POST OPERATIVE CARE

UNIT 2
POSTGRADUATES,
Department of OBGY,
RMC, Kakinada.
A. Introduction and Pain control -Dr Prasanna
B. Diet, fluids and electrolytes, management with foleys- Dr Shreya
C. Post operative delirium and cardiac complications –Dr Rachana
D. Postoperative fever and pulmonary complications Dr Rani neelima.
E. GIT complications –Dr Jhansi
F. Wound management –Dr Sindhu
• Assessment and treatment of postoperative complications is critical
for the comprehensive care of surgical patients.
• The goal of postoperative assessment is to ensure proper healing as
well as rule out the presence of complications, which can affect the
patient from head to toe, including the neurologic, cardiovascular,
pulmonary, renal, gastrointestinal, hematologic, endocrine and
infectious systems.
• Fluids and electrolyte shifts are normal after surgery, and their
management is very important for healing and progression.
• The women’s condition is assessed in the immediate post-operative
period.
• On collecting and returning to the post-natal area with the woman from
the recovery room:
• 1. Assess level of consciousness
• 2. Record BP, temperature, pulse every 30minutes for 4hours
• 3. Oxygen administration if necessary
• 4. Patency of urinary catheter, colour and amount of urine
• 5.Blood transfusion is advised if intraoperative blood loss is more than
estimated.
• Wounds for ooze
• Breast feeding has to be inititated within 1hour.
IMMEDIATE POSTOPERATIVE
CARE
A. Pain control
B .Diet
C. Fluid and electrolytes
D. Management with Foley’s catheter.
INTERMEDIATE POST OPERATIVE
CARE
A. Post operative delirium
B. Cardiac complications
C. Pulmonary complications
D. Gastrointestinal complications
E. Renal and electrolyte imbalances
F. Post operative transfusion
G. Wound care
H. Venous thromboembolism
PAIN CONTROL
• Patients with preexisting pain syndromes and patients with a
history of opioid use may have a high tolerance for opioid
analgesics
• Thus different levels of postoperative pain exist in different
patients even after similar procedures.
• The factors responsible for these differences include duration of
surgery, type of incision, and magnitude of intraoperative
retraction.
• Gentle handling of tissues, minimally invasive approaches, and
good muscle relaxation help lessen the severity of postoperative
pain.
• The physiology of postoperative pain involves transmission of pain
impulses via splanchnic afferent fibers to the central nervous system,
where they initiate spinal, brain stem, and cortical reflexes.
• Skeletal muscle spasm, vasospasm, and gastrointestinal (GI) ileus
result from stimulation of neurons in the anterior horn.
• Brain stem responses to pain include alterations in blood pressure,
ventilation, and endocrine function.
• Voluntary movements and psychological changes, such as fear and
anxiety, are cortical responses. These emotional responses lower the
threshold for pain perception and perpetuate the pain experience
• Postoperative pain can lead to the release of catecholamines and
other stress hormones that cause vasospasm and hypertension, which
may contribute to complications such as stroke, myocardial infarction
(MI), and bleeding.
• Poor pain control leads to
• Decreased satisfaction with care
• Prolonged recovery time
• Increased use of health care resources, and
• Increased costs.
 Non opioid Treatment
• The two major classes of non opioid therapies are Acetaminophen and
nonsteroidal anti-inflammatory drugs (NSAIDs).
• Multimodal pain control postoperatively using a combination of
intravenous (IV) NSAIDs and Acetaminophen can ,
• 1.Enhance analgesia
• 2.Lower narcotic need
• 3 .Decrease the incidence of postoperative nausea and vomiting by as
much as 30%.
• Acetaminophen is hepatotoxic in high doses, and the total daily dose
should not exceed 4000 mg/day.
• NSAIDs can be nephrotoxic and should be used with caution in
patients with chronic kidney disease
Opioid Treatment
• The management of moderate to severe pain typically includes the
administration of opioids.
• Most evidence suggests that oral and parenteral modes of
administration are equally effective
• The three most commonly prescribed parenteral opioids are
• 1.Morphine
• 2. Hydromorphone
• 3.Fentanyl.
• Morphine is prescribed most frequently following gynecologic surgery
and is a potent μ opiate receptor agonist, which leads to
• 1. Euphoria
• 2. Respiratory depression
• 3.Decreased GI motility
• Hydromorphone (Dilaudid) is a semisynthetic analogue of morphine.
It is available for delivery by multiple routes, including oral,
intramuscular, IV, rectal, and subcutaneous
• It is a suitable patient-controlled analgesia alternative in patients with
a morphine allergy.
• Fentanyl, a potent synthetic opiate, is more lipophilic than is
morphine and displays a shorter duration of action and half-life.
