Postoperative Complications PDF

Outline 1.Postoperative fever 2. Hemorrhage 3.Infection 4.Respiratory complications 5.Thromboembolism 6.Common urinary problems 7.Gastrointestinal Complications 8. Emotional disturbances  Specific post-operative complications 1.Postoperative fever Days 0-2 *Mild fever (temperature 38°C): Ate...

Outline 1.Postoperative fever 2. Hemorrhage 3.Infection 4.Respiratory complications 5.Thromboembolism 6.Common urinary problems 7.Gastrointestinal Complications 8. Emotional disturbances  Specific post-operative complications 1.Postoperative fever Days 0-2 *Mild fever (temperature 38°C): Atelectasis: the collapsed lung may become secondarily infected. Specific infections related to the surgery - e.g., biliary infection following biliary surgery, UTI ,following urological surgery. Blood transfusion or drug reaction. Bronchopneumonia, sepsis, wound infection, DVT, abscess a formation - e.g., sub phrenic or pelvic, depending on the surgery involved. 1.Postoperative fever The Five Ws of Post-op Fever 2. Hemorrhage Primary hemorrhage : (starting during surgery) or reactionary hemorrhage (following postoperative increase in blood pressure) - replace blood loss and may require return to theatre to re-explore the wound. 2. Hemorrhage Late postoperative hemorrhage : occurs several days after surgery and is usually due to infection damaging vessels at the operation site. Treat the infection and consider exploratory surgery  2. Hemorrhage Management of hemorrhage  Perform clotting screen and platelet count; ensure good intravenous (IV) access.  Place patient on shock position  Inspect wound for bleeding  Apply direct pressure using a sterile dressing pad or bandage  Elevate the bleeding part whenever possible  Blood transfusion(Order cross-matched blood).  Monitor vital signs every 15 minutes.  Sedation or narcosis may be prescribed.  Give protamine if heparin has been used. 3.Infection Infectious complications are the main causes of postoperative morbidity in abdominal surgery. Postoperative incidence has lessened with the advent of prophylactic antibiotics, but multi-resistant organisms present an increasing challenge.  3.Infection -Wound infection: the most common form is superficial wound infection occurring within the first week, presenting as localized pain, redness and slight discharge usually caused by skin staphylococci.  3.Infection Cellulitis and abscesses:  Usually occur after bowel-related surgery.  Most present within the first week but can be seen as late as the third postoperative week, even after leaving hospital.  Present with pyrexia and spreading cellulitis or abscess.  Cellulitis is treated with antibiotics.  Abscess requires suture removal and probing of the wound, but deeper abscess may require surgical re-exploration. The wound is left open in both cases to heal by secondary intention.  3.Infection Gas gangrene is uncommon and life-threatening. -Wound sinus: is a late infectious complication from a deep chronic abscess that can occur after apparently normal healing. It usually needs re- exploration to remove non-absorbable suture or mesh, which is often the underlying cause.  3.Infection *Disordered wound healing Most wounds heal without complications and healing is not impaired in the elderly unless there are specific adverse factors or complications. Factors which may affect healing rate are:  Poor blood supply.  Excess suture tension.  Long-term steroids.  Immunosuppressive therapy.  Radiotherapy.  Severe rheumatoid disease.  Malnutrition and vitamin deficiency  Types of Wound complications 1-Wound Infection (Sepsis): It occurs around 3-6 days after surgery. Manifestation of wound sepsis:  Redness, swelling, tenderness and heat in area of wound  Appearance of purulent drainage on the dressing  Increase in pulse rate and temperature  Positive laboratory examination of a specimen of wound drainage  Treatment The surgeon removes one stitch or more Irrigates and cleanse wound with sterile normal saline Order appropriate antibiotic therapy on the basis of the findings of the culture II- Wound dehiscence or wound disruption: Refers to a partial-to-complete separation of the wound edges III-Wound Evisceration: Refers to protrusion of the abdominal viscera through the incision and onto the abdominal wall.  Management:  Notify the surgeon at once  Position the client to low Fowler’s position  Instruct the client not to cough, sneeze, eat or drink, and remain quiet until the surgeon arrives  Protruding viscera should be covered with sterile dressing moisten with sterile normal saline.  4.Respiratory complications - Respiratory complications occur after major surgery, particularly after general anesthesia and can include : Atelectasis (alveolar collapse):  This is caused when airways become obstructed, usually by bronchial secretions. Most cases are mild and may go unnoticed.  Symptoms are slow recovery from operations, poor color, mild tachypnea and tachycardia. A presumed association between atelectasis and early postoperative fever has not been supported by recent studies.  