Post-operative Care and

Complications

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Outline

• Introduction
• Phases of post OP care
• Post OP complications
a. Immediate
b. Early
c. Late

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Introduction
 Care is given to the patient after an operation in order to minimize post
operation complications.
 To provide the patient with quick, painless and safe recovery from
surgery
 Early detection and treatment is possible if there is optimal care and
assessment
 Requires appropriate skills and knowledge to manage medical as well
surgical post OP problems

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 Phases of Post-operative Care
1. Immediate phase
2. Intermediate phase
3. Convalescent phase

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Immediate Phase
• ASA and AAGBI standards for procedures requiring GA and CNB
• Transfer to recovery room/PACU
• Staff trained
• Standards of equipment and discharge criteria
• post op observations
• Ensure airway, breathing & circulation are satisfactory
• Monitor pain
• Watch for complications (like bleeding from the wound)
• Monitor BP, pulse, oxygen saturation
• Temperature
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Con..
The patient can be discharged from the recovery room when they fulfill
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 surgical procedure

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Intermediate Phase
• Starts with complete recovery from anesthesia & lasts for the rest of
hospital stay. It includes
 Wound care,
 Drains,
 Nasogastric tube,
 Urinary catheters,
 Oxygen therapy
 Fluid management and
 Pain control

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1. Wound Care
• Dressings should be applied and
removed correctly.
• Skin sutures should be removed at the
appropriate time and replaced by tape.
• Wound healing and wound problems.

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 2. Drains
• Drains & tubes are placed in
a wide variety of locations.
• To prevent accumulation of
air and to prevent
accumulation of fluids
(blood, pus, infected fluids)

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3. Nasogastric tube
• Is specialized tube that
carries foods and
medicines to stomach
through nose.
• It is commonly placed
in GI operations for
treatment of ileus.
• Usually for drainage of
gastric secretions.

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4. Urinary catheters
• Commonly placed after
bladder or GU surgery
• Used to empty bladder and
collect urine in drainage bag
• To provide accurate
measurement of volume output

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 5. Oxygen therapy
• Often necessary after a surgical
procedure.
• Indicators
• shallow breathing & pain
• atelectasis
• operative manipulation in the chest
cavity
• post-op impairment of breathing
mechanics

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6. Fluid management
• To restore lost volume

7. Pain control
• To relieve the suffering and stress
• Through the use of analgesics

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Convalescent Phase
• Between the end of a disease and the patient’s restoration to complete
health.
• Transition period from the time of hospital discharge to full recovery.

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In summary
• All anaesthetized patients should be recovered in dedicated PACU
• All vital parameters should be monitored and documented acc.to the
local protocols
• Treat pain and nausea/vomiting
• Observe for complications

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 Post-operative Complication Classification
• Immediate complications ; <24 hours
• Early complications ; 1-10 days
• Late complications ; >10days

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Immediate Complications

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• Immediate complications are complications that happen within 24hour
period of time. Like:
 Fever
 Primary hemorrhage
 Low urinary output
 Cardiovascular complications and
 Respiratory complications

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Fever (Pyrexia)
• Pyrexia (fever) refers to a raised body temperature, typically greater
than 37.5c.
• Common in surgical patients, either normal immediate post-
operative response or as feature of a specific post-operative
complication.
• The most common cause of pyrexia in the post-operative patient is
infection.
• Drug interaction and transfusion reaction are less common causes.

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• The specific post-operative day on which the fever develops may
indicate the source of the infection:
• Day 1-2 – consider a respiratory source (or body’s routine response to
surgery)
• Day 3-5 – consider a respiratory or urinary tract source
• Day 5-7 – consider a surgical site infection or abscess/collection
formation
• Any day post-operatively – consider infected IV lines or central lines as
a source
Hemorrhage
• It is the most common complication.
• Can be due to
• coagulation or clotting factor defect, continuous bleeding from wound site,
• failed hemostasis, and
• associate injury which went unnoticed during surgery.
• The clinical manifestation will be according to the volume of blood
that is lost.

