
Understand the principles of patient management in the recovery phase immediately after surgery
Understand the general management of the surgical patient in the ward
Consider the initial management of common acute complications during postop period.

3. Definition of Postoperative care :
The management of a patient after surgery . This includes care given during the immediate postoperative period , both in the operating room and postanesthesia care unit (PACU), as well as during the days following surgery .
The goal of postoperative care :
to prevent complications such as bleeding,
to promote healing of the surgical incision,
and to return the patient to a state of health.

4. Post op care has 3 phases:
Immediate post-op care (Recovery phase)
Care in the ward
Continued care after discharge from the hospital

5. Discharge from the theatre
Anesthetic and surgical staff should record the following items in the patients case notes:
Any anesthetic, surgical or intraoperative complications.
Any specific treatment or prophylaxis required(eg: fluids, nutrition, antibiotics , analgesia , anti-emetic , thromboprophylaxis)

6. Postanesthesia care unit (PACU)
The patient is transferred to the PACU after the surgical procedure, anesthesia reversal, and extubation (if it was necessary).
The amount of time the patient spends in the PACU depends on the length of surgery, type of surgery, status of regional anesthesia (e.g., spinal anesthesia), and the patient's level of consciousness. Rather than being sent to the PACU, some patients may be transferred directly to the critical care unit.

7. Assessment Postanesthesia care unit (PACU)
airway patency + respiratory status , vital signs , and level of consciousness .
Other assessment categories:
surgical site (intact dressings with no signs of overt bleeding)
patency (proper opening) of drainage tubes/drains
body temperature (hypothermia/hyperthermia)
patency/rate of intravenous (IV) fluids
circulation/sensation in extremities after vascular or orthopedic surgery
level of sensation after regional anesthesia
pain status
nausea/vomiting

8. Assessment Postanesthesia care unit (PACU)
If the patient at risk of deterioration he need frequent assessment.
Risk factors for deterioration are:
ASA grade ≥ 3
Emergency or high risk surgery.
Operation takes hours.
American Society of Anesthesiologists :
1-A normal healthy patient.
2- A patient with mild systemic disease.
3- A patient with severe systemic disease.
4- A patient with severe systemic disease that is a constant threat to life.
5- A moribund patient who is not expected to survive without the operation.
6- A declared brain-dead patient whose organs are being removed for donor purposes.

9. Check list for 1st postoperative assessment
Intraoperative Hx &postoperative instructions:
Past medical Hx
Medications
Allergies
Intraoperative complications
Postoperative instructions
Recommended Rx & prophylaxis
medication for nausea or vomiting, as well as pain.
Patients with a patient-controlled analgesia pump may need to be reminded how to use it. If the patient is too sedated immediately after the surgery, the nurse may push the button to deliver pain medication. The patient should be asked to rate his or her pain level on a pain scale in order to determine his or her acceptable level of pain. Controlling pain is crucial so that the patient may perform coughing, deep breathing exercises, and may be able to turn in bed, sit up, and, eventually, walk.

10. Check list for 1st postoperative assessment
Respiratory assessment status:
O2 saturation.
Effort of breathing ..
Respiratory rate.
Trachea central or not.
Symmetry of inspiration and expiration.
Breath sounds.
Percussion.
Respiratory exercises (coughing, deep breathing, and incentive spirometry) should be done every two hours. The patient should be turned every two hours to prevent pressure sores
must perform respiratory exercises to prevent pneumonia; and that movement is imperative for preventing blood clots, encouraging circulation to the extremities, and keeping the lungs clear

11. Check list for 1st postoperative assessment
Volume status assessment:
Hands-warm or cool pink or pale.
Pulse rate , volume and rhythm.
blood pressure.
Conjunctival pallor.
Jugular venous pressure.
Urine color & Out put .
Drainage from drains, wound& NG tube
4\2\1 rule – hourly rate
4ml\kg for first 10 kg
2ml|kg for next 10 kg
1ml/kg for every kg over 20
Minimal urine out put = .5cc\kg\hr

12. Check list for 1st postoperative assessment
Mental status assessment:
Patient conscious and normally responsive?(AVPU: Alert,respond for Verbal & Painful stimuli,unresponsive)
Finally RECORD any significant symptoms (e.g. chest pain, breathlessness) Pain and pain adequacy control.
Vital signs, respiratory status, pain status, the incision, and any drainage tubes should be monitored every one to two hours for at least the first eight hours
aAfter 24 hours form surgery :
After the initial 24 hours, vital signs can be monitored every four to eight hours if the patient is stable. The incision and dressing should be monitored for the amount of drainage and signs of infection. The surgeon may order a dressing change during the first postoperative day.
The hospitalized patient should be sitting up in a chair at the bedside and ambulating with assistance by this time. Respiratory exercises are still be performed every two hours, and incentive spirometry values should improve. Bowel sounds are monitored, and the patient's diet gradually increased as tolerated, depending on the type of surgery and the physician's orders.

