PRE-OPERATIVE & POST-OPERATIVE CARE

1. PRE-OPERATIVE &POST-OPERATIVE CARE Begashaw M (MD)

2. General consideration • General medical &surgical history • Complete P/E • Lab: _Complete blood count _Blood typing & Rh-factor, crossmach _Urinalysis _Chest x-ray

3. Assessment Cardiovascular System Pulmonary system Renal system Hematologic system Endocrine system

4. Cardiovascular System • Heart diseasehigh-risk • chest pain, dyspnea, pretibial edema or orthopnea • Recent history of CHF • Recent MI • Severe hypertension • DVT

5. Pulmonary system • High risk: • Upper airway infections • Pulmonary infections • Chronic obstructive pulmonary diseaseschronic bronchitis, emphysema, asthma • Elective surgery should be postponed

6. Renal system • Renal function test: -history of kidney disease -diabetes mellitus -hypertension -over 60 years of age -proteinuria, casts or red cells • creatinine clearance, blood urea nitrogen and electrolyte

7. Haematological system • Anemia • affects the oxygen carrying capacity of the blood • Iron deficiency • Megaloblastic • Hemolytic • Aplasticanemia • Patients with iron deficiency anemia respond to oral or parenteral iron therapy

8. Thrombocytopenia • Normal platelet 150,000 to 450,000/ml • Manifestations: • Petechia • Epistaxis • Menorhagia • Uncontrolled bleeding • Treatment -treat the underlying cause -support with platelet transfusions & clotting factors

9. Diabetes mellitus • poorly controlled DM -susceptible to post-operative sepsis • In type - II patients-avoid hypoglycemia • not use longer acting oral hypoglycemic agents -2 days before operation • Insulin dependent diabetics with good control-sliding scale • Chronic cxs - Hypertension, myocardial ischemia which may be silent-proper workup &treatment

10. Thyroid disease Elective surgery should be postponed when thyroid function is either excessive or inadequate In Hyperthyroidism, the patient should be rendered euthyroid before surgerymaytake up to 2 months with anti-thyroid medications

11. Post-operative care is care given to patients after an operation in order to minimize postoperative complications Early detection &treatment of post operative complications

12. Post-operative care Aims: Comfortable, pain free recovery from operation Immediaterecoveryroom Intermediate ward Long term home

13. Immediate care a. Vital sign b. Chest auscultation c. Input and output monitoring d. Checking for bladder &abdominal distention e. Potent analgesics for pain relief

14. On subsequent post-operative days a. Oral intake can be started b. Patients encouraged to ambulate

15. Post Op Complications General Immediate Primary hemorrhage Reactive hemorrhage Basal Atelectasis Minor lung collapse Shock Blood loss MI, Pulmonary Embolism Low Urine Output

16. Cardiac complications Abnormal ECG Acute MI Arrhythmia Pulmonary embolus

17. Shock • Postoperative efficiency of circulation depends on blood volume, cardiac function, neurovascular tone • Shock: • Excessive blood loss • Third spacing • Marked peripheral vasodilatations • Sepsis • Pain or emotional stress

18. Treatment • Arresting hemorrhage • Restore fluid &electrolyte balance • Correct cardiac dysfunction • Establish adequate ventilation • Control pain &relief apprehension • Blood transfusion if required

19. Thrombophlebitis • Superficial thrombophlebitis -within the first few days after operation • Clinical features A segment of superficial saphenous vein becomes inflamed manifested by: • Redness • Localized heat • Swelling • Tenderness

20. Treatment • Warm moist packs • Elevation of the extremity • Analgesics • Anticoagulants

21. Thrombophlebitis of the deep veins • Occurs most often in the calf Clinical features • asymptomatic • dull ache • tender &spasm • swelling of calf • Dorsiflexion of the foot may elicit pain in the calf Homan’s sign • pulmonary embolism

