PRE AND 

POST
O P E R AT I V E   C A R E  

TO: DR.BINIYAM.G
BY: BINIAM.M
OUTLINE 

Introduction
General consideration 
Assessment and Minimization of Surgical Risks
Post-operative care, complications and their Treatment 
INTRODUCTION

Surgery is an important treatment option for a wide range of acute and chronic
diseases. Around 10 million patients undergo a surgical procedure each year and
this number will continue to rise. 
For most patients surgery is a success, both in terms of the procedure itself and
the care before and afterwards. 
However, the population is changing and so must our services.  There are over
250,000 patients at higher risk from surgery and this number is set to rise. So
with increasing demand and the increasing complexity of surgical procedures,
come new challenges that we must address.
C O N T. . .

Surgery success depends on pre-op diagnosis and evaluation to ensure the

patient can handle the stress.
High-risk factors should be controlled beforehand. 
Adequate postoperative care is crucial for the patient's recovery and
managing postoperative complications.
H I S T O R Y TA K I N G

A standard history should be taken focusing on the patient’s hopes and

expectations (open questions and then listen), then on specific questions
aimed at clarifying the diagnosis and severity of symptoms (closed
questions). 
A set of fixed questions are needed to determine ‘fitness’ for
surgery.Surgery specific symptoms (including features not present), onset,
duration and exacerbating and relieving factors should also be documented.
C O N T.

The history of past surgery and anaesthesia can reveal problems that may
present during current hospitalisation (e.g. intraabdominal adhesions and
suxamethonium apnoea). 
The use of recreational drugs and alcohol consumption should be noted as
they are known to be associated with adverse outcomes. Check for
allergies and risk factors for deep vein thrombosis (DVT).
 Social history, ability to communicate and mobility are important in
planning rehabilitation after surgery 
E X A M I N AT I O N

 Patients should be treated with respect and dignity, receive a clear explanation of the examination
undertaken and kept as comfortable as possible
 General: Positive findings even if not related to the proposed procedure should be explored
 Surgery related: Type and site of surgery, complications which have occurred due to underlying
pathology
 Systemic: Comorbidities and their severity 
  Specific: For example, suitability for positioning during surgery
I N V E S T I G AT I O N S
I N V E S T I G AT I O N S

Type of surgery: Major surgery can lead to organ system dysfunction so

needs most investigations 
Comorbidities: the existence of more than one disease or condition within
your body at the same time.
C O N T.

Full blood count. A full blood count (FBC) is needed for major
operations, in the elderly and in those with anaemia or pathology with
ongoing blood loss.
Urea and electrolytes. Urea and electrolytes (U&E) are needed before all
major operations, in most patients over 60 years of age especially with
cardiovascular, renal and endocrine disease or if significant blood loss is
anticipated
C O N T.

It is also needed in those on medications which affect electrolyte levels, e.g.

steroids, diuretics, digoxin, NSAIDs (non-steroidal anti-inflammatory
drugs), intravenous fluid or nutrition therapy.
Electrocardiography. Electrocardiography (ECG) is required for those
patients aged over 60 years, cardiovascular, renal and cerebrovascular
involvement, diabetes and in those with severe respiratory problems.
C O N T. . .

Chest radiography. A chest x-ray is not required unless the patient has a
significant cardiac history, cardiac failure, severe chronic obstructive
pulmonary disease (COPD), acute respiratory symptoms, pulmonary
cancer, metastasis or effusions, or is at risk of tuberculosis.
Urinalysis. Dipstick testing of urine should be performed on all patients to
detect urinary infection, biliuria, glycosuria and inappropriate osmolality.
C O N T. . .

Human chorionic gonadotrophin. Pregnancy needs to be ruled out in all

women of childbearing age
Blood glucose and HbA1c. These should be performed in patients with
diabetes mellitus and endocrine problems. HbA1c indicates how well
diabetes has been controlled over a longer duration.
qC A R D I O VA S C U L A R S Y S T E M / C A R D I A C
PROBLEMS

Patients with heart disease should be considered high-risk surgical

candidates and must be fully evaluated. 
At preoperative assessment, it is important to identify the patients who
have a high perioperative risk of myocardial infarction (MI) and make
appropriate arrangements to reduce this risk. 
C O N T. . .

