Postoperative period

is a time from the end of surgery to the patients recovery.

The main objectives of the postoperative period are:

prevention and treatment of postoperative complications; acceleration of regeneration in tissues and organs; restoration of the patients work capability.

Many aggressive factors affect the body during surgery:

psychic trauma, anesthesia, pain, cooling of the body, forced position on the operating table and in the postoperative period, blood loss, trauma of tissues and so on.

The reactive changes in the body

disturbance of carbohydrate metabolism in the form of hyperglycemia and glycosuria (minor surgical diabetes); disturbance of protein metabolism manifested as high level of residual nitrogen and hypoproteinemia, negative nitrous balance in the first 5-7 days; disturbance of water-electrolyte balance associated with dehydration of body tissues due to higher body temperature, accelerated respiratory movements, increased sweating, surgical bleeding;

The reactive changes in the body

change of blood formula due to increased leucocytes count (the bodys response to the absorption of protein waste products in the surgical area, to the penetration of microorganisms into the wound), decreased erythrocyte count and decreased hemoglobin amount (associated with blood loss during surgery) decreased thrombocyte count.

Control of central nervous system

clinical

observation of the patients mental state, neurological symptoms, body temperature.

Control of respiratory organs

clinical

observation of the respiratory depth, rate, rhythm and volume, cyanosis of skin and visible mucous membranes, patency of bronchi and condition of lungs (percussion, auscultation).

Haemodynamics and myocardial function

clinical observation of peripheral and central pulse (its rate, rhythm, filling and tension); of arterial and venous blood pressure (rhythm, heart sounds, additional murmurs); of the amount of transfused and lost blood (hemoglobin, erythrocytes, hematocrit of peripheral blood).

Metabolic processes
observation

of the intake of fluid and its excretion (registration of daily amounts); of acid-base and electrolyte balance; of biochemical changes in blood and urine.

Monitoring equipment
rate of respiratory movements, respiratory volume, respiratory minute volume, oxygen and carbon dioxide tension in peripheral blood, rate of heartbeat, arterial and central venous pressure, ECG, electroencephalography and body temperature.

Adequate analgesia is one of the main conditions for a normal postoperative period.

Narcotic analgesics (morphine, omnopone, promedol). Analgin 2-4 ml of 50% solution or intramuscularly in combination with antihistamine drugs (25 mg of suprastine or 20 mg of benadryl) or with neuroleptic drugs (2.5 mg of droperidol). Prolonged epidural analgesia.

The maximum change in water-electrolyte balance is noted on the 3rd-4th day of postoperative period. The contributing factors are vomiting, diarrhea, wound exudation, external liquid losses due to hyperpnoea or tachypnoea, hypercatabolism, temperature reaction.

The characteristic laboratory signs are hemoconcentration (increased hemoglobin level), increased level of total proteine, residual nitrogen, sodium, chlorine, potassium in blood. The amount of erythrocytes drops, the hemoglobin concentration in the erythrocyte rising, the urine density rising, too (1030-1040).

 The

rule of preventive antibiotic administration in postoperative period adds up to administering a broad spectrum antibiotic 1-6 hours before surgery and not later than 24-26 hours after it in maximum admissible doses.

The infusion media should be as follows:

10% glucose solution (with insulin per 3-4 g of dry substance) 0.9% of sodium chloride solution 7.4% of potassium chloride solution (about 100 ml) 25% magnesium sulphate (5 ml) 10% calcium chloride solution (10 ml).

Balanced electrolyte solutions (Ringers solution) are preferable.

Diet

On the second day the patient is allowed to drink (mineral water, fruit water without sugar), the volume of infusion decreases correspondingly. When peristalsis restores, usually on the 3rd day the patient is given diet 3: low fat broth, dried bread. It is important that the patient eat 6-8 times a day, the volume of food per meal should not exceed 200 ml. In another day the patient is given diet 1.

Wound complications

Hemorrhage, hematoma: it is caused by a ligature slipping from the vessel or disturbance of blood clotting. Infiltrations, suppuration: caused by the presence of necrotized tissue, crude manipulations, infection. Wound disruption: abrupt slowdown of regeneration processes, cachexy. Eventration: development of suppurative infection.

