4. SUMMARY OF MOST COMMON
CAUSES OF POST-OP FEVER WHEN
STARTING ON
1st Day : Reactive to drugs or surgical tissue trauma
2nd Day : Atelectasis
3rd Day : IV line infection (STP)
4th Day : Pneumonia, DVT, UTI
5th Day : Wound infection (still pneumonia, DVT, UTI)
7th Day : Abscess somewhere
After first week : allergy to drugs, transfusion-related-fever,
septic pelvic vein thrombosis and intraabdominal abscesses
5. AIM OF PHASE I & II
Homeostasis
Treatment of pain
Prevention & early detection of
complications
6. IMMEDIATE PHASE
DISCHARGE FROM RECOVERY SHOULD
BE AFTER COMPLETE STABILIZATION OF
CARDIO-VASCULAR, PULMONARY AND
NEUROLOGICAL FUNCTIONS WHICH
USUALLY TAKES 2 – 4 HOURS
IF NOT SPECIAL CARE IN ICU
7. POST-OPERATIVE ORDERS
MONITOR
V i t a l s i g n s
E C G
F l u i d b a l a n c e
O t h e r t y p e s o f m o n i t o r i n g ( a r t e r i a l p u l s e s a f t e r v a s c u l a r s u r g e r y,
l e v e l o f c o n s c i o u s n e s s a f t e r n e u r o s u r g e r y )
RESPIRATORY CARE
O x y g e n m a s k
Ve n t i l a t o r
Tr a c h e a l s u c t i o n
C h e s t p h y s i o t h e r a p y
8. POST-OPERATIVE ORDERS
POSITION IN BED AND MOBILIZATION
Tu r n i n g i n b e d u s u a l l y e v e r y 3 0 m i n u t e s u n t i l f u l l m o b i l i z a t i o n
S p e c i a l p o s i t i o n r e q u i r e d s o m e t i m e s
D V T p r e v e n t i o n m e c h a n i c a l l y ( i n t e r m i t t e n t c a l f c o m p r e s s i o n )
DIET
N P O
L i q u i d s
S o f t d i e t
N o r m a l o r s p e c i a l d i e t
9. POST-OPERATIVE ORDERS
ADMINISTRATION OF IV FLUIDS
D a i l y r e q u i r e m e n t s
L o s s e s f r o m G I T & U T
L o s s e s f r o m s t o m a s & d r a i n s
I n s e n s i b l e l o s s e s
C a r e o f r e n a l p a t i e n t s
C a r e o f d r a i n a g e t u b e s
MEDICATION
A n t i b i o t i c s
P a i n k i l l e r s
S e d a t i v e s
P r e - o p e r a t i v e m e d i c a t i o n
C a r e o f p a t i e n t s o n p r e - o p
s t e r o i d s
H 2 b l o c k e r s ( e s p . I C U )
A n t i c o a g u l a n t s
A n t i d i a b e t i c s
A n t i h y p e r t e n s i v e s
11. POST-OPERATIVE
PULMONARY CARE
Functional residual capacity (FRC) and vital capacity (VC)
decrease after major intra-abdominal surgery down to 40% of
pre-operative level
They go up slowly to 60-70% by 6th – 7th day and to normal pre-
operative level after that
FRC, VC and post-operative pulmonary edema (post
anesthesia). Contribute to the changes in pulmonary functions
post-operative
The above changes are accentuated by obesity, heavy smoking
or pre-existing lung diseases especially in elderly
12. POST-OPERATIVE
PULMONARY CARE
Post-operative atelectasis is enhanced by shallow breathing,
pain, obesity and abdominal distension (restriction of
diaphragmatic movements)
Post-operative physiotherapy especially deep inspiration helps
to decrease atelectasis. Also oxygen mask and periodic
hyperinflation using spirometry
Early mobilization helps a lot
Antibiotics and treatment of heart failure post-operative by
adequate management of fluids will help to reduce pulmonary
edema
13. WHEN CAN PATIENT LEAVE
RECOVERY ROOM?