These patients include those who have suffered coronary artery disease,
congestive cardiac failure, arrhythmias, severe peripheral vascular disease,
cerebrovascular disease or renal failure, especially if they are undergoing
intra-abdominal or intrathoracic surgery.
In patients with ischaemic heart disease (IHD), the left ventricular status
can be evaluated using a stress test
C O N T. . .

The test has a high negative predictive value and a low positive predictive
value. 
In other words, if the test is negative, then the patient is unlikely to have
IHD and if it is positive the chances of the patient actually having IHD is
not high.
C O N T. . .

For patients with symptomatic valvular heart disease or poor left

ventricular function, an echocardiography should be performed.
 Pressure gradients across the valves, dimensions of the chambers and
contractility can be determined using echocardiography; an ejection
fraction of less than 30 per cent is associated with poor patient outcomes.
C O N T. . .

Cardiopulmonary exercise testing when performed provides a non-

invasive assessment of combined pulmonary, cardiac and circulatory
function
The patient should be referred to a cardiologist if:
A murmur is heard and the patient is symptomatic. 
The patient is known to have poor left ventricular function or
cardiomegaly.
C O N T. . .

Ischaemic changes can be seen on ECG even if patient is not symptomatic

(silent MI).
There is an abnormal rhythm on the ECG, tachy/bradycardia or a heart
block that may lead to cardiovascular compromise
H Y P E RT E N S I O N

Prior to elective surgery, blood pressure should be controlled to near

160/90 mmHg. If a new antihypertensive is introduced, a stabilisation
period of at least 2 weeks should be allowed.
Elective surgery should be postponed for three to six months after a
proven myocardial infarct to reduce the risk of perioperative reinfarction
C O N T. . .

Patients may have had coronary stents inserted for IHD and should be
asked about effectiveness of the treatment, concurrent antiplatelet
medications, e.g. clopidrogel and/or aspirin.
Risk of stent thrombosis with consequences of MI and death is reduced if
elective surgery is delayed until after dual antiplatelet therapy is stopped
(about 6 weeks after bare metal and 12 months after drug-eluting stent
insertion).
C O N T. . .

If surgery cannot be postponed and the risk of significant perioperative

bleeding is low, the dual antiplatelet therapy can be continued during
surgery.
If surgery poses a significant risk (spinal, intracranial, cardiac, posterior
chamber of eye and prostate surgery), clopidrogel may be stopped and
aspirin continued, however, cardiology opinion will need to be sought. 
C O N T. . .

Most long-term cardiac medications should be continued

over the perioperative period
Ongoing treatment with betablockers and statins is known to reduce
perioperative morbidity and mortality. 
SMOKING

Information should be provided to indicate perioperative risks associated

with smoking. Stopping smoking reduces carbon monoxide levels and the
patient is better able to clear sputum.
Asthma It is important to establish the severity of the asthma,
precipitating causes, frequency of bronchodilator and steroid use, PEFR
(peak expiratory flow rate) and any previous intensive care unit
admissions. 
C H R O N I C O B S T R U C T I V E P U L M O N A RY
DISEASE(COPD)

Patients on steroid treatment, or oxygen therapy, or who have a forced

expiratory volume in the first second (FEV1) less than 30 per cent of
predicted value (for age, weight and height) have severe disease and may
have respiratory failure in the postoperative period
C O N T. . .

Preoperative chest x-ray or scans are useful in patients with

known emphysematous bullae, pulmonary cancer, metastasis or effusions.
Patients with significant COPD who are undergoing major surgery will need to
be referred to the respiratory physicians for optimisation of their condition. 
An arterial blood gas analysis may also be useful as it can give an indication of
carbon dioxide retention. This is associated with an increased risk of
perioperative respiratory complications
INFECTION
GASTROINTESTINAL DISEASE

Nil by mouth and regular medications Patients are advised not to take
solids within 6 hours and clear fluids (isotonic drinks and water) within 2
hours before anaesthetic to avoid the risk of acid aspiration syndrome. 
Infants are allowed a clear drink up to 2 hours, mother’s milk up to 3
hours and cow or formula milk up to 6 hours before anaesthetic
C O N T. . .