22. Treatment • Elevation • Application of full leg gradient pressure elastic hose • Anticoagulants • Prevention: Early ambulation

23. Pulmonary embolism • Pre-disposing factors -Pelvic surgery -Sepsis -Obesity -Malignancy History of pulmonary embolism or deep vein thrombosis • 7thto 10thpost-operative day • cardiac or pulmonary symptoms occur abruptly

24. Clinical features • chest pain; severe dyspnea, cyanosis, tachycardia, hypotension or shock, restlessness and anxiety • pleuritic chest pain • blood-streaked sputum, and dry cough • pleural friction rub

25. Investigation • Chest X-ray=pulmonary opacity in the periphery-triangular in shape with the base on pleural surface, enlargement of pulmonary artery, small pleural effusion and elevated diaphragm • ECG • Treatment Cardiopulmonary resuscitation measures Treatment of acid-base abnormality Treatment of shock Immediate therapy with Heparin

26. Respiratory complications Atelectasis Aspiration pneumonitis/Pneumonia Pulmonary edema Pneumonia Respiratory failure

27. Atelectasis • early postoperative period-48 hrs • airway collapse distal to an occlusion • Predisposing factors • chronic bronchitis, asthma, smoking and respiratory infection • Inadequate immediate postoperative deep breathing and delayed ambulation

28. Clinical features • Fever • Increased pulse , respiratory rate • Cyanosis • Shortness of breath • Dull with absent breath sounds

29. Investigation and Treatment • CXR - patchy opacity - mediastinal shift Prevention and treatment • stop smoking • Treat chronic lung diseases • Postpone elective surgery • encourage sitting, early ambulation • Adminster analgesics • Supplemental oxygen

30. Pneumonia and aspiration pneumonitis • Pneumonia -atelectasis or aspiration • Preexisting bronchitis • Clinical features • Fever • Respiratory difficulty • Cough becomes productive • pulmonary consolidation

31. Chest-x-ray _diffuse patchy infiltrates or lobar consolidation • Prevention and treatment • minimized by - Fasting - Naso-gastric tube decompression • Treatment • Deep breathing and coughing • Change position • Broad spectrum antibiotics

32. Paralytic Ileus • functional intestinal obstruction usually noted within the first 48-72 hours Clinical features • Abdominal distention • Absent bowel sounds • Generalized tympanicity on percussion Investigation • Plain x-ray-generalized dilatation and gaseous distention of the bowel loops Treatment • NGT decompression • Fluid and electrolyte balance

33. Post operative intestinal obstruction • Causes _Peritonitis,Peritoneal irritation, Fibrinous adhesion • Clinical features • between the 5th and 6th POD • vomiting • Crampy abdominal pain • Focal typmpanicity • Exaggerated bowel sounds • Investigation • Plain film _distension of small bowel with air fluid levels • Treatment • Hydration & electrolyte • keet NPO • NGT • After 48-72 hours, reoperation

34. Urinary and renal complications Urinary retention Acute renal failure Urinary tract infection

35. Urinary retention • pelvic operations • spinal anesthesia • Pain Mx • encouraged to get out of bed • Bladder drainage _a urethral catheter

36. Urinary tract infection • Predisposing factor contamination of the urinary tract Catheterization • Clinical presentation Fever Suprapubic or flank tenderness Nausea and vomiting • Investigation Urine analysis • Treatment Increase hydration Encourage activity appropriate antibiotic therapy

37. Wound infections • Pre disposing factors Age General health Nutritional status hygiene Malignancy Poor surgical technique Diagnosis: clinical Fever during the 4th to 5th POD Redness or induration

38. Treatment • Sutures _remove • wound exploration and culture • drainage • wound care • antibiotics if systemic manifestations like fever

39. Hematoma, Abscess and Seromas may occur in the pelvis or under the fascia of abdominal rectus muscle falling of hematocrit low-grade fever Small hematoma or seroma _resolve spontaneously Ultrasonography Drainage of infected hematoma