DIET
• Patients should resume eating and drinking as soon as possible after
surgery.
• Clear liquids can be offered as soon as the patient is awake, alert, and
capable of swallowing.
• Solid food can be provided on postoperative day 1.
• In 2014, the Cochrane Collaborative reviewed “early feeding” after
gynecologic surgery, defined as oral intake of fluids or food within the first
24 hours after surgery, regardless of the presence of signs that indicate
the return of bowel function.
• It has been associated with a faster return of GI function, reduced
morbidity (less infectious complications and improved wound healing),
and improved patient quality of life (satisfaction and ambulation)
FLUIDS AND ELECTROLYTES
• Postoperative fluid replacement should account for
1.Intraoperative blood loss
2.Insensible losses as well as maintenance requirements, loss from drains
3.Third-space losses from tissue edema, ascites, and ileus.
• IV fluid replacement is particularly important in patients who are not
able to tolerate oral fluids.
• A rough estimate of daily maintenance requirements for sensible and
insensible losses can be obtained by multiplying the patient’s weight
(in kilograms) times 30 mL (Ex. 1800 mL/24 h in a 60-kg patient).
• Fever and hyperventilation can increase maintenance requirements.
• Sepsis and bowel obstructions will require ongoing fluid replacement
beyond maintenance.
• Clinical signs such as
• 1.Urine output
• 2.Heart rate
• 3.Blood pressure can guide fluid management in patients with
normal renal function.
ELECTROLYTES
• Routine measurement of serum electrolytes is not necessary for
patients requiring IV fluid replacement for a short period.
• Patients with significant medical comorbidities (such as type I
diabetes or chronic kidney disease) and those with extra fluid losses,
sepsis, preexisting electrolyte abnormalities, or other complicating
factors may warrant electrolyte assessment.
• Traditional surgical management includes provision of dextrose containing IV
fluids, such as 5% dextrose in normal saline or in lactated Ringer solution.
• The goal of the administration of dextrose containing IV fluids is to provide
enough carbohydrate to prevent breakdown of lean body mass.
• If intake is insufficient to meet the requirement of key vital organs, the body
metabolizes hepatic glycogen to provide glucose.
• Once hepatic glycogen stores have been depleted (after about 1 day of no
intake), lean muscle mass is converted to glucose via gluconeogenesis.
• Provision of only 100 g of exogenous glucose per day is sufficient to prevent
breakdown of lean muscle mass in otherwise healthy subjects
Hypovolemic Shock
• Circulatory dysfunction decreases tissue oxygenation and results in
multi organ failure if not recognized and treated promptly
• In gynaecology, the most frequent cause of shock is haemorrhage
related hypovolemia, although cardiogenic, septic, and neurogenic
shock are considered during patient evaluation.
• Hypovolemic shock may develop before, after, or during surgery.
 Hyponatremia
• This common imbalance is defined as a serum sodium level < 135
mEq/L and may produce symptoms as levels drop below 125 mEq/L.
• Most common causes are
• 1. Hypotonic fluid administration .
• 2. Aggressive IV crystalloid resuscitation with comparatively hypotonic
fluids
• 3 . Pain or drugs can induce water retention through a syndrome of
inappropriate ADH (SIADH).
• 4. Excessive renal excretion of sodium seen with diuretic overuse and
Adrenal insufficiency.
• 5. Extrarenal sodium losses may follow profuse diarrhoea,vomiting
and nasogastric suctioning.
• Severe hyponatremia can lead to Metabolic Encephalopathy with
associated Cerebral Edema, Seizures, increased intracranial pressure,
and even respiratory arrest.
• Treatment strategies incorporate the patient’s extracellular volume
status and the presence or absence of symptoms.
• The speed of correction ideally does not exceed 0.5 mEq/L/hr or a
serum Sodium goal of 130 mEq/L.
• Over aggressive correction can result in a specific demyelination
disorder known as Central Pontine Myelinolysis.
• In those without symptoms, careful replacement with isotonic fluids
and treatment of underlying conditions will correct most cases.
• With associated hypervolemia, furosemide may be added.
• In those with acute neurologic symptoms,3percent saline can be
given in 100ml infusion over 30minutes and repeated on additional 2
times if needed.
Hypernatremia
• Hypernatremia is defined as a serum sodium concentration exceeding
145 mEq/L.
• Common causes are diarrhoea, gastric secretions, and sweat.
• The resulting plasma hypertonicity draws water out of cells to
maintain intravascular fluid compartment volume.
• Brain cell shrinkage can cause vascular bleeds and permanent neurologic damage.

