Preoperative care & complications

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Post operative care &

complications

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INTRODUCTIONThe post operative period begins from the time the

patient leaves the operating room and ends with thefollow up visit by the surgeon.

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PURPOSES

To enable a successful and faster recovery of the patient post operatively.

To reduce post operative mortality rate.

To reduce the length of hospital stay of the patient.

To reduce hospital and patient cost during post operative period.

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*Immediate post op. peroid ( post-anaesthetic )

*Intermediate ( hospital stay ) phase (2) *convalescent ( after discharge to full recovery

Phase (3 )

@Aim of phase 1&2To ensure that pt .Is protecting their airway, breathing freely & perfusing adequately (ABC(

Also monitor pt’s pain, bleeding or loss of distal circulation or sensation.Vital signs monitoring

PHASES

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Simple system for ensuring that

everything checked represented as:

Subjective ,aesuan ,niap tuoba ksa :

ytixna & ytilibom.

Objective ecnalab diulf ,sngis lativ kcehc :

dna aera erusserp osla , noitavesbo yna dna

gnisserd dnuora aera dluohs dna ,dekcehc eb

dba ni dnuos lewob eht enimaxe . Surgery &

distal neurovascular status after orthopedic

surgery.

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Assessment suoiverp lla rotinom :

gnicaf smelborp wen eht tsil dna snoitamrofni

tp.

Plan ffats & .tp htiw nalp a etalumrof : .Include anticipating when discharge from

hospital ocurr

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KEEP MONITORING VITALS

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MAINTAIN INTAKE AND OUTPUT

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Chest Physiotherapy

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Epithelialisation takes 48 hs.

Dressing can be removed 3-4 days after operation.

Wet dressing should be removed earlier and changed.

Symptoms and signs of infection should be looked for, which if present compression, removal of few stitches and daily dressing with swab for C & S.

Tensile strength of wound minimal during first 5 days, then rapid between 5th 20th day then slowly again (full strength takes 1-2 years).

Good nutrition.

Care of the wound

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*To drain fluids accumulating after surgery, blood or

pus.

*Open or closed system.

*Other types (Suction, sump, under water etc.)

*Should be removed as long as no function.

*Should come out throw separate incision to minimize

risk of wound infection.

*Inspection of contents and its amount.

*Soft drains e.g. Penrose should not be left more than

40 days because they form a tract and acts as a plug.

Management of drains

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Functional residual capacity ( FRC) and vital capacity

(VC) decrease after major intra-abdominal surgery

down to 40% of the Pre-Op. Level.

They go up slowly to 60-70% by 6th -7th day and to

normal Pre-Op. Level after that.

FRC, VC, and Post-Op. pulmonary oedema (Post

anaesthesia) Contribute to the changes in pulmonary

functions Post-Op.

The above changes are accentuated by obesity,

heavy smoking or Pre-existing lung diseases specially

in elderly.

Post-Operative pulmonary Care

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Post-Op. atelectasis is enhanced by shallow breathing,

pain, obesity and abdominal distension

(restriction of diaphragmatic movements)

Post-Op. physiotherapy especially deep inspiration

helps to decrease atelectasis. Also O2 mask and

periodic hyperinflation using spirometer.

Early mobilization helps a lot.

Antibiotics and treatment of heart failure Post-Op. by

adequate management of fluids will help to reduce

pulmonary oedema. 15

Considerations:

Maintenance requirements.

Extra needs resulting from systemic factors e.g. fever, burn

diarrhea and vomiting etc.

Losses from drains and fistulas.

Tissue oedema (3rd space losses)

The daily maintenance requirements in adult for sensible and

insensible losses are 1500-2500mls. depending on age, sex,

weight and body surface area.

Rough estimation of need is by body weight x 30/day. e.g. 60 KG

x 30 = 1800ml/day.

Post-Operative fluid & Electrolytes management

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Estimation of electrolytes daily is only necessary in

critical patients.