Patient is fully conscious
Respiration and oxygenation are adequate
Patient is normotensive
Not in pain nor nauseous
Cardiovascular parameters are stable
Oxygen, fluids and analgesics have been
prescribed
There are no concerns related to the
surgical procedure
14. GENERAL POST-OPERATIVE
PROBLEMS
Pain
IV nutrition
Nausea & vomiting
Bleeding
Deep vein thrombosis
Hypothermia / shivering
Fever
Prophylaxis against
infection
Pressure sores
Confusional states
Drains
Wound care
Wound dehiscence
Enhanced recovery
Discharge of patients
Follow-up in clinic
15. PAIN
Nociceptive pain arises from inflammation and ischemia
Neuropathic pain arises from a dysfunction in the central
nervous system
Psychogenic pain is modified by the mental state of the patient
Surgical patients may have persistent pain from a variety of
disorders including chronic inflammatory disease, recurrent
infection, degenerative bone or joint disease, nerve injury and
sympathetic dystrophy.
Effective analgesia is an essential part
Important injectable drugs for pain are opiate analgesics.
NSAIDS such a diclofenac, ibuprofen and paracetamol can also
be given orally.
Commonly inexpensive opiates are pethidine and morphine.
16. FLUID AND NUTRITION
Fluid therapy and nutritional support are fundamental to
good surgical practice.
This requires knowledge of the consequences of surgical
intervention and, in particular, intestinal resection.
Malnutrition is common in hospital.
All patients who have sustained or who are likely to sustain 7
days of inadequate oral intake should be considered for
nutritional support.
The success or otherwise of nutritional support should be
determined by tolerance to nutrients provided and nutritional
end points, such as weight.
17. NAUSEA & VOMITING
Nausea and vomiting occur when there is
stimulation of vomiting centre by multiple
factors.
Adequate treatment of pain, anxiety,
hypotension and dehydration will minimize the
risk of the patient developing PONV.
Mx : Administer antiemetics that work at
different sites, such as :
i. HT3 receptor antagonists (e.g.
ondansetron)
ii. Steroids (e.G. Dexamethasone)
iii. Phenothiazines (e.G. Prochlorperazine)
iv. Antihistamines (e.G. Cyclizine)
18. BLEEDING
The patient’s blood pressure, pulse, urine output, dressings and drains
should be checked regularly in the first 24 hours after surgery.
If bleeding is more than expected for a given procedure, then pressure
should be applied to the site and blood samples should be sent for
blood count, coagulation profile and crossmatch.
Fluid resuscitation should also be started.
Ultrasound or CT scan may need to be arranged to determine the size
and extent of the hematoma.
If immediate control of bleeding is essential, the patient may be taken
back to the operating theatre.
If surgical hemostasis is not successful using conventional methods,
hemostatic dressings or surgical glue may be tried.
The radiological embolization of bleeding vessels can also prove useful.
19. DEEP VEIN THROMBOSIS
Patients suffering postoperative deep vein thrombosis (DVT)
may present with calf pain, swelling, warmth, redness
and engorged veins.
However, most will show no physical signs.
On palpation, the muscle may be tender and there is a positive
Homans’ sign (calf pain on dorsiflexion of the foot)
Venography or duplex Doppler ultrasound is used to assess
flow and the presence of thromboses.
20. DEEP VEIN THROMBOSIS
MANAGEMENT
Initially starts with intravenous heparin followed by longer-
term warfarin, should be started.
In some patients with a large DVT, a caval filter may be
required to decrease the possibility of pulmonary embolism.
Most hospitals have a DVT prophylaxis protocol.
i. use of stockings
ii. calf pumps
iii. pharmacological agents, such as low molecular weight
heparin
22. HYPOTHERMIA / SHIVERING
Anesthesia induces loss of thermoregulatory control
Hypothermia is due to exposure of skin and organs to:
i. A cold operating environment
ii. Volatile skin preparation (which cool by
evaporation)
iii. The infusion of cold IV Fluids
This, in turn, leads to increased :
i. Cardiac morbidity
ii. Hypo coagulable state
iii. Shivering with imbalance of oxygen supply and
demand
iv. Immune function impairment with the possibility
of wound infection
Active warming devices should be used to treat
hypothermia as appropriate.
23.
24. SUMMARY OF MOST COMMON
CAUSES OF POST-OP FEVER WHEN
STARTING ON
1st Day : Reactive to drugs or surgical tissue trauma
2nd Day : Atelectasis
3rd Day : IV line infection (STP)
4th Day : Pneumonia, DVT, UTI
5th Day : Wound infection (still pneumonia, DVT, UTI)
7th Day : Abscess somewhere
After first week : allergy to drugs, transfusion-related-fever,
septic pelvic vein thrombosis and intraabdominal abscesses
25. INFECTION
Prophylactic antibiotics should be administered, in patients
who have had foreign material inserted during the operation,
including a hip or knee prosthesis in orthopedic surgery or
aortic valves in cardiovascular surgery, up to three dose.
