1. 1

2. Post operative care &
complications
2

3. INTRODUCTION
The post operative period begins from the time the
patient leaves the operating room and ends with the
follow up visit by the surgeon.
3

4. PURPOSES
To enable a successful and faster
recovery of the patient post operatively.
To reduce post operative mortality rate.
To reduce the length of hospital stay of the
patient.
To reduce hospital and patient cost during
post operative period.
4

5. PHASES
*Immediate post op. peroid ( post-anaesthetic )
*Intermediate ( hospital stay ) phase (2)
*convalescent ( after discharge to full recovery
Phase )3(
@Aim of phase 1&2
To ensure that pt .Is protecting their airway, breathing freely &
perfusing adequately (ABC(
Also monitor pt’s pain, bleeding or loss of distal circulation or
sensation.
Vital signs monitoring
5

6. Simple system for ensuring that
everything checked represented as:
Subjective ,aesuan ,niap tuoba ksa :
.ytixna & ytilibom
Objective ecnalab diulf ,sngis lativ kcehc :
dna aera erusserp osla , noitavesbo yna dna
dna ,dekcehc eb dluohs gnisserd dnuora aera
.dba ni dnuos lewob eht enimaxeSurgery &
distal neurovascular status after orthopedic
surgery.
6

7. Assessment suoiverp lla rotinom :
gnicaf smelborp wen eht tsil dna snoitamrofni
.tp
Plan . ffats & .tp htiw nalp a etalumrof :
Include anticipating when discharge from
hospital ocurr
7

8. KEEP MONITORING VITALS
8

9. MAINTAIN INTAKE AND OUTPUT
9

10. Chest Physiotherapy
10

11. Care of the wound
Epithelialisation takes 48 hs.
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.
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.
11

12. Management of drains
*To drain fluids accumulating after surgery, blood or
pus.
*Open or closed system.
*Other types (Suction, sump, under water etc.)
*Should be removed as long as no function.
*Should come out throw separate incision to minimize
risk of wound infection.
*Inspection of contents and its amount.
*Soft drains e.g. Penrose should not be left more than
40 days because they form a tract and acts as a plug.
12

13. 13

14. Post-Operative pulmonary Care
 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.
14

15. 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. 15

16. Post-Operative fluid & Electrolytes management
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.
16

17. 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.
Usual daily requirements of fluids is between 2000-
2500ml/day.
17

18.  NPO until peristalsis returns.
 Paralytic ileus usually takes about 24hs.
 NGT is necessary after esophageal and gastric
surgery.
 NGT is NOT necessary after cholecystectomy, pelvic
operation or colonic resections.
 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.
Post-Operative Care of GIT
18

19. Post-Operative Pain
 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.
 Pain transmission:
◦ Splanchnic nerves to spinal cord.
◦ Brain stem due to alteration in ventilation, BP and endocrine
functions.
◦ Cortical response from voluntary movements and emotions.
19

20. Complications of Pain:
Causes vasospasm.
Hypertension.
May cause CVA, MI or bleeding.
 Management of Post-Op. pain:
 Physician – patient communication (reassurance).
 Analgesics (NSAIDS).
 Parenteral opioids.
 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).
20
 Nerve block (Post-thoracotomy and hernia repair).

21. COMPLICATIONS OF MAJOR SURGERY
a disease or problem that arises in addition to the initial condition
or during a surgical operation
◦
 CLASSIFICATION
◦ Due to anesthesia .
• Due to surgery
21

22. DUE TO ANESTHESIA
Anesthetic complications depend on the mode
(General or Local) and types of anesthetic agent
used
*Slow recovery from anesthesia .
*Hypothermia
*Allergic reaction
*Minor effect: post-op nausea & vomiting
*Major effect: CVS collapse, respiratory depression
toxicity).
22

23. DUE TO SURGERY
 Perioperative complications
 Postoperative complications
 Immediate/early complications
 Late complications
23