Potassium should not be added to IV fluid during first

24hs. Post-Op. (because Potassium enters circulation

during this time and causes increased aldosterone

activity).

Other electrolytes are corrected according to deficits.

5% dextrose in normal saline or in lactated Ringer’s

solution is suitable for most patients.

Usual daily requirements of fluids is between 2000-

2500ml/day.

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NPO until peristalsis returns.

Paralytic ileus usually takes about 24hs.

NGT is necessary after esophageal and gastric surgery.

NGT is NOT necessary after cholecystectomy, pelvic operation or colonic resections.

Gastrostomy and jujenostomy tubes feeding can start on 2nd Post-Op. day because absorption from small bowel is not affected by laparotomy.

Enteral feeding is better than parenteral feeding.

Gradual return of oral feeding from liquids to normal diet.

Post-Operative Care of GIT

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Factors affecting severity :◦ Duration of surgery.◦ Degree of Operative trauma (intra-thoracic, intra-abdominal

or superficial surgery).◦ Type of incision.◦ Magnitude of intra-operative retraction.◦ Factors related to the patient :

Anxiety.

Fear.

Physical and cultural characteristics.

Pain transmission:◦ Splanchnic nerves to spinal cord.◦ Brain stem due to alteration in ventilation, BP and endocrine

functions.◦ Cortical response from voluntary movements and emotions.

Post-Operative Pain

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Complications of Pain:Causes vasospasm.

Hypertension.

May cause CVA, MI or bleeding.

Management of Post-Op. pain:

Physician – patient communication (reassurance).

Analgesics (NSAIDS).

Parenteral opioids.

Anxiolytic agents (Hydroxyzine) potentiates action

of opioids and has also an anti-emetic effects.

Oral analgesics or suppositories e.g. Tylenol.

Epidural analgesia (for pelvic surgery).

Nerve block (Post-thoracotomy and hernia repair).20

a disease or problem that arises in addition to the initial condition

or during a surgical operation

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CLASSIFICATION

◦ Due to anesthesia .

• Due to surgery

COMPLICATIONS OF MAJOR SURGERY

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Anesthetic complications depend on the mode

(General or Local) and types of anesthetic agent

used

*Slow recovery from anesthesia .

*Hypothermia

*Allergic reaction *Minor effect: post-op nausea & vomiting

*Major effect: CVS collapse, respiratory depression

toxicity).

DUE TO ANESTHESIA

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Perioperative complications

Postoperative complications

Immediate/early complications

Late complications

DUE TO SURGERY

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Refers to problems arising during surgery, which include:

@Hypotension◦ Blood loss

◦ Mismatched blood transfusion

@Raised blood pressure◦ Use of ketamine

◦ Uncontrolled hypertension

◦ Phaechromocytoma

@Hypoxia◦ Reduced o2

◦ Inadequate blood flow

◦ Inadequate alveolar ventilation

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PERIOPERATIVE COMPLICATIONS

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@Cardiac arrest

Air embolism

Tissue hypoxia

Blood loss

Air embolism

@Asphyxia

Combination of hypoxia & hypercapnia, caused by

respiratory obstruction

SIGNS:-

Noisy breathing during partial obstruction

In the presence of endotracheal tube, difficulty in inflating &

deflating the lungs

Cyanosis

Increase in circulating catecholamine 25

◦ CAUSES:-

◦ @physical & mechanical.

Flexed head in anesthetized px with/without endotracheal

tube.

Endotracheal tube blocked by pus, blood, foreign bodies.