Usually one dose 30 minutes before ‘knife to skin’ and two
postoperatively.
Bacteria can be incorporated into the biofillm that forms on
the surface of the implant, where they are protected from
antibiotics and from the natural defenses of the body
Prophylactic antibiotics appear to reduce the risk of any
contamination developing into infection by destroying bacteria
before they are incorporated into the biofilm.
26. PRESSURE SORES
These occur as a result of friction or persisting pressure on soft
tissues
They particularly affect the pressure points of a recumbent
patient, including the sacrum, greater trochanter and heels
Risk factors are :
i. Poor nutritional status
ii. Dehydration and lack of mobility
iii. Use of a nerve block anesthesia technique
Early mobilization prevents pressure sores, while those who
are unable to turn in bed should be turned every 30 minutes to
prevent pressure sores from developing
High-risk patients may be nursed on an air lter mattress, which
automatically relieves the pressure areas
27. CONFUSIONAL STATE
Acute confusional states can occur on recovery from anesthesia
(postoperative delirium (POD)) or a few days after surgery.
The overall incidence of POD is 5–15 per cent, but is higher in the elderly
with hip fractures and is associated with increased morbidity and mortality
Confusion may present as :
i. Anxiety
ii. Incoherent speech
iii. Clouding of consciousness or destructive behavior, e.G. Pulling out of
cannula
Risk factors for POD include :
i. Pre-existing cognitive impairment (dementia)
ii. Use of narcotics
iii. Benzodiazepines
iv. Alcohol (and withdrawal from it)
v. Severe illness
vi. Renal impairment
vii. Depression
28. DRAINS
Drains are used to prevent accumulation of blood, serosanguinous
or purulent fluid or to allow the early diagnosis of a leaking surgical
anastomosis.
The complications are trauma to surrounding tissues, and act as a
conduit for infection.
The quantity and character of drain fluid can be used to identify any
abdominal complication, such as fluid leakage (e.g. bile or
pancreatic uid) or bleeding.
This lost fluid should be replaced with additional intravenous fluids
with the same electrolyte contents.
Continued loss of blood through the drain should be investigated
for the source.
Drains should be removed as soon as possible and certainly once
the drainage has stopped or become less than 25 mL/day.
29. WOUND CARE
Epithelialization takes 48 hours
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 to 20th day then slowly again
(full strength takes 1-2 years)
Good nutrition
30. WOUND DEHISCENCE
Wound dehiscence is disruption of any or all of the layers in a
wound.
Dehiscence may occur in up to 3 per cent of abdominal
wounds and is very distressing to the patient.
Wound dehiscence most commonly occurs from the 5th to the
8th postoperative day when the strength of the wound is at its
weakest.
It may herald an underlying abscess and usually presents with
a serosanguinous discharge.
The patient may have felt a popping sensation during straining
or coughing.
Most patients will need to return to the operating theatre for
resuturing.
In some patients, it may be appropriate to leave the wound
open and treat with dressings or vacuum-assisted closure
(VAC) pumps
31. WOUND DEHISCENCE
RISK FACTORS
GENERAL
Malnourishment
Diabetes
Obesity
Renal failure
Jaundice
Sepsis
Cancer
Treatment with steroids
LOCAL
Inadequate or poor closure of
wound
Poor local wound healing
i. Because of infection,
haematoma or seroma
Increased intra-abdominal
pressure
i. In postoperative patients
suffering from chronic
obstructive airway disease,
during excessive coughing
33. RESPIRATORY
COMPLICATIONS
The most common respiratory complications in the
recovery room are:
Hypoxemia
Hypercapnia
Aspiration (occurs when unconscious)
Pneumonia (later)
Pulmonary embolism may occur later in the post-
operative period
34. POST-OPERATIVE
HYPOXEMIA
Defined as an oxygen
saturation of less than
90%
Presentations are ;
i. Shortness of breath
ii. Agitation
iii. Upper airway
obstruction (absence
of air movement,
seesaw motion of
chest, suprasternal
recession)
iv. Cyanosis
v. Combination of any of
the above
WHY DOES IT OCCUR?
Upper airway obstruction due to the
residual effect of general anesthesia,
secretions or wound hematoma after
neck surgery.
Laryngeal edema from traumatic tracheal
intubation, recurrent laryngeal nerve
palsy and tracheal collapse after thyroid
surgery.
