Transcript 9 -Post-OP Management and Complicationsx

Postoperative Assessment,
Management And Complications
Supervised By : prof. S.Al-Salamah
Khaled Al-Qarni
Mansour Al-Harthi
Yazeed 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
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This tutorial composed of two topics :
▪ Post-op care
▪ Post-op surgical complications
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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
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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)
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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.
Assessment Postanesthesia
care unit (PACU)
• 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
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If the patient at risk of deterioration he need
frequent assessment.
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Risk factors for deterioration are:
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ASA grade ≥ 3
Emergency or high risk surgery.
Operation takes hours.
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Intraoperative Hx &postoperative
instructions:
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Past medical Hx
Medications
Allergies
Intraoperative complications
Postoperative instructions
Recommended Rx & prophylaxis
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Respiratory assessment status:
O2 saturation.
Effort of breathing ..
Respiratory rate.
Trachea central or not.
Symmetry of inspiration and expiration.
Breath sounds.
 Percussion.
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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
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Mental status assessment:
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Patient conscious and normally
responsive?(AVPU: Alert,respond for Verbal &
Painful stimuli,unresponsive)
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Finally RECORD any significant
symptoms (e.g. chest pain,
breathlessness) Pain and pain adequacy
control.
1. Education ( + family)
2. Prescriptions
3. Follow up
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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).
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Local Anasthesia:
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Injection site:
Pain, haematoma, Nerve trauma, infection
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Vasoconstrictors:
( C.I in nose , fingers , penis , scrotum , ears ,
toes ) it may lead to ischemic necrosis
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Systemic effects of LA agent: Allergic
reactions, toxicity
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SPINAL, EPIDURAL & CAUDAL ANESTESIA:
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Technical failure
Headache due to loss of CSF
Intrathecal bleeding
Permanent N. or spinal cord damage
Paraspinal infection
Severe hypotension
Urinary retention
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General Anasthesia :
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Direct trauma to mouth or pharynx.
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Slow recovery from anesthesia due to drug
interactions OR in-appropriate choice of
drugs or dosage.
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Hypothermia due to long operations with
extensive fluid replacement OR cold blood
transfusion.
Malignant hyperthermia!!
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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 & rhabdomyolysis
Treatment :
Discontinue the anesthesia then wrapping the patient in a cooling blanket
cangeneral help reduce fever
Benzodiazepine
Then >>>((dantrolene))
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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 hemorrhage
Basal 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
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A- primary Hemorrhage :
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Inadequate hemostasis.
Unrecognized damage to blood vessels.
Defective vascular anastomosis.
Clotting factor deficiency.
Intraoperative anticoagulants
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Early recognition & management
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Surgical re-exploration is usually required
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B-secondary hemorrhage:
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Usually Related to infection.
Treatment
traet the Underlying cause ( infection)
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Note: the DR said that the infection is related to tertiary
hemorrhage not 2ndry !!!!
1- Infection:
Classification
1.
Superficial(skin and SC tissue)
2.
deep(fascia and muscle )
3.
space (anatomical space and organ)
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Causes
It based on the site of operation
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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 antibiotic
2.
Deep >>> surgical debridement with systemic antibiotic
3.
Space >>> CT scan guided percutaneous drainage and may need open drainage
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2-Hematoma
Localized collection of blood.
Treatment :
Small hematoma : spontaneously absorbed
Large hematoma : may required drainage
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3-Seroma
Localized collection of serous fluid.
Common sites : breast and abdominal surgery
Treatment
Small seroma : spontaneously absorbed
Large seroma : may required drainage
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4-incisional hernia
10 %
Risk Factors: chronic cough , and causes of
Increase abdominal pressure like lifting
Heavy object …etc
Treatment :
Herniorrhaphy
Hernioplasty ( with mesh)
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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.
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A hollow latex blanket covers the patient and hot air
is forced through it.
 It can be used before, during or after the operation
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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:
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Pneumonia
Atelectasis
Wound Infections
UTI
Deep vein thrombosis\Pulmonary embolism
Abscess
Medication
• Within 48 Hours
- Usually Atelectasis
• After 48 Hours
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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
• Regular work up includes:
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CBC
Blood cultures
Urine analysis and urine cultures
CXR
Sputum cultures
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Could be life threatening
Incidence is reduced by preparation and correction
of any existing cardiac condition pre-operatively.
