We only wish to share with you some basic precepts of postoperative care ,which may be forgotten,drowned in a sea of fancy technology and gimmicks.

1. POST OPERATIVE CARE
Presented by:-
Dr.Mohsin Khan
PG Resident MS (General Surgery)
GRMC Gwalior

2.  The long operation is finished,leaving you to
savour the sweet postoperative HIGH and
Elation.But soon ,when your serum level of
endorphins declines ,you start worrying about
the outcome.And worry you must,for the
cocksure,macho attitude is a recipe for disasters.
 We do not intend here to have a detailed
discussion of postoperative care or to write a new
surgical intensive care manual.
 We only wish to share with you some basic
precepts,which may be forgotten,drowned in a sea
of fancy technology and gimmicks.

3. The post operative
period begins from
the time the patient
leaves the operating
room and ends with
the follow up visit by
the surgeon.
The post operative
care is provided by -
 PACU
 SICU

8.  Transferring of the patient from
the OR to the PACU is the
responsibility of the
anesthesiologist.
 During transport the
anesthesiologist remains at the
head part of the patient and a
surgical team member remains
at the opposite side.
 Transporting the patient
involves the special
consideration of the incision
site, potential vascular changes
and exposure.

9.  Location:
◦ Close to Operating Rooms
◦ Easy access to Lab, X-ray, Blood bank
◦ Close to ICU
 Size:
◦ Ideal 1.5 PACU bed for every OT
◦ 120 square foot per patient
◦ Minimum of 7 feet between beds
February 6, 2015 9

10.  Facilities:
◦ Fowler’s cot with side rails
◦ Piped Oxygen, Vacuum and Air
◦ Multiple electrical outlets
◦ Large doors
◦ Good lighting
◦ Isolation for Immuno-compromised patients
February 6, 2015 10

11.  Tray with labeled Emergency drugs
 Airway maintenance kit:
◦ Laryngoscope with all size blades
◦ All sizes Endotracheal tubes
◦ Face masks, Airways, Ambu Bag, Venturi masks
◦ Tracheostomy set
◦ ICD set
◦ Transport ventilator
February 6, 2015 11

12.  Personnel:
◦ Requirement varies
◦ 1 : 1 ratio good
◦ 1 : 3 ratio acceptable for busy OR’s
 Monitors:
◦ ECG
◦ Pulse oximeter
◦ Non invasive BP
◦ EtCO2
◦ Invasive pressure monitor
◦ Temperature
February 6, 2015 12

13. Before receiving the patient, there should be proper functioning of
monitoring and suctioning devices, oxygen therapy equipment, and
all other equipment. The following initial assessment is made by the
nurse in the PACU.
1. Verify the patient’s identity, the operative procedures, and the
surgeon who performed the procedures.
2. Evaluate the following signs & verify their level of stability with the
anesthesiologist.
 Respiratory Status
 Circulatory Status
 Pulses
 Temperature
 Hemodynamics Values

14. A) All vitals Monitoring
◦ Vital sign (pulse, BP, R.R,
Temp) every 15-30 min.
◦ C.V.P (? Swan – gins for
pulmonary artery wedge
pressure) and arterial line
for continuous BP
measurement.
◦ ECG
◦ Fluid balance ( intake and
output) ? Needs urinary
catheter.
◦ Other types of monitoring :
 Arterial pulses after
vascular surgery.
 Level of consciousness
after neurosurgery.

17. Diet:
◦ NPO
◦ Liquids.
◦ Soft diet.
◦ Normal or special diet.
Extreme care in Administration of
I.V. fluids:
◦ Daily requirements.
◦ Losses from G.I.T and U.T.
◦ Losses from stomas and drains.
◦ Insensible losses.
◦ Care of renal patients.
◦ If care of drainage tubes.

18. Maintain airway
 By proper positioning of patient’s head.
 By clearing airway.
◦ O2 mask.
◦ Ventilator.
◦ Tracheal suction.
◦ Chest physiotherapy.
Position in Bed and mobilization:
◦ Turning in bed usually every 30 min. until full mobilizatio
◦ Special position required sometimes.
◦ DVT prevention mechanically ( intermittent calf
compression).