13. After Discharge Care : Education ( + family) Prescriptions Follow up
Ambulation to prevent DVT
Respiratory excersise .

14. Post-op Surgical Complications

15. General risk factors Age both extremes (Very young & Very old) Obesity
Smoking
Co-morbid conditions
Drug therapy
e.g steroids , immunosuppressant, antibiotics and contraceptive pills

16. Complications maybe : I. Due to Anesthesia II. Due to Surgery

17. Anasthesia Complications
Depend on:
The mode (General, Regional & Local)
Type of anesthetic (the anesthetic agent toxicity).

18. Local Anasthesia: Injection site:
Pain, haematoma, Nerve trauma, infection
Vasoconstrictors:
( C.I in nose , fingers , penis , scrotum , ears , toes ) it may lead to ischemic necrosis
Systemic effects of LA agent: Allergic reactions, toxicity

19. SPINAL, EPIDURAL & CAUDAL ANESTESIA:
Technical failure
Headache due to loss of CSF
Intrathecal bleeding
Permanent N. or spinal cord damage
Paraspinal infection
Severe hypotension
Urinary retention

20. General Anasthesia : Direct trauma to mouth or pharynx.
Slow recovery from anesthesia due to drug interactions OR in-appropriate choice of drugs or dosage.
Hypothermia due to long operations with extensive fluid replacement OR cold blood transfusion.

21. Malignant hyperthermia!!
Malignant hyperthermia is disease passed down through families that causes a fast rise in body temperature (fever) and severe muscle contractions when the affected person gets general anesthesia.
symptoms :
High tempreture
Tachycardia
Tachypnea
increased carbon dioxide production
increased oxygen consumption
acidosis
rigid muscle & rhabdomyolysis
Treatment :
Discontinue the anesthesia then wrapping the patient in a cooling blanket cangeneral help reduce fever
Benzodiazepine
Then >>>((dantrolene))

22. Allergic reactions to the anesthetic agent:
 Minor effects
e.g. Postoperative nausea & vomiting
 Major effects
e.g. Cardiovascular collapse, respiratory depression)

23. Complications due to surgery :
Immediate (0-24hrs)
Primary hemorrhage
Basal atelactasis
Shock
Early (2days- 3weeks)
Mental state change
Fever
2ndry hemorrhage
Wound infecton
Paralytic ileus
Late (Weeks –months)
Bowel obstruction
Incisonal hernia

24. Complications due to surgery :
Hemorrhage
Wound
Cardiovascular
Respiratory
Gastrointestinal
Urinary tract
Cerebral

25. Hemorrhage A- primary Hemorrhage : Early recognition & management
Inadequate hemostasis.
Unrecognized damage to blood vessels.
Defective vascular anastomosis.
Clotting factor deficiency.
Intraoperative anticoagulants
Early recognition & management
Surgical re-exploration is usually required

26. B-secondary hemorrhage:
Usually Related to infection.
Treatment
traet the Underlying cause ( infection)
Note: the DR said that the infection is related to tertiary hemorrhage not 2ndry !!!!

27. Wound Complications 1- Infection: Classification
Superficial(skin and SC tissue)
deep(fascia and muscle )
space (anatomical space and organ)
Causes
It based on the site of operation
staph. In thoracic , neuro , vascular, breast , ophtha
G –negative for GIT and urologic operation
Strept. Head and neck
Symptoms & signs
hotness, redness , swelling , pain
And in sever cases may lead to systemic symptoms like fever , chills and rigor
Treatment
Superficial >> incision and drainage with or without systemic antibiotic
Deep >>> surgical debridement with systemic antibiotic
Space >>> CT scan guided percutaneous drainage and may need open drainage

28. Wound Complications 2-Hematoma Localized collection of blood.
Treatment :
Small hematoma : spontaneously absorbed
Large hematoma : may required drainage

