lecturerProf Saleh M Alsalamah

BSc.MBBS.FRCS

Professor of Surgery &Consultant General & Laparoscopic Surgery

College of Medicine King Saud University,Riyadh KSA

References/ Books1/principal and practice of surgery .by

James garden 2/current surgical diagnosis and treatment By Laurence w. way3/surgery by peter Laurence4/Churchill pocket book by Andrew

T.raftery

Overview This tutorial composed of two topics to

be discussed– Post op care– Post op surgical complications

Post operative Care Objective

– Understand the principles of patient management in the recovery phase immediately after surgery (in the theatre there is the operating room and the recovery room and the 1st place where post-op complications start is in the recovery room)

– Understand the general management of the surgical patient in the ward

– Consider the initial management of common acute complications during postop period.

Students will be aware of

Common general complications of surgery (the immediate and the late ones)

How to diagnose and manage (once diagnosis is made you have to manage immediately)

Impact of complications on the outcome of surgery (did the complication affect your surgery)

Reducing the risks of complication (i.e asses risk factors before surgery) Good pre-operative evaluation (this

happens in OPD, ER, when they are in the floor and take history, examination and proper lab evaluation. And treat any factors that will cause complication.

Optimizing the general condition of patients

Medical issues (cardiac or respiratory)

Nutritional issues (malnutrition, obesity). If the patient is malnourished and is not in an emergency surgery setting optimize his nutrition before surgery; if its an emergency case then do the surgery. Obese patients have a lot of complications. Minimizing preoperative hospital stay (to

avoid DVT, hospital acquired infections)

Good surgical technique (most important by using good proper materials and avoiding experimental techniques)

Early mobilization (to avoid surgical infections, DVT, bed sores)

General complications Immediate Complications: Nausea/ vomiting (seen in most patients speically

those patients of general anaesthesia

Persistent hiccups (seen in patients that are undergoing gastric surgeries without placement of a NG tube . They may develop as a result -

gastric distension renal failure

Headache - spinal anaesthesia

IV site- bruising, haematoma, phlebitis, vein thrombosis, air embolism, infection

Overview Post op care has 3 phases (very

important) Immediate post op care (Recovery phase) Care in the ward while discharging from

the hospital Continued care after discharge from the

hospital (give appointment after discharge to either remove wound or to revise histopathology, or to check for any complications that may develop after discharge)

MONITORING IN RECOVERY ROOM

Immediate post operative monitoring should be done in accordance with the ABC of emergency

A ……. Airway attention to maintenance of airway. B ……. Breathing ensure adequate ventilation. C…….. Circulation adequacy of circulatory status with heamorrhage control.

IN RECOVERY ROOMPatient should be thoroughly reassessed by both the

surgeon and anesthetist before being shifted out of OR. Clinical notes available with the patients in recovery room should include:-

Immediate post-op care before going to recovery room should include the ABC at all times specially if patients had intubations to check for aspiration, hemorrhage

Operation notes describing the procedure performed. Anesthesia record of the patient ‘s progress during

surgery. Post operative instructions sheet including all drugs,

intravenous fluids and fluids balance sheet.

Once the patient is conscious in the recovery room, the specialized nurse will make sure that the patients is hooked up to the monitors and ventilators with the attendance of the surgeon and the anesthesiologist.

The nurse will then check the operation procedure note to make sure that everything was done smoothly along with the anesthesia notes to make sure that patients vitals did not fluctuate at any point during the surgery.

Post-op instruction sheet include all drugs IV fluid and fluid balance sheet.

Time out = check name of the patient, hospital number, name of operation surgeon assistant anesthesiologist and assistant scrubbing and running nurse. This should all be found in the operation notes.

ALL THESE ARE POST-OP ORDERS; IF THE PATIENT DOESN’T HAVE THESE NOTES WRITTEN THEN HE WILL NOT LEAVE THE OR ROOM AND THE SURGOEN AND ANESTHESIOLOGIST WILL BE CALLED FOR REASSESMENT.

Complications developing in recovery room Airway obstruction (most important and should always

be assesesd

Acute pulmonary complications

Cardio-vascular complications (silent MI that turns to active MI)

Fluid derangements

Reactive haemorrhage Slipped ligature Dislodgement of clot

Discharge from the theatre and post anesthetic recovery (before going to the ward )

Anesthetic (most imp)and surgical staff should record the following items in the patients case notes before leaving the OR patients should be thoroughly assessed by Surgeon and anesthesiologis :

Any anesthetic (difficult intubation, spinal, BP fluctuation, surgical (if any developed and how it was managed) or intraoperative complications.