Pressure on trachea from without, during operations on

large tumors of the neck e.g. thyroidectomy

@Chemical causes

Inhalation of intestinal contents

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Refers to complications arising after surgical

operations

Immediate/Early complications

Respiratory,

Cardiovascular,

CNS,

Genito-urinary,

GIT

Wound complications

POST OPERATIVE COMPLICATIONS

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Pyrexia after operation may be caused by:

◦ *Metabolic response to trauma in the first 24hrs

◦ *Infection or hematoma of the wound

◦ *Laryngo-tracheitis from endotracheal intubation

◦ *Peritonitis or intra-abdominal abscess

◦ *Complications of blood transfusion: mismatched blood

◦ *Drug sensitivity

◦ *Injection abscess

POST OPERATIVE PYREXIA

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Postoperative Pulmonary

Complications

A. Atelectasis:

90% postoperative

pulmonary complications

Etiology:

1. Obstruction of the

tracheobronchial airway

a) Changes in bronchial

secretions

b) Defects in expulsion

mechanism

c) Reduction in bronchial

caliber

2. Pulmonary insufficiency

(hypoventilation)

Decrease surfactant

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Predisposing factors:

1. Smoking

2. Pulmonary problem (bronchitis, asthma, etc)

3. Anesthesia: GA - duration and depth

Postop narcotics – depress cough reflex

4. Depress cough reflex Chest pain

Immobilization

Splinting w/ bandages

5. NGT – increased secretions and predisposed aspiration

6. Congestion of the bronchial walls

Manifestations:

1st 24 hrs postop ----> fever, tachycardia, decrease

breath sound ----> persist ----> pneumonia

(increase fever, dyspnea, tachycardia and

cyanosis) ---> lung abscess30

Treatment:

1. Preop prophylaxis:

a. No smoking (2 wks)

b. Treatment of pulmonary problem

2. Postop prophylaxis:

− Minimal use of depressant drugs

− Prevent pain

− Early ambulation

− Changes body position

− Deep breathing and coughing exercises

3. Drugs:

a. Expectorants

b. Mucolytic

c. bronchodilators

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B. Pulmonary Aspiration: General anesthesia – pts are in supine position and

absence of normal protective reflexes.

Increased risk:

1. Pregnant

2. Elderly

3. Obese

4. Pts w/ bowel obstruction

Prevention:

NPO 6hrs prior to surgery

Emergency – NGT do gastric lavage and give antacid to prevent

dev. of Mendelian’s Syndrome. (It is marked by

bronchoconstriction and destruction of the tracheal mucosa,

progressing to a syndrome resembling acute respiratory distress

syndrome. Also called pulmonary acid aspiration syndrome.)

Treatment:

Continuous mechanical ventilation

antibiotics

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C. Pulmonary Edema:Etiology:

1. Circulatory overload (infusion of fluid during operation)

Most common cause

2. Left ventricular failure (incomplete cardiac emptying)

Due to anesthetic, narcotic or hypnotic agents w/c decrease

myocardial contractility

Decrease peripheral perfusion -----> peripheral

vasoconstriction ----> cause blood to shift centrally ---->

pulmonary edema

3. Negative pressure in airway.

Treatment:

1. Provide oxygen (increase inspired concentration)

2. Remove obstructing fluid (diuretics, head up or sitting position,

phlebotomy, spinal anesthesia, ganglionic blocking agents)

3. Correcting the circulatory overload

4. Increase airway pressure (PEEP)33

D. Respiratory Failure:

Etiologic Factors:

1. Sepsis

2. Massive transfusion

3. Fat embolism

4. Pancreatitis

5. Aspiration

Associated w/ a decreased Functional Residual

Lung Capacity, indicating that the amount of air

w/ in the lung at the end of normal expiration is

reduced ----> diminished ventilation-perfusion

ratio and ultimately arterial hypoxemia

Treatment:

Mechanical ventilation (PEEP)34

@Hemorrage@Reactionary (occurring within 24hrs)

@Secondary hemorrhage (after 7days)

SIGNS

Pallor, sweating and cool skin &Bleeding from wound

@hypertension

@hypotension

@Deep venous thrombosis

@Myocardial infarction

CVS complications

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@Failure to recover consciousness

◦ May be due to cerebral hypoxia as a result of e.g.

hypoglycemia

@Convulsion

Predisposing fx in the post-op period are:

Pyrexia

Epilepsy

hypocalcaemia

CNS

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Postoperative Renal FailureRenal failure index:

(Urine Na x Plasma creatinine)

Urine creatinine

< 1 usually indicates pre-renal oliguria

> 1 indicates acute renal failure

Etiologies:

1. Catheter obstruction

2. Pre-renal failure;

Diminished circulating blood volume

3. Acute parenchymal renal failure

Fluid restriction (daily allowance 500ml plus previous 24 hrs. UO)

Electrolyte imbalance (hyperkalemia)

Hemodialysis37

@Retention of urine◦ failure to pass urine within 12-24hrs of surgery when

bladder is distended.

