PRE-OPERATIVE & POSTOPERATIVE CARE
Begashaw M (MD)
General consideration

General medical & surgical history
 Complete P/E
 Lab:
_Complete blood count
_Blood typing & Rh-factor, crossmach
_Urinalysis
_Chest x-ray
Assessment

Cardiovascular System
 Pulmonary system
 Renal system
 Hematologic system
 Endocrine system
Cardiovascular System

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Heart diseasehigh-risk
chest pain, dyspnea, pretibial edema or
orthopnea
Recent history of CHF
Recent MI
Severe hypertension
DVT
Pulmonary system
 High
risk:
• Upper airway infections
• Pulmonary infections
• Chronic obstructive pulmonary diseases
chronic bronchitis, emphysema, asthma
 Elective surgery should be postponed
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
Haematological system


Anemia
affects the oxygen carrying capacity of the
blood
 Iron deficiency
 Megaloblastic
 Hemolytic
 Aplastic anemia
 Patients with iron deficiency anemia respond
to oral or parenteral iron therapy
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

Diabetes mellitus

poorly controlled DM -susceptible to postoperative sepsis
 In type - II patients-avoid hypoglycemia
 not use longer acting oral hypoglycemic
agents -2 days before operation
 Insulin dependent diabetics with good controlsliding scale
 Chronic cxs - Hypertension, myocardial
ischemia which may be silent-proper workup
& treatment
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may
take up to 2 months with anti-thyroid
medications
Post-operative care

is care given to patients after an operation in
order to minimize postoperative
complications
 Early detection & treatment of post
operative complications
Post-operative care

Aims: Comfortable, pain free recovery from
operation
– Immediaterecovery room
– Intermediate  ward
– Long term  home
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
On subsequent post-operative
days
a. Oral intake can be started
b. Patients encouraged to ambulate
Post Op Complications
General Immediate
1.
2.
3.
4.
5.
6.
7.
8.
Primary hemorrhage
Reactive hemorrhage
Basal Atelectasis
Minor lung collapse
Shock
Blood loss
MI, Pulmonary Embolism
Low Urine Output
Cardiac complications
1.
2.
3.
4.
Abnormal ECG
Acute MI
Arrhythmia
Pulmonary embolus
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
Treatment

Arresting hemorrhage
 Restore fluid & electrolyte balance
 Correct cardiac dysfunction
 Establish adequate ventilation
 Control pain & relief apprehension
 Blood transfusion if required
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
Treatment
 Warm
moist packs
 Elevation of the extremity
 Analgesics
 Anticoagulants
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
Treatment
 Elevation
 Application
of full leg gradient pressure
elastic hose
 Anticoagulants
 Prevention: Early ambulation
Pulmonary embolism

Pre-disposing factors
-Pelvic surgery
-Sepsis
-Obesity
-Malignancy
History of pulmonary embolism or deep vein
thrombosis
 7th to 10th post-operative day
 cardiac or pulmonary symptoms occur abruptly
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
Investigation

Chest X-ray=pulmonary opacity in the peripherytriangular 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
Respiratory complications
1.
2.
3.
4.
5.
Atelectasis
Aspiration pneumonitis/Pneumonia
Pulmonary edema
Pneumonia
Respiratory failure
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
Clinical features
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Fever
Increased pulse , respiratory rate
Cyanosis
Shortness of breath
Dull with absent breath sounds
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
Pneumonia and aspiration
pneumonitis
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Pneumonia -atelectasis or aspiration
Preexisting bronchitis
Clinical features
Fever
Respiratory difficulty
Cough becomes productive
pulmonary consolidation

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
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
Post operative intestinal
obstruction
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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
Urinary and renal complications

Urinary retention

Acute renal failure

Urinary tract infection
Urinary retention
 pelvic
operations
 spinal anesthesia
 Pain
Mx
 encouraged to get out of bed
 Bladder drainage _a urethral catheter
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
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
 Treatment
 Sutures
_remove
 wound exploration and culture
 drainage
 wound care
 antibiotics if systemic manifestations like
fever
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