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Postoperative care.pptx
Postoperative care aims to ensure a quick, safe recovery for patients, focusing on monitoring, pain management, and prevention of complications. The document outlines key aspects of care, including patient monitoring, positioning, nutrition, and medication administration, as well as complications categorized by time after surgery. Careful attention to the specific needs of surgical patients, including potential complications and their management, is essential for improving patient outcomes.
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Postoperative care.pptx
- 1. POSTOPERATIVE CARE DR. AZAN RID HOUSEOFFICER SURGICAL UNIT-II (GMMMC TEACHING HOSPITAL SUKKUR)
- 2. Introduction The aimof postoperative care is to provide the patient with as quick, painless and safe a recovery from surgery as possible. Postoperative care is a critical phase due to the following reasons; o Optimizing patient recovery o Preventing complications o Pain management o Wound care o Reducing hospital stay o Improving patient outcomes o Patient education o Emotional support o Rehabilitation o Quality of life
- 4. Phases POST-ANESTHETIC Immediate • PHASE I HOSPITALSTAY Intermediate • PHASE II AFTER DISCHARGE TO FULL RECOVERY Convalescent
- 5. Immediate postoperative period All patients undergoing major surgery initially monitored in the post anesthetic recovery room under direct supervision of specially trained personnel.
- 6. Care during thisperiod Monitoring of the patient: 1. Basic noninvasive monitoring: Pulse, BP, temperature, R/R, oxygen saturation, urine output and ECG. 2. Additional invasive monitoring (in CCU): • Central venous pressure (CVP) • Arterial blood gas (ABG) • Pulmonary artery wedge pressure (PAWP) 3. Fluid balance (monitoring): • Record fluid loss • NG suction • Drain tube • Catheter • Stoma output • Maintenance of input-output chart strictly
- 7. 4) Others: Dependingon the nature of operation. E.g., Neurosurgery patients. • Level of consciousness • ICP should be monitored
- 8. Positioning ofthe bed and mobilization • Patient should be turned from side to side in every 30 minutes until conscious, then hourly for 8-12 hours. To minimize atelectasis. • Early ambulation and intermediate compression of calf by pneumatic device to minimize DVT. Diet Type of diet depends upon the type of operation. Drain tube The drain tube should be examined frequently to assess the bleeding and fistula.
- 9. Respiratory care •Patients who are not intubated- should be encouraged to take deep breath to prevent atelectasis, supplementation of O2 by mask. • Patients who are intubated- Give mechanical ventilation (if needed). Medications • Adequate analgesia • Appropriate antibiotics • Sedatives • H2 blockers • Antipyretics etc.
- 10. The patientcan be discharged from postanesthetic care unit when they fulfil the following criteria: • Patient is fully conscious. • Respiration and oxygenation are satisfactory. • Patient is normothermic, not in pain and not nauseous. • Cardiovascular parameters are stable. • Oxygen, fluids and analgesics have been prescribed. • There are no concerns related to the surgical procedure.
- 12. Classification of Postoperative complications Based on time after surgery. • Immediate (Within 6hr of procedure) • Early (6-72hr) • Late (>72hr)
- 13. General Postoperative Complications Bleeding Deep vein thrombosis Pulmonary embolus Fever Wound dehiscence Pressure sores
- 14. Bleeding Common inthe immediate postoperative period. It may be arterial, venous or from any coagulopathy. If hemorrhage is suspected, blood samples should be taken for CBC, coagulation profile and cross match. A large bore IV cannula should be sited, and fluid resuscitation commenced. If the source of bleeding is in doubt and the patient is stable an U/S or CT Scan is required. If the cardiovascular system is unstable patient should be taken back to OT immediately.
- 15. Treatment ofhemorrhage is to stop the bleeding and supportive management. Supportive management includes oxygen and fluid resuscitation. It may require correction of coagulopathy. The decision about when to transfuse should be based on individual patient; in general; however, the accepted transfusion trigger is 75 g/L except in the presence of known or suspected coronary artery disease when a higher trigger is acceptable.