24. PERIOPERATIVE COMPLICATIONS
Refers to problems arising during surgery, which
include:
 @Hypotension
◦ Blood loss
◦ Mismatched blood transfusion
 @Raised blood pressure
◦ Use of ketamine
◦ Uncontrolled hypertension
◦ Phaechromocytoma
 @Hypoxia
◦ Reduced o2
◦ Inadequate blood flow
◦ Inadequate alveolar ventilation
◦
24

25. @Cardiac arrest
Air embolism
Tissue hypoxia
Blood loss
Air embolism
@Asphyxia
Combination of hypoxia & hypercapnia, caused by
respiratory obstruction
SIGNS:-
Noisy breathing during partial obstruction
In the presence of endotracheal tube, difficulty in inflating &
deflating the lungs
Cyanosis
Increase in circulating catecholamine 25

26. ◦ CAUSES:-
◦ @physical & mechanical.
 Flexed head in anesthetized px with/without endotracheal
tube.
 Endotracheal tube blocked by pus, blood, foreign bodies.
Pressure on trachea from without, during operations on
large tumors of the neck e.g. thyroidectomy
@Chemical causes
 Inhalation of intestinal contents
26

27. POST OPERATIVE COMPLICATIONS
 Refers to complications arising after surgical
operations
 Immediate/Early complications
 Respiratory,
 Cardiovascular,
 CNS,
 Genito-urinary,
 GIT
 Wound complications
27

28. POST OPERATIVE PYREXIA
 Pyrexia after operation may be caused by:
◦ *Metabolic response to trauma in the first 24hrs
◦ *Infection or hematoma of the wound
◦ *Laryngo-tracheitis from endotracheal intubation
◦ *Peritonitis or intra-abdominal abscess
◦ *Complications of blood transfusion: mismatched blood
◦ *Drug sensitivity
◦ *Injection abscess
28

29. 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
29

30. 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
Manifestations:
1st 24 hrs postop ----> fever, tachycardia, decrease
breath sound ----> persist ----> pneumonia
(increase fever, dyspnea, tachycardia and
cyanosis) ---> lung abscess 30

31. 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
31

32. 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
Prevention:
 NPO 6hrs prior to surgery
 Emergency – NGT do gastric lavage and give antacid to prevent
dev. of Mendelian’s Syndrome. (It is marked by
bronchoconstriction and destruction of the tracheal mucosa,
progressing to a syndrome resembling acute respiratory distress
syndrome. Also called pulmonary acid aspiration syndrome.)
Treatment:
 Continuous mechanical ventilation
 antibiotics
32

33. 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.
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)
33

34. 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)
34

35. CVS complications
@Hemorrage
@Reactionary (occurring within 24hrs)
@Secondary hemorrhage (after 7days)
SIGNS
Pallor, sweating and cool skin &Bleeding from wound
@hypertension
@hypotension
@Deep venous thrombosis
@Myocardial infarction
35

36. @Failure to recover consciousness
◦ May be due to cerebral hypoxia as a result of e.g.
hypoglycemia
@Convulsion
 Predisposing fx in the post-op period are:
 Pyrexia
 Epilepsy
 hypocalcaemia
CNS
36

37. Postoperative Renal Failure
Renal failure index:
(Urine Na x Plasma creatinine)
Urine creatinine
< 1 usually indicates pre-renal oliguria
> 1 indicates acute renal failure
Etiologies:
1. Catheter obstruction
2. Pre-renal failure;
 Diminished circulating blood volume
3. Acute parenchymal renal failure
 Fluid restriction (daily allowance 500ml plus previous 24 hrs. UO)
 Electrolyte imbalance (hyperkalemia)
 Hemodialysis 37

38. @Retention of urine
◦ failure to pass urine within 12-24hrs of surgery when
bladder is distended.
◦ more common after pelvic and perineal operations.
◦ Due to action of atropine & other cholinergic anesthetic
agents
◦ Pain in operation site
 @Urinary tract infections
38