Any specific treatment or prophylaxis required(eg: fluids (how many fluid is to given should be kept NPO

or not), nutrition, antibiotics , analgesia , anti-emetic , thromboprophylaxis)

First Postoperative Assessment

Its start after the patient discharge from the theatre to the ward/floor. The nurse will also check the operative notes:

if the patient at risk of deterioration he need frequent assessment Q6; Q12 check CBC.

If patient is high risk should be shifted to HDU or ICU Risk factors for deterioration are: ASA grade ≥ 3 (1 no problem, 2 minor, 3 affected, 4 severely affected

and can develop complications, 5 patient is cor-morbid and can die within 24hours)

Emergency or high risk surgery ex. Mesenteric occlusion and open heart surgery).

Operation out for hours (6pm till 8am).

The patient must be reassessed within 2hours of the 1st postopreative assessment/round. Done by senior registrar and resident. If problem is minor then the resident deals with it if major consultant deals with it.

The doctor complete 1st postoperative assessment with the monitoring regimen.

Check list for 1st postoperative assessment

Intraoperative Hx &postoperative instructions: Past medical Hx (may be high risk patients MI pr bronchial

asthma ) Medications (asked to be given post-op) Allergies Intraoperative complications Postoperative instructions Recommended Rx & prophylaxis

ALWAYS TALK TO THE PATIENT EASIEST WAY TO ASSESS CONCIOUSNESS)

Check list for 1st postoperative assessment Respiratory assessment status: O2 saturation. Effort of breathing .. Respiratory rate. Trachea central or not for thyroid surgery. Symmetry of respiration and expiration. Breath sounds. Percussion.

Check list for 1st postoperative assessment

Circulation ;Volume status assessment: Hands-warm or cool pink or pale. Capillary return <2s or not . Pulse rate , volume and rhythm. blood pressure. Conjunctival pallor. Jugular venous pressure. Urine color & rate of production. Drainage from drains, wound& NG tube how much these

things are producing if they are within normal minutes

Check list for 1st postoperative assessment Mental status assessment: patients should be fully

conscious within 10 minutes after anesthesia.

Patient conscious and normally responsive?(AVPU: Alert,respond for Verbal & Painful stimuli,unresponsive) if unresponsive find the cause

Finally RECORD any significant symptoms (e.g. chest pain cardiac or from tube, breathlessness) Pain and pain adequacy control is very important.

Post op Surgical Complications (immediate and late)

Must consider morbidity in this case specially in day case surgeries. Example hernia day case with complication (such as hypotension or bleeding) seen in post op round before discharge. In this case patients cannot be discharged and will be admitted and managed appropriately)

OBJECTIVES

RISK FACTORS

TYPES OF PATHOLOGY

TYPES OF SURGERY

COMPLICATIONS & THEIR MANAGEMENT

Postoperative Complications (Morbidity) Account for:

1. Considerable human pain and suffering.

2. Increased cost of the health- care when considering to admit a day case patient and weigh the risks versus benefits.

3. Can lead to postoperative death.

Accept that complications are best anticipated and avoided always anticipate complications so you can deal with them appropriately.

Recognize the incidence of co-morbidity by good history and examination and treat accordingly before considering admittance for surgery.

OBJECTIVES:-

Understand the importance of matching the procedure to the associated risks. 1. Elective hernia with a patient that had an MI 6 months ago. If it is not an emergency wait 1-2 years to avoid significant complications.

2. Patient umbilical hernia with no strangulation or obstruction with SOB shouldn’t be admitted for surgery because he has an underlying condition that should be managed before hand.

Appreciate the importance of recognizing complications early and treating them vigorously. Never ignore any post op sign such as signs of wound infection. Either deal with them alone or call your senior

Risk factors

General anesthesia Surgery

General risk factors Age both extremes (Very young & Very old). In young children they

have an underdeveloped Immune system so any complication can affect them more severely than other age groups. And same goes for their management; if you over or undertreat the baby it may result in catastrophic effects. In elderly, more cardiac, respiratory problems and they are on medication that should all be considered.

Obesity risks to the patient and difficulty operating to the surgeon and risks of anesthesia. They are classified as obese, morbid and super obese. More liable to bleeding, DVT, short neck so difficult intubation. Very thin blood vessels that are easily injured. Very obese patients the operating table may not accommodate the patient..

