P0ST-OPERATIVE

CARE

PHASES
IMMEDIATE
PHASE (1)

( POST-ANAESTHETIC )

INTERMEDIATE
PHASE (2)

( HOSPITAL STAY )

CONVALESCENT
TO FULL RECOVERY )

( AFTER DISCHARGE

AIM OF PHASES 1 & 2

HOMEOSTASIS
TREATMENT OF PAIN
PREVENTION & EARLY
DETECTION OF COMPLICATIONS

IMMEDIATE
POST-OPERATIVE
PERIOD

CAUSES OF
COMPLICATIONS & DEATH
ACUTE PULMONARY PROBLEMS
CARDIO-VASCULAR PROBLEMS
FLUID DERANGEMENTS

PREVENTION

RECOVERY ROOM :

TRAINED NURSING STAFF :

CONTINUOUS MONITORING OF
PATIENT ( VITAL SIGNS etc.)

ANAESTHETIST RESPONSIBILITIES TOWARDS

CARDIO-PULMONARY FUNCTIONS.
SURGEONS RESPONSIBILITIES TOWARDS THE
OPERATION SITE.
T0 HANDLE INSTRUCTIONS.

DISCHARGE FROM RECOVERY

SHOULD BE AFTER COMPLETE
STABILIZATION OF CARDIOVASCULAR, PULMONARY AND
NEUROLOGICAL FUNCTIONS
WHICH USUALLY TAKES 2-4
HOURS.
IF NOT
SPECIAL CARE IN
ICU.

Post-Operative
Orders
A) Monitoring

Vital sign (pulse, BP, R.R, Temp) every 15-30

min.
C.V.P (? Swan gins for pulmonary artery
wedge pressure) and arterial line for
continuous BP measurement.
ECG
Fluid balance ( intake and output) ? Needs
urinary catheter.
Other types of monitoring :

Arterial pulses after vascular surgery.

Level of consciousness after neurosurgery.

Post-Operative Orders
B) Respiratory Care:

O2 mask.
Ventilator.
Tracheal suction.
Chest physiotherapy.

C) Position in bed and mobilization:

Turning in bed usually every 30 min. until full
mobilization.
Special position required sometimes.
DVT prevention mechanically ( intermittent calf
compression).

D) Diet:

NPO
Liquids.
Soft diet.
Normal or special diet.

E) Administration of I.V. fluids:

Daily requirements.
Losses from G.I.T and U.T.
Losses from stomas and drains.
Insensible losses.
Care of renal patients.
If care of drainage tubes.

G) Medication:

Antibiotics.
Pain killers.
Sedatives.
Pre-operative medication.
Care of patients on Pre-Op. Steroids.
H2 Blockers specially in ICU patients.
Anti-Coagulants.
Anti Diabetics.
Anti Hypertensives.

H) Lab. Tests and Imaging:

To detect or exclude Post-Op. complications.

The Intermediate
Post-Operative period
Starts with complete recovery
from anaesthesia and lasts for
the rest of the hospital stay.

Care of the wound

Epithelialisation takes 48 hs.
Dressing can be removed 3-4 days after operation.
Wet dressing should be removed earlier and changed.
Symptoms and signs of infection should be looked
for, which if present
compression, removal of
few stitches and daily dressing with swab for C & S.
R.O.S. usually 5-7 days Post-Op.
Tensile strength of wound minimal during first 5
days, then rapid between 5th
20th day then slowly
again (full strength takes 1-2 years).
Good nutrition.

Management of drains
To drain fluids accumulating after surgery,
blood or pus.
Open or closed system.
Other types (Suction, sump, under water etc.)
Should be removed as long as no function.
Should come out throw separate incision to
minimize risk of wound infection.
Inspection of contents and its amount.
Soft drains e.g. Penrose should not be left
more than 40 days because they form a tract
and acts as a plug.

Post-Operative
pulmonary Care
Functional residual capacity ( FRC) and vital capacity
(VC) decrease after major intra-abdominal surgery
down to 40% of the Pre-Op. Level.
They go up slowly to 60-70% by 6th -7th day and to
normal Pre-Op. Level after that.
FRC, VC, and Post-Op. pulmonary oedema (Post
anaesthesia) Contribute to the changes in pulmonary
functions Post-Op.
The above changes are accentuated by obesity,
heavy smoking or Pre-existing lung diseases
specially in elderly.