39. Postoperative Shock
 Poor tissue perfusion ---> hypotension,
pallor, sweating, tachycardia, oliguria,
peripheral vasoconstriction ----> progressive
metabolic acidosis ----> multiple organ
failure ---> death.
 Hypotension in early post-operation:
1. Over sedation
2. Effect of anesthesia
39

40. Categories:
1. Hypovolemia – most common
 Uncorrected volume deficit (preop, intraop, postop)
 Continuing hge postop period
 30-40% loss of ECV
 Monitored w/ UO/hr, CVP
 Crystalloid hydration / blood transfusion
2. Cardiogenic shock (MI / cardiac tamponade)
3. Septic shock:
 Due to gram (-) infection; nosocomial
 Uro-genital infection (foley catheter) > resp. tract >
integumentary 40

41. GIT complications
 N & V : it may cause wonud dehiscence &
pulmonary aspiration.
Predisposing factors:
 Uncontrolled pain
 Opiods
 Surgery on GIT, orthopedic surgery or ENT
surgery
 Hx .Of preop .Vomiting
 Hx . Of migraine
 Acute gasteric dilatation 41

42. Rx of N&V:
General measures:
 Adequate pain control
 Avoid opiates
 NGTube
 Maintain hydration
Drugs:
 Dopamine antagonist: prochlorperazine
 Metoclopromide
 H1 receptor antagonist: cuclizine
 5HT antagonist: ondansetron 42

43. Other GIT Cx:
Vascular Complication:
1. Hemorrhage:
 Occurs gastrointestinal anastomosis
 Manifest – hematemesis, melena, hematochezia
 Bleeding arise from the suture line (usually after
gastric resection
Treatment:
 Ist conservative: irrigation w/ cold lavage /
endoscopy
 Reoperation – direct control
43

44. 2. Gangrene:
 Due to poor tissue perfusion
a. Stomach:
 Following subtotal gastrectomy w/ ligation of left
gastic and splenic arteries; thrombosis
b. Small bowel and colon:
 Thrombosis; mechanical strangulation (internal
herniation) – volvulus, adhesions
Treatment:
 Resection of gangrenous segment, re-established
continuity
44

45. Intestinal Obstruction
Mechanical Problem:
1. Intestinal Obstruction:
1. Stomal obstruction (due to local edema)
Causes of edema:
a. Electrolyte imbalance
b. Incomplete hemostasis
c. Hypoprotenemia
d. Leakage from anastomosis
e. Inadequate proximal decompression
f. Incorporation of too much tissue w/in
the suture 45

46. 2. Other causes of intestinal obstruction
a. Intussuception
b. Volvulus
c. Post-operative adhesion
d. Herniation
46

47. INTUSSUCEPTION
47

48. VOLVULOUS
48

49. Treatment of Intestinal
Obstruction :
Proximal decompression (NPO / NGT)
1. Correct fluid and electrolyte imbalance
2. Hyperalimentation (TPN):
 No improvement ------> re-operation
49

50. Small bowel volvulous
50

51. Small bowel internal herniation
51

52. Intestinal Obstruction
Postoperative
fibrous adhesion:
 The most common cause
of bowel obstuction
 Could be partial or
complete
 Fluid and electroyte
imbalance
 Usually present a colicky
abdominal pain with
abdominal distention w/o
bowel movement.
 Late cases might present
with silent abdomen
52

53. Treatment:
 NGT decompression, NPO, correct
fluid and electrolyte imbalance
 Surgical intervention – adhesiolysis
w/ or w/o resection
53

54. Non-mechanical intestinal
obstruction:
Ileus:
Physiologic / functional bowel obstruction
 Stomach --> w/in few hours
 Small bowel ---> 12-36 hrs
 Large bowel ---> 24-72 hrs.
Treatment:
 NGT decompression
 NPO
 Fluid & electrolyte balance (hypo K)
 Metaclopromide or bethanechol
54