• To restore brain cell volume, the brain metabolically generates compensatory

compounds, termed idiogenic osmoles, which pull water back into its cells.

• Therefore, aggressive treatment with hypotonic fluids to overcorrect can create

1. Cerebral edema
2. Seizure
3. Coma
4. Death.

• Volume replacement to correct hemodynamic instability is initiated with isotonic

fluids or colloid fluids.
• Diabetes insipidus is a condition of renal water wasting, and an
excessive amount of urine devoid of solutes is produced.
• Central diabetes insipidus is caused by a failure to release ADH
whereas nephrogenic diabetes insipidus is caused by a deficit in the
renal responsiveness to ADH.
• As treatment, the free water deficit is replaced over 2 to 3 days.
• In cases of central diabetes insipidus, the addition of ADH
(vasopressin) prevents ongoing free water loss .
Hypokalemia
• It is defined as serum potassium below 3.5 mEq/L.
• Is usually caused by diarrhoea or by abnormal renal loss secondary to
metabolic alkalosis.
• Mild hypokalemia is often asymptomatic, but nonspecific symptoms
seen with progression include generalized weakness and constipation
• When the serum levels fall below 2.5 mEq/L, muscle necrosis can begin,
and an ascending paralysis can develop with levels below 2.0 mEq/L.
• Hypokalemia in isolation does not produce cardiac arrhythmia, but it
can promote dysfunction in combination with Magnesium depletion
and Myocardial Ischemia.
 MANAGEMENT WITH FOLEYS
CATHETER
• After pelvic surgery, 20%-50% of patients experience postoperative urinary
retention, with the highest rates after surgery for pelvic organ prolapse or
urinary incontinence.
• The causes of postoperative urinary retention are multifactorial, including
• 1. Local inflammation
• 2. Decreased detrusor contractions
• 3. Impaired sensation of bladder fullness.
• To reduce catheter-associated urinary tract infections and promote
ambulation, the use of indwelling Foley catheters should be minimized
after gynecologic surgery.
Passive Voiding Trial
• At the conclusion of surgery, the Foley catheter is removed in the
operating room.
• The patient is given up to 6 hours to spontaneously void. If the patient
urinates >200 mL and feels subjectively empty, the he/she is
considered to have “passed” the voiding trial.
• However, if the patient is unable to urinate, the bladder is scanned.
• If the bladder volume is >500 mL, the patient is diagnosed with
postoperative urinary retention, the Foley is replaced, and a voiding
trial is repeated in 24-48 hours.
• Patients with urinary retention who otherwise meet criteria for
hospital discharge are sent home with a catheter after being provided
with instructions for catheter care.
Active Voiding Trial
• The patient is transferred to the recovery area with the Foley catheter in
place. After the initial recovery period, the bladder is backfilled with 300
mL of sterile saline.
• The Foley catheter is removed and the patient is given up to 30 minutes
to urinate.
• If the patient is able to void >200 mL and feels subjectively empty, the
patient is considered to have “passed” the voiding trial.
• If the volume is 1/3 of the original instillation, the Foley catheter is
replaced, and a voiding trial is repeated in 24- 48 hours.
• A recently published RCT compared passive and active voiding trials
on time to hospital discharge and rates of urinary tract infection and
urinary retention.
• Active voiding trial was associated with a 63% reduction in urinary
tract infection,
• 3.6-hour reduction in time to void, and
• no differences in urinary retention rates
INTERMEDIATE POSTOPERATIVE
CARE
• Postoperative Delirium