If the surgery is delayed, oral (until 2 hours of surgery) or intravenous

fluids should be started especially in the vulnerable groups of patients, e.g.
children, elderly and diabetics.
 Patients can continue to take their specified routine medications with sips
of water in the nil by mouth period.
R E G U R G I TAT I O N R I S K

Patients with hiatus hernia, obesity, pregnancy and diabetes are at high
risk of pulmonary aspiration even if they have been NBM before elective
surgery. Clear antacids, H2-receptor blockers,
           e.g. Ranitidine or proton pump inhibitors, e.g. omeprazole, may be
given at the appropriate time in the preoperative period.
LIVER DISEASE

In patients with liver disease, the cause of the disease needs to be known,
as well as any evidence of clotting problems, renal involvement, and
encephalopathy
Elective surgery should be postponed until any acute episode has settled
(e.g. cholangitis). The blood tests which need to be performed are liver
function tests, coagulation, blood glucose, urea and electrolyte levels. 
G E N I TO U R I N A RY D I S E A S E

Renal disease Underlying conditions leading to chronic renal failure, such as

diabetes mellitus, hypertension and ischaemic heart disease, should be stabilised
before elective surgery. Appropriate measures should be taken to treat acidosis,
hypocalcaemia and hyperkalaemia of greater than 6 mmol/L. 
Arrangements should be made to continue peritoneal or haemodialysis until a
few hours before surgery.
 After the final dialysis before surgery, a blood sample should be sent for FBC
and U&E.
C O N T.

Chronic renal failure patients often suffer chronic microcytic anaemic that
is well tolerated, therefore preoperative blood transfusion is usually not
necessary.
Acute renal failure can present with acute surgical problems, for example
bowel obstruction needing emergency surgery.
In such patients, simultaneous medical and surgical treatment and critical
care unit support will be needed in the perioperative period.
U R I N A RY T R A C T I N F E C T I O N

Urinary tract infection Uncomplicated urinary infections are common in

women, while outflow uropathy with chronically infected urine is common in
men. 
These infections should be treated before embarking on elective surgery where
infection carries dire consequences,  
          e.g. joint replacement. For emergency procedures, antibiotics should be
started and care taken to ensure that the patient maintains a good urine output
before, during and after surgery
C O N T.

Associated sleep apnoea can be predicted by using a clinical scoring

system of perioperative sleep apnoea prediction (P-SAP) score or sleep
apnoea studies.
 Patients should be asked to continue to use a CPAP device for obstructive
sleep apnoea and cholesterol-reducing agents in the perioperative phase. If
possible, delay surgery until the patients are more active and have lost
weight. 
C O N T. . .

If this fails, prophylactic measures need to be taken (such as

preventative measures for acid aspiration and deep vein thrombosis (DVT)
and associated risks need to be explained prior to the surgery. 
DIABETES MELLITUS

Diabetes and associated cardiovascular and renal complications should be

controlled to as near normal level as possible before embarking on elective
surgery. 
Any history of hyper- and hypoglycaemic episodes, and hospital
admissions, should be noted. HbA1c levels should be checked.
 Lipid-lowering medication should be started in patients who are in a high-
risk group of cardiovascular complications of diabetes.
C O N T. . .

qPatients with diabetes should be first on the operating list and if they are
operated on in the morning advised to omit the morning dose of
medication and breakfast.
q Though tight control of blood sugar is not needed, the patient’s blood
sugar levels should be checked every 2 hours. 
C O N T. . .

qFor those on the afternoon list, breakfast can be given with half their
regular dose of insulin (or full-dose oral anti-diabetic agents) and then
managed with regular blood sugar checks as above. 
qAn intravenous insulin sliding scale should be started for insulin-
dependent diabetes mellitus undergoing major surgery or if blood sugar is
difficult to control for other reasons
A D R E N O C O RT I C A L S U P P R E S S I O N