Smoking and its effects on the systems of the body

Co-morbid conditions: Cardiovascular diseases Respiratory diseases DM Renal diseases Metabolic factors Infections Wound healing Peripheral vascular diseases

Drug therapy (Concurrent drugs used) due to drug-drug interaction

e.g steroids , immunosuppressant, antibiotics and contraceptive pills DVT and PE

Blood transfusion

Anesthesia risk factors Anaphylactic reactions to

medications, injury during laryngoscopy, neuropathy from positioning stretch the patient surgery.

Even spinal/epidural carries risk: inadequate, need to convert to general, sympathectomy with vasodilation, etc excess vasodilation the patient may go into neurogenic shock.

Obstructive Jaundice. Coagulation will be less therefore bleeding and hematoma. Wound healing will be prolonged. And metabolism is also affected so must make sure that the patient is well nourished. Renal failure and kidney failure. Metabolism of drugs is another problem. Must rehydrate them, build them up and treat the underlying cause. Ex: ERCP to remove stones.

Neoplastic Diseases. More liable to get DVT, poor wound healing , pulmonary embolism because blood is viscous.

Patients with these pathologies are more prone to complications

Minimally Invasive Surgery laproscopic. Less complication than open technique.

Orthopedic Surgery most DVT happen in these types of surgeries due to prolonged rest. Major nerves and blood vessels.

Gynaecology bowel obstruction and major blood vessels.

Thoracic & Upper Abdominal Surgery atelectasis , brochestais as a result of difficulty breathing post op

Prolonged Operations. For example a 2 hour operation is converted to a 6 hour due to either difficult patients or complications that develop intra-op. Patient may develop hypothermia that will lead to thrombosis. Must always warm the fluid or they will go into hypothermia and its complications

Complications of surgery may broadly be classified as those:

I. Due to Anesthesia II. Due to Surgery Any complication is under the surgeon because the patient

is under the name of the patient

The anesthetic complications depend upon the mode (General, Regional & Local) and types of anesthetic (the anesthetic agent toxicity). Must have an pre-op anesthesia round to determine certain risk factors that are contraindicated against certain anesthetics for example patients with jaundice should not be given hepatotoxic anesthetics.

(A) LOCAL ANESTHESIA: Can be done by the surgeon him self. Injection site: Pain, haematoma, Nerve trauma,

infection if you miss the area which you will anesthetize

Vasoconstrictors: Ischemic necrosis if injected at the

digist

Systemic effects of LA agent: Allergic reactions, toxicity

(B) SPINAL, EPIDURAL & CAUDAL ANESTESIA: Technical failure most commonly seen in

juniors Headache due to loss of CSF Intrathecal bleeding may cause hematoma

and lead to paralysis. Permanent N. or spinal cord damage may

also lead to paralysis Paraspinal infection Systemic complications (Severe

hypotension) Associated with a lot of complications less

than that of general

(C) GENERAL ANESTESIA: Direct trauma to mouth or

pharynx specially in those with risk factors such as short neck.

Slow recovery from anesthesia due to drug interactions OR in-appropriate choice of drugs or dosage.

Hypothermia major complication due to long operations with extensive fluid replacement OR cold blood transfusion.

Allergic reactions to the anesthetic agent:

Minor effects; mostly (2-3 hour operations

eg: Postoperative nausea & vomiting

Major effects; more worrisome

eg: Cardiovascular collapse: arrhythmia, respiratory depression and patient may be shifted to ICU

Haemodynamic Problems: Vasodilation & shock due to too

much anesthetic agent.

Postoperative Surgical Complications:1-Haemorrhage:a- Immediate (during surgery)Inadequate haemostasis , unrecognized damage to blood vessels can be seen in appendectomy b- Early postoperative: in which hemorrhage is missed (24-48 hours)defective vascular anastomosis , clotting factor deficiency , intraoperative anticoagulants . Check NGT and Drain for blood# surgical re-exploring is usually required to check for the damage.c-Secondary hemorrhage this is usually late complication:Related to infection which erodes blood vessel Several days postoperative. Patient may be in shock, resuscitate the patient give patient anti-biotic and treat the cause for example abscesses require drain and may take the patient to the OR. Very rare. # treatment of infection

2. Hypothermia; very dangerous

Drop in body temperature of 2 degrees C if they reach 35 they are hypothermic

Causes : Trauma, Exposure of the abdomen, Cool Fluids – IV / Irrigation with cold saline must warm it but not hot to burn the bowel.