◦ more common after pelvic and perineal operations.

◦ Due to action of atropine & other cholinergic anesthetic

agents

◦ Pain in operation site

@Urinary tract infections

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Postoperative Shock

Poor tissue perfusion ---> hypotension,

pallor, sweating, tachycardia, oliguria,

peripheral vasoconstriction ----> progressive

metabolic acidosis ----> multiple organ

failure ---> death.

Hypotension in early post-operation:

1. Over sedation

2. Effect of anesthesia

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Categories:

1. Hypovolemia – most common

Uncorrected volume deficit (preop, intraop, postop)

Continuing hge postop period

30-40% loss of ECV

Monitored w/ UO/hr, CVP

Crystalloid hydration / blood transfusion

2. Cardiogenic shock (MI / cardiac tamponade)

3. Septic shock:

Due to gram (-) infection; nosocomial

Uro-genital infection (foley catheter) > resp. tract >

integumentary40

GIT complications

N & V : it may cause wonud dehiscence &

pulmonary aspiration.

Predisposing factors:

Uncontrolled pain

Opiods

Surgery on GIT, orthopedic surgery or ENT

surgery

Hx .Of preop .Vomiting

Hx . Of migraine

Acute gasteric dilatation 41

Rx of N&V:General measures: Adequate pain control

Avoid opiates

NGTube

Maintain hydration

Drugs: Dopamine antagonist: prochlorperazine

Metoclopromide

H1 receptor antagonist: cuclizine

5HT antagonist: ondansetron 42

Other GIT Cx:Vascular Complication:

1. Hemorrhage: Occurs gastrointestinal anastomosis

Manifest – hematemesis, melena, hematochezia

Bleeding arise from the suture line (usually after gastric resection

Treatment:

Ist conservative: irrigation w/ cold lavage / endoscopy

Reoperation – direct control

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2. Gangrene:

Due to poor tissue perfusion

a. Stomach: Following subtotal gastrectomy w/ ligation of left

gastic and splenic arteries; thrombosis

b. Small bowel and colon: Thrombosis; mechanical strangulation (internal

herniation) – volvulus, adhesions

Treatment:

Resection of gangrenous segment, re-established continuity

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Intestinal Obstruction

Mechanical Problem:

1. Intestinal Obstruction:

1. Stomal obstruction (due to local edema)

Causes of edema:

a. Electrolyte imbalance

b. Incomplete hemostasis

c. Hypoprotenemia

d. Leakage from anastomosis

e. Inadequate proximal decompression

f. Incorporation of too much tissue w/in

the suture 45

2. Other causes of intestinal obstruction

a. Intussuception

b. Volvulus

c. Post-operative adhesion

d. Herniation

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INTUSSUCEPTION

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VOLVULOUS

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Treatment of Intestinal

Obstruction :

Proximal decompression (NPO / NGT)

1. Correct fluid and electrolyte imbalance

2. Hyperalimentation (TPN):

No improvement ------> re-operation

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Small bowel volvulous

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Small bowel internal herniation

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Intestinal ObstructionPostoperative

fibrous adhesion: The most common cause

of bowel obstuction

Could be partial or complete

Fluid and electroyte imbalance

Usually present a colicky abdominal pain with abdominal distention w/o bowel movement.

Late cases might present with silent abdomen

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Treatment:

NGT decompression, NPO, correct fluid and electrolyte imbalance

Surgical intervention – adhesiolysisw/ or w/o resection

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Non-mechanical intestinal

obstruction:Ileus:Physiologic / functional bowel obstruction

Stomach --> w/in few hours

Small bowel ---> 12-36 hrs

Large bowel ---> 24-72 hrs.

