Postoperative - MU

Postoperative Phase

• Begins at the end of surgery, when the patient is transferred to 'recovery' or 'PACU' (Post Anesthesia Care Unit).
• A 'sign out' is performed as part of the WHO checklist at the end of surgery.
• The theatre team hands over the care of the patient to the PACU staff

Information that should be provided includes:

• Patient's name and age
• Surgical procedure performed
• Anesthetic and analgesics used
• Fluid replacement, blood loss, and urine output
• Any surgical/anesthetic problems encountered or expected
• Existing medical problems and allergies
• Plan for management of pain, nausea, or vomiting

Postoperative observations monitored in the recovery room:

• Patient's vital signs (pulse, blood pressure, pulse oximetry)
• Level of consciousness
• Pain
• Hydration status
• Supportive treatment is given

National Early Warning Score (NEWS)

• Patient observations collated to provide early warning of clinical deterioration.
• Recording begins in recovery and continues until hospital discharge

Six simple physiological parameters used to calculate the score:

• Respiration rate
• Oxygen saturation
• Systolic blood pressure
• Pulse rate
• Level of consciousness (or new-onset confusion, disorientation and/or agitation)
• Temperature

Interpretation of NEWS score:

• Aggregate score 0-4: Low risk, ward-based response
• Red score (score of 3 in any individual parameter): Low-medium risk, urgent ward-based response
• Aggregate score 5-6: Medium risk, key threshold for urgent response
• Aggregate score 7 or more: High risk, urgent or emergency response

PACU Discharge Criteria

• Patient is fully conscious
• Respiration and oxygenation are satisfactory.
• The patient is normothermic, not in pain, and not nauseous
• Cardiovascular parameters are stable
• Oxygen, fluids, and analgesics have been prescribed
• There are no concerns relating to the surgical procedure

Notes

• Patients who have had complex surgery or who have severe chronic health conditions will stay for a period of 24–48 hours in the PACU or an overnight intensive recovery unit

Postoperative care in the ward includes:

• Vital signs observation
• Fluid therapy
• Analgesia
• Medications
• Gastric protection
• Thrombo-prophylaxis
• Early ambulation
• When to feed
• Care of drains
• Wound care

Classification of Postoperative Complications

• Important cause of morbidity, mortality, extended hospital stay, and increased costs.
• The Clavien-Dindo classification objectively and reproducibly measures the impact on the outcome.
• Complications are graded according to the treatment they require, eliminating subjective bias and preventing complications from being downgraded

Clavien-Dindo classification of postoperative complications:

• Grade I: Any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic, or radiological intervention. Includes drugs as antiemetics, antipyretics, analgesics, diuretics, electrolytes & physiotherapy. Includes wound infections opened at the bedside
• Grade II: Requiring pharmacological treatment with drugs other than allowed for Grade I complications, blood transfusions and total parenteral nutrition also included.
• Grade III: Requiring surgical, endoscopic, or radiological intervention.
  • Grade IIIa: Intervention not under general anaesthesia
  • Grade IIIb: Intervention under general anaesthesia.
• Grade IV: Life-threatening complication (including CNS complications, e.g. brain haemorrhage, but excluding TIAs) requiring ICU management.
  • Grade IVa: Single-organ dysfunction (including dialysis)
  • Grade IVb: Multiorgan dysfunction
• Grade V: Death of a patient

General vs Specific Complications

• General complications occur in all types of surgeries
• Specific complications are unique to a particular surgery.
  • Examples of general complications include postoperative fever, lung atelectasis, wound infection, embolism and deep vein thrombosis (DVT).
  • Colon or stomach surgery can have its own unique complications.
• Specific complications occur in the early postoperative, several days after the operation, throughout the postoperative period and in the late postoperative period.