Hypoventilation related to anesthesia or
surgery.
Atelectasis and pneumonia especially
after upper abdominal and thoracic
surgery.
Pulmonary edema of cardiac origin or
related to fluid overload.
Pulmonary Embolism
35. PULMONARY ASPIRATION
GERD patients, food in the stomach, or position of the
patient
Intestinal obstruction, pregnancy increased intra-
abdominal pressure and decreased gastric motility
are also risk of aspiration.
60% of cases of aspiration follow thoracic or
abdominal surgery
50% result in pneumonia mostly on right side.
Mortality from subsequent pneumonia is about 50%.
Minor amounts of aspiration are frequent during
surgery and are apparently well tolerated
36. PULMONARY ASPIRATION
PREVENTION & TREATMENT OF ASPIRATION
i. Preoperative fasting
ii. Proper positioning of patient
iii. Careful intubation.
iv. A single dose of H2-blocker or PPI before induction.
v. Treatment is by re-establishing patency of the airway and
preventing further damage to the lung.
vi. Endotracheal suction immediately, stimulates coughing,
which helps to clear the airway.
vii. Bronchoscopy may be required to remove solid matter.
viii. Fluid resuscitation should be undertaken concomitantly.
ix. Antibiotics if aspirate is heavily contaminated.
37. POST-OPERATIVE
PNEUMONIA
Tend to appear later in the post operative period.
Atelectasis, aspiration, and copious secretions are
important predisposing factors
Pathogens Gm-ve, or mixed bacteria from aspiration
Pseudomonas aeruginosa and klebsiella can survive in the
moist reservoirs of the machines ( ventilators, suctions )
TREATMENT : Clear secretions, antibiotics, specific
identification of the infecting organism, supportive
measures
38. PULMONARY EMBOLISM
Sudden onset of chest pain and shortness of breath.
In large embolism, there will be systemic
hypotension, pulmonary hypertension and an
elevated central venous pressure (CVP).
PATIENTS WITH HYPOXIA , URGENT
ACTIONS
If breathing spontaneously give O2 at 15 L/min,
by non-rebreathing mask.
A head tilt, chin lift or jaw thrust should relieve
obstruction related to reduced muscle tone.
Suctioning of any blood or secretions and
insertion of an oropharyngeal airway
Call the anaesthetist as tracheal intubation and
manual ventilation may be needed.
Quick ANTI-COAGULATION reduce mortality from 30 to 3%
39. ATELECTASIS
Affects 25% of patients with abdominal surgery.
More common in elderly or overweight and smokers or with
symptoms of respiratory disease. (loss of elastic recoil of
the lung)
Most frequently in the first 48 h after operation.
Responsible for 90% of febrile episodes during that period.
Most cases are self-limited and recovery is uneventful.
Pathogenesis involves obstructive and nonobstructive
factors. (Secretions resulting from chronic obstructive
pulmonary disease, intubation, or anesthetic agents.
Occasional cases may be due to blood clots or malposition
of the endotracheal tube.)
40.
41. ATELECTASIS
SYMPTOMS
Fever (pathogenesis unknown), tachypnoea, and tachycardia
SIGNS
Scattered rales, and decreased breath sounds
TREATMENT
Early mobilization, frequent changes in position, encourage to cough,
and use of an incentive spirometer
42. SUMMARY OF RESPIRATORY
COMPLICATIONS
Can occur either immediately or a few days later on
the ward
Obese, smokers and those with chronic lung
conditions are more likely to have respiratory
complications
Early intervention and multidisciplinary involvement
can prevent life threatening respiratory complications
44. CARDIOVASCULAR
COMPLICATIONS
Life threatening, but incidence is reduced by
appropriate preoperative preparation
Regional anesthesia is safer than GA, as GA drugs and
gases may cause dysrhythmia and hypotension.
1. Postoperative Dysrhythmias
2. Postoperative Myocardial Infarction
3. Postoperative Cardiac Failure
4. Severe hypertension
NB: non-cardiac complications ( hypoxia, sepsis ) increase incidence of cardiac
complications.
45. POST-OPERATIVE
DYSRHYTHMIAS
Mostly appear during the operation or within the first 3
postoperative days.
More in or after thoracic than abdominal procedures.
Generally causes are reversible: Hypokalemia, hypoxemia,
hypercapnia, alkalosis, digoxin toxicity, stress during recovery,
mostly asymptomatic
It can be 1st sign of myocardiac ischemia, especially when
associated with chest pain, sweating, palpitation, dyspnea
SVT less dangerous than ventricular dysrhythmias.