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Cont.
• Presentation
• low blood pressure,
• rapid pulse, paleness,
• hematoma formation,
• bruising at the site of surgery,
• Continuously soaking wound dressing
• Rx:
• adequate resuscitation,
• reopen the wound to secure hemostasis,
• Tx of blood or blood products such as platelets or fresh frozen plasma

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Acute Kidney Injury/Oliguria

• Oliguria, or low urine output, is common in the postoperative patient and

is often the first presenting sign of acute kidney injury (AKI) or acute
renal failure (ARF).
• While oliguria can occur in any patient, patients with preexisting chronic
kidney disease (CKD) are at higher risk.
• Other risk factors include advanced age, heart failure, hypertension,
peripheral vascular disease, diabetes,

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Respiratory system Complications
o Atelectasis
o Pneumonia
o Aspiration pneumonitis
o Pulmonary edema
o ARDS
o Pulmonary embolism

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1. Atelectasis
• A condition characterized by areas of airway collapse distal to an
occlusion.
• Most common post operative pulmonary complication.
• Often a precursor or contributor to other important, and often more severe,
post-operative pulmonary complications such as pneumonia.

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Predisposing factors
• The main risk factors for developing atelectasis in the surgical patient
include:
1. Smoking
2. Pulmonary problem(bronchitis, asthma etc)
3. Depressed cough reflex
4. NGT
5. Congestion of bronchial wall

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Clinical Features
• The most common clinical
features are increased
respiratory rate and
reduced oxygen saturations.

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Cardiac complications
• Individuals with cardiovascular conditions are at an increased risk for
postoperative complications.
• For this reason, underlying vascular conditions, such as hypertension,
should be corrected as much as possible before the procedure.
• Most common cardiac complications are
• Myocardial Infarction
• Heart Failure
• Arrythmia
• Stroke

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Presentation of cardiac complications
 Dyspnea
 Tachycardia
 Arrhythmia
 Hypotension

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Myocardial Infarction
• The most common cardiac complication.
• Diagnosis:
• ECG: characteristic abnormalities depending on the location/type of MI
• Troponin levels: elevated
• Echocardiography : can help predict survival and look for complications of MI
• Coronary angiography: gold standard test 
• Management:
• Varies according to hemodynamic stability
• MONA therapy: morphine, oxygen, nitroglycerin , and aspirin Statins to reduce
in-hospital mortality

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Early Complications

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Early complications
• Acute confusional state
• DVT and PTE
• Acute urinary retention, UTI
• Surgical site infection
• Pressure sores
• Wound complications
• Pneumonia ,Pneumothorax, Atelectasis

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Confusional State
• Develops in 10% of patients especially elderly
• High morbidity and mortality
• Anxiety, incoherent speech, cloudy consciousness, destructive
behavior, sleep deprivation…
• Various causes
• Renal
• Respiratory
• Cardiovascular
• Drugs
• Idiopathic
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Deep Vein Thrombosis
• It presents with calf pain, swelling,
warmth, tenderness, engorged veins and
Homan’s sign.
• Risk factors include
• Age > 60
• Recent surgery
• Immobilization
• Trauma
• OCP
• Obesity
• Heart Failure
• Cancer

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Cont…
Treatment
• IV heparin initially, then long-term warfarin
• Untreated DVT results in chronic venous insufficiency and pulmonary
embolism.
• Preventive measures include
o Early ambulation
o Hydration
o Compression stockings
o LMWH as prophylaxis
o Minimal use of tourniquets

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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.

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Urinary Retention
• Inability to void after surgery is common with pelvic and perineal
operations, or after procedures performed under spinal anesthesia.
• Pain, hypovolemia, problems with access to urinals and bed pans and a
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.
• Catheterization should be performed prophylactically when an
operation is expected to last 3 hours or longer, or when large volumes
of fluid are administered.
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Paralytic Ileus
• Paralytic ileus describes a deceleration or arrest in
intestinal motility following surgery.
• It is classified as a functional bowel obstruction and
is very common, particularly after abdominal surgery
or pelvic orthopaedic surgery.

