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Postoperative care & gENeRAL Complications OF SURGERY M K ALAM MS; FRCS Professor of Surgery ALMAAREFA COLLEGE Intended learning objectives • At the end of this presentation students will be able to: Recognize the importance of proper postoperative care. Describe immediate and delayed complications of surgery. Explain immediate postoperative care of pain, fluids, drains, and wound. • Describe prevention and management of postoperative complication. Introduction • • • • • • All surgeons expect speedy, uneventful recovery. Always have recognized the risk of complications. Affects result of surgery: poor scar, hernia. Prolongs hospital stay and increased cost. Increased morbidity/ mortality. Raises medico-legal issues. Reducing the risks of complications • Good pre-operative evaluation. • Optimizing the general condition of patients. -Medical issues- diabetes, hypertension. -Nutritional issues- malnutrition, obesity. • Minimizing preoperative hospital stay. • Good surgical technique. • Early mobilization. Phases of post-op. patient care • Recovery room. • Surgical ward. • On discharge. Complications developing in recovery room • Airway obstruction. • Acute pulmonary complications. • Cardio-vascular complications. • Fluid derangements. • Reactive haemorrhage. -Slipped ligature. -Dislodgement of clot. Immediate post-operative care • Observation in recovery room until patient fully conscious. • Frequent monitoring of ABC (vital signs). • Surgical wound and drain- surgeon’s responsibility. • Drain- nature & volume. • Urine output. • ECG, pulse oximetry, CVP. • Supplemental O₂ after extubation. Causes of postoperative airway problems • Obstruction by tongue fall back- depressed level of consciousness, loss of muscle tone. • Bleeding into oropharynx. • Loose tooth / denture causing obstruction. • Laryngeal spasm or oedema. • Tracheal compression- bleeding after thyroid surgery. • Bronchospasm- aspiration, drug reaction. Management • Defining and rectifying the cause. • Chin lift or jaw thrust-protects tongue fall back. • Suction of oropharynx. • Oropharyngeal airway. • Supplemental oxygen. • Re-intubation if no improvement. Haemorrhage • • • • Blood coming through drain. Bleeding from suture line- rarely a problem Hypovolaemic shock- if blood loss is large. Reactionary haemorrhage. Slipped ligature. Dislodged clot. • Management: Patient back to theatre. Fluid resuscitation. Post-op. care in ward • • • • • • • Monitoring vital signs. Intake (oral/IV)- output ( urine, NG tube, vomitus and drain) record. Regular analgesia. Chest expansion and coughing encouraged. Early mobilization. Legs checked regularly for DVT. NG tube removed- ↓ drainage, bowel sound returned, passage of flatus. Post-op. care in ward (contd.) • • • • • • • • • • IV fluid - adjusted daily until free oral intake. Daily IV fluid in adults- NS 1 L+ D5 2L. KCl- from 2nd day (60-80 mmols/ 24 Hrs). Oral feeding started once bowel activity returns. Surgical drains- removed once effluent diminishes. FBC & electrolytes usually checked on 1st postoperative day. Blood transfusion- hemoglobin <8 Gm/dl. Oral feeding delayed or cannot commence in 5 daysnutritional support by enteral or parenteral feeding. DVT prophylaxis(heparin, anti-embolic stocking) until freely mobile. Sutures- removed in 7-8 days. Postoperative complications • Local complications: Specific to the type of surgery. Example: Hypocalcemia after thyroidectomy. • General complications: may develop as a result of any surgery. Example: UTI, chest infection, DVT General complications • Nausea/ vomiting. • Persistent hiccups -gastric distension renal failure • Headache - spinal anaesthesia. • IV site- bruising, haematoma, phlebitis, vein thrombosis, air embolism, infection. Pulmonary complications • Largest single cause of post-op. morbidity. • Common cause of death in over 60 age. • Higher risk: chronic pulmonary disease (COPD). Pulmonary collapse (atelectasis) • Inability to breath deeply/ cough up secretions. • Paralysis of cilia, impaired diaphragmatic movement, abdominal distension, pain. • Bronchus/bronchiole obstructed by secretions. • Distal alveolar space close (atelectasis), solidify. • Usually occurs within 24 hours. • Tachypnoea, tachycardia, mild fever, ↓ breath sound, ↓PaO2. • Chest X-ray- areas of opacification. Pulmonary collapse (atelectasis) • Untreated: Infection- lobar or bronchopneumonia. • Prophylaxis: stop smoking, physiotherapy for COPD. • Delay surgery if chest infection. • Treatment: encourage deep breathing/cough, mobilization, analgesia, chest physiotherapy. • Severe hypoxia- intubation, suction, bronchoscopy. Pulmonary infection • Follows atelectasis, gastric aspiration. • Strep. pneumo.,H influenzae or gram negatives. • Pyrexia, tachypnoea, greenish sputum. • ↓ breath sounds, coarse crepit., bronchial breath. • Chest X-ray: patchy fluffy opacities. • Treatment: antibiotics, encourage to cough. • Severe cases: O2, bronchoscopy, ventilation. Respiratory failure • Definition: Inability to maintain normal PaO2 & PaCO2. • Normal PaO2= 11.6 -13 kPa. • Resp. failure PaO2 < 6.7 kPa. • Central cyanosis. • ABG- key to early recognition. • Treatment: Intubation and ventilation. Acute respiratory distress syndrome (ARDS) • Impaired oxygenation, diffuse lung opacification and lung stiffness (↓ compliance). • Aetiology: Systemic or lung sepsis, massive BT, aspiration. • Endotoxin activated leucocyte→ oxygen-derived free radicals, cytokines & chemical ↑capillary permeability →interstitial & alveolar oedema. • Tachypnoea, ↑ventilatory effort, confusion, hypoxia. • CXR- bilateral diffuse fluffy opacities. • Lung-increasing stiffness, difficult to ventilate. • Treat: ventilation PEEP, sepsis, hypovolaemia. • Mortality: 50% PLEURAL EFFUSION • Pulmonary pathology: collapse, consolidation, infarction, tumour deposit. • Abdominal pathology: sub-phrenic abscess. • Small effusions left to reabsorb. • Large effusions aspirated for culture/ cytology. PNEUMOTHORAX • Insertion of central venous line. • Positive pressure ventilation- rupture of pre-existing bullae. • CXR after insertion central venous line is necessary. • Drained by underwater seal. CARDIAC COMPLICATIONS • Risk of anaesthesia/surgery high in patients with cardiovascular disease • Whenever possible, treat these before surgery • Aortic stenosis impairs heart response to increased post-operative demand • Severe aortic/mitral valve dis.- carefully monitor iv fluid administration Myocardial Infarction • • • • • • Usually history of preceding cardiac disease Gripping chest pain, hypotension ECG changes Cardiac enzymes Cardiologist consultation 1/3rd postoperative MI fatal Arrhythmias • Sinus tachycardia: hypovolaemia, hypotension, pain, fever, restlessness • Sinus bradycardia: pharyngeal suction anaesthic agents, • Atrial fibrillation may need medications Post-operative shock • Hypovolaemic: Inadequate fluid replacement, bleeding • Cardiogenic: acute MI, arrhythmias • ↑pulse, ↓BP, sweating, pallor, vasoconstriction,↓ urine • Septic: early-hyperdynamic circulation, bounding pulse, fever, rigor and warm extremity. Later- hypotension and peripheral vasoconstriction Cardiac failure • • • • • Ischaemic or valvular diseases, arrythmia Fluid overload Progressive dyspnoea, hypoxaemia CXR- diffuse congestion Treatment: avoid fluid overload, CVP monitoring • Diuretics, cardiac inotropes • Cardiologist consultation Urinary complications Post-op. urinary retention • Groin, pelvic, perineal surgery, operations under spinal/epidural anaesthesia • Pain, effect of anaesthetic drugs, lying/sitting position, BPH • Males > females • Palpable distended bladder, • Catheterization Urinary tract infection • Most common nosocomial infection • Pre-existing UTI, urinary retention, catheterization • Frequency, dysuria, fever, flank tenderness • Urine culture • Adequate hydration, urinary drainage, antibiotics Renal failure • ARF: protracted inadequate renal perfusion • Hypovolaemia, sepsis, nephrotoxic drugs • Susceptible- pre-existing renal disease, jaundice • Prevention: adequate IV fluid, urine >0.5ml/ hr Renal failure • Treatment: replace fluid loss+ 500ml dietary protein to <20Gm/day u/e monitoring, haemodialysis • Polyuric phase: monitor of fluid intake and u/e • Recovery 2-4 weeks • Mortality up to 50% Neurological complications • Cerebrovascular accidents (CVA): sudden ↓ in BP during/ post surgery, hypertensive patients. Carotid endarterectomy, cardiac surgery • Psychiatric disturbance: elderly, dementia due to cerebral atrophy, use of sedatives/ hypnotics • Acute toxic confusion: sepsis, hypoxia, uraemia, electrolytes imbalance • Sleep deprivation particularly in ICU • Delirium tremens: agitation, tremors, hallucinations Deep venous thrombosis (DVT) • Virchow’s triad: stasis, ↑coagulability, vessel wall injury • Risk factors: old age, obesity, prolonged surgery, pelvic/ hip surg. malignancy, past DVT, varicose veins, pregnancy, use of oral contraceptive pills • Presentation: painful swollen tender calf & fever. • Diagnosis: Duplex ultrasonography • Prevention: Compression stockings, mechanical compressions of calf during surgery, subcutaneous heparin • Treatment: iv bolus/ infusion heparin, LMWH, Warfarin for 3-6 months (INR 2-3 times normal) Pulmonary embolism • Massive PE: severe chest pain, pallor & shock • CP resuscitation, heparinization, CT angiography, streptokinase/ urokinase (if >6 days post surgery). • • • • Small PE: chest pain, tachypnoea, haemoptysis. CXR, ECG , V/Q scan, CT Haparinization Warfarin for 3-6 months Wound infection • • • • • • • • The most common complication. Incidence: 1% (clean) to 30% (dirty). Haematoma formation common before infection. Manifests within 7 days of surgery. Fever, tachycardia, increased pain at operation site. Red, tender, swollen, discharging wound. Remove few sutures to drain the wound. Antibiotics- if septicaemic. Malignant hyperthermia • Trigger by GA in susceptible patients. • Halogenated anaesthetics, succinylcholine, suxamethionine. • Abnormal release of Ca⁺. • Prolonged muscle activation and heat generation. • Patients develop high fever. • Dantrolene + cooling of patient. Postoperative fever • 2/3rd postoperative patients. • 48-72 hours after surgery. Lung atelectasis- commonest cause. Streptococcal or clostridial infection- uncommon. • 4-5 days postoperative. Chest infection. Urinary tract infection. Wound infection. DVT. Wound dehiscence • Involves abdominal wall, Incidence <1%. • Partial (deep layer), Complete (deep+ skin). • Serosanguinous discharge, evisceration. • Manifests within 2 weeks. • Risk factors: Obesity, resp. disease, infection, malnourishment, renal failure, malignancy, diabetes, steroid use,& poor surgical technique. • Resuture under GA. Develops hernia later. Recommended book Principle & Practice of Surgery 5th edition Garden, Bradbury, Forsyth & Parks THANK YOU!