• It is an acute cognitive dysfunction marked by

1. Fluctuating disorientation
2. Sensory disturbance
3. Decreased attention
• While delirium is experienced by nearly 10%-25% of all postoperative
patients, the impact is highest in the elderly population.
Risk Factors for Postoperative
Delirium
• The postoperative phase of surgery exposes patients to many other
factors that may precipitate or exacerbate delirium .
• Frail patients are particularly vulnerable to these risk factors and are
more susceptible to developing dementia.
• These factors can augment each other, and the result may be a vicious
cycle
• For example, postoperative pain can lead to decreased mobility,
causing
• 1.Respiratory compromise
• 2.Atelectasis
• 3. Hypoxemia
• Escalating doses of narcotics to treat pain can cause respiratory
depression and respiratory acidosis.
• Hypoxemia and delirium can cause
• Agitation, prompting treatment with benzodiazepines, further
worsening respiratory function, and delirium.
• Serious complications or even death can result if this vicious cycle is
not interrupted.
Evaluation of the Patient With
Delirium
• Once the diagnosis of postoperative delirium is established, it is
important to recognize that some of the causes of delirium are
potentially life threatening, and immediate action is necessary.
• The history should focus on precipitating events such as
• 1. Falls
• 2. Acute change in medications used (opioids and sedation).
• 3. Alcohol withdrawal, as alcohol use is under reported.
• Review of vital signs and labs or hypoxemia may suggest
1.Sepsis
2.Hypovolemia
3.Anemia
4.Dehydration
Treatment of Delirium
• Treatment of postoperative delirium should first address the
underlying causes.
• Family members and friends should be encouraged to provide
daytime stimulation and orientation and to promote nighttime rest.
• Regular mealtimes and orienting communication are simple and
effective.
• A dark room which is quiet throughout the evening, and minimization
of interruptions help promote sleep.
 Cardiac Complications
• Patients with poorly controlled hypertension preoperatively (diastolic
blood pressure >110 mm Hg) tend to have more blood pressure lability
after surgery as compared to those with well-controlled hypertension.
• Several possible triggers may raise blood pressures in the first 24 hours
after surgery.
• An abrupt withdrawal of a β blocker or centrally acting sympatholytic
agents such as Clonidine can cause rebound hypertension.
• Postoperative recovery, sympathetic hyperactivity may stem from
inadequate pain management or from alcohol withdrawal.
• Fluid overload and hypertension can be seen with the return of excess
interstitial fluid back into the vascular space.
• For acute blood pressure management, the mean blood pressure
should not be lowered by more than 20%.
 SHOCK
• Shock is a state of circulatory failure causing either
organ hypo perfusion or cellular derangement in
oxygen and energy utilization leading to anaerobic
metabolism.
• Shock can be diagnosed by
• Clinical ( hypotension, tachypnoea, absent distal
pulses)
• Laboratory (lactate)
• Hemodynamic (Swan-Ganz catheter, transthoracic
echocardiography) criteria.
• Shock is classified into four different categories based upon the
underlying pathophysiologic alteration:
• 1. Hypovolemic
• 2. Distributive
• 3 Cardiogenic
• 4. Obstructive.
• Common causes of hypovolemic shock include
• 1. Haemorrhage
• 2. Dehydration
• 3. GI losses (diarrhoea, vomiting).
• The various causes of distributive shock include
• 1. Sepsis
• 2. Spinal cord injury with neurogenic shock,
• 3. Adrenal insufficiency
• 4. Anaphylaxis
• 5. Ischemia/reperfusion.
• Cardiogenic shock may be caused by
• Acute MI
• Severe valvular lesions, and
• Myopathies induced by ischemia, viral diseases, and inflammatory
conditions.
• Causes of Obstructive shock include
• Tension Pneumothorax
• Cardiac tamponade, Constrictive pericarditis, and
• Acute pulmonary embolism (PE).
Cardiogenic Shock
• Cardiogenic shock is uncommon after gynaecologic surgery.
• Treatment relies on diagnosis and identification of the reason for
pump failure.
• Physical examination, EKG, cardiovascular labs (troponins, pro-brain
natriuretic peptide), and imaging are key in the diagnosis.
• The most common cause of postsurgical cardiac failure in
gynaecologic patients is MI.
POSTOPERATIVE FEVER AND
PATHOPHYSIOLOGY
• Fever is a response to inflammatory mediators, termed pyrogens,
which originate either endogenously or exogenously.
• Circulating pyrogens lead to production of prostaglandins (primarily
