Post operative care

Dr. Mubasher Ali

House Surgeon-Surgical Unit - 2
 AIMS

•The Aim of post operative

care is to provide the patient
with as quick, painless and
safe recovery from surgery as
possible.
 PHASES

Immediate:
Post anesthetic = Phase 1
Intermediate :
Hospital stay = Phase 2
Convalescent:
After discharge to full recovery = Phase 3
General post operative problems
Pain Myocardial Infarction
Nausea/Vomiting Confusional state
Bleeding Wound care
DVT Drains
Infection Wound dehiscence
Fever Urinary problems
Aspiration/ Pneumonia
Atelectasis /
Dysrhythmia
 PAIN
Pain can be nociceptive, neuropathic
or psychogenic
Nociceptive pain arises from
inflammation and ischemia
Neuropathic pain arises from
dysfunction of central nervous
system
Psychogenic pain is modified by
mental state of patient
Continuation...
Surgical patient may also have pain from verity of
disorders like; chronic inflammatory disease, nerve injury,
degenerative bone or joint diseases, etc...
Therefore, effective analgesia is essential part of post op
care
Let us discuss some of the effective analgesia modalities
 Modalities
Opioid Analgesia:
Morphine
Hydromorphone
Fentanyl
Morphine is mostly widely used in our hospital
setting.
Intravenous patient controlled analgesia:
Use of opioid analgesic through patient controlled
analgesia (PCA) pump.
A meta-analysis of 5 randomized controlled trials and
subsequent COCHRANE review that compares IV-PCA
with conventional IV analgesia reported that IV-PCA
had more analgesic effect and patient satisfaction.
Epidural & Spinal Analgesia:
A combination of local anesthetic and opioid can be
administered via patient controlled epidural pump
which lowers dose requirements for each individual
drugs as well as frequency of side effects.
Non Opioid Analgesics:
NSAIDS like ketorolac
Acetaminophen can also be used (It is a centrally acting
analgesic but lacks peripheral anti-inflammatory
effect.
Peripheral Nerve block:
Peripheral nerve block can also be used for post op
analgesia.
On of the example is TAP block (Transversus abdominis
plane block) in which peripheral nerve block results in
anesthesia of abdominal wall.
In it a signal shot is given in to plane between internal
oblique and trans-abdominal muscle, this is the plane
where nerves leave to innervate abdominal muscle and
skin.
Local Infiltration:
Local anesthetic infiltration can also be used for post
op analgesia
Recently a new formulation of liposomal bupivacaine
has received approval from FDA and can provide
analgesia for up to 72 hrs.
2 Pivotal studies leading to approval were in
haemorrhoidectomy and bunionectomy.
 FEVER
Timing of post op fever:
Immediate post op:
Surgical induced inflammation
immune mediated reaction
Malignant hyperthermia
prexisting infection
Early post op:
Continued inflammation
Myocardial infarction
UTI/Pneumonia
SSI
Late post op:
SSI
Surgery specific complications
Infectious & non-infectious causes
Ileus
Anastomotic leakage
Thromboembolism
 Treatment

General Measures:
Oxygen
IV fluids
Nutrition
Spirometry
 Drugs
Drugs:
Antibiotics
Prophylactic antibiotic should be
administered
Usually one dose 30 min before ‘knife to
skin’ and 2 post operatively.
Analgesics
Antiemetics
Thromboembolism prophylaxis, etc...
 Respiratory complications

Atelectasis
Hypoxemia
Hypercapnia
Aspiration
Pneumonia
Pulmonary embolism
 Pulmonary Aspiration
Prevention & Treatment:
Pre op fasting
Proper positioning
Careful intubation
A single dose of H2 blocker or PPI before
induction
Endotracheal suction
Bronchoscopy may be required to remove solid
matter
Fluid resuscitation & Antibiotics
 Atelectasis
Symptoms
Fever, tachycardia, tachypnoea
Signs
Decrease breath sounds and rales
Treatment
Early mobilization, changes in position,
encourage to cough and spirometery
 CVS Complication
Myocardial infarction
Cardiac failure
Dysrhythemia
Severe hypertension
 Myocardial infarction
Symptoms
Chest pain, apperhension
Diagnosis
ECG, Trop-I, elevated CPK-MB
Treatment
ICU, Oxygenation, Fluid and electrolyte balance,
Anticoagulation, Beta-blockers, ACEI, Statins
 Cardiac failure

Preload reduction with diuretics

After load reduction with Na nitroprruside
Nitroglycerine
Vasodilators
ACEI/ARBS
Beta-blockers
 Bleeding
If bleeding is more than expected than pressure should be
applied to the site.
Fluid resuscitation,
USG or Ct-scan to determine size and extend of hematoma
Hemostatic dressing or surgical may be tried
Radiological embolization of bleeding vessel
If immediate control is required shift to theater.
 DVT
Symptoms
Calf pain, swelling, warmth, redness, engorged veins
Examination
Positive HOMAN signs (calf pain on dorsiflexion of
foot)
Investigation
Venography, Doppler USG
Management
Initially IV heparin followed by longer term
warfarin, Stockings, calf pump
 Wound care

Good nutrition
Daily dressing
Dressing can be removed 3 to 4 days after operation
Wet dressing should be removed earlier and changed
Look for sign & symptoms of infection & deal accordingly
 Wound Dehiscence

It is disruption of any or all of the layers in a wound

It can occur in 3% of abdominal wounds
Patient may have felt popping sensation during coughing or
straining
Most patients will need re-suturing
In some patient it may be appropriate to leave the wound open
and treat with dressing or VAC pump.
 Drains
Drains are used to prevent accumulation of blood,
serosanguinous and purulent fluid or to allow early
diagnosis of a leaking surgical anastomosis.
Quantity and character of drain fluid can be used to
identify complications.
The lost fluid should be replaced with additional IV fluids
with same electrolyte control
Drains should be removed as soon as possible & certainly
once the drainage has stopped or become less than
25ml/day.
Position and moblization:
Turn in bed every 30 min until mobilization
DVT prevention (intermittent calf compression)
Diet:
Npo
Liquids
Semisolids
Solids
IV fluids:
Daily requirement lost from GIT & UT
Losses from STOMAS & drains
Insensible losses
care of renal patients
Monitore:
Vital signs
ECG
Fluid balance
Special monitoring (arterial pulses after vascular
surgery, level of consciousness after
neurosurgery
Respiratory care:
Oxygen mask
Ventilator
Tracheal suction
Chest physiotherapy
ERAS guidelines (suggest deep breathing and
spirometery prevents atelectasis)
 Operative Notes
After a surgical procedure, an OPERATIVE NOTES must be
written in the patient notes including orders for post op care.
all patients should be assessed daily, vitals recorded in
standard form of graph and can also include fluid balance
record.
Daily progress notes must comment on patients condition,
active complaints and any changes in management plan, they
should be signed by the person writing the notes.
Healing Yourself Is Connected With Healing Others!

Thank you