Prevention is by pre-operative and postoperative physiotherapy.  In severe cases, positive pressure ventilation may be required Pneumonia: requires antibiotics, and physiotherapy. Aspiration pneumonitis:  Up to 4.5% has been reported in adults; higher in children.  Sterile inflammation of the lungs from inhaling gastric contents.  Presents with a history of vomiting or regurgitation with rapid onset of breathlessness and wheezing. A non-starved patient undergoing emergency surgery is particularly at risk.  It may be of help to avoid this by crash induction technique and use of oral antacids or metoclopramide.  Mortality is nearly 50% and requires urgent treatment with bronchial suction, positive pressure ventilation, prophylactic antibiotics and IV steroids.  Acute respiratory distress syndrome:  Rapid, shallow breathing, severe hypoxemia with scattered crepitation but no cough, chest pains or hemoptysis, appearing 24-48 hours after surgery.  it occurs in many conditions where there is direct or systemic insult to the lung - eg, multiple trauma with shock.  The complication is rare and various methods have been described to predict high-risk patients.  It requires intensive care with mechanical ventilation with positive end pressure  Medical and nursing management of pulmonary complications  Careful preoperative instruction concerning moving , coughing and breathing exercise  Adequate hydration  Lateral semi -prone positioning of the patient during recovery from general anesthesia to prevent obstruction of the air way and promote drainage of vomit.  Use of suction when necessary  Early ambulation  Avoiding exposure to persons with a respiratory infection If these complications develop the patient may need to:  Undergo bronchoscope (to remove mucus)  Postural drainage (to remove secretion)  Antibiotic therapy  Expectorants  Oxygen therapy  5.Thromboembolism - Deep vein thrombosis (DVT) and pulmonary embolism are major causes of complications and death after surgery. *DVT: Many cases are silent but present as swelling of the leg, tenderness of the calf muscle and increased warmth with calf pain on passive dorsiflexion of the foot.  Diagnosis is by: A positive Homan’s sign (pain on dorsiflexion of foot), venography or Doppler ultrasound.  Pulmonary embolism: Classically presents with sudden dyspnea and cardiovascular collapse with pleuritic chest pain, pleural rub and hemoptysis. However, smaller pulmonary emboli are more common and present with confusion, breathlessness and chest pain. Diagnosis is by: ventilation/perfusion scanning and/or pulmonary angiography or dynamic CT. Medical and nursing management thromboembolism - Prevention of thrombus formation via:  Adequate administration of fluid after operation  Early ambulation postoperatively  Leg exercises  Avoid the pillow-roll or any form of elevation that will cause constriction under the knee - Active treatment  Anticoagulant therapy  Bed rest and elevation of affected limb  Application of elastic compression stockings to prevent swelling and stagnation of venous blood in the legs.  6.Common urinary problems -Urinary retention: this is a common immediate postoperative complication that can often be dealt with conservatively with adequate analgesia. If this fails, catheterization may be needed, depending on surgical factors, type of anesthesia, comorbidities and local policies. -UTI: this is very common, especially in women, and may not present with typical symptoms. Treat with antibiotics and adequate fluid intake.  6.Common urinary problems -Acute kidney injury:  This may be caused by antibiotics, obstructive jaundice and surgery to the aorta.  It is often due to an episode of severe or prolonged hypotension.  Mild cases may be treated with fluid restriction until tubular function recovers. However, it is essential to differentiate it from pre-renal acute kidney injury due to hypovolemia which requires rehydration.  7.Gastrointestinal Complications -Paralytic Ileus: Refers to absence of intestinal motility caused by decreased or absence movement of the smooth muscles in the intestine. It may caused by;  Manipulation of abdominal organs during surgery  Trauma to the intestines  Reaction of the anesthesia  Electrolyte imbalance especially potassium  7.Gastrointestinal Complications Clinical findings:  Decreased or absent bowel sounds on the 2nd or 3rd day after surgery  Abdominal pain and distention  Little or no passage of flatus  Vomiting may occur. Management: NPO until peristalsis has returned as evidenced by auscultation of bowel sounds or by passing out of flatus  7.Gastrointestinal Complications -Nausea and Vomiting: Post-operative nausea and vomiting (PONV) may cause an unplanned hospital admission. Strategies to prevent PONV include considering regional anesthesia, reducing the use of opioids, adequate hydration and a combination of anti-emetic drugs.  8. Emotional disturbances: Etiology: - Grief over loss of a body organ or part. - Disturbances of body image. - Exhaustion and extreme debilitation. Symptoms: - Insomnia. - Agitation - Restlessness. - - Suicidal thoughts.