PGE2), which elevate the thermoregulatory set point.
• The inflammatory cascade also produces several cytokines after
various events, namely, surgery, cancer, trauma, and infection
• Thus, fever is common after surgery and is self-limited in most cases
• However, for those with persistent symptoms, a systematic approach
to patient evaluation helps differentiate inflammatory from infectious
etiologies.
• Fevers that develop more than 2 days after surgery are more likely to be
infectious.
• More broadly, causes may be categorized by the mnemonic, the “Five Ws,” which
represent
• 1.wind
• 2.Water
• 3.Walking
• 4.Wound
• 5. Wonder drug as in a drug which can cause fever Sulfonamides ,Vancomycin
• Pneumonia is considered, and women at greatest risk are those who have been
mechanically ventilated for a prolonged period, have an NG in place, or have
preexisting chronic obstructive pulmonary disease (COPD).
• Catheterization increases risk of urinary tract infection.
• Logically, catheterization duration correlates positively with this infection risk
• DVT may present with low-grade fever and other disease-specific
symptoms. For example, women with DVT often complain of unilateral
lower-extremity edema and erythema.
• Those with PE may note dyspnea, cough with blood-tinged sputum,
chest pain, tachycardia, and symptoms of hypotension.
• Fever related to surgical site infections usually develops 5 to 7 days
after surgery.
These infections may involve the pelvis or abdominal wall layers.
Last, medications commonly used postoperatively—such as heparin, β-
lactam antibiotics, and sulfonamide antibiotics— may cause a rash,
eosinophilia, or drug fever.
• "Wonder drugs" is a term used to describe fever caused by certain
medications after surgery.
• This type of fever is also known as drug fever and can be caused by a
number of medications, including:
• Serotonergics, which can cause serotonin syndrome
• Antipsychotics or anti emetics, which can cause neuroleptic malignant
syndrome
• Penicillins
• Cephalosporins
• Antitubercular drugs
• Quinidine
• Procainamide
• Methyldopa
• Phenytoin
• Drug-induced fever is usually a hypersensitivity reaction that occurs
after 7 to 10 days of taking the drug. It will continue while the drug is
being taken, but will go away shortly after stopping the drug. If the
drug is started again, the fever will likely return quickly.
PULMONARY COMPLICATIONS
• Postoperative pulmonary complications after gynecologic surgery
remain an important cause of increased morbidity, mortality, and
resource use.
• Atelectasis, pneumonia, and pulmonary thromboembolic disease
continue to occur following abdominal surgery despite continuous
advances in anesthetic, surgical, and postoperative treatment.
• This may be because gynecologic surgery is increasingly performed in
patients with advanced age and multiple comorbid conditions, who
are at increased risk for the development of postoperative pulmonary
complications.
Effects of Anesthesia
• General anesthesia results in important alterations in respiratory
physiology.
• Anesthetic agents influence not only the ventilatory response to oxygen
and carbon dioxide but also the pattern of respiration.
• Inhalational agents and IV agents both result in reduction of the
ventilatory response
• During surgery, there is only modest metabolism of inhalational
anesthetics, with most of the anesthetic agents stored in the tissues, such
as muscle and fat.
• At the conclusion of anesthesia, most of the stored anesthetic agent is
eliminated via the lungs.
• Long anesthetic time can lead to significant concentrations of the
anesthetic agent, leading to increased tissue storage in the recovery
phase.
• This prolonged anesthetic effect can lead to clinically significant
respiratory depression in the postoperative period.
 Atelectasis
• It is conceptually the absence of gas from a
part or the whole of the lungs that is due to
1. Failure of expansion or
2. Resorption of gas from the alveoli.
• The generally accepted criteria for the
diagnosis of atelectasis include Impaired
oxygenation in a clinical setting where
atelectasis likely is
• Unexplained temperature of >38 °C, and
• Chest radiographic evidence of volume loss or
new airspace opacities.
• The pathophysiologic effects of atelectasis include
1.Decreased respiratory compliance
2.Increased pulmonary vascular resistance
3.Predisposition to acute lung injury, and hypoxemia.
• It occurs in the dependent areas of the lungs within 5 minutes of
anesthetic induction in a patient with healthy lungs and leads to shunt
physiology.
