Postoperative care and

complications

By

Tumwebaze Richard
Magale Ivan
Overview
• This tutorial composed of two topics :
• Post-op care
• Post-op surgical complications
Objective
1. Discuss the postoperative care and its complications
2. Understand the principles of patient management in the
recovery phase immediately after surgery
3. Understand the general management of the surgical patient
in the ward
4. Consider the initial management of common acute
complications .
 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 :

To provide the patient with as quick, painless and safe recovery from surgery as possible
promote healing of the surgical incision and return the patient to a state of health
Classification of postoperative care
Post op care has 3 phases:
1. Immediate post-op care (Recovery phase)

2. Care in the ward

3. Continued care after discharge from the hospital

Immediate postoperative care
• Place: Recovery area
• What is done: one to one nursing and continuous monitoring which
includes the following:
Ensure airway
breathing
 circulation are satisfactory (ABC)
Monitor pain
• Watch for complications (e.g. bleeding)
• Monitor blood pressure, pulse and oxygen saturation
Materials: Monitoring charts which reassure the nurse that patient is
recovering or warn that some complications are developing
Cont…..
• Sometimes there are special aspects of monitoring that are
written in the postoperative notes to be closely monitored by
nurse postoperatively.
• Target; once patient is fully conscious and comfortable with
stable vital functions, they are then transferred to general
ward.
• However, if patient’s condition detoriates instead of improving
(recovering), they are instead transferred to HDU or ICU.
 Care on return surgical ward
• Medical staff should visit patients on ward at least every morning and
evening to ensure steady progress
• Caution: Washing hands between patients
• Method: SOAP system which ensures everything is checked and
recorded is used.
• Subjective, objective, assessment and plan(SOAP system) .
1. Subjective:
• ask the patient how they are, pain, nausea, mobility to notice first
signs of complications(anxiety, disorientation and change in
behaviour)
 2. Objective

• check patient’s chart for trends of TPR, Bp, fluid balance and any
observation recorded by nurse, medical student etc.
• Also check patient’s wound(preferably after 48hrs to prevent
contamination), skin around the dressing(redness, blistering) and pressure
areas(pressure sores)
• Specific examinations:
Bowel sounds(GIT surgery)
distal neurovascular status after orthopaedics surgery
• Review nutritional status of patient
• Review all lab results and investigations
• Review the drug chart to ensure no drugs are being continued unnecessarily
• Record the relevant findings(notes)
 Cont…
3. Assessment
• Review all information obtained under S and O and list the problems
that the patient is currently facing that need addressing
• Result: problem list
4. Plan
• Formulate and agree on a plan with the patient and the staff and record
that plan in the notes. The notes should be dated, signed and legible.
E.g if patient’s current problem is pain(pain mgt), poorly hydrated (fliud
management)
• This continues until the medical staff are convinced that patient is no
longer under threat of high risk complication (stable vitals), any
remaining medication/management can obtained as an outpatient e.g
stich removal, then they are discharged.
Discharge of patients
• Education + family, prescriptions, follow up (Review at SOPD).
• To rehabilitation centres for specialised care like physiotherapy for
orthopaedic patients.
• To home for continued recovery. Such patients need a discharge letter
detailing the postoperative plan for the patient. completed by the house
surgeon and contains the final diagnosis, treatment, complications that
may have occurred, advice for referral back to hospital, indications for
re-admission, subsequent care plan, follow up arrangements.

Concept of fast track surgery or Enhanced Recovery After Surgery (ERAS).

Multimodal comprehensive program aimed at enhancing postoperative
recovery and outcome. Involves preoperative patient education, pre
operative prophylaxis, improved anaesthesia, adoption of modern
surgical principles and techniques, optimised dynamic pain relief (PCA),
early ambulation and early oral nutritional supplementation.
Postoperative 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
 Classification of postoperative
complications

