Postoperative Assessment, Management And Complications

Supervised By : prof. S.Al-Salamah

Khaled Al-QarniMansour Al-HarthiYazeed 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

Overview

This tutorial composed of two topics :

▪ 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.

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 :

1. to prevent complications such as bleeding,2. to promote healing of the surgical incision,3. and to return the patient to a state of health.

Post op care has 3 phases:

Immediate post-op care (Recovery phase)

Care in the ward

Continued care after discharge from the hospital

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)

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.

• 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

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.

Assessment Postanesthesia care unit (PACU)

Check list for 1st postoperative assessment

Intraoperative Hx &postoperative instructions:

Past medical Hx Medications Allergies Intraoperative complications Postoperative instructions Recommended Rx & prophylaxis

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.

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

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.

1. Education ( + family)

2. Prescriptions

3. Follow up

After Discharge Care:

Post-op Surgical Complications

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

Complications maybe :

I. Due to Anesthesia

II. Due to Surgery

Anasthesia Complications

Depend on: The mode (General,

Regional & Local) Type of anesthetic (the

anesthetic agent toxicity).

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

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

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.

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 & rhabdomyolysisTreatment :Discontinue the anesthesia then wrapping the patient in a cooling

blanket cangeneral help reduce feverBenzodiazepine Then >>>((dantrolene))

Allergic reactions to the anesthetic agent:

Minor effects e.g. Postoperative nausea & vomiting

Major effects e.g. Cardiovascular collapse,

respiratory depression)

Complications due to surgery :

• Immediate (0-24hrs)Primary hemorrhageBasal atelactasis Shock

• Early (2days- 3weeks)• Mental state change • Fever • 2ndry hemorrhage• Wound infecton• Paralytic ileus

• Late (Weeks –months)Bowel obstruction Incisonal hernia

Complications due to surgery :

• Hemorrhage• Wound• Cardiovascular• Respiratory• Gastrointestinal• Urinary tract• Cerebral

Hemorrhage

A- primary Hemorrhage :• Inadequate hemostasis.• Unrecognized damage to blood vessels. • Defective vascular anastomosis. • Clotting factor deficiency. • Intraoperative anticoagulants

Early recognition & management

• Surgical re-exploration is usually required

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 !!!!

Wound Complications 1- Infection:Classification1. Superficial(skin and SC tissue) 2. deep(fascia and muscle ) 3. space (anatomical space and organ)

CausesIt 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 1. Superficial >> incision and drainage with or without systemic antibiotic2. Deep >>> surgical debridement with systemic antibiotic 3. Space >>> CT scan guided percutaneous drainage and may need open

drainage

Wound Complications

2-HematomaLocalized collection of blood.Treatment :Small hematoma : spontaneously absorbedLarge hematoma : may required drainage

3-SeromaLocalized collection of serous fluid.Common sites : breast and abdominal surgery Treatment Small seroma : spontaneously absorbedLarge seroma : may required drainage

4-incisional hernia10 %

Risk Factors: chronic cough , and causes of Increase abdominal pressure like lifting Heavy object …etc

Treatment :HerniorrhaphyHernioplasty ( with mesh)

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.

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

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

• 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

Postoperative Fever

• Regular work up includes:

• CBC• Blood cultures• Urine analysis and urine cultures• CXR• Sputum cultures

Postoperative Fever

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

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

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.

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.

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.

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.

Atelectasis

Incentive Spirometer

Aspiration Pneumonia

• 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).

Post-OP Pneumonia Risk Factors:• 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.

Pneumothorax

• 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.

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.

Urinary Complications

Urinary Retention:• Enlarged bladder from spinal anesthesia or

medication.

Symptoms\Signs:• Palpable bladder and inability to void.

Treatment:• Foley catheter.

UTI Risk Factors:• 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.

GI Complications Postoperative ileus:• 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).

Paralytic Ileus

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.

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.

Enterocutaneous Fistula

Neurologic

Drug Induced ICU Psychosis Neuropsychiatric Complications Operative Nerve Injuries

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.

Thank You