Postoperative care

INTRODUCTION

 The aim of postoperative care is to provide the patient with as quick,

painless and safe recovery from surgery as possible.
 Trainees should acquire knowledge and skills to manage surgical, as well as
medical, postoperative problems.
GENERAL MANAGEMENT
The immediate postoperative period: recovery
room
 The theatre team should formally hand over the care of the patient to the
recovery staff. The information provided should include the patient’s name,
age, the surgical procedure, existing medical problems, allergies, the anaesthetic
and analgesics given, fluid replacement, blood loss, urine output, any surgical
and anaesthetic problems encountered or expected.
 Patient’s vital parameters, consciousness, pain and hydration status are
monitored in the recovery room and supportive treatment is given.
 Specific monitoring, such as Doppler flow for a free flap, observations like
neurological evaluation and laboratory tests such as blood gas analysis may
also be requested where necessary.
 The patient can be discharged from the recovery room when they fulfil the
following criteria:
 Patient is fully conscious.
 Respiration and oxygenation are satisfactory.
 Patient is Normothermic, 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.
SYSTEM-SPECIFIC POSTOPERATIVE COMPLICATIONS

 The presentation of complications may be similar for more than one

underlying condition.
 Shortness of breath can be due to respiratory or cardiac problems,
abdominal pain can be due to surgical causes or sepsis, while chest pain may
be present in cardiac, respiratory and even in gastrointestinal problems.
Respiratory complications

 The most common respiratory complications in the recovery room are

hypoxaemia, hypercapnia and aspiration.
 Pneumonia and pulmonary embolism tend to appear later in the
postoperative period.
Postoperative hypoxia

 Hypoxia is defined as an oxygen saturation of less than 90 percent.

Hypoxia may present as shortness of breath or agitation or as upper airway
obstruction (absence of air movement, seesaw motion of chest, suprasternal
recession) or cyanosis or as a combination of any of the above.
 Hypoxia in the postoperative period may occur due to a variety of reasons, for
example:
 Upper airway obstruction due to the residual effect of general anaesthesia, secretions or
wound haematoma after neck surgery.
 Laryngeal oedema from traumatic tracheal intubation, recurrent laryngeal nerve palsy and
tracheal collapse after thyroid surgery.
 Hypoventilation related to anaesthesia or surgery.
 Atelectasis and pneumonia especially after upper abdominal and thoracic surgery.
 Pulmonary oedema of cardiac origin or related to fluid overload. Pulmonary embolism: this
often presents with the sudden onset of chest pain and shortness of breath.
 In the presence of a large embolism, there will be systemic hypotension, pulmonary
hypertension and an elevated central venous pressure (CVP).
 In obese patients or in those with acute or chronic lung disease, hypoxia develops
more quickly.
 Patients with hypoxia or imminent signs should be treated urgently.
 If the patient is breathing spontaneously administer oxygen at 15 L/min, using a
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
may be needed.
 Call the anaesthetist as tracheal intubation and manual ventilation may also be
needed.
 Neck wound haematoma can become a life-threatening emergency, and must
be evacuated immediately under local or general anaesthetic.
 Along with the immediate management of hypoxia, appropriate antibiotics,
chest physiotherapy and bronchodilators will be needed to treat pneumonia.
 In the case of pulmonary oedema, diuretics should be started and a
cardiology opinion should be sought.
Cardiovascular complications

 Hypotension in the immediate postoperative period may be due to

inadequate fluid replacement, vasodilatation from subarachnoid and epidural
anaesthesia or rewarming of the patient.
 However, other causes of hypotension such as surgical bleeding, sepsis,
arrhythmias, myocardial infarction, cardiac failure, tension pneumothorax,
pulmonary embolism, pericardial tamponade and anaphylaxis should be also
sought.
 Patients with hypotension are likely to have cold clammy extremities,
tachycardia and a low urine output ≤0.5 mL/kg per hour and low CVP.
 Hypovolaemia should be corrected with intravenous crystalloid or colloid
infusions (see below under Bleeding).
Myocardial ischaemia and infarction