• Although most gynecologic surgery is done in the pelvis, extension of
the surgical incision and operative procedure into the upper abdomen
increase the respiratory effects
• It may also be a precursor to more serious postoperative pulmonary
complications, such as postoperative pneumonia.
• The principal means of minimizing atelectasis is deep breathing.
• Early mobilization and encouragement to take deep breaths
(especially when standing) are sufficient for most patients.
 Pulmonary Edema
• Postoperative pulmonary edema is caused by high hydrostatic pressures
(due to left ventricular failure or fluid overload, increased capillary
permeability, or both).
• Edema of the lung parenchyma narrows small bronchi and increases
resistance in the pulmonary vasculature.
• Pulmonary edema may increase the risk of pulmonary infection.
• Systemic sepsis significantly increases capillary permeability.
• In the absence of an obvious source, the development of pulmonary
edema postoperatively should be regarded as evidence of sepsis.
• Adequate management of fluids postoperatively and early treatment
of cardiac failure are important preventive measures.
 PNEUMONIA
Hospital-acquired pneumonia (HAP) is the second most
common nosocomial infection
• The most common bacterial pathogens causing HAP
include Aerobic Gram-negative bacilli,
• Pseudomonas aeruginosa
• Escherichia coli
• Klebsiella pneumonia
• Acinetobacter species.
• The nonspecific clinical findings make the diagnosis of HAP difficult.
• It develops 48 hours or more after hospital admission and is caused
by an organism that was not incubating at the time of hospitalization.
• The 2016 Infectious Diseases Society of America/American Thoracic
Society guidelines for the management of HAP continue to
recommend a clinical diagnosis based upon a finding of a new lung
infiltrate plus
• Clinical evidence that the infiltrate is of infectious origin, which
includes the new onset of fever >38 °C,
• Purulent sputum,
• Leukocytosis, and decline in oxygenation.
Respiratory Failure
• Respiratory failure presents with tachypnea (25-30 breaths/min) with
a low tidal volume.
• Laboratory indications are
• Acute elevation of PCO2 above 45 mm Hg
• Depression of PO2 below 60 mm Hg.
• Risk factors for early respiratory failure are
1.Major upper abdominal operations,
2.Severe trauma, and
3.Preexisting lung disease.
• Most patients tolerate the postoperative changes in pulmonary
function without difficulty.
• Patients who have marginal preoperative pulmonary function may be
unable to maintain adequate ventilation in the immediate
postoperative period and may develop respiratory failure
• In most patients afflicted by this condition, respiratory failure develops
over a short period (up to 2 hours) without evidence of a precipitating
cause
• Initial treatment consists of immediate endotracheal intubation and
ventilatory support to ensure adequate alveolar ventilation.
• After intubation, it is important to determine whether there are any other
associated pulmonary problems that require immediate treatment, such as
• Atelectasis
• New-onset pneumonia
• Pneumothorax.
• Prevention of respiratory failure requires careful postoperative pulmonary
care.
• It is important to avoid dehydration in patients with preexisting
pulmonary disease.
• This is because compensation for the inefficiency of the lungs occurs
through hyperventilation and this extra work causes greater evaporation
of water and dehydration.
• Hypovolemia leads to dry secretions and thick sputum, which are
difficult to clear from the airway.
• Alveolar collapse can occur with displacement of the stabilizing gas
nitrogen from the alveoli by high fraction of inspired O2 (fiO2 ).
• High fiO2 may also impair the function of the respiratory center,
which is driven by the relative hypoxemia, and thus further decrease
ventilation.
 Gastrointestinal Complications
• Following laparotomy, GI peristalsis temporarily decreases.
• Peristalsis returns in the small intestine within 24 hours, but gastric
peristalsis may return more slowly.
• Function returns in the right colon by 48 hours and in the left colon
by 72 hours.
Postoperative ileus
• It is a transient impairment of normal GI motility after major
abdominal surgery characterized by
• Nausea
• Vomiting
• Bloating
• Abdominal pain/distension
• Absence of stool or flatus passage, and
• Accumulation of gas and fluid in the bowel—all with poor tolerance of
oral intake.
• A prolonged ileus is a common complication following laparotomy seen
in up to 40% of patients, even if the intestines are not manipulated.