 Post-Op. atelectasis is enhanced by shallow

breathing, pain, obesity and abdominal distension
(restriction of diaphragmatic movements)
Post-Op. physiotherapy especially deep inspiration
helps to decrease atelectasis. Also O2 mask and
periodic hyperinflation using spirometer.
Early mobilization helps a lot.
Antibiotics and treatment of heart failure Post-Op.
by adequate management of fluids will help to
reduce pulmonary oedema.

Respiratory failure
Early :

Occurs minutes to 1-2 hs. Post-Op.

No definite cause.
Occurs suddenly.

Late :

Occurs 48 hs. Post-Op.

Due to pulmonary embolism, abdominal distension or
opioid overdose.

Manifestation :

Tachypnea > 25-30/min.

Low tidal volume < 4ml /kg
High Pco2 > 45mmHg.
Low Po2 < 60mmHg.

 Treatment :

Immediate intubation and mechanical ventilation.

Treatment of atelectasis, pneumonia or pneumothorax if
any.

Prevention:

Physiotherapy (Pre. & Post-OP.) to prevent atelectasis.

Treatment of any Pre-existing pulmonary diseases.
Hydration of patient to avoid hypovolaemia and later on
atelectasis and infection.
May be hyperventilation to compensate for insufficiency of
lungs.
Use of epidural block or local analgesia in patients with
COPD to relieve pain and permits effective respiratory
muscle functions

Post-Operative fluid &

Electrolytes management
Considerations:

Maintenance requirements.
Extra needs resulting from systemic factors e.g. fever, burn
diarrhea and vomiting etc.
Losses from drains and fistulas.
Tissue oedema (3rd space losses)

The daily maintenance requirements in adult for sensible and

insensible losses are 1500-2500mls. depending on age, sex,
weight and body surface area.
Rough estimation of need is by body weight x 30/day. e.g. 60 KG
x 30 = 1800ml/day.
Requirements is increased with fever, hyperventilation and
increased catabolic states.

 Estimation of electrolytes daily is only necessary in

critical patients.
Potassium should not be added to IV fluid during first 24hs.
Post-Op. (because Potassium enters circulation during this
time and causes increased aldosterone activity).
Other electrolytes are corrected according to deficits.
5% dextrose in normal saline or in lactated Ringers
solution is suitable for most patients.
Usual daily requirements of fluids is between 20002500ml/day.

Post-Operative Care of
GIT
NPO until peristalsis returns.
Paralytic ileus usually takes about 24hs.
NGT is necessary after esophageal and gastric
surgery.
NGT is NOT necessary after cholecystectomy,
pelvic operation or colonic resections.
Gastrostomy and jujenostomy tubes feeding can
start on 2nd Post-Op. day because absorption from
small bowel is not affected by laparotomy.
Enteral feeding is better than parenteral feeding.
Gradual return of oral feeding from liquids to
normal diet.

Post-Operative Pain
Factors affecting severity :

Duration of surgery.
Degree of Operative trauma (intra-thoracic, intra-abdominal or
superficial surgery).
Type of incision.
Magnitude of intra-operative retraction.
Factors related to the patient :
Anxiety.
Fear.
Physical and cultural characteristics.

Pain transmission :

Splanchnic nerves to spinal cord.

Brain stem due to alteration in ventilation, BP and endocrine
functions.
Cortical response from voluntary movements and emotions.

 Complications of Pain:

Causes vasospasm.
Hypertension.
May cause CVA, MI or bleeding.

Management of Post-Op. pain:

Physician patient communication (reassurance).

Parenteral opioids.
Analgesics (NSAIDS).
Anxiolytic agents (Hydroxyzine) potentiates action of
opioids and has also an anti-emetic effects.
Oral analgesics or suppositories e.g. Tylenol.
Epidural analgesia (for pelvic surgery).
Nerve block (Post-thoracotomy and hernia repair).