Patients receiving oral adrenocortical steroids should be asked about the

dose and duration of the medication in view of supplementation with extra
doses of steroids perioperatively to avoid an Addisonian crisis.
C O A G U L AT I O N D I S O R D E R S

Thrombophilia Patients with a strong family history or previous personal

history of thrombosis should be identified. They will need
thromboprophylaxis in the perioperative period
The progesterone-only pill should be continued, however, the risks of
continuing the combined pill (slight increased risk of significant thrombosis)
should be weighed against the risks of an unplanned pregnancy. Hormone
replacement therapy (HRT) should be stopped 6 weeks prior to surgery.
C O N T. . .

Patients with a low risk of thromboembolism can be given

thromboembolism-deterrent stockings to wear during the perioperative
period. High-risk patients with a history of recurrent DVT, pulmonary
embolism (PE) and arterial thrombosis will be on warfarin. 
This should be stopped before surgery and replaced by low molecular weight
heparin or factor Xa inhibitors. Each hospital has guidelines which advise
what type of DVT prophylaxis should be used for each type of surgery.
N E U R O L O G I C A L A N D P S Y C H I AT R I C
DISORDERS

In patients with a history of stroke, pre-existing neurological deficit

should be recorded. These patients may be on antiplatelet agents or
anticoagulants. If it is felt that the neurological
And cardiovascular thrombotic risks are low, antiplatelet agents should be
withdrawn (7 days for aspirin, 10 days for clopidogrel). 
C O N T. . .

If the thrombotic risks are perceived to be high and the patient is
undergoing surgery with a high risk of bleeding, aspirin alone should be
continued. 
Anticonvulsant and antiparkinson medication is continued perioperatively
to help early mobilisation of the patient
C O N T. . .

Lithium should be stopped 24 hours prior to surgery; blood levels should

be measured to exclude toxicity. 
The anaesthetist should be informed if patients are on psychiatric
medications such as tricyclic antidepressants or monoamine oxidase
inhibitors, as these may interact with anaesthetic drugs
M U S C U L O S K E L E TA L A N D O T H E R
DISORDERS

Rheumatoid arthritis can lead to unstable cervical spine with the

possibility of spinal cord injury during intubation. Therefore, flexion and
extension lateral cervical spine x-rays should be obtained
Assessment of severity of renal, cardiac valvular and pericardial
involvement, as well as restrictive lung disease, should
C O N T. . .

Rheumatologists will advise on steroids and disease-modifying drugs so

as to balance immunosuppression (chance of infections) against the need
to stabilise the disease perioperatively (stopping disease-modifying drugs
can lead to flare up of the disease).
In ankylosing spondylitis patients in addition to the problems discussed
above, techniques of spinal or epidural anaesthesia are often challenging.
P R E O P E R AT I V E A S S E S S M E N T I N
E M E R G E N C Y S U R G E RY
In urgent or emergency surgery, the principles of preoperative assessment
should be the same as in elective surgery, except that the opportunity to
optimise the condition is limited by time constraints.
 Medical assessment and treatments should be started (e.g. according to the
Advanced Trauma Life Support (ATLS) guidelines) even if there is no time to
complete those before the surgical procedure is started.
Some risks may be reduced, but some may persist and whenever possible these
need to be explained to the patient
C O N T. . .

Start: Similar principles to that for elective surgery 

constraints: Time, facilities available 
Consent: May not be possible in life-saving emergencies 
Organisational efforts: For example, local/national algorithms for
treatment of multi-trauma patient
RISK ASSESSMENT AND CONSENT

All life- or limb-threatening complications and all complications with an

incidence of 1 per cent or more should be discussed with the patient
The risk of death doubles with every seven years of adult life lived. The
presence of peripheral vascular disease, stroke, heart failure, myocardial
infarction or renal failure each independently increases the risk of death by
C O N T. . .

-About 1.5 times the baseline. The risks of the surgical procedure itself are
then to be added on separately. 
 Valid consent implies that it is given voluntarily by a competent and
informed person who is not under duress 
 In emergency situations or in an unconscious patient, consent may not be
obtained and the procedure carried out ‘in the best interests of the
patient’.
C O N T. . .