• Studies suggest that there may be neurologic and inflammatory

mechanisms involved.
• Inflammatory mediators such as Nitric oxide are present in
manipulated bowel and in peritonitis and may play a role in the
development of ileus.
• Nonsurgical causes of ileus include medications and electrolyte
abnormalities.
• Early ambulation has long been held to be useful in prevention of
postoperative ileus.
• While standing and walking in the early postoperative period have
been proven to have major benefits in pulmonary function and
prevention of pneumonia, mobilization has no demonstrable effect on
postoperative ileus.
• The impact of chewing gum on shortening the duration of
postoperative ileus remains unclear.
• According to the colorectal literature, gum chewing may reduce time
to first flatus and the time to first bowel movement
• Abdominal x-ray typically shows dilated loops of
small bowel and colon.

• While there is no specific lab test for the

assessment of mechanical ileus, it may be useful
to check serum electrolytes to ensure normal
potassium levels.
• Treatment is supportive, starting with IV fluids to replace volume
deficits and correction of electrolyte/acid-base disturbances.
• Selective GI decompression (via nasogastric tube) can be considered
in patients with vomiting.
• If there is any evidence of infection/sepsis, antibiotics should be
given early.
• Conservative treatment can be continued for several days with close
clinical and electrolyte observations.
Small Bowel Obstruction
• Early postoperative bowel obstruction is defined as a mechanical
bowel obstruction, primarily involving the small bowel, which occurs
in the first 30 days following abdominal surgery.
• Symptoms include abdominal pain, vomiting, abdominal distension,
and obstipation.
• The clinical picture may frequently be mistaken for ileus, and these
conditions can overlap .
• Computed tomography (CT) or other contrast imaging may be
required to distinguish ileus from obstruction.
• Early postoperative bowel obstruction is caused by inflammatory
adhesions.
• These result from injury to the surfaces of the bowel and peritoneum
during surgical manipulation.
• Release of inflammatory mediators after injury leads to the formation
of fibrinous adhesions between the serosal and peritoneal surfaces.
• As the inflammatory mediators are cleared and the injury subsides,
these adhesions eventually mature into fibrous, firm, and band like
structures.
• Management depends on differentiation from ileus and on identifying
the cause.
• X-ray erect abdomen demonstrate air/fluid levels, dilated bowel loops
and paucity of gas beyond the site of obstruction.
• An abdominal CT with and without IV contrast will allow for
localization and determination of grade, severity, and etiology of a
suspected postoperative bowel obstruction.
• Treatment –
• 1. Rest
• 2. Decompression via nasogastric tube
• 3. Maintaining euvolemia
Diarrhea
• When diarrhea presents while patients are on antibiotics (or for up to 8
weeks after discontinuation of antibiotics), the condition is defined as
antibiotic-associated diarrhea.
• Nearly one-third of these cases in adults are due to Clostridium
difficile.
• C difficile infections are the most common health care– associated
diarrhea
• The antibiotics that present the highest risk for C difficile include
1. Clindamycin
2. Broad-spectrum Penicillins, and
3. Fluoroquinolones.