30. 3-Seroma 4-incisional hernia Localized collection of serous fluid.
Common sites : breast and abdominal surgery
Treatment
Small seroma : spontaneously absorbed
Large seroma : may required drainage
4-incisional hernia
10 %
Risk Factors: chronic cough , and causes of
Increase abdominal pressure like lifting
Heavy object …etc
Treatment :
Herniorrhaphy
Hernioplasty ( with mesh)
Incsional hernia They occur more commonly among adults than among children

32. Hypothermia Body temperature below 35° C.
Causes : Trauma, Exposure, Cool Fluids – IV / Irrigation
Hypothermia could lead to:
Coagulopathy
Platelet dysfunction
Increased O2 consumption due to shivering
Mild: 32 – 35C
Mod: 28 – 32C
Severe: 25 – 28C
Treatment with warmers like forced air devices and warm fluids.
Meperidine (opioid analgesic) in small doses can be used to stop the shivering.

33. Forced Air Warming
A hollow latex blanket covers the patient and hot air is forced through it.
It can be used before, during or after the operation

34. Postoperative Fever Body temperature greater than 38.5° C
Occurs in about 40% of patients after a major surgery.
In most patients it resolves without specific treatment, however a patient must be evaluated for the following causes:
Pneumonia
Atelectasis
Wound Infections
UTI
Deep vein thrombosis\Pulmonary embolism
Abscess
Medication

35. Postoperative Fever Within 48 Hours - Usually Atelectasis
After 48 Hours
UTI
Catheter related phlebitis
Pneumonia
After the 5th PO day
- Wound infection
- Anastomotic breakdown
- Intra-Abdominal abscess
After the 7th PO day
- Deep vein thrombosis
- Pulmonary embolism

36. Postoperative Fever Regular work up includes: CBC Blood cultures
Urine analysis and urine cultures
CXR
Sputum cultures

37. Cardiovascular Complications
Could be life threatening
Incidence is reduced by preparation and correction of any existing cardiac condition pre-operatively.
It includes: MI
Arrhythmia
DVT

38. MI Two thirds occur between the 2nd to 5th day post OP
Risk factors include:
-Previous MI within the past 6 months
-Chronic heart failure
-Angina
-Advanced age
Presentation:
-Often asymptomatic
-Symptoms include: new onset CHF, new onset dysrhythmia, hypotension, chest pain, tachycardia ,nausea and vomiting.
Investigations:
-ECG
-Troponin I \ creatinine kinase MB fraction
Treatment:
-Nitrates, Aspirin, Oxygen, Pain control, Heparin and ICU monitoring

39. Arrhythmia
Usually due to reversible causes like hypokalemia, hypoxemia, alkalosis and stress after the operation.
Could be the 1st sign of a post-OP MI.
Usually asymptomatic but could present with chest pain, palpitations or dyspnea.
Atrial flutter\fibrillation:
-If the patient is stable, the heart rate could be controlled with
β-blockers, digitalis or Ca channel blockers.
-If the patient is unstable (eg. In shock) cardioversion is used.
-If hypokalemia is present, it should be corrected.
Premature Ventricular contractions (PVC):
-Risk factors include: hypercapnia, hypoxemia, fluid overload.
-Oxygen, sedation, analgesia and correction of fluid\electrolyte disturbances is the treatment of choice.
Ventricular Tachycardia:
-Could lead to the life threatening ventricular fibrillation.
-Lidocaine is the treatment of choice
Complete Heart Block:
-Insertion of a pacemaker is necessary.

40. DVT Risk Factors: Advanced age Obesity Hormonal therapy Immobilization
Smoking
DM\HTN
Symptoms:
- 50% are asymptomatic
-Pulmonary embolism, lower limb pain, tenderness and swelling
Homan’s sign:
-Calf pain with dorsiflexion of the foot found in less than 1\3 of patients
investigations:
-Duplex US.

41. Pulmonary Embolism Symptoms: Dyspnea, fever, tachypnea and hemoptysis.
Investigations:
-ABG, CT angiogram, Pulmonary angiogram [Gold Standard].
Treatment:
-Stable Patient: Low molecular weight heparin or a green field filter.
-Unstable Patient: Thrombolytic therapy, pulmonary artery embolectomy or catheter suction embolectomy.
Prophylactic measures for DVT\PE:
Preoperative heparin.
Elastic stockings.
Early ambulation.