It includes:
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MI
Arrhythmia
DVT
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
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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.
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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.
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Symptoms:
Dyspnea, fever, tachypnea and
hemoptysis.
Investigations:
-ABG, CT angiogram, Pulmonary
angiogram [Gold Standard].
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Treatment:
-Stable Patient: Low molecular
weight heparin or a green field filter.
-Unstable Patient: Thrombolytic
therapy, pulmonary artery
embolectomy or catheter suction
embolectomy.
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Prophylactic measures for
DVT\PE:
Preoperative heparin.
Elastic stockings.
Early ambulation.
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Atelectasis [Most common]
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Collapse of the alveoli.
Occurs within the first 48 hours post op.
Affects 25% of patients who have abdominal surgery.
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Risk Factors:
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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
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It is pneumonia after aspiration of gastric contents.
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Risk Factors:
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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).
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Risk Factors:
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Prolonged ventilation support, peritoneal infection, atelectasis and
aspiration.
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Signs\Symptoms:
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Fever, tachypnea, increased secretions and signs of pulmonary
consolidation.
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Investigations:
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Sputum culture and CXR showing consolidation.
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Treatment:
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Antibiotics and clearing the airway of secretions.
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May follow insertion of a subclavian catheter, positive pressure
ventilation or after an operation which has damaged the pleura.
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Symptoms\Signs:
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Pleuritic chest pain, dyspnea, tachycardia and hyper-resonant lungs.
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Investigations:
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CXR and ABG.
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Treatment:
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Thoracostomy tube.
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Cerebrovascular Accident:
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Risk factors:
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Advanced age and atherosclerosis.
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Symptoms\Signs:
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Aphasia, motor and sensory deficits usually lateralizing.
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Investigations:
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Head CT
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Treatment:
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Aspirin and heparin if feasible.
Thrombolytic therapy is usually NOT an option after surgery.
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Urinary Retention:
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Enlarged bladder from spinal anesthesia or medication.
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Symptoms\Signs:
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Palpable bladder and inability to void.
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Treatment:
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Foley catheter.
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Risk Factors:
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Urinary retention, preexisting contamination of urine and
instrumentation.
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Symptoms\Signs:
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Cystitis: Dysuria and mild fever.
Pyelonephritis: High fever, flank tenderness and ileus.
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Diagnosis:
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Urine examination and cultures.
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Treatment:
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Hydration, proper drainage of the bladder and antibiotics.
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Postoperative ileus:
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It is an obstruction due to paralysis of the bowel.
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Risk factors:
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Hypokalemia, narcotics and GI surgery.
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Symptoms and signs:
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Constipation, abdominal pain, absent bowel sounds and bowl
distention with gases on AXR.
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Treatment:
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Supportive until motility returns (usually within 3-5 days).
Paralytic Ileus
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It is an antibiotic associated diarrhea usually caused by clindamycin.
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Symptoms\Signs:
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Diarrhea, fever, hypotension and tachycardia.
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Diagnosis:
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C.difficile toxin in stool, fecal WBCs and mucus membranes in the
lumen of the colon
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Treatment:
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Metronidazole orally or IV.
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Fistula from GI tract to the skin.
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Causes:
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Anastomotic leak, trauma\injury, infection , etc.
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Investigations:
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CT, fistulagram.
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Treatment:
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NPO, total parenteral nutrition, half will resolve spontaneously, but the
other half will require resection of the involved bowel segment.
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Drug Induced
ICU Psychosis
Neuropsychiatric Complications
Operative Nerve Injuries
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Late Complications :
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Wound:
Hypertrophic scar, keloid, wound sinus,
dermoids, incisional hernia
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Adhesions:
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Altered anatomy/Pathophysiology:
implantation
Intestinal obstruction, strangulation
Bacterial overgrowth, short gut syndrome, postgastric surgery
syndromes, etc.
 Susceptibility to other diseases:
Malabsorption, incidence of cancer, tuberculosis, etc.