The document discusses postoperative care and chest complications. It covers several key points: 1) Respiratory complications occur in up to 15% of major surgeries and can negatively impact outcomes through increased mortality, morbidity, hospitalization duration, and costs. 2) Patients face respiratory risks in the immediate postoperative period from issues like atelectasis, pulmonary edema, and respiratory failure due to changes in lung volumes and function. 3) Preventing postoperative pulmonary complications requires evaluating patient risk factors, optimizing pre- and postoperative pulmonary status through measures like smoking cessation, treating infections, and encouraging deep breathing exercises.

2. POST-OPERATIVE CARE &
CHEST COMPLICATIONS
DR.NADIR MEHMOOD
Asst professor
Department ofSurgery, RMC

3. Learning Objectives
• Accept that complications are best anticipated
and avoided.
• Recognize the incidence of co-morbidity.
• Understand the importance of matching the
procedure to the associated risks.
• Appreciate the importance of recognizing
complications early and treating them
vigorously.
• Enumerate the risk factors- Patient vs procedure
related
• Enlist Prediction tools and their efficiency
• Outline available guidelines
• Enlist preventive measures

4. The Importance of Pulmonary Complications
 Adversely affects mortality and morbidity
Increases the duration of hospitalization
Increases the need for intensive care
Increases the cost
Sweitzer BJ, Anesthesiology Clin 27 (2009); 673 – 86

5. Respiratory complications
Occur in up to 15% of general anaesthetic and
major surgery

6. Factors related to PPCs
• Patients-related risk factors
• Risk factors related to preoperative care
• Operation-related risk factors
• Anesthetic-related risk factors
• Risk factors related to postoperative care

7. PHASES
• IMMEDIATE ( POST-ANAESTHETIC ) PHASE (1)
• INTERMEDIATE ( HOSPITAL STAY ) PHASE (2)
• CONVALESCENT ( AFTER DISCHARGE TO FULL RECOVERY )

8. AIM OF PHASES 1 & 2
• HOMEOSTASIS
• TREATMENT OF PAIN
• PREVENTION & EARLY DETECTION OF
COMPLICATIONS

9. IMMEDIATE
POST-OPERATIVE PERIOD

10. CAUSES OF COMPLICATIONS & DEATH
• ACUTE PULMONARY PROBLEMS
• CARDIO-VASCULAR PROBLEMS
• FLUID DERANGEMENTS

11. The Intermediate Post-Operative
period
Starts with complete recovery from
anaesthesia and lasts for the rest of the
hospital stay.

12. Pathophysiology
• Functional residual capacity ( FRC) and vital capacity (VC)
decrease after major intra-abdominal surgery down to 40% of
the Pre-Op. Level.
• These go up slowly to 60-70% by 6th -7th day and to normal
Pre-Op. Level after that.
• FRC, VC, and Post-Op. pulmonary oedema (Post anaesthesia)
Contribute to the changes in pulmonary functions Post-Op.
• The above changes are accentuated by obesity, heavy
smoking or Pre-existing lung diseases specially in elderly.

13. • Post-Op. atelectasis is enhanced by shallow
breathing, pain, obesity and abdominal distension
(restriction of diaphragmatic movements)
• Post-Op. physiotherapy especially deep inspiration
helps to decrease atelectasis. Also O2 mask and
periodic hyperinflation using spirometer.
• Early mobilization helps a lot.
• Antibiotics and treatment of heart failure Post-Op. by
adequate management of fluids will help reduce
pulmonary oedema.

14. Respiratory pathophysiology during/after surgery
Postoperative pain
& Muscle splinting
Diaphragmatic
dysfunction due to CNS
output to phrenic nerves
Changes in lung volumes
Restrictive lung function
FRC Hypoxia
Airway closure
Atelectasis

15. Respiratory pathophysiology during/after surgery
Changes in control of breathing
Residual effects of
anesthetics
Narcotics for
analgesics
Respiratory depression
Difficulty
weaning
Hypoxia
Hypercapnia
Deep breaths
Atelectasis

16. Respiratory pathophysiology during/after surgery
Impaired lung defence
Pain
Excessive use of
analgesics
Damage to cilia
Presence of ETT
Anesthetic gases
Cough
Mucociliary clearance
AtelectasisSecretions
ColonisationInfections