19. Hypovolemic shock: can be
avoided by timely administration of
IV Fluids, blood and blood
products and medication.
 Replacement of fluids.[colloids
and crystalloids]
 Keep the patient warm.
 Monitor intake and output balance.
 Monitor the vitals continuously
with the patient condition.

20.  Haemorrhage
It is a serious
complication of surgery
that resulting death.
 It can occur in
immediate post
operatively or upto
several days after
surgery.
 If left untreated,cardiac
output decreases and
blood pressure and Hb
level will fall rapidly.

21.  Blood transfusion only absolutely
if necessary.
 The surgical site+incision should
always be inspected.
 If bleeding,pressure dressing are
placed.
 If the bleeding is concealed,the
patient is taken in OR for
emergency exploration of
concealed haemorrhage in body
cavity.

22.  Use warmer(Bair
Hugger) blankets
 Use warm lights

23. 1. Monitor temperature hourly to be alert from malignant
hyperthermia or to detect hypothermia.
2. A temperature over 37.7 c (100F) or under 36.1 c (97F) is
reportable.
3. Monitor for post anesthesia shivering (PAS) it is most significant
in hypothermic patients 30 to 45 minutes after admission to the
PACU. It represents a heat gain mechanism and relates to
regaining thermal balance.
4. Provide a therapeutic environment with proper temperature and
humidity, when cold, provide the patients with warm blanket.

24.  Perhaps the most useful factor in trying to establish the cause of a
patient's fever is THE RELATIONSHIP BETWEEN THE
TIME OF ONSET OF THE FEVER AND THE
PROCEDURE.
 Fever within the first 24 hours of an operation is common and may
reflect little more than the body's metabolic response to injury.
 Atelectasis is common during this time and may produce a self-
limiting low-grade fever.
 A fever that is evident between 5 and 7 days after an operation is
usually due to infection.
 While pulmonary infections tend to occur in the first few days after
surgery, fever at this later stage is more likely to reflect infection of
the wound, operative site or urinary tract.
 Cannula problems and deep vein thrombosis (DVT) should also
be considered.
 A fever occurring more than 7 days after a surgical procedure may
be due to abscess formation.
 Apart from infection as a cause of fever, it is important to
remember that drugs, transfusion and brainstem problems can
also produce an increase in the body's temperature.

25.  Administer opioid
analgesia as per
Doctor’s order.
 Epidural analgesia.
 NSAIDS.
 Psychological support to
relieve fear+To give
support.

26.  These are common
problem in post operative
period.
 Medication can be
administered as per
doctor’s order.
Example:
Inj Metaclopramide
Inj Ondansetron
( Emeset )

27. General and specific Medication:
◦ Antibiotics.
◦ Pain killers.
◦ Sedatives.
◦ Pre-operative medication.
◦ Care of patients on Pre-Op. Steroids.
◦ H2 Blockers specially in ICU patients.
◦ Anti-Coagulants.
◦ Anti Diabetics.
◦ Anti Hypertensives.
Lab. Tests and Imaging:
◦ To detect or exclude Post-Op. complications.

29.  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.)

30. The major goals include:
 Restoration of optimal respiratory function
 Relief of pain
 Optimal cardiovascular function
 Increased activity tolerance
 Unimpaired wound healing
 Maintenance of body temperature
 Maintenance of nutritional balance
 Resumption of usual bowel and bladder elimination
 Acquisition of sufficient knowledge to manage self-care after
discharge
 Absence of complications

31. 1. Keep side rails up until the patient is fully awake.
2. Protect the extremity to which IV fluids are running so
the needle will not become accidentally dislodged.
3. Avoid nerve damage and muscles train by properly
supporting and padding pressure areas.
4. Recognize that the patient may not be able to complain
of injury such as the pricking of an open safety pin or
clamp that is exerting pressure.
5. Check dressing for constriction.
6. Determine return of motor control following anesthesia
indicated by how the patient responds to a pinprick or a
request to move a part.

