postoperative care & general complications of surgery m k alam ms; frcs professor of surgery...

Postoperative care &

gENeRAL ComplicationsOF SURGERY

M K ALAM MS; FRCS

Professor of SurgeryALMAAREFA 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 days-

nutritional 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: anaesthic agents, pharyngeal suction

• 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 complicationsPost-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!