 Patients with previous cardiac problems undergoing major surgery are at risk
of developing an acute coronary syndrome.
 They commonly present with retrosternal pain radiating into the neck, jaw or
arms and may also have nausea, dyspnoea or syncope.
 Typically, there is a ST-elevation in two continuous leads on the ECG or new
left bundle branch block (STEMI), though this may not always be present
(non-ST-elevation myocardial infarction (NSTEMI)).
 However, serum troponin levels will be high in both types of MI (myocardial
ischemia and myocardial infarction).
 Start treatment with oxygen, glycerol trinitrate, morphine and aspirin and
involve a cardiologist.
 Beta-blockers and/or calcium antagonists may be started to reduce further
episodes of ischaemia.
 Cardiologists may start coronary reperfusion therapy for STEMI in the form
of primary percutaneous coronary intervention or thrombolysis.
 However, these should be discussed first with a senior due to the risk of
bleeding after major surgery.
Arrhythmias

 Arrhythmia in the postoperative period can cause hypotension and ischaemia.

 Therefore, these patients will need to be continuously monitored.
Treatment should be delivered according to the Resuscitation Council peri-
arrest guidelines, correcting underlying causes including acid-base and
electrolyte imbalance, hypoxia and hypercapnia.
 Tachycardia (sinus or supraventricular) may be caused by anxiety, pain, MI,
hypovolaemia, sepsis or hypoxia in the postoperative period.
 Correct any underlying causes of the dysrhythmia and control the heart rate
with beta-blockers, amiodarone or cardioversion.
 Sinus bradycardia may be normal in athletes, but it may also be associated
with hypoxia, preoperative beta-blockers, dioxin and increased intracranial
pressure.
 If the heart rate is 40 bpi or less, glycopyrrolate 0.2–0.4 mg or atropine 0.6
mg should be given intravenously and the patient reviewed.
Renal and urinary complications

Acute renal failure

 About a quarter 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 known 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.
 If urine output is less than 0.5 mL/kg per hour for 6 hours, check that the
catheter is not blocked, correct hypovolaemia, correct metabolic and
electrolyte disturbances, and stop nephrotoxic drugs.
 Stage I of kidney failure is associated with a rise in serum creatinine levels to
more than 1.5 times baseline or a greater than 25% decrease in GFR
(glomerular filtration rate); aggressive treatment should be started at this early
stage to avoid further damage.
Urinary retention

 Inability to void after surgery is common with pelvic and perineal operations
or after procedures performed under spinal anaesthesia.
Pain, fluid deficiency, problems in accessing urinals and bed pans, and lack of
privacy on wards may contribute to the problem of urine retention.
 The diagnosis of retention may be confirmed by clinical examination and by
using ultrasound imaging.
 Catheterisation should be performed prophylactically when an operation is
expected to last 3 hours or longer or when large volumes of fluid are
administered.
Urinary infection

 Urinary infection is one of the most commonly acquired infections in the

postoperative period.
 Patients may present with dysuria and/or pyrexia. Immunocompromised
patients, diabetics and those patients with a history of urinary retention are
known to be at higher risk.
 Treatment involves adequate hydration, proper bladder drainage and
antibiotics depending on the sensitivity of the microorganisms.
COMPLICATIONS RELATED TO SPECIFIC
SURGICAL SPECIALTIES
Abdominal surgery

 The abdomen should be examined daily for excessive distension, tenderness

or drainage from wounds or drain sites.
 In certain operations, such as those for intestinal obstruction, oesophageal
and gastric procedures (but not in lower intestinal operations), a nasogastric
tube may be used.
 It is of particular value in those patients suffering from ileus or a marked
level of altered consciousness who are therefore liable to aspirate.
Paralytic ileus

 Paralytic ileus may present with nausea, vomiting, loss of appetite, bowel
distension and absence of flatus or bowel movements.
 Following laparotomy, gastrointestinal motility temporarily decreases.
 Treatment is usually supportive with maintenance of adequate hydration and
electrolyte levels. However, intestinal complications may present as prolonged
ileus and so should be actively sought and treated.
 Return of function of the intestine occurs in the following order: small
bowel, large bowel and then stomach.
 This pattern allows the passage of faeces despite continuing lack of stomach
emptying and, therefore, vomiting may continue even when the lower bowel
has already started functioning normally.
Localised infection

 An abscess may present with persistent abdominal pain, focal tenderness and
a spiking fever.
 The patient may have a prolonged ileus.
 If the abscess is deep-seated, these symptoms may be absent.
 The patient will have a neutrophilic leukocytosis and may have positive
blood cultures.
 An ultrasound or computed tomography (CT) scan of the abdomen should
identify any suspicious collection and will identify the subphrenic abscess
which can otherwise be difficult to find.
Orthopaedic surgery

