Podcast
Questions and Answers
What is the definition of postoperative care?
What is the definition of postoperative care?
Postoperative care refers to the combination of physical and psychosocial care given to a surgical patient after their surgery. This care is designed to help the patient recover and return to a normal state of health.
What are the three main stages of postoperative care?
What are the three main stages of postoperative care?
The three stages of postoperative care are the immediate or postanesthetic recovery period, the intermediate care period, and the convalescent period.
What is the most common pulmonary complication that affects 25% of patients who have abdominal surgery?
What is the most common pulmonary complication that affects 25% of patients who have abdominal surgery?
What are the signs of atelectasis?
What are the signs of atelectasis?
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Postoperative bleeding is usually the result of a technical problem with hemostasis.
Postoperative bleeding is usually the result of a technical problem with hemostasis.
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What is the most common cause of shock in the first 24 hours after surgery?
What is the most common cause of shock in the first 24 hours after surgery?
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Gastric dilatation is a life-threatening but rare complication where the stomach expands excessively due to the accumulation of gas and fluid.
Gastric dilatation is a life-threatening but rare complication where the stomach expands excessively due to the accumulation of gas and fluid.
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What are three predisposing factors for gastric dilatation?
What are three predisposing factors for gastric dilatation?
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What is the most common cause of complications after major surgical procedures?
What is the most common cause of complications after major surgical procedures?
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Which of the following are predisposing factors for atelectasis? (Choose all that apply)
Which of the following are predisposing factors for atelectasis? (Choose all that apply)
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How can atelectasis be prevented?
How can atelectasis be prevented?
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What is the treatment for atelectasis?
What is the treatment for atelectasis?
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Study Notes
Preoperative Care
- Preoperative care is the physical and psychosocial care preparing a patient for surgery safely
- The preoperative period begins when the patient is booked for surgery and ends with their transfer to the operating room
- Preoperative care involves a diagnostic work-up, preoperative preparation, and preoperative evaluation
Classification of Operations
- Elective operations: gastric or duodenal ulcers
- Limitative operations: cancer
- Emergent operations: rupture of the spleen
Preoperative Evaluation and Preparation
- Assess the patient's overall health
- Determine the risk of the impending surgical treatment
- Guide preoperative preparation
General Health Assessment
- Complete History: Examines present, past, and family history to identify issues that may influence surgical risk or future well-being
- Physical Exam: A rectal examination is always required
Laboratory Tests
- Routine: Urine analysis, blood count, and chest X-rays
- Specific (patients over 40): ECG and stool tests for occult blood
- Liver and Kidney Function: Tested if impairment is suspected
Factors Affecting Operational Risk
- Nonsurgical disorders frequently increase the risk of surgical procedures
- Fatal complications often relate to preexisting organic disease or deficient immune and nutritional status
Nutrition
- Malnutrition increases operative death rate
- Weight loss greater than 20% due to illness (cancer, intestinal disease) is a concern
- Inadequate nutrition has various causes
Pulmonary Dysfunction
- Hypoxia, atelectasis, pneumonia are assessed pre-op
- Evaluate respiratory impairment
- Patients with heavy smoking, cough, obesity, or known pulmonary disease are assessed pre-op.
- Chest X-ray, ECG, and blood gases are used to assess
- CO2 retention suggests severe pulmonary dysfunction (PaCO2 > 50mmHg)
Cardiovascular System
- Risk of operation in cardiac patients is increased
- Patient symptoms and contraindications are assessed
- Cardiovascular system preparation is crucial
Renal Disease
- Renal disease is less common compared to cardiovascular or respiratory issues
- Appropriate hydration helps reduce complications from major surgery
Screening for Renal Issues
- Blood urea nitrogen (BUN), creatinine, and urinalysis are screened
- Hypovolemia is the primary cause of oliguria in surgical settings, not renal failure
Strict Attention to Fluid Balance
- Maintain fluid balance to avoid nephrotoxic drugs
- Ensure free drainage of the obstructed urinary tract
- Eliminate infection
Hepatic Disease
- Risk of surgery is correlated with the patient's classification
- Cirrhosis patients require recovery of function before surgery
- Malnutrition, ascites, jaundice, and acute hepatitis are risk factors
Diabetic Disease
- All patients screened via urine exam and blood sugar testing
- Ideal management involves keeping blood sugar slightly elevated and with moderate glycosuria
- Regular insulin is often necessary
Preoperative Notes (day before surgery)
- Record pertinent findings, decisions, indications for surgery
- Discuss complications and risks of surgery
Preoperative Preparation
- Psychological Preparation: Patient cooperation is needed for understanding of procedure and risk. Surgeons are responsible for procedure description, risks, and consequences.