42. Respiratory Complications
Atelectasis [Most common]
Collapse of the alveoli.
Occurs within the first 48 hours post op.
Affects 25% of patients who have abdominal surgery.
Risk Factors:
Thoracic\abdominal surgery, COPD, smoking, poor pain control and poor ventilation during surgery.
Signs:
Fever, decreased breath sounds, tachypnea, tachycardia and increased density on CXR.
Treatment:
Incentive spirometry, deep breathing, coughing, early ambulation and chest physical therapy.
Prophylaxis
Smoke cessation and good pain control.

43. Atelectasis
Incentive Spirometer

44. Aspiration Pneumonia Risk Factors: Signs\Symptoms: Investigations:
It is pneumonia after aspiration of gastric contents.
Risk Factors:
Intubation\extubation, impaired consciousness, dysphagia, emergent intubation with a full stomach.
Signs\Symptoms:
Respiratory failure, increased sputum production, fever, cough, tachycardia, cyanosis and infiltrates on CXR.
Investigations:
CXR, sputum gram stain\culture and bronchoalveolar lavage.
Treatment:
Bronchoscopy, antibiotics (if there is an infection) and intubation (if respiratory failure occurs).

45. Post-OP Pneumonia Risk Factors: Signs\Symptoms: Investigations:
Prolonged ventilation support, peritoneal infection, atelectasis and aspiration.
Signs\Symptoms:
Fever, tachypnea, increased secretions and signs of pulmonary consolidation.
Investigations:
Sputum culture and CXR showing consolidation.
Treatment:
Antibiotics and clearing the airway of secretions.

46. Pneumothorax Symptoms\Signs: Investigations: Treatment:
May follow insertion of a subclavian catheter, positive pressure ventilation or after an operation which has damaged the pleura.
Symptoms\Signs:
Pleuritic chest pain, dyspnea, tachycardia and hyper-resonant lungs.
Investigations:
CXR and ABG.
Treatment:
Thoracostomy tube.

47. Cerebral complications
Cerebrovascular Accident:
Risk factors:
Advanced age and atherosclerosis.
Symptoms\Signs:
Aphasia, motor and sensory deficits usually lateralizing.
Investigations:
Head CT
Treatment:
Aspirin and heparin if feasible.
Thrombolytic therapy is usually NOT an option after surgery.

48. Urinary Complications
Urinary Retention:
Enlarged bladder from spinal anesthesia or medication.
Symptoms\Signs:
Palpable bladder and inability to void.
Treatment:
Foley catheter.

49. UTI Risk Factors: Symptoms\Signs: Diagnosis: Treatment:
Urinary retention, preexisting contamination of urine and instrumentation.
Symptoms\Signs:
Cystitis: Dysuria and mild fever.
Pyelonephritis: High fever, flank tenderness and ileus.
Diagnosis:
Urine examination and cultures.
Treatment:
Hydration, proper drainage of the bladder and antibiotics.

50. GI Complications Postoperative ileus: Risk factors:
It is an obstruction due to paralysis of the bowel.
Risk factors:
Hypokalemia, narcotics and GI surgery.
Symptoms and signs:
Constipation, abdominal pain, absent bowel sounds and bowl distention with gases on AXR.
Treatment:
Supportive until motility returns (usually within 3-5 days).

51. Paralytic Ileus

52. Pseudomembranous Colitis
It is an antibiotic associated diarrhea usually caused by clindamycin.
Symptoms\Signs:
Diarrhea, fever, hypotension and tachycardia.
Diagnosis:
C.difficile toxin in stool, fecal WBCs and mucus membranes in the lumen of the colon
Treatment:
Metronidazole orally or IV.

53. Enterocutaneous Fistula
Fistula from GI tract to the skin.
Causes:
Anastomotic leak, trauma\injury, infection , etc.
Investigations:
CT, fistulagram.
Treatment:
NPO, total parenteral nutrition, half will resolve spontaneously, but the other half will require resection of the involved bowel segment.

54. Enterocutaneous Fistula

55. Neurologic Drug Induced ICU Psychosis Neuropsychiatric Complications
Operative Nerve Injuries

56. Late Complications : Wound:
Hypertrophic scar, keloid, wound sinus, implantation dermoids, incisional hernia
Adhesions:
Intestinal obstruction, strangulation
Altered anatomy/Pathophysiology:
Bacterial overgrowth, short gut syndrome, postgastric surgery syndromes, etc.
Susceptibility to other diseases:
Malabsorption, incidence of cancer, tuberculosis, etc.

57. Thank You