Postoperative care

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Postoperative care
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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

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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

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Postoperative orders

• Venous thrombosis prophylaxis
• Other medications

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Postoperative vascular complications

• Venous thromboembolism (VTE) includes DVT and PE
  and are a major but preventable cause of
  morbidity and mortality

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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

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Prevention of VTE

• Unfractionated heparin
• LMWH
• Graduated compression stockings
• Intermittent pneumatic compression stockings

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Risk factors of postop thrombosis

• Virchows triad hypercoagulability, stasis,
  trauma to vessels

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Diagnosis of VTE

• Venography
• Impedence plethysmography
• Doppler ultrasound
• MRI/MRI Venography

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Treatment of VTE

• UFH
• LMWH

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Postoperative pulmonary complications

• Atelectasis
• Pneumonia
• Respiratory failure
• Pulmonary thromboembolic disease

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Risk factors for PPCs

• Age gt 60 years
• Cancer
• Congestive cardiac failure
• Smoking (within 8 weeks of surgery)
• Upper abdominal incision
• Vertical incision
• Incision length gt 20cm

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Atelectasis

• Definition not uniform in clinical studies
• Generally accepted criteria include
• impaired oxygenation in a clinical setting where
  atelectasis is likely
• Unexplained fever gt 38oC
• CXR evidence of volume loss or new airspace
  opacity

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Risk factors for atelectasis

• Advanced age
• Obesity
• Intraperitoneal atelectasis
• Prolonged anaesthesia time
• NG tube placement
• Smoking

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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

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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

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Pathogens causing early onset (lt4 days) HAP

• Strep pneumonia
• MS Staph aureus
• H influenza
• E coli
• K pneumonia
• Enterobacter spp.
• Proteus spp.
• Serratia marcescens

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Pathogens causing late onset (gt5 days) HAP

• Pseudomonas aeruginosa
• MDR K pneumonia
• Acinetobacter spp

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HAP clinical definition

• New opacity on CXR( PA and lat views preferred)
  plus 2 of the following
• Fever gt38oC
• Leukocytosis or leukopenia
• Purulent respiratory secretions
• Diagnosis should be supported by sample of lower
  resp tract secretions-bronchoscopy

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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

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Respiratory failure

• Def inability to maintain normal tissue oxygen
  transport or the normal excretion of carbon
  dioxide
• Arterial PO2 lt 60 mmHg or arterial PCO2 gt 45 mmHg
  generally indicate significant respiratory
  compromise
• Generally managed in ICU including endotracheal
  intubation

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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 gt100ml catheterization duration is extended
• Once residuals are less than 100ml on 2
  successive voidings of gt200ml catheters can be
  removed

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Postoperative GIT managenent

• Advancing of diets should be individualized
• Patients with uncomplicated surgery may be given
  a regular diet on the 1st 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