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Clinical Features
• Common presenting features therefore are:
• Failure to pass flatus or feces
• Loss of appetite,
• Sensation of bloating and distention
• Nausea and vomiting
• On examination, there will be abdominal distention and absent bowel
sounds (whereas in mechanical obstruction there are classically
‘tinkling’ bowel sounds present).

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Risk Factors
• Patient Factors
• Increased age
• Electrolyte derangement (e.g. Na+, K+ and Ca2+ derangement)
• Use of anti-cholinergic medication
• Surgical Factors
• Use of opioid medication
• Pelvic surgery
• Peritoneal contamination (by free pus or faeces)
• Intestinal resection

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Management
• Treatment is usually supportive, with maintenance of adequate
hydration and electrolyte levels.
• Any established postoperative ileus should be initially managed
with:
• Nil-by-mouth (NBM), ensuring adequate maintenance intravenous fluids
• Correct any electrolyte abnormalities
• Encourage mobilization as tolerated
• Reduce opiate analgesia and any other bowel mobility reducing
medication

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Pressure sores
• Are injuries to skin and
underlying tissue primarily
caused by prolonged
pressure on the skin
• Mainly occur in sacrum,
greater trochanter and heels.
• Poor nutritional status,
dehydration, lack of
mobility
• Careful positioning and
padding

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Pulmonary embolus
• The blockage of
pulmonary arteries in the
lungs by blood clot.
• Signs and symptoms
• Diagnosis by history and
physical examination
• Investigation
• management

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 Late complications
Bowel Obstruction due to Fibrous Adhesions

• Major cause of small bowel obstruction

• causes

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 Clinical Features
• Adhesions themselves are generally asymptomatic. 
Rather, it is the effect of the adhesions that present with
clinical features .

Investigations and Management

• The patient should be kept nil-by-
mouth, prescribed intravenous fluids, and provided with
adequate analgesia.
• Surgical intervention in adhesional bowel obstruction is
warranted in any patient with clinical features of ischemia
or perforation.
• For those warranting surgical management, adhesiolysis
can be performed laparoscopically or via an open approach.

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Incisional hernia
• An incisional hernia is the protrusion of the contents
of a cavity through a previously made incision in
the compartment’s wall.

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Clinical Features
• The characteristic clinical feature of an incisional hernia is a reducible,
soft and non-tender swelling at or near the site of a previous surgical
wound. If the hernia is incarcerated, it can become painful, tender, and
erythematous.
• On examination, a mass is palpable at or near the site of the surgical
incision, which may be reducible into the abdominal cavity.

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Investigations
• In most cases of incisional hernia, the diagnosis is made on a
clinical basis. However, often radiological imaging can be used to
confirm the diagnosis, most commonly CT imaging.
Management
• surgical intervention.

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Prevention of Complications
• To avoid surgical complications, there are standard
preventive mechanisms including:
• Preoperative “huddles” and/or “time-outs”: a time when
the entire team meets to review plans and address any
potential safety concerns prior to the case
• Policies regarding antibiotic, catheter, and drain use

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Cont….
• Prophylaxis measures against some of the most common
complications, based on individual risk factors:
• Anticoagulation and early ambulation to prevent DVT /PE
• Holding anticoagulation to prevent hemorrhage
• β-blockers to prevent MI
• Preoperative antibiotics and surgical preparations to prevent SSI
• Incentive spirometry to prevent atelectasis 
• Discontinuing catheters, drains, and lines as soon as possible to prevent
infection

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References
• Williams, N. S., K., B. C. J., O'Connell, P. R., Bailey, H., & McNeill, L. R. J.
(2018). Bailey & Love's short practice of surgery. CRC Press.
• Brunicardi, F. C., & Schwartz, S. I. (2005). Schwartz's principles of surgery. New
York: McGraw-Hill, Health Pub.

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 THANK YOU!

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