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Postoperative care

Presenter:Noor Eliza Binti Kamaruddin


Supervisor Dr Muhd Noor Azrie Taha
• The aim of postoperative care is to provide the
patient with as quick, painless and safe
recovery from surgery as possible.
Enhanced recovery after surgery (ERAS)
-multimodal perioperative care pathways
*Maintain preop organ fx and reduce
profound stress response
Key principles of ERAS include

i) pre-op counselling
ii)pre-op nutrition
iii)avoidance of pre-op fasting
iv)carbohydrate loading up to 2 hours pre-op
v) standardized anesthetic
vi) analgesic regimens
vii)early mobilization
Components of ERAS
Post OP monitoring starts from the
post anesthetic care unit
1. Vital signs
2. Conscious level
3. Airway
4. DXT monitoring
5. Pain control
6. Input – IVD, oral
7. Output – urine & bowel, drain
Keep monitoring vitals
Maintain intake and output
Keep the patient warm
• Use warmer (Bair
Hugger) blankets
Controlling nausea and vomiting

• Common in
post-op
• IV maxolon
• IV kytril
Relieving pain and anxiety
• Epidural analgesia
• NSAIDs
-IV dynastat
-C arcoxia/celebrex
-T ponstan/ voltaren
• Psychological
support to relieve
fear and to give
support
ERAS in short
Common post op
complications
Renal complications
1) OLIGURIA (Urine output < 0.5 mL/kg/hour)
cause by – hypovolemia
-preop renal dysfunction
-preop urinary retention due to
anaes
- home diuretic use
! Investigations: RP, FBC, ultrasound bladder scan

>Management:
i) insert Foley’s catheter (if persistent oliguria)
ii) Fluid challenge with 0.5 to 1L of IV crystalloid
(if normal cardiac and renal function)
2) URINARY RETENTION
Failure to void with acute pain due to overdistended
bladder, if > 6 hours, investigate for oliguria as above

Mangement: Foley catheter insertion (if urine > 500


cc) – either “in-out”
@
short duration (24 hours) Tamsulosin 0.4 mg daily
3) Acute kidney injury
increase in serum creatinine level by 0.3mg/dL or 1.5 fold

Prerenal azotemia – decreased renal perfusion that might be secondary


to hypotension, intravascular volume contraction, or decreased effective
renal perfusion.
Mx: Fluid challenge (NS bolus of 500 mL)
a) Intrinsic renal – drug-induced acute tubular necrosis, contrast-
induced renal injury, rhabdomyolysis, acute interstitial nephritis
Mx: Treat the underlying cause
b) Postrenal causes – Obstruction of the ureters or bladder (higher risk
if dissection near the ureters – colectomy, colostomy closure or
hysterectomy), narcotic use, obstructed CBD or enlarged prostate
Mx: Percutanoues nephrostomy tube insertion – ureteral injury
Foley catheter or suprapubic catheter insertion

Strict IO charting, renal adjustment of medications, Off potassium


supplementation
Referral to medical to consider for HD if overload symptoms,
hyperkalemia, metabolic acidosis, uraemia
Thrombotic complications
• Deep venous thrombosis
SX: pain and swelling of the affected extremity distal to site of
venous obstruction
May also present as unexplained fever or leucocytosis

Risk Factor: Prolonged immobilization / ICU stay, poor functional


status

Signs: Limb edema, erythema, warmth, palpable cord or calf pain


with dorsiflexion of foot (Homan sign)

Investigations:
1. Doppler ultrasonography of the affected limb
2. If negative but strongly suspicious contrast venography

Management:
Moderate risk– suggested for unfractionated S/C heparin 5,000 units
BD / TDS
Low risk – mechanical prophylaxis / aggressive ambulation
Pulmonary embolism (PE)
SX: chest pain. shortness of breath (low O2 saturation).
Can also have mental changes, pleuritic pain, coughing
and hemoptysis