- 16. Deep vein thrombosis Thesymptoms and signs of DVT include calf pain, swelling, warmth, redness and engorged veins. On palpation the muscle may be tender and there may be a positive Homans sign (calf pain on dorsiflexion of foot), but this test is neither sensitive nor specific.
- 17. Duplex dopplerultrasound and venography can be used to assess flow and the presence of a thrombosis. If a significant DVT is found (one that extends above the knee), treatment with parenteral anticoagulation initially, followed by long-term warfarin or new anticoagulant. In some patients with large DVT, a caval filter may be required to decrease the possibility of pulmonary embolism.
- 18. Pulmonary embolism PEtypically occurs on PO day 7 in elderly or immobilized patients. Thrombus can arise from DVT in the legs/pelvis, venae cava or right atrium. Pain is pleuritic, of sudden onset and is accompanied by SOB. The patient is anxious, diaphoretic and tachycardia with prominent distended veins in the neck and forehead. The gold standard pulmonary angiogram is rarely done, spiral CT, often with help of IV contrast is the standard diagnostic test. After confirming the diagnosis, start treatment with heparinization.
- 19. Fever 40% patientsdevelop fever after major surgery. Malignant hyperthermia develops shortly after the onset of anesthetic (halothane or succinylcholine. Temperature exceeds 104 F with metabolic acidosis and hypercalcemia. Treat with IV dantrolene, 100% oxygen, correction of acidosis and cooling blankets. The causes of raised temperature postoperatively include: o Day 2-5: Atelectasis of lungs. o Day 3-5: Superficial and deep wound infection. o Day 5: Chest infection, UTI, thrombophlebitis. o >5 days: Wound infection, anastomic leakage, abscess.
- 20. Wound dehiscence Wounddehiscence is disruption of any or all the layers in a wound. Most commonly occurs from the fifth to eighth postoperative day when the strength of the wound is at its weakest. Evisceration is a catastrophic complication of wound dehiscence, where the skin itself opens and the abdominal contents rush out. It happens when patient coughs, strains or get out of bed. The patient must be kept in bed, and the bowel covered with large sterile dressings soaked with warm saline. Emergency abdominal closure is required.
- 22. Management Ensure thereis IV access Give IV antibiotics Superficial o Continue regular wound lavage and dressing. o For large defects consider vacuum assisted lavage. Full thickness: o Resuturing the defect in theatre may be appropriate. o In some cases (e.g., presence of infection) the wound should be allowed to form a chronic wound and close by secondary intention.
- 23. Pressure sores Pressuresores occur because of friction or persisting pressure on soft tissues. Risk factors are poor nutritional status, dehydration and lack of mobility and nerve block anesthesia technique. Early mobilization prevents pressure sores. High risk patients may be nursed on an air mattress, which automatically relives the pressure areas. Surgical management: Exploration, debridement of devitalized and scarred soft tissue. Vacuum assisted closure.
- 24. Staging Stage 1:Non-blanchable erythema, without breach in the epidermis. Stage 2: Partial thickness skin loss involving epidermis and dermis. Stage 3: Full thickness skin loss extending into subcutaneous tissue but not through underlying fascia. Stage 4: Full thickness skin loss through fascia with extensive tissue destruction, may be involving muscle, bone, joint or tendon.
- 25. System-specific Postoperative complications Respiratorysystem - Atelectasis - Pneumonia - Pleural effusion - Pneumothorax
- 26. Cardiovascular system •Immediate cardiovascular complications - Hypotension - Hypertension - Myocardial ischemia - Arrhythmias - Stroke • Early and late cardiovascular complications - MI - CHF - Arrhythmias - Stroke Renal and Urinary System • Acute Kidney Injury • Urinary retention • Urinary infection
- 27. Central nervous system Postoperative delirium Stroke Seizures
- 28. Surgery-specific complications Abdominalsurgery Paralytic ileus • Expected in first few days after abdominal surgery. • Presents with nausea, vomiting, loss of appetite, bowel distension and absence of flatus or bowel movements but there is no pain. • Bowel sounds are absent. • Paralytic ileus is prolonged by hypokalemia. • Treatment: Supportive with maintenance of adequate hydration and electrolyte levels. • Return of function of the intestine occurs in the following order: small bowel, large bowel and then stomach.
