PRE-OPERATIVE & POST- OPERATIVE CARE Begashaw M (MD)

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 auscultation

c. Input and output monitoring

d. Checking for bladder & abdominal distention

e. Potent analgesics for pain relief

On subsequent post-operative days

a. Oral intake can be started

b. Patients encouraged to ambulate

Post Op Complications

General Immediate

1. Primary hemorrhage

2. Reactive hemorrhage

3. Basal Atelectasis

4. Minor lung collapse

5. Shock

6. Blood loss

7. MI, Pulmonary Embolism

8. Low Urine Output

Cardiac complications

1. Abnormal ECG

2. Acute MI

3. Arrhythmia

4. 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 features

A 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 calf

Clinical 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. Atelectasis

2. Aspiration pneumonitis/Pneumonia

3. Pulmonary edema

4. Pneumonia

5. 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 hours

Clinical features Abdominal distention Absent bowel sounds Generalized tympanicity on percussion

Investigation Plain x-ray-generalized dilatation and gaseous distention of the bowel

loops

Treatment 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 Pain

Mx 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 technique

Diagnosis: 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