Signs: Tachypnea, tachycardia, drop in SPO2

!Investigations:
1. ECG: non specific ST segment or T wave changes
2. Chest x-ray
3. ABG
4. D-dimer assay
5. CT pulmonary angiography
Management of PE
1. Supportive measures:
- Oxygen to correct hypoxemia
- IV fluid resuscitation to maintain BP
- Referral to ICU (high risk patients)
2. Anticoagulation
- Start unfractionated heparin or low MW heparin
- Oral warfarin can be started concurrently
3. Thrombolysis
4. Surgical approach – for massive PE causing shock refractory to
anticoagulation
- transvenous embolectomy, open pulmonary embolectomy,
percutaneous removal via extracorporeal venous bypass
5. Inferior vena cava filter placement – when contraindication to
anticoagulation exists
Pulmonary complications
Dyspnea
Differential diagnosis: atelectasis, lobar collapse, pneumonia, chronic
heart failure, COPD, asthma exacerbation, pneumothorax, pulmonary
embolism, and aspiration, MI, intra-abdominal complications, systemic
sepsis, and fever
Examination: Raised JVP, abnormal breath sounds (wheezing, crackles),
asymmetry, and increased respiratory effort, reduced SPO2
Investigations: FBC, ABG, Chest X ray, ECG
Management:
a) Atelectasis: common in first 36 hours post op, presents as dyspnea
and hypoxia. Aim is tor re-expand the collapsed alveoli. Control of
post operative pain (to prevent impairment of pulmonary
mechanics), Deep breathing exercises, coughing and incentive
spirometry. Chest physiotherapy, nasotracheal suction.
b) Gastric aspiration: Acute dyspnea and fever. CXR may be initially
normal, but subsequently shows intersitial infiltrates. Therapy is
supportive, empirical antibiotics not usually given.
c) Pneumothorax: Chest tube insertion. If suspected tension
pneumothorax  immediate needle decompression through the second
intercostal space in the midclavicular line using a 14-gauge needle
should precede controlled placement of a chest tube.
Gastrointestinal complications
• Postoperative paralytic ileus
Presentation: Severe or complete constipation, persistent nausea
despite antiemetic use, intolerance of oral diet, belching,
abdominal distension with mild discomfort, and absence of flatus
Differentials: Bowel obstruction, constipation, Ogilvie syndrome,
intra-abdominal infection, and retroperitoneal bleeding.
Investigations: Upright and lateral decubitus AXR  dilated
stomach / loops of bowel
CT abdomen/pelvis with oral contrast (sensitivity 90%, specificity
100%)
Management:
Nil by mouth, intravenous fluid
Ryle’s tube insertion for decompression
Correct potassium or magnesium abnormalities
Reduce the use of opioids (can prolong ileus)
If ileus lasts > 7 days, dietician referral for TPN
Cardiovascular complications
• Post operative hypotension
In post operative patients, hypotension
 Post operative bleeding (especially day 0-2)
 sepsis
Signs: oliguria and tachycardia  Severe hypovolemia
Possible causes: Bleeding, under- resuscitation, sepsis,
anesthetics and analgesics (epidural), antihypertensive
medication served.
Investigations:
FBC to look for active bleed
GSH / GXM
Management:
Initial fluid challenge, with insertion of Foley catheter to
monitor urine output, adequate IV access
Wean down / off epidural.
Blood transfusion if sign of bleed / hypotension not resolved
with fluid resuscitation
Neurologic complications
• Initial workup
Vital signs with pulse oximetry and DXT
FBC with basic metabolic profile  hemorrhage /
infection / electrolyte disturbance
Arterial blood gas
Electrocardiogram  arrhythmias / myocardial infarction
(may need serum troponin)
CT brain  intracranial hemorrhage (patients with new
focal neurologic findings)
• PERIOPERATIVE STROKE
Acute onset of focal neurological dysfunction (unilateral
weakess / sensory or speech disorder / vertigo or
diplopia). Massive stroke can present with altered
sensorium.

Investigations: CT imaging / echocardiography / ECG /


carotid ultrasound / MRI

Management: General supportive management


- Supplemental oxygen, IV fluids, T aspirin 325 mg stat
(ischemic stroke)
- Thrombolysis may be helpful for ischemic stroke, but
needs consultation as may cause postoperative bleed
• Seizures
Causes:
- perioperative medication changes in patients with a history of seizure
- metabolic derangements including electrolyte abnormalities (new onset
seizure)
- alcohol withdrawal, hypoglycemia, fever, and drugs (e.g., imipenem)
Simiology of the seizure (general vs focal)