17. Respiratory pathophysiology during/after surgery
Bronchoconstriction
Aspiration of gastric
contents
Exacerbation of underlying
asthma or COPD
Endotracheal intubation
or surgical stimulation
Histamine release
secondary medication
Bronchospasm

18. Independent Risk Factors
for Pulmonary Complications
• Age over 60
• History of COPD
• History of CHF
• Functional Dependence
• Tobacco cessation within past 8 weeks?
• ASA Class II or greater
• Serum Albumin < 3.5

19. ASA (American Society of Anesthesiology)
Score
1 A normal healthy person
2 Mild systemic disease
3 Systemic disease that is not incapacitating.
4 Incapacitating systemic disease that is
a threat to life
5 Moribund, not expected to survive 24 hours
with or without operation.

20. Factors associated with a
Moderate Increase in Risk
• Chronic Tobacco or Alcohol Use
• Altered Mental Status
• Weight Loss (>10% in last 6 months)
• History of CVA/stroke
• Clinical Chest Findings/Abnormal CXR
• BUN > 21
• Perioperative Transfusion
• Preoperative stay >4 days

21. No independent Risk of
Pulmonary Complications
• Obesity
• Controlled Asthma
• Diabetes Mellitus
• Obstructive Sleep
Apnea
• Chronic Steroid Use
• HIV Infection
• History of Cardiac
Arrythmias
• Poor Exercise Tolerance
• Abnormal Pre-Op
Spirometry

22. Procedure-related Risk
• Procedures lasting > 3 hours
• Emergency Surgery
• Aortic/Vascular Surgery
• Thoracic or Upper Abdominal Surgery
• Neurosurgery
• Neck Surgery
• General Anesthesia
• Use of Long-acting NM blockade
• Duration of anaesthesia
• Nasogastric intubation
• Type of surgery

23. Procedures not associated with increased
risk
• Esophageal Surgery
• Gynecologic Surgery
• Urologic Surgery
• Hip Fracture Repair
• Open vs. Laparascopic Procedures

24. Respiratory complications
• Atelectasis
• Pneumonia
• Aspiration
• Pulmonary edema
• Pulmonary embolism
• Acute respiratory depression
• Acute respiratory failure

30. ARDS

31. Postoperative Pulmonary Complications
A. Atelectasis:
– 90% postoperative pulmonary complications
Etiology:
1. Obstruction of the tracheobronchial airway
a) Changes in bronchial secretions
b) Defects in expulsion mechanism
c) Reduction in bronchial caliber
2. Pulmonary insufficiency (hypoventilation)
– Decrease surfactant

32. Postoperative Atelectasis
A. Normal
bronchiole and
alveolus
B. Mucous plug in
bronchiole
C. Collapse of alveoli
due to absorption of air

33. Postoperative Pulmonary Complications
A. Atelectasis:
Predisposing factors:
1. Smoking
2. Pulmonary problem (bronchitis, asthma, etc)
3. Anesthesia:
– GA - duration and depth
– Postop narcotics – depress cough reflex
4. Depress cough reflex
– Chest pain
– Immobilization
– Splinting w/ bandages
5. NGT – increased secretions and predisposed aspiration
6. Congestion of the bronchial walls

34. Postoperative Pulmonary Complications
A. Atelectasis:
Manifestations:
1st 24 hrs postop ----> fever, tachycardia, rales,
decrease breath sound ----> persist ---->
pneumonia (increase fever, dyspnea,
tachycardia and cyanosis) ---> lung abscess

35. Postoperative Pulmonary Complications
A. Atelectasis:
Treatment:
1. Preop prophylaxis:
a. No smoking (2 wks)
b. Treatment of pulmonary problem
2. Postop prophylaxis:
− Minimal use of depressant drugs
− Prevent pain
− Early ambulation
− Changes body position
− Deep breathing and coughing exercises
3. Drugs:
a. Expectorants
b. Mucolytic
c. bronchodilators

36. Postoperative Pulmonary Complications
B. Pulmonary Aspiration:
– General anesthesia – pts are in supine
position and absence of normal protective
reflexes.
– Increased risk:
1. Pregnant
2. Elderly
3. Obese
4. Pts w/ bowel obstruction

