Postoperative care Introduction Postoperative complications are the most

Postoperative care

Introduction �Postoperative 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 orders �Vital signs �Diet: NPO until bowel sounds present �Intravenous fluids �Care of drains �Input and output chart �Pain medication: dose and route of administration �Antibiotics

Postoperative orders �Venous thrombosis prophylaxis �Other medications

Postoperative vascular complications �Venous thromboembolism (VTE) includes DVT and PE and are a major but preventable cause of morbidity and mortality

Pulmonary embolism �Has few definite symptoms �But 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 VTE �Unfractionated heparin �LMWH �Graduated compression stockings �Intermittent pneumatic compression stockings

Risk factors of postop thrombosis �Virchow’s triad: hypercoagulability, stasis, trauma to vessels

Diagnosis of VTE �Venography �Impedence plethysmography �Doppler ultrasound �MRI/MRI Venography

Treatment of VTE �UFH �LMWH

Postoperative pulmonary complications �Atelectasis �Pneumonia �Respiratory failure �Pulmonary thromboembolic disease

Risk factors for PPCs �Age > 60 years �Cancer �Congestive cardiac failure �Smoking (within 8 weeks of surgery) �Upper abdominal incision �Vertical incision �Incision length > 20 cm

Atelectasis �Definition not uniform in clinical studies �Generally accepted criteria include: �impaired oxygenation in a clinical setting where atelectasis is likely �Unexplained fever > 38 o. C �CXR evidence of volume loss or new airspace opacity

Risk factors for atelectasis �Advanced age �Obesity �Intraperitoneal atelectasis �Prolonged anaesthesia time �NG tube placement �Smoking

Prevention of atelectasis �Cessation of smoking (6 -8 weeks before surgery) �Laporoscopic procedure �Deep breathing exercises �Mobilization �Adequate analgesia (epidural or PCA preferred) �Selective gastric decompression

Postoperative pneumonia �Hospital-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) HAP �Strep pneumonia �MS Staph aureus �H influenza �E coli �K pneumonia �Enterobacter spp. �Proteus spp. �Serratia marcescens

Pathogens causing late onset (>5 days) HAP �Pseudomonas aeruginosa �MDR K pneumonia �Acinetobacter spp

HAP: clinical definition �New opacity on CXR( PA and lat views preferred) plus 2 of the following: �Fever >38 o. C �Leukocytosis or leukopenia �Purulent respiratory secretions �Diagnosis should be supported by sample of lower resp tract secretions-bronchoscopy

HAP treatment �Initial therapy should be given IV �Combination therapy for those at risk of MDR pathogens �Monotherapy for those at low risk of MDR

Respiratory failure �Def: inability to maintain normal tissue oxygen transport or the normal excretion of carbon dioxide �Arterial PO 2 < 60 mm. Hg or arterial PCO 2 > 45 mm. Hg generally indicate significant respiratory compromise �Generally managed in ICU including endotracheal intubation

Postoperative care of the urinary bladder �Most 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 used � 7 -10 days postop postvoid residuals are evaluated �If >100 ml catheterization duration is extended �Once residuals are less than 100 ml on 2 successive voidings of >200 ml catheters can be removed

Postoperative GIT managenent �Advancing of diets should be individualized �Patients with uncomplicated surgery may be given a regular diet on the 1 st 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