55. Fistula:
Abnormal
communication
between two lining
epithelium
Etiology:
1. Anastomotic leak
2. Poor blood supply
3. Trauma
4. Infection
5. Inadvertent suturing of
bowel wall while closing
the fascia
6. Carcinoma
55

56. Fistula:
1. Gastric and duodenal fistula:
 Subtotal gastrectomy --->
gastrojejunal (tears of surrow) and
duodenal stump
 Due to suture line failure
56

57. Fistula:
1. Gastric and duodenal fistula:
Treatment:
 NPO / TPN
 Place NGT past the leak and give elemental
diet
 Antibiotic
 Majority close spontaneously w/in 6 wks
Failure to close
1. distal obstruction
2. large leak
3. Infection
4. Cancer
Surgery – resect the fistula and the bowel
segment then re-anastomosis
57

58. 2. Small bowel fistula:
 Drainage is less compared to duodenal
fistula, but jejunal fistula have a poorer
prognosis than ileal fistula
Treatment:
 Supportive:
 correct fluid & electrolyte imbalance
 Give proper nutrition
 Proximal jejunal fistula: - Distal feeding jejunostomy
 Distal ileal fistula: - low residue diet
 Control diarrhea ----> lomotil / protect the skin
58

59. 3. Colonic fistula:
 Fluid & electrolyte imbalance less common but has higher
infection can lead to peritonitis, peritoneal abscess and
wound infection.
 Skin digestion and irrigation are rare
Treatment:
1. Nutrition (low residue or elemental diet)
2. Antibiotics
 Spontaneous healing of fistula is the rule rather than the
exception
 Medical management is generally indicated for 6 wks to
permit active inflammation to subside ---> fails ---->
surgery
3. Defunctionalizing colostomies for descending colon
4. Ileal transverse colostomies for ascending and distal ileal
fistulas
59
 If w/ generalized peritonitis do emergency resection

60. Wound Complications:
A. Wound dehiscence:
 Separation of an abd. wound
involving the anterior fascial and
deeper layers
 0.5 – 3.0%
Causes:
 General factors:
1) Age: < 45y/o = 1.3% > 45 y/o =
5.4%
2) Debilitated pts. w/ poor nutrition
 carcinoma, hyponatremia, obesity
3) Causes of increase intra-abd.
pressure
 pulmonary & urinary problem
60

61.  Local Factors:
1) Hemorrhage
2) Infection
3) Poor technique:
a. Excessive suture material
b. Drain and stoma placed along incision
4) Type of incision (> in vertical incision)
 Manifestation:
1. Sero-sanguinous drainage (pathognomonic)
2. Postoperative ventral hernia
 Treatment:
 secondary operative procedure (if medical condition allows)
 conservatively with an occlusive wound dressing and binder
----> postoperative hernia.
 Prognosis:
 Mortality = 0.5 – 0.3% due to pathologic conditions 61

62. Wound Complications:
B. Wound Infection:
 Major factors:
1) Breaks in surgical technique
2) Host parasite relationship
 Potential sources of contamination:
1) Patients themselves
2) Operating room and personels
 Organisms:
1) Staphylococcus aureus
2) Enteric organism (E. coli, Bacteroides, Proteus,
Klebsiella, Pseudomonas) 62

63.  Factors:
1. Nature of the wound:
a. Clean atraumatic and uninfected operative wound (3.3%)
b. GIT / Respiratory / Urinary tract entered but w/ out
unusual contamination (10.8%).
c. Open, traumatic wounds w/ major break in sterile
technique (16.3%)
d. Traumatic wound involving abscesses of perforated
viscera (28.6%).
2. Age
3. Presence of medical problems (diabetes/steroid tx)
4. Duration of operations and preoperative stay in the
hospital
63

64. 64

65. Presented by :
Shaimaa Adil
Hawraa Ali
Fatin Mohmmad
Jehan Ali
65