Chapter 7 : Postoperative Care
Postoperative care is the management of a patient after surgery.
Immediate postoperative period is the crucial period when numerous physiological and pharmacodynamics changes occur due to surgical trauma and anesthesia.
The goals of postoperative care is to prevent complications such as,
Topics covered in this snack-sized chapter:
- To promote healing of the surgical incision.
Patients have generalized deterioration of organ function and loss of reserve capacity to withstand even minor stress like surgical trauma causing life-threatening complications.
The condition of older patients can change rapidly and therapy may need to be adjusted every few hours if optimum cardio-respiratory function is to be maintained.
- To return the patient to a state of health.
- Diagnose and treat complications quickly.
- Plan intensive monitoring during surgery and in postoperative wards.
- Institute invasive monitoring and elective ventilation when required.
Monitoring the following is essential:
- Continue with postoperative care to increase the rate of recovery.
- Blood pressure, temperature, pulse, respiratory rate.
- Electrolytes, glycemic control, liver and renal functions.
- Good nutritional intake and bowel movement.
- Fluid balance and urine output.
- Drain and wound status and appropriate care.
- Medication for pain relief.
The three factors which are interlinked to each other and produce combined ill effects leading to life threatening complications are:
- Mental and cardio respiratory status.
Anesthetic drugs and muscle relaxants may lead to profound vasodilatation and lot of fluid is diverted to extra cellular space.
Hypotension causes poor perfusion thereby leading to hypoxia.
Abdominal pain and the effects of opioid drugs given to relieve postoperative pain can depress respiratory function.
It is necessary to give oxygen to patients after surgery to prevent hypoxia.
There is a heat loss in the operating room under general anesthesia.
It is necessary to cover the patient with warm blankets in cold.
Control of infection is done with appropriate antibiotics after culture and sensitivity if required.
Prevention of pressure ulcers is a critical part of postoperative management.
Rehabilitation and follow up is important to continue the comprehensive care.
Postoperative complications can range from minor self-limiting problems to major life threatening ones depending on the nature of the surgery and the organ operated upon.
Complications can be due to:
Following are the complications associated with surgery:
- A reaction to the stress of surgery itself.
Circulatory Complications include:
- Circulatory Complications.
Shock is a life-threatening condition that occurs when the body is not getting enough blood flow.
Hypovolemic shock: Hypovolemia is a direct loss of effective circulating blood volume leading to:
Signs and Symptoms of Shock:
- A rapid, weak, thready pulse due to decreased blood flow combined with tachycardia.
- Cool, clammy skin due to vasoconstriction and stimulation of vasoconstriction.
- Rapid and shallow breathing due to sympathetic nervous system stimulation and acidosis.
- Hypothermia due to decreased perfusion and evaporation of sweat.
Cardiogenic shock: Cardiogenic shock occurs whenever the heart is unable to pump as much blood as the body needs.
- Thirst and dry mouth, due to fluid depletion.
- Symptoms of cardiogenic shock include:
- Distended jugular veins due to increased jugular venous pressure
- Arrhythmia, often tachycardic
Distributive shock: Distributive shock includes infectious, anaphylactic, Endocrine and neurogenic causes.
- Pressure on the heart due to a buildup of the fluid around it (pericardial tamponade).
Treatment of shock depends on the type of shock and the cause.
The primary treatment of Hypovolemic shock is the restoration of a blood volume.
Primary treatments for other types of shock might include the following:
- Checking of the airway and the administration of oxygen.
- Checking or changing the patient’s position to relieve pain or assist the airway.
- Attention to urinary volume and medication.
Hemorrhage is any profuse internal or external bleeding from the blood vessels.
Symptoms of Hemorrhage:
- The patient is apprehensive, restless and thirsty.
- The skin is cold, moist, pale and temperature falls.
Treatment of Hemorrhage:
- The pulse rate increases and respirations become rapid and deep.
- The surgeon must be notified immediately and emergency measures are instituted until patient arrives.
- The patient should be given oxygen, and the rate of intravenous drip should be increased.
- His feet should be elevated, if possible.
The patients who have a respiratory disease at the time of surgery are more likely to develop postoperative pulmonary complications.
Postoperative pulmonary complications, including pneumonia, bronchospasm, respiratory failure and prolonged mechanical ventilation, occur commonly and are a significant source of morbidity and mortality.
Treatment involved removal of fluid or air by needle aspiration and sedation.
Urinary Retention or complications may occur after any operation, but it occurs most frequently after operations on the rectum, anus, vagina or lower abdomen.
Urinary retention is defined as the inability to completely or partially empty the bladder.
Treatment depends on the individual patient but may include diuretics or increasing intravenous fluids.
Diuretics are the drugs that act directly on the kidneys to increase urine volume and to produce a net loss of solute and water.
Urinary incontinence (UI), involuntary urination, or enuresis is any involuntary leakage of urine. It can be a common and distressing problem, which may have a profound impact on the quality of life.
Pain is one of the main postoperative adverse outcomes causing distress to patients, prolonging hospital stay, and increasing the incidence of admissions after surgery.
Postoperative pain management aims not only to decrease pain intensity but also to increase patient’s comfort and to improve postoperative outcome.
The major goal in the management of postoperative pain is minimizing the dose of medications to lessen side effects while still providing adequate analgesia.
A multidisciplinary team approach is useful for formulating a plan for pain relief, particularly in complicated patients.
Multimodal analgesia is currently recommended for effective postoperative pain control.
- Blood pressure should be checked again.
Multimodal analgesia is achieved by combining different analgesics that act by different mechanisms resulting in additive pain relief, lower total doses of analgesics, and fewer side effects.
Multimodal analgesia includes various classes of drugs that are:
- A multimodal combination of regional analgesic techniques and systemic administration of analgesic agents results in better pain control.
- Non-steroidal anti-inflammatory drugs
- Cyclooxygenase-2-selective inhibitors
- N-methyl-D-aspartate antagonists
- Alpha-2 adrenergic agonists