Temperature below 35 C Coagulopathic; DVT, PE Platelet dysfunction

Mild - 32 – 35C = 90-95F recovery is good Moderate – 28 – 32C = 82–90F recovery is good Severe – 25 – 28C = 77-82F may recover with

complication Extreme may patient may get brain damage

usually don’t recover Treatment with warmers and warm fluids

3. Postoperative Fever Causes

Pneumonia Infections UTI DVT (possible PE) Abscess Medication

Noninfectious Within the first 48-72 hours (Atelectasis, anesthetic drugs overdose, ARDS)

Infectious Fevers POD 3-8

UTI 3rd POD burning micturition Wound Infection 3rd to 5th POD Abscess 5th to 7th POD DVT 7th to 10th POD

Standard work up includes Blood cultures UA and Urine Cultures CXR Sputum cultures/ analyisis Tylenol/Motrin given by treating the underlying cause is more important

Treatment involves the treatment of the cause if abscess drain it etc.

4. Wound a-bleeding more liable to vessel injury and lead to

hematoma b-hematoma lead to seroma specially in obese

patients c-seroma (pocket of clear serous fluid that sometimes develops in the body after surgery) lead to infections

d-infection immediate e-suture sinus late due to non-absorbable suture or

forgotten suture f- breakdown of anastomosis:

-incisional hernia -anastomotic breakdown either technical or patient has

malignancy or jaundice

Wound Dehiscence

Wound dehiscence due to wound infection what you see is omentum. There are grades: Grade1: skin opening Grade 2: the muscle and sheath opening Grade 3: all omentum and bowel is out in this case you need to resuscitate the patient cover with AB and take to OR. In the OR check for underlying cause such as infection

Evisceration

Patient with bowel obstruction and presented with wound infectionBowel is all out and worse than wound dehiscence patient can go into septic shock. This patient was taken to OR for management.

Incisional Hernia

5. Cardiovascular MI (coronary artery thrombosis) cardiac arrest (cardiac shock) in patients with co-morbid

conditions arrhythmia pulmonary oedema ( usually old pt or young with cardiac or renal disease ) Cardiogenic:  left ventricular failure , arrhythmias , Hypertensive crisis ,

cardiac tamponade , Fluid overload, e.g., from kidney failure or intravenous therapy

DVT in those with hormonal therapy and prolonged bed rest.

advanced age Obesity Hormonal therapy Immobilization Infection

6. Respiratory Complications most dangerous complication

Aspirationfasting for six hours before elective surgery is enough to empty the stomach, but sometimes patient is not honest. If ER surgery then an NGT is usually inserted and the gastric contents are sucked to prevent aspiration but in routine surgeries this is not usually done. Food is usually emptied within 4 hours

Atelectasis   post-surgical atelectasis, characterized by restricted breathing after abdominal

surgerySmokers , elderly ===<< High risk

Pneumothorax (iatrogenic ) or due to central line Pneumonia Hospital acquired pneumonia (nosocomial pneumonia)

# mechanical ventilation or from theatre

ARDS due to vomiting and aspiration after extubation as a result food contents go to lung. Treatment includes ventilation and suction using ETT and give steriods then intubate. Seen in patient with major surgery or ICU patients

7. Cerebral

Confusion usually are confused post-op but check patient *sepsis*electrolyte/glucose if diabetic with high blood glucose*hypoxia*alcohol withdrawal if history suggests he is alcoholic

Stroke may get it intraoperative specially in head and neck surgeries or brain surgeries

8. Urinary

a-acute retention a big problem

b-UTI folly's catheter make sure to clean the area in a septic technique.

c-acute renal failure such as pre-renal failure and you do not hydrate the patient

9. Gastrointestinal Complications common in open technique Postoperative ileus (immediate) Anastomotic Leak seen in IBD patients

after surgery (immediate) GI Bleeding (immediate) Enterocutaneous fistula (late) Adhesions (late) Pseudomembranous colitis a lot of AB

(late)

Paralytic Ileus

Anastomotic leak

Dye from bowel

Enterocutaneous Fistula in IBD

10. Neurologic Drug Induced ICU Psychosis once patient is stable

shift him to ward avoid prolonged stay in ICU

Neuropsychiatric Complications Operative Nerve Injuries

Wound: Hypertrophic scar, keloid, wound sinus,

implantation dermoids, incisional hernia Adhesions: Intestinal obstruction, strangulation. For

example: GIT perforated peptic ulcer u clean the wound the patient develops adhesions post op that can lead to obstructions.

Altered anatomy/Pathophysiology: Bacterial overgrowth, short gut syndrome

seen in patients with mesenteric occlusion , postgastric surgery syndromes, etc.

Susceptibility to other diseases: Malabsorption, incidence of cancer, tuber-

culosis, etc.