General Postoperative Complications

• Immediate complications
  • Primary hemorrhage happens during surgery or after surgery
  • Basal atelectasis is a minor lung collapse
  • Shock is blood loss, acute myocardial infarction pulmonary embolism or Septicemia
  • Low urine output is inadequate fluid replacement intra-operatively & postoperatively
• Early complications:
  • Acute confusion is dehydration and sepsis
  • Nausea and vomiting: analgesia or anesthetic related, paralytic ileus
  • Fever
  • Secondary hemorrhage: results as a result of infection.
  • Pneumonia
  • Wound or anastomosis dehiscence.
  • DVT
  • Acute urinary retention
  • UTI
  • Postoperative wound infection.
  • Bowel obstruction is due to fibrinous adhesions.
  • Paralytic Ileus
• Late complications:
  • Bowel obstruction is due to fibrous adhesions
  • Incisional hernia
  • Persistent sinus
  • Recurrence of reason for surgery e.g. malignancy

Postoperative Complications can be related to:

• Wound
• Thermal regulation
• DVT & pulmonary embolism
• Infections & fever
• Pulmonary
• Cardiovascular
• GI
• Renal
• Neurological
• Complications of diabetes

Wound Complications

• Seroma: Collection of liquefied fat, serum, and lymphatic fluid under the incision in places where tissue has been removed with surgery
  • Diagnosis is localized well circumscribed swelling. Occasional drainage of clear yellow fluid.
  • Causes can be Damage to neighboring lymphatic vessels during surgery → leakage of serous fluid in the empty spaces → seroma formation
    • Treatment through Aspiration or Opening the wound and packing
    • Prevention techniques are Place drain during surger and use Synthetic Mesh
• Hematoma: Abnormal collection of blood usually in SC or in a potential space in abdominal cavity where there is a potential for secondary infection
  • Diagnosis: Expanding unsightly swelling, purple bluish swelling, compromise airway in neck
  • Occurs because of Inadequate hemostasis or Depletion of clotting factors and Coagulopathy
  • Treat by fixing clotting abnormalities
    • Small hematomas can be resolved by an expectant wait and watch for resorption and Large hematomas are opened in the operating theatre
• Wound Dehiscence (burst abdomen): separation of the abdominal Musculo-aponeurotic layers.
  • Mostly occurs in approx. 7-10 days by
    • Technical error in wound closure
    • Previous wound dehiscence, Emergency surgery, Wound infection, hematoma&seroma, Radiation therapy & chemotherapy, Malnutrition, Advanced age, Intra abdominal infection, Elevated intra abdominal pressure, Obesity, Chronic Corticorsteroid use, Systemic disease
  • Diagnosis - Sudden drainage of a relatively large volume of a clear fluid on probing the wound with a sterile tipped applicator or a gloved finger
    • shifts the patient to operating theatre & cover the wound with saline soaked towel and Closure with absorbable mesh to avoid tension
  • Fix by avoiding predisposing causes, use Interrupted suturing and avoid tension during suturing of fascia.
• Surgical Site Infection Surgical wound includes the area of the body, both internally and externally, that involves the entire operative site.
  • Types: Superficial (includes Skin & SC tissue), Deep (includes Fascia and muscle) Organ apace (The internal organs of the body if the operation includes that area)
  • Diagnosis of infection: Erythema, tenderness, edema and drainage (clinically) and Leukocytosis & Fever (laboratory)
  • Treatment is remove sutures/staples. Followed by, Drainage of the pus and IV antibiotics and Debridment Keep open/Healing by 2nd intention
  • According to the type of infection you either use IV antiobiotics or open in operating theatre
  • Prevention: Select high risk patients and give Prophylactic antibiotics, or use Intraoperative Precautions

SSI Risk Factors

• Patient factors: Ascites, Chronic inflammation, Undernutrition, Obesity, Diabetes, Extremes of age, Hypercholesterolemia, Hypoxemia, Peripheral vascular disease, Postoperative anemia, Previous site of irradiation, Recent operation, Remote infection, Skin carriage of staphylococci, Skin disease in the area of infection and Immunosuppression.
• Environmental factors: Contaminated medications, Inadequate skin antisepsis, Inadequate disinfection / sterilization and Inadequate ventilation.
• Treatment factors: Drains, Emergency procedure, Inadequate antibiotic coverage, Preoperative hospitalization and Prolonged operation.