Adults are presumed to have capacity to consent unless there is contrary

evidence. For adults who are not deemed competent to give consent,
treatment can still proceed in their best interests by filling in an inability to
consent form. 
Those under 16 years who demonstrate the ability to appreciate the risks
and benefits fully are deemed competent. This is known as Gillick
competence 
RISK ASSESSMENT AND CONSENT

Risks: Related to the comorbidities, anaesthesia and surgery 

■ Explain: Advantages, side effects, prognosis
■ Language: Simple, use daily life comparisons to explain risks
■ Consents: Valid consent is necessary except in life-saving circumstances
 TA K I N G A C O M P R E H E N S I V E C O N S E N T
(ACRONYM LED TO REASON).

• Lead: in Introduce yourself and identify the patient 

• Explore: How much does the patient know 
• Diagnosis: Why the operation is being proposed 
• Treatment: whether the treatment proposed is in accordance with
protocols and if not why not
C O N T. . .

Options Discuss all the options including that of doing nothing, use lay
language 
Results Explain likely outcome in terms of pain, mobility, work, diet and
return to normal activities 
Eventualities For example, the possibility of needing to remove the
testicle in a hernia operation 
C O N T. . .

qAdverse events Myocardial infarction, stroke and embolus, bleeding

and specific damage 
qSound mind Ask if they have understood 
qOpen question Check if further clarification is needed Notes 
qDocument everything discussed and agreed 
NUTRITION AND FLUID THERAPY

Fluid therapy and nutritional support are fundamental to good surgical

practice. Accurate fluid administration demands an understanding of
maintenance requirements and an appreciation of the consequences of
surgical disease on fluid losses.
 This requires knowledge of the consequences of surgical intervention and,
in particular, intestinal resection. Malnutrition is common in hospital
patients.
C O N T. . .

All patients who have sustained or who are likely to sustain 7 days of
inadequate oral intake should be considered for nutritional support. This
may be dietetic advice alone, sip feeding or enteral or parenteral nutrition. 
These are not mutually exclusive. The success or otherwise of nutritional
support should be determined by tolerance to nutrients provided and
nutritional end points, such as weight. 
C O N T. . .

The success or otherwise of nutritional support should be determined by

tolerance to nutrients provided and nutritional end points, such as weight. 
It is unrealistic to expect nutritional support to alter the natural history of
disease.
It is imperative that nutrition-related morbidity is kept to a This necessitates the
appropriate selection of feeding method, careful assessment of fluid, energy and
protein requirements, which are regularly monitored, and the avoidance of
overfeeding.
      P O S T O P E R AT I V E
       CARE
C O N T. . .

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.
C O N T. . .

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.
GENERAL MANAGEMENT

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
C O N T. . .

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.
C O N T. . .

  Oxygen, fluids and analgesics have been prescribed. 

  There are no concerns related to the surgical procedure
S Y S T E M - S P E C I F I C P O S T O P E R AT I V E
C O M P L I C AT I O N S

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. 
R E S P I R AT O R Y C O M P L I C AT I O N S

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.
C A R D I O VA S C U L A R C O M P L I C AT I O N S

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
C O N T. . .

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
A N D   I N FA R C T I O N

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. 
R E N A L A N D U R I N A R Y C O M P L I C AT I O N S

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 
C O N T. . .

Postoperative renal failure is associated with high mortality. 

Prophylactic measures to prevent renal failure should be taken in high risk
cases. 
Urinary retention and infection are a common problem postoperatively
C O N T. . .