- 29. Localized infection • Presentswith persistent abdominal pain, focal tenderness and a spiking fever. • Prolonged ileus. • CBC may show neutrophilic leukocytosis with positive blood cultures. • Investigations: CBC, U/S abdomen or CT scan of abdomen.
- 30. Orthopedic surgery Compartmentsyndrome Raised pressure in an osteofascial compartment can prevent adequate tissue perfusion and present after surgery. • Presents with pain out of proportion. • Paralysis and paresthesia. • Pallor and pulselessness. Management: Circumferential casts split, dressing cut down to skin and limb elevated.
- 31. Neck surgery •Accumulation of blood in the wound, which may cause rapid asphyxia. • Damage to the recurrent laryngeal nerve, which can produce voice change. Thoracic surgery • Susceptible to fluid overload in the first 24-48hr postoperatively. • Chest drains require regular review. • If the fluid in a chest drain swings, then the drain has been correctly inserted into the pleural cavity. • If the chest drain continues to bubble, then a bronchopleural fistula probably exists • Hemothorax is prolonged loss of blood. • Pleural effusion is prolonged loss of fluid. • Cardiac patients require continuous ECG monitoring postoperatively.
- 32. Neurosurgery • Risein intracranial pressure may be signaled by a deterioration in the state of consciousness as well as neurological signs. Vascular surgery • The patency of grafts and anastomosis needs to be checked by regular clinical assessment of the limbs and by doppler ultrasound. Plastic surgery • The viability of flaps is crucial, and the perfusion needs to be monitored regularly. Urology • Catheter patency must be checked regularly following urological surgery.
- 33. General Postoperative Problemsand their management Nausea and Vomiting Hypothermia and shivering Drains Wound care
- 34. Nausea and Vomiting Postoperative nausea and vomiting (PONV) can delay recovery and prolong length of stay. They can lead to serious complications including aspiration pneumonia, precipitation of bleeding and dehiscence of wounds. Risk factors: Female gender, non-smoking, and a history of PONV, motions sickness or migraine and use of volatile anesthetic agents. Treatment: o Treatment of pain, anxiety, hypotension and dehydration. o Antiemetics prophylactically and for treatment.
- 35. Hypothermia and Shivering Anesthesia induces loss of thermoregulatory control. Exposure of skin and organs to a cold operating environment, antiseptic skin preparation (that cools by evaporation), and infusion of cold IV fluids all lead to hypothermia and shivering. Active warming device should be used to treat hypothermia.
- 36. Drains Drains areused to prevent accumulations of blood, serosanguinous or purulent fluid or to allow the early diagnosis of a leaking surgical anastomosis. The complications of drains include trauma to surrounding tissues and infection. The quantity and character of drain fluid can be used to identify an abdominal complication such as fluid leakage (e.g., bile or pancreatic fluid) or bleeding. Drains should be removed as soon as possible and certainly once drainage has stopped or become less than 25mL/day.
- 37. Wound care Withinhours of the wound being closed, the dead space fills up with inflammatory exudate. Within 48 hours of closure a layer of epidermal cells from wound edge bridges the gap. Consequently, sterile dressing applied in the operation theatre should not be removed before this time. If the wound is inflamed, a wound swab can be taken and sent for microbiological examination. Skin sutures or clips are usually removed between 6 and 10 days after surgery. Wound healing is delayed in patients who are malnourished or have vitamin A and C deficiency. Steroids also inhibit wound healing. Poorly controlled diabetes delays wound healing and increases risk of surgical site infection.
- 38.