PRE-OPERATIVE & POST-OPERATIVE CARE

PRE-OPERATIVE & POST-OPERATIVE CARE

Begashaw M (MD)

General consideration

General medical & surgical historyComplete P/E Lab:_Complete blood count_Blood typing & Rh-factor, crossmach_Urinalysis_Chest x-ray

Assessment

Cardiovascular SystemPulmonary systemRenal systemHematologic systemEndocrine system

Cardiovascular System

Heart diseasehigh-risk• chest pain, dyspnea, pretibial edema or

orthopnea• Recent history of CHF• Recent MI• Severe hypertension• DVT

Pulmonary system

High risk:• Upper airway infections• Pulmonary infections• Chronic obstructive pulmonary diseases

chronic bronchitis, emphysema, asthma Elective surgery should be postponed

Renal system

Renal function test:-history of kidney disease-diabetes mellitus-hypertension-over 60 years of age-proteinuria, casts or red cells creatinine clearance, blood urea nitrogen and

electrolyte

Haematological system

Anemiaaffects the oxygen carrying capacity of the blood Iron deficiency MegaloblasticHemolyticAplastic anemia Patients with iron deficiency anemia respond to

oral or parenteral iron therapy

Thrombocytopenia Normal platelet 150,000 to 450,000/ml Manifestations:• Petechia• Epistaxis• Menorhagia• Uncontrolled bleeding Treatment -treat the underlying cause -support with platelet transfusions & clotting factors

Diabetes mellitus poorly controlled DM -susceptible to post-operative

sepsis In type - II patients-avoid hypoglycemia not use longer acting oral hypoglycemic agents -2

days before operation Insulin dependent diabetics with good control-

sliding scaleChronic cxs - Hypertension, myocardial ischemia

which may be silent-proper workup & treatment

Thyroid disease

Elective surgery should be postponed when thyroid function is either excessive or inadequate

In Hyperthyroidism, the patient should be rendered euthyroid before surgerymay take up to 2 months with anti-thyroid medications

Post-operative care

is care given to patients after an operation in order to minimize postoperative complications

Early detection & treatment of post operative complications

Post-operative care

Aims: Comfortable, pain free recovery from operation

– Immediaterecovery room

– Intermediate ward

– Long term home

Immediate care

a. Vital sign b. Chest auscultationc. Input and output monitoringd. Checking for bladder & abdominal

distentione. Potent analgesics for pain relief

On subsequent post-operative days

a. Oral intake can be startedb. Patients encouraged to ambulate

Post Op Complications

General Immediate

1. Primary hemorrhage2. Reactive hemorrhage3. Basal Atelectasis4. Minor lung collapse5. Shock6. Blood loss7. MI, Pulmonary Embolism 8. Low Urine Output

Cardiac complications

1. Abnormal ECG2. Acute MI3. Arrhythmia4. Pulmonary embolus

Shock

Postoperative efficiency of circulation depends on blood volume, cardiac function, neurovascular tone

Shock: Excessive blood loss Third spacing Marked peripheral vasodilatations Sepsis Pain or emotional stress

Treatment

Arresting hemorrhage Restore fluid & electrolyte balance Correct cardiac dysfunction Establish adequate ventilation Control pain & relief apprehension Blood transfusion if required

Thrombophlebitis Superficial thrombophlebitis -within the first few days after operation Clinical featuresA segment of superficial saphenous vein becomes

inflamed manifested by:RednessLocalized heatSwellingTenderness

Treatment

Warm moist packs Elevation of the extremity Analgesics Anticoagulants

Thrombophlebitis of the deep veins

Occurs most often in the calfClinical features asymptomatic dull ache tender & spasm swelling of calf Dorsiflexion of the foot may elicit pain in the calf Homan’s sign

pulmonary embolism

Treatment

Elevation Application of full leg gradient pressure

elastic hose Anticoagulants Prevention: Early ambulation

Pulmonary embolism Pre-disposing factors-Pelvic surgery-Sepsis-Obesity-Malignancy History of pulmonary embolism or deep vein thrombosis 7th to 10th post-operative day cardiac or pulmonary symptoms occur abruptly

Clinical features

chest pain; severe dyspnea, cyanosis, tachycardia, hypotension or shock, restlessness and anxiety

pleuritic chest pain blood-streaked sputum, and dry cough pleural friction rub

Investigation Chest X-ray=pulmonary opacity in the periphery-

triangular in shape with the base on pleural surface, enlargement of pulmonary artery, small pleural effusion and elevated diaphragm

ECG Treatment Cardiopulmonary resuscitation measures Treatment of acid-base abnormality Treatment of shock Immediate therapy with Heparin

Respiratory complications

1. Atelectasis2. Aspiration pneumonitis/Pneumonia3. Pulmonary edema4. Pneumonia5. Respiratory failure

Atelectasis

early postoperative period-48 hrsairway collapse distal to an occlusion Predisposing factorschronic bronchitis, asthma, smoking and

respiratory infectionInadequate immediate postoperative deep

breathing and delayed ambulation

Clinical features

Fever Increased pulse , respiratory rate Cyanosis Shortness of breath Dull with absent breath sounds

Investigation and Treatment CXR - patchy opacity - mediastinal shift

Prevention and treatment stop smoking Treat chronic lung diseases Postpone elective surgery encourage sitting, early ambulation Adminster analgesics Supplemental oxygen

Pneumonia and aspiration pneumonitis

Pneumonia -atelectasis or aspiration Preexisting bronchitis Clinical features Fever Respiratory difficulty Cough becomes productive pulmonary consolidation

Chest-x-ray _diffuse patchy infiltrates or lobar consolidation Prevention and treatmentminimized by- Fasting- Naso-gastric tube decompression Treatment Deep breathing and coughing Change position Broad spectrum antibiotics

Paralytic Ileus functional intestinal obstruction usually noted within the first 48-72

hoursClinical features Abdominal distention Absent bowel sounds Generalized tympanicity on percussionInvestigation Plain x-ray-generalized dilatation and gaseous distention of the bowel

loopsTreatment NGT decompression Fluid and electrolyte balance

Post operative intestinal obstruction

Causes _Peritonitis,Peritoneal irritation, Fibrinous adhesion Clinical features between the 5th and 6th POD vomiting Crampy abdominal pain Focal typmpanicity Exaggerated bowel sounds Investigation Plain film _distension of small bowel with air fluid levels Treatment Hydration & electrolyte keet NPO NGT After 48-72 hours, reoperation

Urinary and renal complications

Urinary retention

Acute renal failure

Urinary tract infection

Urinary retention

pelvic operations spinal anesthesia PainMx encouraged to get out of bed Bladder drainage _a urethral catheter

Urinary tract infection Predisposing factor contamination of the urinary tract Catheterization Clinical presentation Fever Suprapubic or flank tenderness Nausea and vomiting Investigation Urine analysis Treatment Increase hydration Encourage activity appropriate antibiotic therapy

Wound infections

Pre disposing factors Age General health Nutritional status hygiene Malignancy Poor surgical techniqueDiagnosis: clinical Fever during the 4th to 5th POD Redness or induration

Treatment Sutures _remove wound exploration and culture drainage wound care antibiotics if systemic manifestations like

fever

Hematoma, Abscess and Seromas

may occur in the pelvis or under the fascia of abdominal rectus muscle

falling of hematocrit low-grade feverSmall hematoma or seroma _resolve

spontaneouslyUltrasonography Drainage of infected hematoma