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

Overview
This

tutorial composed of two topics :

Post-op care
Post-op surgical complications

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

Discharge from the theatre

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 , antiemetic , thromboprophylaxis)

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

Assessment Postanesthesia
care unit (PACU)

If the patient at risk of deterioration

he need frequent assessment.

Risk factors for deterioration are:

ASA grade 3
Emergency or high risk surgery.
Operation takes hours.

Check list for 1st

postoperative assessment
Intraoperative

Hx &postoperative

instructions:
Past

medical Hx
Medications
Allergies
Intraoperative complications
Postoperative instructions
Recommended Rx & prophylaxis

Check list for 1st

postoperative assessment
Respiratory
O2

assessment status:

saturation.
Effort of breathing ..
Respiratory rate.
Trachea central or not.
Symmetry of inspiration and
expiration.
Breath sounds.
Percussion.

Check list for 1st

postoperative assessment
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

Check list for 1st

postoperative assessment
Mental

status assessment:

Patient

conscious and normally

responsive?(AVPU: Alert,respond for
Verbal & Painful stimuli,unresponsive)

Finally

RECORD any significant

symptoms (e.g. chest pain,
breathlessness) Pain and pain
adequacy control.

:After Discharge Care

1. Education ( + family)
2. Prescriptions
3. Follow up

Post-op Surgical Complications

General risk factors

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).

 Local

Anasthesia:

Injection site:
Pain, haematoma, Nerve trauma, infection

Vasoconstrictors:
( C.I in nose , fingers , penis , scrotum , ears ,
toes ) it may lead to ischemic necrosis

Systemic effects of LA agent: Allergic

reactions, toxicity

 SPINAL,

EPIDURAL & CAUDAL

ANESTESIA:

Technical failure
Headache due to loss of CSF
Intrathecal bleeding
Permanent N. or spinal cord damage
Paraspinal infection
Severe hypotension
Urinary retention

General Anasthesia :

Direct trauma to mouth or pharynx.

Slow recovery from anesthesia due to drug

interactions OR in-appropriate choice of
drugs or dosage.

Hypothermia due to long operations with

extensive fluid replacement OR cold blood
transfusion.

Malignant hyperthermia!!

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))

 Allergic

agent:

reactions to the anesthetic

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

Hemorrhage

A- primary Hemorrhage :

Inadequate hemostasis.
Unrecognized damage to blood vessels.
Defective vascular anastomosis.
Clotting factor deficiency.
Intraoperative anticoagulants

Early recognition & management

Surgical re-exploration is usually required

 B-secondary

hemorrhage:

Usually Related to infection.

Treatment
traet the Underlying cause ( infection)

Note: the DR said that the infection is related to

tertiary hemorrhage not 2ndry !!!!

Wound Complications
1- Infection:
Classification
1.
Superficial(skin and SC tissue)
2.
deep(fascia and muscle )
3.
space (anatomical space and organ)

Causes
It based on the site of operation
.
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

Wound Complications

2-Hematoma

Localized collection of blood.

Treatment :
Small hematoma : spontaneously absorbed
Large hematoma : may required drainage

 3-Seroma
Localized collection of serous fluid.
Common sites : breast and abdominal surgery
Treatment
Small seroma : spontaneously absorbed
Large seroma : may required drainage

4-incisional hernia
10 %
Risk Factors: chronic cough , and causes of
Increase abdominal pressure like lifting
Heavy object etc
Treatment :
Herniorrhaphy
Hernioplasty ( with mesh)

Hypothermia

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.

Forced Air Warming

A hollow latex blanket covers the patient

and hot air is forced through it.
It can be used before, during or after the
operation

Postoperative Fever

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:

Pneumonia
Atelectasis
Wound Infections
UTI
Deep vein thrombosis\Pulmonary embolism
Abscess
Medication

Postoperative Fever
Within 48 Hours
- Usually Atelectasis

After 48 Hours

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

Postoperative Fever
Regular work up includes:

CBC
Blood cultures
Urine analysis and urine cultures
CXR
Sputum cultures

Cardiovascular Complications

Could be life threatening

Incidence is reduced by preparation
and correction of any existing cardiac
condition pre-operatively.

It includes:

MI
Arrhythmia
DVT

MI
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

Arrhythmia
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
-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.