Complications may be :
1. Due to Anesthesia
2. Due to Surgery
3. General complications
4. Specific complications
5. Classification according to time of onset
General post op complications
1. Haemorrhage: my be internal or external, early or delayed
Reason of post op bleeding:
a. Poor surgical technique
b. Coagulation problem:- causes
 Thrombocytopenia(after over transfusion of stored blood)
 DIC
 Mild coagulations defects(underlying medical condition)
2. Thrombo-embolic events
3. Wound infection
4. Haematoma formation and seromas
5. Respiratory complication :post op respiratory failure
6. GIT complications: nausea and vomiting.
7. Renal complications: oliguria and ARF
General complications &management
1. Nausea and Vomiting (antiemetic e.g. IM prochlorperazine 12.5mg)
2. Trauma while passing NG tube, tracheal tube, catheter
3. Damage to teeth while passing a laryngoscope
4. Damage to eyes (corneal ulceration)
5. Headache due to spinal anaesthesia resulting from CSF
leakage(analgesic)
6. Vascular complication and nerve injuries
7. Pain(analgesics following the analgesic ladder)
8. Pressure sores (Prevent, turning in bed, unconscious-turned ever 30
mins, air filter mattress, early mobilisation)
9. Wound dehiscence (Re-suturing, dressing, antibiotics)
10. Confusional state(anxiolytics and other CNS drugs)
General complications continued
• Fever: mainly due to inflammatory response to trauma(80%) not necessarily
due sepsis(20%)
Causes of postoperative pyrexia include:
• 2-5 days: lung atelectasis
• 3-5days: superficial and deep wound infection
• Day 5 : chest infection, UTI, thrombophlebitis
• Beyond 5days: wound infections, anastomotic leakages, intracavitary
collections and abscesses
Other causes of postoperative pyrexia
Infected IV cannula sites, DVT, transfusion reactions, wound hematomas and drug
reactions
Management of postoperative fever
Investigations: CBC, Urine C&S, blood culture, chest radiography,
Treatment: Antipyretics, result specific
 Specific postoperative complications
&Mgt
• Pulmonary complications
• Cardiac complications
• Renal complications
• Venous thrombosis and pulmonary embolism
Pulmonary complications

Pulmonary collapse and pulmonary infections

Pulmonary collapse
Inability to breathe deeply or cough up bronchial secretions
Clinical features
Dyspnea, reduced breath sounds, dull percussion note, tachycardia, x-ray
shows increased opacity, decreased arterial oxygen circulation
Management
Tracheal stimulation using a catheter or using 1-2mls of saline
• Bronchoscopy(suck aspirations)
• Antibiotics
• Endotracheal intubation
• Assisted ventilation
Pulmonary infections
Follow pulmonary collapse or aspiration of gastric contents.
Clinical features
Pyrexia, green sputum, basal crepitations, bronchial breathing,
patchy fluffy opacities on X-ray.
Management
• Antibiotics especially against strep. Pneumonae
• Bronchoscopy (suck aspirations)
• Encourage patient to cough
Postoperative renal complications
Due to inadequate perfusion, sepsis, transfusion reactions
associated with surgery.
Clinical features
Oliguria, elevated serum urea, creatinine and electrolytes
Prevention
Adequate fluid replacement(40ml/hr), monitor urine out put, early
detection of infections.
Management
• Replace observed fluid loss
• Dietary restriction to protein
• Haemodialysis
 Venous thrombosis and pulmonary embolism
DVT
Prevention;
Avoid compression of leg veins
Graded compression support stockings
Low dose subcutaneous heparin: 5000 units 12 hourly
Features
Usually asymptomatic
Calf tenderness
Swelling of foot or leg
Management
Immobility -48 hr bed rest , heparin , rise leg(s).
Ambulation-support stockings
Pulmonary embolism
Features; Severe chest pain, Pallor , Shock
Investigations;
Perfusion ventilation lung scan ,chest x ray, ecg
Management
• Immediate cardio pulmonary resurstation
• ,heparinisation,
• fibrinolytic agents,
• cardio pulmonary by pass,
• open pulmonary embelectomy,
• Warfarin therapy- all patients for 3-6 months
Cardiac complications
• Immediate acute cardiac failure
• Ischemic heart disease
• Valvular heart disease
• Arrhythmias
• Major surgical insults
 Classification according to time
Immediate (0-24hrs)
1. Primary hemorrhage
2. Basal atelactasis
3. Shock

Early (2days- 3weeks)

4. Fever
5. Mental state change
6. 2ndry hemorrhage
7. Wound infecton
8. Paralytic ileus
Late (Weeks –months)
9. Bowel obstruction
10. Incisonal hernia
 Late complications continued,
Wound:
Hypertrophic scar, keloid, wound sinus, implantation dermoids, incisional
hernia
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.
Q&A

Thank you
Asante
Mwebale
Mwanyala
Elakara
Eyalama
Tabon