Abdominal complications
Peritonitis: incompetent sutures on the walls of gastrointestinal tract, postoperative pancreatitis. Obstruction of gastrointestinal tract: paresis of gastrointestinal organs; mechanical obstacle (tightening of anastomosis, adhesions, infiltration).

Prevention and treatment of this complication are of special importance after surgery of abdominal organs. They should consist of the following components: The surgery should be as less traumatizing and prolonged as possible; during major long operations 80-100 ml of warm 0.25% Novocain solution should be introduced into the root of mesentery (mesenterial root block); Until peristalsis is restored the nasogastric tube should remain in; if paresis develops, flatus tube should be there (decompression of gastrointestinal tract).

Prevention and treatment of this complication are of special importance after surgery of abdominal organs. They should consist of the following components:

Beginning on the 1-2 postoperative day intestinal motor activity should be stimulated with drugs (0.5-1 ml of proserine 1-2-3 times a day; 0.5 ml of ubretid once a day; 2.0 of cerucal thrice a day). Disturbance of water-electrolyte balance should be taken care of in time (especially the balance of potassium and magnesium).

General complications
Shock: it is caused by intensive surgical trauma, inadequate analgesia. Hypotension: caused by adrenal insufficiency, blood loss. Thrombosis and embolism: caused by slow blood flow, increased blood clotting.

Respiratory complications

Disorder of central regulatory respiratory mechanisms occur due to 1) narcotic depression of respiratory center under the impact of anesthetic drugs, 2) considerable traumatic, hypoxic, metabolic and other damage to the brain. Prevention consists in adequate administration of anesthesia; extubation of the patient only when independent breathing has restored; observation and care of the patient in the first hours after surgery. Disorder of peripheral regulatory respiratory mechanisms is caused by residual myorelaxation occurring mostly in weak, cachectic patients. Prevention and treatment are the same.

Limitation of respiratory chest excursion and limitation of lung movement is caused by:

Bad pains, especially after chest and abdominal surgery; adequate analgesia is necessary. Obesity. Paresis of gastrointestinal tract. pneumohtorax, hydrothorax, hemothorax.
Treatment and prevention consist in eliminating the reason for limitation of chest excursion.

Obstruction of airways is caused by

Falling back of tongue and mandibular retraction in weak patients, patients in narcotic depression and medication sleep. Accumulation of blood, pus, phlegm and gastric contents in airways. bronchospasm and edema of mucous membrane. Prevention consists in atrumatic intubation, observation of the patient after surgery, stimulation of cough, respiratory exercises, percussion massage, postoperative inhalations of bronchial spasmilytics and mucolytics (saltalkaline solutions, decoctions with chamomile, eucalypt, solutan, chimopsin, aminophylline and so on).

Atelectasis.

The immediate cause may be obstruction of bronchus by phlegm, a foreign body (obturation atelectasis), compression of the lung from outside by air, blood, fluid (compression atelectasis), neural-reflex reactions with disorder of ventilation and pulmonary flow (neurogenous atalectasis).

The following measures are important in the prevention of postoperative pneumonia:

Sanation of oral cavity, fauces, upper respiratory tract especially if there were suppurative lung diseases before surgery. Adequate general anesthesia with limitation of drugs depressing respiration and epithelial fibrillation. Prevention of vomiting, regurgitation and aspiration; careful intubation and sanation of bronchial tree. Replenishing operational blood loss, elimination of hypovolemia. Adequate artificial lung ventilation during anesthesia. Proper care of the patient in the immediate postoperative period. Early mobilization of the patient.

Intensive therapy of postoperative pneumonia includes:

Respiratory exercises; oxygen therapy with warmed moistened oxygen through nasal tube; administration of drugs improving bronchial draining function and mucolytic drugs administration of antihistamines, broncholytic and corticosteroid drugs, means of aerosol inhalation therapy; stimulation of coughing, chest massage with cupping glasses, percussion and vibration; infusion therapy to maintain fluid balance; use of cardiac cocarboxylase glycosides, vitamins; artificial pulmonary ventilation in progressing pneumonia and respiratory failure; antibacterial therapy as the main component of intensive therapy of postoperative pneumonia.