Post-Operative problems in Patients…

Submitted By… M.Abdullah 3rd Year O.T.T

Learning Objectives…Wound complicationsSeromaHaematomaWound DehiscenceSSIOliguriaAltered sensorium DVTPulmonary embolism

First Post-operative Assessment…

The first postoperative assessment should take place immediately after surgery on return to the ward.

It provides A baseline against the patient’s condition. Identifies problems occurred on transfer from the

operating department. Respiratory status Mental status

Post-operative Complications … Days……..(0-2) Fever Days……( 3-5 )Bronchopneumonia.SepsisDrip site infection Abscess formation

After 5 days:Specific complications related to surgery eg. fistula formation.

After the first week:HaemorrhageWound infection. UTI. DVT.

Wound Complications….

Seroma

Haematoma

Wound Dehiscence

SSI (Surgical Site Infections)

Seroma…Collection of liquid , serum and lymphatic fluid under

the incision. Mostly yellow fluid.Localised and swelling.Place drain during surgery/ aspiration.

Hematoma…Abnormal collection of blood, usually in a potential

space in abdominal cavity.

Wound Dehiscence… Separation of ant. abd. wound involving the

anterior fascia and deeper layers. Causes….

Pat. with poor nutrition , obesity. Increased intra-abd. pressure. Hemorrhage Infection Poor suture technique Drain and stoma placed along incision.

Treatment….. Occlusive dressing

Wound Infection…. Major factors:

1) Breaks in surgical technique2) Host parasite relationship

Potential sources of contamination:1) Patients themselves2) Operating room and personnel.

Organisms:1) S. aureus2) E. coli, Bacteroides , Proteus, Klebsiella ,

Pseudomonas.

Pulmonary infections:1. Atelectasis2. Aspiration pneumonia

Urinary tract infection: Indwelling urinary catheter

E. coli, Pseudomonas, klebsiella

Intra-abdominal infection:

Abdominal abscess Sites:

1. Sub-phrenic ---> most common2. Pelvis3. Liver

Treatment: drain ---> explor lap / needle aspiration

Wound Infections… Most common form is superficial wound infection

occurring within the first week.

Presenting as Localised painRedness and slight discharge usually caused by skin

staphylococci.

Cellulitis and Abscesses…

Most present within the first week But can be seen as late as the third postoperative week, even

after leaving hospital.

Present with fever and spreading cellulitis or abscess.Cellulitis is treated with antibiotics.

Abscess requires suture removal and probing of the wound but deeper abscess may require surgical re-exploration. The wound is left open in both cases to heal by secondary intention.

Gas Gangrene ….. Is uncommon and life-threatening.

Wound Sinus… A late infectious complication from a deep chronic

abscess that can occur after apparently normal healing.

It usually needs re-exploration to remove non-absorbable suture or mesh, which is often the underlying cause.

Disordered wound healing…Most wounds heal without complications.

Factors which may affect healing rate are:Poor blood supply.Excess suture tension.Long-term steroids.Immunosuppressive therapy.Radiotherapy.Severe rheumatoid disease.Malnutrition and vitamin defi.

Oliguria…. Urine volume less than 1ml/kg/hr or <400ml /day. This may be the result of fluid and blood loss. Considered acute renal failure.

There is an increased release of aldosterone and ADH in the first 24 hours after surgery. This results in both salt and water retention.

Causes…..1. Catheter obstruction2. Pre-renal failure3. Electrolyte Imbalance (hyperkalemia)4. Hemodialysis

Management of Oliguria….

Minimal acceptable output is 1 ml/kg/hrTake records of fluid intake and output.

If oliguria is associated with other symptoms of fluid depletion, it should be treated initially with a fluid challenge.

Exclude obstruction of the urinary tract like urinary catheter.

Diuretics (NSAIDS), Dopamine should not be used .

Altered Sensorium….

• Sensorium… Ability of the brain to receive and interpret sensory stimuli.

• Good Sensorium = Alertness +Awareness • Altered Sensorium…. • Not a disease but a symptom.• Altered sensorium can be determined by evaluating

level of consciousness.

Some Common Terms in Altered Sensorium….

Confusion..Impaired attention and concentration, Manifest disorientation in time, place and person,

impersistant thinking, speech etc. Delirium… Disturbed state of mind characterized by restlessness ,

illusion , confusing speech and thinking.

Amnesia…Loss of past memories and to an ability to form new ones,

Dementia… Memory loss.

Phychosis….Refers to a mental state often

described as involving a "loss of contact with reality".

Initial Actions….Assessment of the ABC's.

Cardiac monitoring and pulse oximetry .

Supplemental oxygen

Bedside glucose testing

Intravenous access (Dextrose)

Consider naloxone administration if narcotic overdose is suspected.

Neurologic Status….Checked by GCS scale.

Treatment…. ‘’TONG’’ T=Thiamine , O=oxygenN = Naloxone , G= Glucose

DVT ……. Post operative Immobilisation

Prolonged bed rest

Usually occurs within 6 days post op.Signs and symptoms of DVT….Edema , Redness, Warmth ,Prolonged dull pain,Low grade fever,

Investigations… DopplerDVT Prophylaxis….• Graduated compression stockings• • Intermittent pneumatic compression• • Aspirin• • Heparin• • Vitamin K antagonists (warfarin, acenocoumarol, phenindione,

and dicoumarol)• • Fondaparinux

Pulmonary Embolism…No specific signs and symptoms.

Dyspnoea, chest pain, hemoptysis , CVS collapse tachycardia, or dysarrhythmia. Investigations…. Oxygen saturation, CXR, ECG, CT ChestPulmonary Angiography

Pulmonary Embolism…

Management… Supplemental O2Maintain vitalsAnticoagulantsEmbolectomy (surgical removal of embolus)

Thank you....