32. Complications:
a. Urinary retention- inability to urinate as a result of the
recumbent position, effects of anesthesia and narcotics,
inactivity, altered fluid balance, nervous tension or surgical
manipulation of the pelvic area.
Nsg Mgt:
a.1 assess for bladder distension
a.2 monitor I & O
a.3 maintain IVF as prescribed
a.4 increase daily oral intake 2500-3000L
a.5 insert straight or IFC
a.6 promote normal urinary elimination

33. b. Bowel elimination- frequently altered after pelvic or abdominal surgery
and sometimes after other surgery. Return to normal GI function may
be delayed by general anesthesia, narcotic analgesia, decreased
mobility or altered fluid and food intake during perioperative period.
Nsg Care:
1. Assess for return or normal peristalsis:
a. auscultate bowel sounds every 4 hours while the client is awake
b. assess the abdomen for distention
c. determine whether the client is passing flatus
d. monitor for passage of stool including consistency
2. Encourage ambulation within prescribed limits
3. Facilitate a daily intake of fluids 2.5-3L
4. Provide privacy when the patient is using the bedpan, commode or
bathroom
5. If no BM has occurred for 3-4 days post op, a suppository or an
enema may be ordered.

34. A patient remains in the post op unit, untill the patient has fully
recoverd from anesthesia.
Following measures are used to determine the patient
ready for disharge from post operative unit.
 Stable vital signs
 Orientation to Person
Place
Time or events
 Adequate oxygen saturation level.
 Urine out put at least 30ml/hour
 Minimal pain.
 Adequate respiratory function.
 Aldrete score more than ‘ 9 ‘ before shifting from
Post Operative Anaesthesia Care Unit

35. “ Neither an arbitrary time
limit nor a discharge score
can be used to define a
medically appropriate length
stay in the recovery room
accurately ”
February 6, 2015 35

36. DISCHARGE FROM RECOVERY SHOULD BEDISCHARGE FROM RECOVERY SHOULD BE
AFTER COMPLETE STABILIZATION OFAFTER COMPLETE STABILIZATION OF
CARDIO-VASCULAR, PULMONARY ANDCARDIO-VASCULAR, PULMONARY AND
NEUROLOGICAL FUNCTIONS WHICHNEUROLOGICAL FUNCTIONS WHICH
USUALLY TAKES 2-4 HOURS.USUALLY TAKES 2-4 HOURS.
IF NOT SPECIAL CARE IN ICU.IF NOT SPECIAL CARE IN ICU.

37. Starts with complete recovery from
anaesthesia and lasts for the rest of
the hospital stay.

38.  Dressing can be removed 3-4 days after operation.
 Wet dressing should be removed earlier and changed.
 Symptoms and signs of infection should be looked for, which
if present compression, removal of few stitches and
daily dressing with swab for C & S.
 R.O.S. usually 5-7 days Post-Op.
 Tensile strength of wound minimal during first 5 days, then
rapid between 5th
-20th
day then slowly again (full strength
takes 1-2 years).
 Good nutrition.

39. Drains- are tubes that exit the peri-incisional area,
either into a portable suction devise(close) or into the
dressing(open)
 To drain fluids accumulating after surgery, blood or pus.
 Open or closed system.
 Other types (Suction, sump, under water etc.)
 Should come out throw separate incision to minimize risk of wound infection.
 Inspection of contents and its amount.
 Drains are not highly reliable.we should always have a confirmation by inv
(usg) etc when in doubt, bcoz sometimes drain may get blocked by omentum
or intestine or may get displaced as in cholecystectomy
 Should not be left long periods because they form a tract and acts as a plug.
 Drain should be kept till it drains.

40.  Functional residual capacity ( FRC) and vital capacity (VC)
decrease after major intra-abdominal surgery down to 40% of
the Pre-Op. Level.
 They 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.

41.  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 to
reduce pulmonary oedema.

42.  Early :
◦ Occurs minutes to 1-2 hs. Post-Op.
◦ No definite cause.
◦ Occurs suddenly.
 Late :
◦ Occurs 48 hs. Post-Op.
◦ Due to pulmonary embolism, abdominal distension or opioid
overdose.
Manifestation :
◦ Tachypnea > 25-30/min.
◦ Low tidal volume < 4ml /kg
◦ High Pco2 > 45mmHg.
◦ Low Po2 < 60mmHg.