Treatment:

NGT decompression

NPO

Fluid & electrolyte balance (hypo K)

Metaclopromide or bethanechol54

Fistula:

Abnormal

communication

between two lining

epithelium

Etiology:1. Anastomotic leak

2. Poor blood supply

3. Trauma

4. Infection

5. Inadvertent suturing of

bowel wall while closing

the fascia

6. Carcinoma55

Fistula:

1. Gastric and duodenal fistula: Subtotal gastrectomy --->

gastrojejunal (tears of surrow) and duodenal stump

Due to suture line failure

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Fistula:

1. Gastric and duodenal fistula:Treatment:

NPO / TPN

Place NGT past the leak and give elemental diet

Antibiotic

Majority close spontaneously w/in 6 wks

Failure to close 1. distal obstruction

2. large leak

3. Infection

4. Cancer

Surgery – resect the fistula and the bowel segment then re-anastomosis

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2. Small bowel fistula:

Drainage is less compared to duodenal fistula, but jejunal fistula have a poorer prognosis than ileal fistula

Treatment: Supportive:

correct fluid & electrolyte imbalance

Give proper nutrition

Proximal jejunal fistula: - Distal feeding jejunostomy

Distal ileal fistula: - low residue diet

Control diarrhea ----> lomotil / protect the skin

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3. Colonic fistula: Fluid & electrolyte imbalance less common but has higher

infection can lead to peritonitis, peritoneal abscess and

wound infection.

Skin digestion and irrigation are rare

Treatment:1. Nutrition (low residue or elemental diet)

2. Antibiotics

Spontaneous healing of fistula is the rule rather than the exception

Medical management is generally indicated for 6 wks to permit active inflammation to subside ---> fails ----> surgery

3. Defunctionalizing colostomies for descending colon

4. Ileal transverse colostomies for ascending and distal ilealfistulas

If w/ generalized peritonitis do emergency resection59

Wound Complications:

A. Wound dehiscence:

Separation of an abd. wound

involving the anterior fascial and

deeper layers

0.5 – 3.0%

Causes:

General factors:

1) Age: < 45y/o = 1.3% > 45 y/o =

5.4%

2) Debilitated pts. w/ poor nutrition

carcinoma, hyponatremia, obesity

3) Causes of increase intra-abd.

pressure

pulmonary & urinary problem

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Local Factors:

1) Hemorrhage

2) Infection

3) Poor technique:

a. Excessive suture material

b. Drain and stoma placed along incision

4) Type of incision (> in vertical incision)

Manifestation:

1. Sero-sanguinous drainage (pathognomonic)

2. Postoperative ventral hernia

Treatment:

secondary operative procedure (if medical condition allows)

conservatively with an occlusive wound dressing and binder

----> postoperative hernia.

Prognosis:

Mortality = 0.5 – 0.3% due to pathologic conditions61

Wound Complications:

B. Wound Infection:

Major factors:

1) Breaks in surgical technique

2) Host parasite relationship

Potential sources of contamination:

1) Patients themselves

2) Operating room and personels

Organisms:

1) Staphylococcus aureus

2) Enteric organism (E. coli, Bacteroides, Proteus,

Klebsiella, Pseudomonas)62

Factors:

1. Nature of the wound:

a. Clean atraumatic and uninfected operative wound (3.3%)

b. GIT / Respiratory / Urinary tract entered but w/ out unusual contamination (10.8%).

c. Open, traumatic wounds w/ major break in sterile technique (16.3%)

d. Traumatic wound involving abscesses of perforated viscera (28.6%).

2. Age

3. Presence of medical problems (diabetes/steroid tx)

4. Duration of operations and preoperative stay in the hospital

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Presented by :Shaimaa Adil

Hawraa Ali

Fatin Mohmmad

Jehan Ali

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