Thermal Regulation Complications

• Hypothermia by a drop of 2°C in body temperature
  • Cool IV fluids, wash with Cool fluids , Low room temperature and Exposure of extra-operative surface.
• Malignant Hyperthermia that is gene mediated (Autosomal Dominant)
  • Diagnosis: Immediate placement of warm blankets, Covering patient head, Infusion of blood and IV fluids through a warming device, Heating and humidifying inhalational gases, Peritoneal lavage with warmed fluids.
  • Stop Stop causing anesthetic, give Dantrolene, 2.5 mg/kg as a bolus and repeat every 5 minutes &

DVT & Pulmonary Embolism

• DVT (Deep Vein Thrombosis)
  • Causes: Post operative immobilization and Prolonged bed rest Clinically, it usually occurs within 6 days post-operative. Edema, calf pain, low grade fever and Moses test (Pain with gentle squeezing of lower part of calf from side to side)

Treatment

• Conservative: Bed rest & Elevation of the limbs .

• Medical: Anticoagulants (Surgery).

• Pulmonary Embolism (B) Happens when an embolus (e.g. from DVT) suddenly gets inside a pulmonary artery

  • Clinically, there are No symptoms however Patient experiences Dyspnea, chest pain, hemoptysis, syncope, CVS collapse B) Investigations - Oxygen saturation, Chest X-Ray, ECG.
  • To Fix - Supplemental O2, Maintain vitals, Medicaly, give Anticoagulants or Surgery: Embolectomy

Risk of DVT depends on the severity of surgery

• Low Risk: Maxillofacial, neuro or Cardiothoracic Surgeries
• Medium Risk: lnguinal hernia repair, Abdominal, Gynaecological & Urological Procedures
• High Risk: Pelvic, Total Knee or hip replacement Surgeries

Stratification of Surgical Procedure

• Clinical Features: Immobilisation
• If the DVT has signs, there more than likely is a Pulmonary Embolism

Post-operative Fever can occur in 38-38.5°

• Fever can either be from non infectious or infectious causes

  • Lung Atelectasis, Infections manifest in 4–5 days, Viral, fungal.
  • Acute hepatic necrosis, Lymphoma, Myocardial infarction

• Management depends on the amount of hours that have passed since procedure

Respiratory Hypoxia vs Hypercapnia:

• Hypoxia symptoms: Tachypnea, agitation and confusion if not treated that is
• Hypercapnia symptoms: Headache, drowsiness, arrhythmia, vasodialtion

Different Respiratory Complications symptoms depends On type

Lung Complications

• Atelectasis: Most common, Low Grade Fever: Treat with Post operative Cough
• Pneumonia: Thick Sputum. Treat with IV antibiotics
• Aspiration Pneumonitis: Patient with Progressive Wheezing
• Management - Place the patient on Oxygen (face mask), diagnose with CXR & Intubate (If SpO2 is not maintained).

Pulmonary Edema

• Diagnose Acute onset of respiratory symptoms
• After Diagnose the type of Fluid with an ABG TEST.

CardioVascular Complications:

• Hypotension - caused due a low blood of 22% of Body water so Administer IV to rehydrate and check oxygenation.
• Hypertension - Too much Pain which elevates blood pressure and Causes arrhythmia and can be treated with Diuretics.

Myocardial Ischemia

• Check ECG to check for Silent Presentation, also Auscultation Heart Lung

Pulmonary Embolism

• Prophylactic low molecular weight heparin (LMWH ) 2 hours before, Encourage early ambulation & Good hydration.

GI Complications Can occur in the Post Opp Stage:

• Vomiting/Nausea occurs because the patient has high sensitivity with surgery. Treat with IV & Aggressive Pain control. The patient is likely to have Post-Operative Ileus So avoid Handling & Injury.

Post Operative Urinary Complications

• Oliguria/ Urinal Retention symptoms depend depends on the location. Administer adequate fluid hydration to increase urine.
• Administer IV to rehydrate and check oxygenation and catheterization can be placed if severe
• Anuria occurs due to renal system failures so maintain output with an maintain in order not cause renal failure.

Neurological Complications

• Pre Operative Stroke - Occurs in cardiovascular as its a Focal loss.

Diabetes Complications

• Occurs due to a over production of blood due to surgery.
• Check Serum Electrolytes. Treat with Fluid resuscitation