Treatment according to type, but all associated abnormalities
should be corrected.
Complete heart block is usually due to serious cardiac disease
and calls for the immediate insertion of a pacemaker
46. MYOCARDIAC INFARCTION
Precipitated by hypotension or hypoxemia.
Over 50% asymptomatic silent MI ( GA, or analgesia )
S&S: chest pain, hypotension, dysrhythmia.
Diagnosis: ECG changes, elevated CPK MB, Troponin I.
Management: ICU, oxygenation and precise fluid and
electrolyte replacement. Anticoagulation, though not always
feasible after major surgery, prevents the development of
mural thrombosis and arterial embolism after myocardial
infarction.
CHF treated with digitalis, diuretics, and vasodilators as
needed.
47. POST-OPERATIVE CARDIAC
FAILURE
LVF and pulmonary edema occur in 4% after age 40
Fluid overload, limited cardiac reserve are main causes,
trauma, transfusions, sepsis are other causes
Manifestations: progressive dyspnea, hypoxemia with normal
CO2 tension, and diffuse congestion on chest x-ray.
Shock require transfer to ICU, placement of a pulmonary artery
line, monitoring of filling pressures, and immediate preload and
afterload reduction.
Preload reduction with diuretics (and nitroglycerin if needed)
Afterload reduction: by administration of sodium nitroprusside.
Patients not in shock may instead be digitalized rapidly IV with
careful monitoring of the serum potassium level)
Fluid restriction, and diuretics may be enough in milder cases.
Respiratory insufficiency calls for endotracheal intubation and a
mechanical respirator.
49. ACUTE RENAL FAILURE
25% of cases of hospital-acquired renal failure occur in
the perioperative period and are associated with high
mortality
especially after cardiac and major vascular surgery
Patients with chronic renal disease, diabetes, liver
failure, peripheral vascular disease and cardiac failure
are at high risk.
Perioperative events such as sepsis, bleeding,
hypovolaemia, rhabdomyolysis or abdominal
compartmental syndrome can all precipitate acute
renal failure.
50. ACUTE RENAL FAILURE
ARF is characterized by a sudden reduction in renal
output that results in the systemic accumulation of
nitrogenous waste.
Diagnostic criteria :
i. Increase in serum creatinine level > 1.5x baseline
ii. Decrease urine output <500 ml/day (20ml/hr)
Causes :
i. Pre renal
ii. Renal
iii. Post renal
51. ACUTE RENAL FAILURE
MANAGEMENT
Ascertain cause of ARF
If urine output decrease;
i. Checked Catheter Is Not Blocked
ii. Correct Hypovolaemia And Hypotension
iii. Correct Metabolic And Electrolyte Imbalance
Treat the cause
Stop nephrotoxic drugs
Hemodialysis
52. URINARY RETENTION
Common with pelvic and perineal operation.
Causes :
i. Pain
ii. Fluid deficiency
iii. Problems with access urinals and bed pans
iv. Lack of privacy in the ward
53. URINARY INFECTION
Most common due to acquired infection.
Patient can come with dysuria and/ or pyrexia.
Treatment :
i. Adequate hydration
ii. Proper bladder drainage
iii. Antibiotic
56. ABDOMINAL
COMPLICATIONS
Paralytic Ileus: signaled by nausea, vomiting, loss of
appetite, bowel distension, and absence of flatus /
bowel movement.
Bleed
Abscess: may present with abdominal pain, focal
tenderness & spiking fever
Anastomotic leak
57. UROLOGY
COMPLICATIONS
Pulmonary Edema: continuous bladder irrigation may
be used after transurethral resection of prostate
(TURP)
Pulmonary edema is developed if a large amount of
irrigation fluid is absorbed.
60. THORACIC
COMPLICATIONS
Susceptible to fluid overload; patient undergoing
lobectomy / pneumonectomy should have fluid
restriction as they are susceptible to overload in the
first 24-48 hours
61. ENHANCED RECOVERY
It is an approach designed to speed clinical recovery of
patient, and reduce the cost and the length of stay of
the patient in the hospital
Achieved by optimizing the health of patient before surgery
Postoperatively achieved by:
i. Early planned physiotherapy & mobilization
ii. Early oral hydration and nourishment
iii. Good pain control
iv. Discharge planning: Includes plan for follow up,
physiotherapy, and other support needed.