IntroductionPostoperative complications are the most

important factors in determining outcome in the first 72 hours following surgery

It is critical to monitor basic physiological parameters such as renal, cardiovascular and respiratory functions

Postoperative ordersVital signsDiet: NPO until bowel sounds presentIntravenous fluidsCare of drainsInput and output chartPain medication: dose and route of

administrationAntibiotics

Postoperative ordersVenous thrombosis prophylaxisOther medications

Postoperative vascular complicationsVenous thromboembolism (VTE) includes

DVT and PE and are a major but preventable cause of morbidity and mortality

Pulmonary embolismHas few definite symptomsBut onset of respiratory distress with

hypotension, chest pain and cardiac arrhythmias may be harbingers of impending death

Can convert a successful operation into a postoperative fatality

Prevention of VTEUnfractionated heparinLMWHGraduated compression stockingsIntermittent pneumatic compression

stockings

Risk factors of postop thrombosisVirchow’s triad: hypercoagulability, stasis,

trauma to vessels

Diagnosis of VTEVenographyImpedence plethysmographyDoppler ultrasoundMRI/MRI Venography

Treatment of VTEUFHLMWH

Postoperative pulmonary complicationsAtelectasisPneumoniaRespiratory failurePulmonary thromboembolic disease

Risk factors for PPCsAge > 60 yearsCancerCongestive cardiac failureSmoking (within 8 weeks of surgery)Upper abdominal incisionVertical incisionIncision length > 20cm

AtelectasisDefinition not uniform in clinical studiesGenerally accepted criteria include:

impaired oxygenation in a clinical setting where atelectasis is likely

Unexplained fever > 38oCCXR evidence of volume loss or new airspace

opacity

Risk factors for atelectasisAdvanced ageObesityIntraperitoneal atelectasisProlonged anaesthesia timeNG tube placementSmoking

Prevention of atelectasisCessation of smoking (6-8 weeks before

surgery)Laporoscopic procedureDeep breathing exercisesMobilizationAdequate analgesia (epidural or PCA

preferred)Selective gastric decompression

Postoperative pneumoniaHospital-acquired pneumonia (HAP) is

pneumonia that develops 48 hours or more after hospital admission because of an organism that was not incubating at the time of hospitalization

HAP after abdominal surgery increases mortality, hospital stay and hospital charges

Caused by a wide range of bacteria. Also by viruses and fungi in immunosuppressed patients

Pathogens causing early onset (<4 days) HAPStrep pneumoniaMS Staph aureusH influenzaE coliK pneumoniaEnterobacter spp.Proteus spp.Serratia marcescens

Pathogens causing late onset (>5 days) HAPPseudomonas aeruginosaMDR K pneumoniaAcinetobacter spp

HAP: clinical definitionNew opacity on CXR( PA and lat views

preferred) plus 2 of the following:Fever >38oCLeukocytosis or leukopeniaPurulent respiratory secretions

Diagnosis should be supported by sample of lower resp tract secretions-bronchoscopy

HAP treatmentInitial therapy should be given IVCombination therapy for those at risk of MDR

pathogensMonotherapy for those at low risk of MDR

Respiratory failureDef: inability to maintain normal tissue

oxygen transport or the normal excretion of carbon dioxide

Arterial PO2 < 60 mmHg or arterial PCO2 > 45 mmHg generally indicate significant respiratory compromise

Generally managed in ICU including endotracheal intubation

Postoperative care of the urinary bladderMost common postop problem of female bladder

is atony caused by overdistension and reluctance of the patient to initiate the voluntary phase of voiding

Urethral or suprapubic catheter is used7-10 days postop postvoid residuals are

evaluatedIf >100ml catheterization duration is extendedOnce residuals are less than 100ml on 2

successive voidings of >200ml catheters can be removed

Postoperative GIT managenentAdvancing of diets should be individualizedPatients with uncomplicated surgery may be

given a regular diet on the 1st POD if bowel sounds are present, if abdominal exam reveals no distention and patient is not nauseated from anaesthesia

Seriously ill patients may reuire TPN