Investigations: electrolytes / TDM anti-epileptics / CT imaging / lumbar


puncture / EEG

Management
- Stabilization of airway, ventilation, venous access, close vital sign
monitoring
- In non-recurring seizure  correction of the underlying cause
- In recurring seizure  neurologic consultation
Loading dose of IV phenytoin 15-20 mg /kg, given in 3 divided doses
Maintenance dose of IV phenytoin 5 mg/kg/day in 3 divided doses
- In status epilepticus (>5 mins / continuous seizures without returning to
baseline mental status)
Urgent neurological consultation
Infective complications
• Generalized fever
Body temperature > 38˚C in an immunocompetent adult
Fever in the first 24 hours post op – usually due to
atelectasis
- High fever > 39 ˚C – commonly due to streptococcus or
constridial wound infection / aspiration pneumonia
Fever more than 72 hours post op:
- Wound infection
- Pneumonia
- Gastroenteritis
- Infectious colitis (C. difficile)
- Abscesses
- Peritonitis
- Urinary tract infection
- Infected prosthetic materials or catheters
- Deep venous thrombosis / thrombophlebitis
- Drug allergy / transfusion reaction
• Look for the source of infection
- Inspection of all wounds, tubes and catheter sites
- FBC, urine FEME, urine cultures, blood cultures, tracheal
aspirate cultures, chest x-ray
- Ultrasound / CT abdomen and pelvis if collection/deep
space infection is suspected
• START EMPIRICAL ANTIBIOTICS
- Can consider to start after appropriate cultures taken
- Based on the suspected site of infection
(cloxacillin for surgical site infections, augmentin for
respiratory infections, fortum or cefoperazone and flagyl
for intraabdominal collections)
- To change the choice of antibiotics based on the culture
sensitivity results
• REMOVAL OF THE SOURCE OF INFECTION
- CBD (Urinary tract infection)
- Branula (thrombophlebitis) / central venous line
• Clostridium difficile infection (CDI)
Presentation: Post operative patient having diarrhea / ileus (low
threshold for suspicion)
a) Mild: Diarrhea, minimal symptoms
b) Moderate: IV fluids needed, abdominal pain, mucus or blood in stool,
TWC 10-20K, low grade fever, colitis on colonoscopy
c) Severe: Hypotension, peritonitis, TWC > 20 K, fever> 38.5 ˚C
d) Life threatening: Perforation, toxic megacolon, ischemia, transfusion
requirement from colonic bleeding, pressor requirement
Management
 Fluid resuscitation, cessation of unnecessary antibiotics, stopping pro-
motility agents, contact isolation
 First time CDI (mild-moderate): T. metronidazole 500 mg TDS x 14
days / vancomycin 125 mg QID x 14 days
 First time CDI (severe-life threatening): oral metronidazole and oral
vancomycin (same dose), consult gastro/ID
- if intolerant orally, then IV metronidazole 500 mg TDS / IV
vancomycin 500 mg QID / vancomycin enema
 Recurrence: first time treated as initial episode, further episodes
need consultation and prolonged vancomycin
 Refractory: Total colectomy / fidaxomicin
• INTRA-ABDOMINAL ABSCESS
- Presentation: asymptomatic leukocytosis, fever, abdominal
pain/tenderness
- Per abdomen: generalized peritonitis  laparotomy with
debridement
If localized tenderness  CT abdomen/pelvic
percutaneous drainage under radiologic guidance
- Empirical antibiotics to cover enteric pathogens / anaerobes
- Antifungals to be considered if patient has underwent GI
surgery / had recent TPN / in severe sepsis
- Duration of empirical antibiotics should not exceed 4-7 days
and needs de-escalation
Surgical site infection
Symptoms : pain over the op site, erythema, pus discharge, induration, fever,
necrosis
Investigations : fbc- leukocytosis, swab c+s, pus c+s, septic workup
kiv us/ct scan based on clinical context to look for deep space infection

Prevention: Antibiotic coverage, proper dressing

Management : open the wound and allow it to drain, kiv for operative
debridement , daily dressing, escalate antibiotics accordingly/based on
culture sensitivity
Take home message
• implement ERAS
• Identify and manage post operative
complications
• Follow up patient until discharge well
from the clinic
References
1. The Washington Manual of Surgery, 7th Edition, Wolters Kluwer
2. NICE guidelines for fluid resuscitation
3. erassociety.org