DVT
Risk Factors:
Advanced age
Obesity
Hormonal therapy
Immobilization
Smoking
DM\HTN
Symptoms:
- 50% are asymptomatic
-Pulmonary embolism, lower limb pain, tenderness
and swelling
Homans sign:
-Calf pain with dorsiflexion of the foot found in less
than 1\3 of patients
investigations:
-Duplex US.

Pulmonary Embolism

Symptoms:
Dyspnea, fever, tachypnea
and hemoptysis.

Investigations:
-ABG, CT angiogram, Pulmonary
angiogram [Gold Standard].

Treatment:
-Stable Patient: Low molecular
weight heparin or a green field
filter.
-Unstable Patient: Thrombolytic
therapy, pulmonary artery
embolectomy or catheter
suction embolectomy.

Prophylactic measures for

DVT\PE:
Preoperative heparin.
Elastic stockings.
Early ambulation.

Respiratory Complications

Atelectasis [Most common]

Collapse of the alveoli.

Occurs within the first 48 hours post op.
Affects 25% of patients who have abdominal surgery.

Risk Factors:

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

Aspiration Pneumonia

It is pneumonia after aspiration of gastric contents.

Risk Factors:

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).

Post-OP Pneumonia

Risk Factors:

Prolonged ventilation support, peritoneal infection,

atelectasis and aspiration.

Signs\Symptoms:

Fever, tachypnea, increased secretions and signs of

pulmonary consolidation.

Investigations:

Sputum culture and CXR showing consolidation.

Treatment:

Antibiotics and clearing the airway of secretions.

Pneumothorax

May follow insertion of a subclavian catheter,

positive pressure ventilation or after an operation
which has damaged the pleura.

Symptoms\Signs:

Pleuritic chest pain, dyspnea, tachycardia and hyperresonant lungs.

Investigations:

CXR and ABG.

Treatment:

Thoracostomy tube.

Cerebral complications

Cerebrovascular Accident:

Risk factors:

Advanced age and atherosclerosis.

Symptoms\Signs:

Aphasia, motor and sensory deficits usually

lateralizing.

Investigations:

Head CT

Treatment:

Aspirin and heparin if feasible.

Thrombolytic therapy is usually NOT an option after
surgery.

Urinary Complications

Urinary Retention:

Enlarged bladder from spinal anesthesia or

medication.

Symptoms\Signs:

Palpable bladder and inability to void.

Treatment:

Foley catheter.

UTI

Risk Factors:

Urinary retention, preexisting contamination of urine

and instrumentation.

Symptoms\Signs:

Cystitis: Dysuria and mild fever.

Pyelonephritis: High fever, flank tenderness and ileus.

Diagnosis:

Urine examination and cultures.

Treatment:

Hydration, proper drainage of the bladder and

antibiotics.

GI Complications

Postoperative ileus:

It is an obstruction due to paralysis of the bowel.

Risk factors:

Hypokalemia, narcotics and GI surgery.

Symptoms and signs:

Constipation, abdominal pain, absent bowel sounds

and bowl distention with gases on AXR.

Treatment:

Supportive until motility returns (usually within 3-5

days).

Paralytic Ileus

Pseudomembranous Colitis

It is an antibiotic associated diarrhea usually caused

by clindamycin.

Symptoms\Signs:

Diarrhea, fever, hypotension and tachycardia.

Diagnosis:

C.difficile toxin in stool, fecal WBCs and mucus

membranes in the lumen of the colon

Treatment:

Metronidazole orally or IV.

Enterocutaneous Fistula

Fistula from GI tract to the skin.

Causes:

Anastomotic leak, trauma\injury, infection , etc.

Investigations:

CT, fistulagram.

Treatment:

NPO, total parenteral nutrition, half will resolve

spontaneously, but the other half will require
resection of the involved bowel segment.

Enterocutaneous Fistula

Neurologic
Drug

Induced
ICU Psychosis
Neuropsychiatric Complications
Operative Nerve Injuries

 Late Complications :

Wound:
Hypertrophic scar, keloid, wound sinus,
dermoids, incisional hernia

implantation

Adhesions:

Intestinal obstruction, strangulation

Altered anatomy/Pathophysiology:

Bacterial overgrowth, short gut syndrome, postgastric surgery

syndromes, etc.
Susceptibility to other diseases:
Malabsorption, incidence of cancer, tuberculosis, etc.

Thank You