43.  Treatment :
◦ Immediate intubation and mechanical ventilation.
◦ Treatment of atelectasis, pneumonia or pneumothorax if any.
 Prevention:
◦ Physiotherapy (Pre. & Post-OP.) to prevent atelectasis.
◦ Treatment of any Pre-existing pulmonary diseases.
◦ Hydration of patient to avoid hypovolaemia and later on atelectasis
and infection.
◦ May be hyperventilation to compensate for insufficiency of lungs.
◦ Use of epidural block or local analgesia in patients with COPD to
relieve pain and permits effective respiratory muscle functions

44.  Considerations:
◦ Maintenance requirements.
◦ Extra needs resulting from systemic factors e.g. fever, burn
diarrhea and vomiting etc.
◦ Losses from drains and fistulas.
◦ Tissue oedema (3rd
space losses)
 The daily maintenance requirements in adult for sensible and
insensible losses are 1500-2500mls. depending on age, sex, weight
and body surface area.
 Rough estimation of need is by body weight x 30/day. e.g. 60 KG x 30
= 1800ml/day.
 Requirements is increased with fever, hyperventilation and increased
catabolic states.

45.  Estimation of electrolytes daily is only necessary in
critical patients.
 Potassium should not be added to IV fluid during first
24hs. Post-Op. (because Potassium enters circulation
during this time and causes increased aldosterone
activity).
 Other electrolytes are corrected according to deficits.
 5% dextrose in normal saline or in lactated Ringer’s
solution is suitable for most patients.

46.  NPO until peristalsis returns.
 Paralytic ileus usually takes about 24hs.
 NGT is necessary after esophageal and gastric surgery.
 NGT is NOT necessary after cholecystectomy and pelvic operation.
 Gastrostomy and jujenostomy tubes feeding can start on 2nd
Post-
Op. day because absorption from small bowel is not affected by
laparotomy.
 Enteral feeding is better than parenteral feeding.
 Gradual return of oral feeding from liquids to normal diet.

47.  Complications of Pain:
◦ Causes vasospasm.
◦ Hypertension.
◦ May cause CVA, MI or bleeding.
 Factors affecting severity :
◦ Duration of surgery.
◦ Degree of Operative trauma (intra-thoracic, intra-abdominal or
superficial surgery).
◦ Type of incision.
◦ Magnitude of intra-operative retraction.
◦ Factors related to the patient :
 Anxiety.
 Fear.
 Physical and cultural characteristics.

48.  Management of Post-Op. pain:
◦ Physician – patient communication (reassurance).
◦ Parenteral opioids.
◦ Analgesics (NSAIDS).
◦ Anxiolytic agents (Hydroxyzine) potentiates action of
opioids and has also an anti-emetic effects.
◦ Oral analgesics or suppositories e.g. Tylenol.
◦ Epidural analgesia (for pelvic surgery).
◦ Nerve block (Post-thoracotomy and hernia repair).

49. Expected outcomes:
1. Indicates that pain is decreased .
2. Maintains optimal respiratory function
a. performs DBE
b. displays clear breath sounds
c. uses incentive spirometry as prescribed
d. splints incisional site when coughing
3. Does not develop DVT
4. Exercises and ambulates as prescribed
a. alternates periods of rest and activity
b. progressively increases ambulation
c. resumes normal activities with prescribed time frame
d. performs activities r/t self care
5. Wounds heal without complications

50. 6. Resumes oral intake and normal bowel function
◦ takes at least 75% of usual diet
◦ is free of abdominal distress and gas pains
◦ exhibits normal bowel elimination pattern
7. Acquires knowledge and skills necessary to manage
therapeutic regimen
8. Experiences no complications and has normal Vs

51.  Expected out comes
 Immediate post
operative changes
 Written instructions like
Wound care
Activity+dietary
recommendation
Medications
Follow up

52.  ‘Seek consultation even if it is not sure to
help;never be a lone wolf’
 It is much better in this modern surgical age to
form a close working relationship with colleagues
who share your philosophy of care and who have
expertise in areas beyond your own.
 Because once you operate on a patient he or she
is all yours!