 In patients who have undergone open reduction and internal fixation of

fractures, and especially if a tourniquet has been used, the neurovascular status
of the limb must be checked every half an hour first in recovery and then on
the ward for at least a further 4 hours.
 Plasters should always be split for the first 24 hours (or until swelling starts
to reduce) and the nurses given instructions to check and record distal
circulation every 4 hours.
 If the patient has an external fixator, the pin sites should be checked daily for
signs of infection.
 Radiographs are taken after the operation to check that the implants are
correctly positioned and that fractures remain reduced.
 Patients with compartment syndrome complain of pain out of proportion
to that expected. It is not relieved by simple analgesics.
 Passive stretching of the muscles in the affected compartment produces
severe pain.
 The limb is usually swollen and tense and, in the later stages, there may be
altered sensation distally.
 Distal pulses are only lost at a very late stage and so their presence does not
exclude a compartment syndrome.
 Intra compartmental pressure studies are not reliable so should only be used
in the unconscious patient.
 If there is any possibility that a patient might have a compartment syndrome
then all circumferential dressings should be removed at once.
 If there is no immediate improvement in the pain, then a fasciotomy should
be performed.
 The diagnosis is a clinical one and is made on suspicion not certainty.
Neck surgery

 Patients having neck surgery, e.g. thyroid surgery, must be observed for
accumulation of blood in the wound, which may cause rapid asphyxia.
 A check also needs to be made pre- and postoperatively for damage to the
recurrent laryngeal nerve.
 The findings must be recorded in the medical notes.
Thoracic surgery
 Fluid intake should be restricted in patients undergoing a lobectomy or
pneumonectomy as they are susceptible to fluid overload in the first 24–48 hours
postoperatively.
 Chest drains require regular review.
 If the fluid in a chest drain swings then the drain has been inserted correctly in the
pleural cavity.
 If the chest drain continues to bubble, then a bronchopleural fistula probably
exists.
 A haemothorax or pleural effusion will reveal itself as a prolonged loss of blood or
fluid, respectively, into the drain.
 Cardiac patients require continuous electrocardiography monitoring
postoperatively
Neurosurgery
 Postoperatively, the patient should be kept under close observation.
 A rise in intracranial pressure may be signalled by a deterioration in the state
of consciousness, as well as by the appearance of new neurological signs.
 Some patients may have an intracranial monitoring device to allow for more
sensitive monitoring.
Vascular surgery
 The patency of grafts and anastomoses in patients with femoropopliteal
bypasses and abdominal aneurysmal repairs needs to be checked by regular
clinical assessment of the limbs and by
 Doppler ultrasound in the postoperative phase.
Plastic surgery
 The viability of flaps is crucial and the perfusion needs to be monitored
regularly.
 The blood supply may be compromised by position, dressings or collection
of fluids or blood beneath the flap.
Urology
 Catheter patency must be checked regularly following urological surgery.
 In patients who have undergone transurethral resection of the prostate
(TURP), continuous bladder irrigation may be used, and pulmonary oedema
may develop if a large amount of irrigation fluid is absorbed into the
circulation.
GENERAL POSTOPERATIVE PROBLEMS AND
MANAGEMENT
Pain

t
Fluid and nutrition

g
Nausea and vomiting
 Postoperative nausea and vomiting (PONV) can precipitate bleeding and
dehiscence of wounds by dislodging the clots and bursting suture lines.
 In neurosurgical patients, it may precipitate raised intracranial pressure with
disastrous effects.
 Women, non-smokers or those who have a past history of PONV, motion
sickness or migraine are known to have a higher risk of developing PONV.
 Use of volatile anaesthetic agents, opioids and nitrous oxide add to the risk.
 Duration and type of surgery also affect the incidence of PONV.
 Adequate treatment of pain, anxiety, hypotension and dehydration will
minimise the risk of the patient developing PONV.
 Administer antiemetics that work at different sites, such as HT3 receptor
antagonists (e.g. ondansetron), steroids (e.g. dexamethasone), phenothiazines
(e.g. prochlorperazine), antihistamines (e.g. cyclizine).
 At least one antiemetic should be given on a regular basis in the high risk
group of patients and a second one written up to be given when needed.