- Operative Permit: Signed permit for emergency life-saving procedures
- Skin Preparation: Shower or bath and immediate shaving before surgery
- Gastrointestinal Preparation: No solid food for 12 hours and no liquids for 6-8 hours. Nasogastric tube may be used. Enemas are not always necessary but might be needed for colon, rectum and anal regions.
- Fluid and Blood Volume: Pre-op hydration may be necessary for patients who are hypovolemic. Replacing blood volume and concentration deficit is done to enhance safety for anesthesia, and surgical procedures
- Nutrition: Oral administration of natural and prepared foods is best for correcting malnutrition. Nasogastric tube feeding may be required if gastrointestinal function is insufficient, specifically designed diets
- Blood Transfusions: Arrange for blood typing and sufficient units for cross-matching
- Bladder Catheter: Hourly monitoring of urine output is required during/after surgery
Postoperative Care
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Immediate Recovery Period: Immediate or post-anesthesia recovery period for patients in recovery room until stable vital signs
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Intermediate Care Period: Rest, sleep, proper nutrition, and gentle exercises are important for successful patient's return to normal.
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Convalescent Period: This is the period of recovery and convalescence that allows gradual return to normal activities and routines
Postoperative Complications & Management
- Immediate Post-op Period (In ICU): Recovery room/ICU-trained staff/equipment are necessary for acute conditions.
- Criteria for ICU Admission: Poor operative, severe respiratory/cardiovascular/renal issues, or frequent physiological monitoring needs.
- Monitoring (ICU): Vital signs, ECG, CVP, hypertension, fluid needs, cardiac arrhythmias, respiratory issues, wound bleeding, or impaired extremities circulation.
- Respiratory Care: Intubation, oxygen (mask)or prongs, tracheal suctioning, deep breathing
- Position: Patient positioned flat, on their side,or seated, elevated foot of bed as needed. Turning the patient every 1-2 hours and moving limbs helps.
- Renal/Bladder Function: Measure urine output (30 ml/hour) or in 6-8 hours after surgery
- Fluid and Electrolyte Management: No food or drinks for 6-8 hours, maintain intravenous fluids and replacement for drainage losses, and balance intake and output
- Drainage Tubes: Prevent fluid/pus build-up. Connect to suctioning. Check drainage quality. Manage necessary complications (perforation, infection, or hernia)
- Medications: Antibiotics, sedatives, pain relief. Order continuation of preoperative medications
- Special Lab Exam: Hematocrit, blood chemistry/ABG, Chest X-rays (portable)
- Wound Care: Sterile dressings, sutures
- Wound Infections: Treatment is through obtaining a sample of any pus or secretion through a needle aspiration or removing sutures for direct culture. In case of infection, wide wound opening for free drainage is needed.
Postoperative Complications (further breakdown of some complications discussed on other pages)
- Bleeding: Most common cause of shock post-surgery. Caused by technical problems with homeostasis and managed via frequent interventions to maintain stabilization
- Hematoma: Collection of blood in a wound caused by imperfect hemostasis, anticoagulants, or vigorous coughing, characterized by elevation/discoloration/discomfort/ swelling/ or skin leakage, requiring clot evacuation, ligation of bleeding vessels, and gentle compression; Neck hematoma compression of trachea is potential
- Wound Infection: Collection of pus requiring a pus or secretion sample and free drainage for treatment via frequent checkups.
- Wound Dehiscence: Partial/complete wound disruption due to malnutrition, cancer, diabetes immunosuppression, obese patients, insufficient suturing, high intra-abdominal pressure or poor healing, manifested by discharge serosanguineous /sudden evisceration, requiring rinsing and mechanical cleansing, and reclosure using sutures
- Evisceration: All layers of abdominal wall rupture with viscera extrusion, needing rinsing, placement back into abdominal cavity via mechanical actions and irrigation and suturing
Other Complication Categories: Less Common
- Respiratory Complications: Atelectasis, Pneumonia - high frequency in chest and upper abdominal surgeries, due to chronic obstructive pulmonary diseases(COPD)
- Urinary Tract Infection: Preexisting contamination/urinary retention/ instrumentation needing hydration,drainage, and antibiotic therapy.
- Alimentary Tract Complications: Post-laparotomy propulsive activity depressed. Gastric and colonic activity recovery. Postoperative ileus (slowed intestinal movement) causes abdominal distention, which is managed by early gastric tube decompression. Gastric dilatation (stomach distension) is rare but potentially fatal requiring frequent decompression to manage excessive fluid.
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