37. Postoperative Pulmonary Complications
B. Pulmonary Aspiration:
Prevention:
• NPO 6hrs prior to surgery
• Emergency – NGT do gastric lavage and give
antacid to prevent dev. of Mendelian’s Syndrome.
Treatment:
• Continuous mechanical ventilation
• antibiotics

38. Postoperative Pulmonary Complications
C. Pulmonary Edema:
Etiology:
1. Circulatory overload (infusion of fluid during
operation)
 Most common cause
2. Left ventricular failure (incomplete cardiac
emptying)
 Due to anesthetic, narcotic or hypnotic agents w/c
decrease myocardial contractility
 Decrease peripheral perfusion -----> peripheral
vasoconstriction ----> cause blood to shift centrally -
---> pulmonary edema
3. Negative pressure in airway.

39. Postoperative Pulmonary Complications
C. Pulmonary Edema:
Treatment:
1. Provide oxygen (increase inspired concentration)
2. Remove obstructing fluid (diuretics, head up or
sitting position, phlebotomy, spinal anesthesia,
ganglionic blocking agents)
3. Correcting the circulatory overload
4. Increase airway pressure (PEEP)

40. Postoperative Pulmonary Complications
D. Respiratory Failure:
– 25% of postoperative deaths
– Tachypnea > 25-30/min
– Low tidal volume < 4ml /kg
– High Pco2 > 45mmHg while the patient is
breathing room air
– Low Po2 < 60mmHg in the absence of metabolic
alkalosis
– Usually seen in patients who underwent
operations for major trauma or who have
multisystem disease.
– Mechanism is unknown

41. Postoperative Pulmonary Complications
D. Respiratory Failure:
Etiologic Factors:
1. Sepsis
2. Massive transfusion
3. Fat embolism
4. Pancreatitis
5. Aspiration
– Associated w/ a decreased Functional Residual Lung
Capacity, indicating that the amount of air w/ in the lung at the
end of normal expiration is reduced ----> diminished ventilation-
perfusion ratio and ultimately arterial hypoxemia
Treatment:
• Mechanical ventilation (PEEP)

42. Pulmoary embolism
• A very serious complication of DVT
• 10% die within the first hour
• 90% live longer than one hour-of these
patients 70 percent go undiagnosed and of
these 30 % die

43. Pulmonary Embolus

44. Diagnosis of PE
• Clinical
– dyspnea
– chest pain
– Hypotension
• D-dimers
• Imaging
– CT
– Ventilation perfusion scan

45. Treatment of PE
• Medical management
– supportive care
– anticogualtion
– thrombolysis
• Surgical management

46. Preoperative Pulmonary Evaluation
• Determination of Risks
• Prevention of Risks
• Rescheduling/ Cancel of the operation?

47. The evaluation of patient
• Clinical Evaluation (History - Physical Examination)
• Laboratory Evaluation
Functional evaluation (PFT)
Arterial Blood Gases
Chest X-ray
ECG
• General Condition Assessment
Classification of ASA (American Society of Anesthesiologists)
Cardiopulmonary Risk Index

48. PREVENTION
• RECOVERY ROOM :
ANAESTHETIST RESPONSIBILITIES TOWARDS CARDIO-
PULMONARY FUNCTIONS.
SURGEON’S RESPONSIBILITIES TOWARDS THE OPERATION
SITE.
• TRAINED NURSING STAFF :
T0 HANDLE INSTRUCTIONS.
• CONTINUOUS MONITORING OF PATIENT (VITAL
SIGNS etc.)

49. Post-Op recommendations to
reduce Pulmonary Complications
• Deep Breathing Exercises/Incentive
Spirometry
• CPAP – if patient cannot cooperate for I.S.
• Avoid routine use of NG tubes
• Adequate Pain Control

50.  Smoking cessation for ≥8 weeks
 Treatment for patients with underlying asthma / COPD (PFT)
 Delay elective surgery and treat with antibiotics if respiratory
infection is present
 Patient education regarding lung expansion maneuvers
 Obese patients should be managed to lose weight
 Choose procedure lasting < 4 hrs (if possible)
 Minimize duration of anesthesia
 Avoid use of long-acting neuroblockers (ie pancuronium) in high risk
patients
Prevention of Risks

52. QUESTIONS?