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 per cent decrease in GFR (glomerular filtration rate); aggressive
treatment should be started at this early stage to avoid further damage.
U R I N A RY R E T E N T I O N

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.
U R I N A RY I N F E C T I O N

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.
G E N E R A L P O S T O P E R AT I V E P R O B L E M S
AND MANAGEMENT

Hypothermia and shivering Anaesthesia induces loss of

thermoregulatory control. Exposure of skin and organs to a cold operating
environment, volatile skin preparation (which cool by evaporation), and
the infusion of cold i.v. fluids all lead to hypothermia. 
.
FEVER

About 40 per cent of patients develop pyrexia after major surgery;

however, in most cases no cause is found.
The inflammatory response to surgical trauma may manifest itself as
fever, and so pyrexia does not necessarily imply sepsis.
However, in all patients with a pyrexia, a focus of infection should be
sought.
C O N T. . .

Patients with a persistent pyrexia need a thorough review. Relevant

investigations include full blood count, urine culture, sputum microscopy
and blood cultures
PROPHYLAXIS AGAINST INFECTION

In patients who have had foreign material inserted during the operation,
including a hip or knee prosthesis in orthopaedic surgery or aortic valves
in cardiovascular surgery, up to three doses of a prophylactic antibiotic
should be administered, usually one dose 30 minutes before ‘knife to skin’
and two postoperatively.
C O N T. . .

Bacteria can be incorporated into the biofilm that forms on the surface of
the implant, where they are protected from antibiotics and from the natural
defences 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
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 poor nutritional status, dehydration and lack of mobility
and also include the use of a nerve block anaesthesia technique.
C O N T. . .

Early mobilisation 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 filter mattress, which automatically
relieves the pressure areas 
Preventing pressure sores
 ■ Recognise patients at risk 
■ Address nutritional status 
■ Keep patients mobile or regularly turned if bed-bound
WOUND CARE

Within hours of the wound being closed, the dead space fills up with an
inflammatory exudate. Within 48 hours of closure, a layer of epidermal
cells from the wound edge bridges the gap. So, sterile dressings applied in
theatre should not be removed before this time.
Wounds should be inspected only if there is any concern about their
condition or the dressing needs changing.
C O N T. .

Inspection of the wound should be performed under sterile conditions. If the

wound looks inflamed, a wound swab may need to be taken and sent for Gram
staining and culture.
 Infected wounds and hematoma may need treatment with antibiotics or even a
wound washout. 
Samples obtained at this time should be sent for bacteriology (before any
antibiotics are given), any dead tissue excised and bleeding vessels identified
and closed off. 
C O N T. . .

The patient should return to theatre every 24–48 hours for further cleaning
until the wound is clean enough to close.
Skin sutures or clips are usually removed between 6 and 10 days after surgery. 
The period can be shorter in wounds on the face or neck, and are left longer if
incision has been closed under tension.
 If the wound is healing satisfactorily, then the patient may be allowed to
shower one week after surgery. Wound healing is delayed in patients who are
malnourished, or have vitamin A and C deficiency.
C O N T. . .

q If the wound is healing satisfactorily, then the patient may be allowed
to shower one week after surgery. Wound healing is delayed in patients
who are malnourished, or have vitamin A and C deficiency.
Steroids also inhibit the adequate healing of wounds as they inhibit protein
synthesis and fibroblast proliferation. Diabetes, particularly if
uncontrolled, also has a deleterious effect on wound healing
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.
C O N T. . .

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 
E N H A N C E D R E C O V E RY

Enhanced recovery is an approach to the perioperative care of patients

undergoing surgery. It is designed to speed clinical recovery of the patient,
and reduce the cost and the length of stay of the patient in the hospital.
It is achieved by optimising the health of the patient before surgery and
then delivering evidence-based best care in the perioperative period. 
C O N T. . .

Postoperative strategies for enhanced recovery include: 

Early planned physiotherapy and mobilisation. 
Early oral hydration and nourishment. 
 Good pain control using regular paracetamol with nonsteroidal anti-
inflammatory drugs (NSAIDs). Epidurals and nerve blocks are managed
by acute pain teams.
C O N T. . .

Discharge planning is started before the patient is even admitted to

hospital and involves support from stoma care nurses, physiotherapists and
other community care workers
C O N T. . .

Early mobilisation is encouraged to reduce the risks of DVT, urinary

retention, atelectasis, pressure sores and faecal impaction.
Telephone follow up is carried out to make sure that the patient is
recovering well once discharged.
REFERENCE