• Three of the most important risk factors for C difficile infection are
• Older age
• Use of antibiotics
• Hospitalization.
• While C difficile infection can involve any part of the colon, the distal
segment is the most common site of infiltration.
• C difficile infections should be considered if a patient presents with
acute diarrhea defined as >3 loose, watery stools that “take the shape
of the container” over the course of 24 hours.
• Other signs and symptoms may include fever, nausea, vomiting,
abdominal pain, and tenesmus.
• The diagnosis is aided by testing for the C difficile organism, the toxin,
or toxin producing gene.
• Once a C difficile infection has been confirmed, discontinuation of the
offending antibiotic therapy should be considered.
• Most patients who have mild diarrhea will recover spontaneously
within 5- 10 days of antibiotic therapy withdrawal.
Postoperative Nausea and Vomiting
• This is one of the most common complaints following surgery, and its
incidence ranges rom 30 to 70 percent in high-risk patients.
• Those at risk of postoperative nausea and vomiting (PONV) include
1. Females
2. Nonsmokers
3. Those with prior motion sickness
4. Prior PONV
5. Those with extended surgeries
• Combination of 4 to 8 mg of Dexamethasone prior to anaesthesia
induction are followed, towards the end of surgery, 1 mg of
Droperidol and 4 mg of Ondansetron (Zofran).
• This pre treatment significantly reduces symptoms by 25 percent.
• If symptoms develop within 6 hours of surgery, antiemetics from a
different pharmacologic class than previously administered are
considered.
POSTOPERATIVE WOUND
MANAGEMENT
• Acute wound healing has three phases—
1. Inflammatory reaction
2. Proliferation
3. Remodeling
• Hemostasis by coagulation initiates the first
step in the inflammatory phase.
• The infiltration of leukocytes and release of cytokines helps initiate
the proliferative phase of wound repair.
• During this, two activities happen simultaneously–the growth of
granulation tissue to fill the wound and the formation of epithelium
to cover the wound.
• The final stage, remodeling, restores the structural integrity and
functional aptitude of the new tissue.
Wound Dehiscence

• The depth to which a wound may open varies and may involve only
the subcutaneous and skin layers.
• Such superficial separation can result solely from a hematoma or
seroma, but more commonly is a Consequence of wound infection.
• The reported incidence of superficial separations ranges from 3 to 15
percent
• More seriously, separation can include the abdominal wall fascia.
• This is less frequent and is fatal in nearly 25 percent of cases.
• Infection or sutures held under too much tension lead to fascial
necrosis.
• Sutures remain poorly anchored in necrotic fascia .
• These layers then separate with only minimal increase in intra
abdominal pressure.
• Prevention
• Rates of wound dehiscence are affected by
A) General patient health
B) Surgical technique
C) Risks associated with wound infections
Of these, patient health actors may or may not be modifiable
• Characteristics that confer an increased wound disruption risk include
• Age greater than 65 years
• Pulmonary disease
• Malnutrition
• Obesity
• Malignancy
• Immunocompromised states
• Diabetes mellitus
• Hypertension
• Using proper surgical technique, a surgeon has multiple opportunities to
lower wound disruption rates.
• Hemostasis
• Gentle tissue handling
• Removal of devitalized tissue
• Closure of dead space
• Use of monofilament suture in tissue at risk or infection
• Judicious use of closed-suction drains
• Sustained normothermia
Infection is a common underlying cause of wound disruption.
Preoperative
• Reduce HBA1c levels to < 7% before operation
• Stop smoking 30 days before operation
• Administer specialized nutritional supplements or enteral nutrition for
severe malnutrition for 7–14 days preoperatively
• Adequately treat preoperative infections, such as UTI or cervicitis
Perioperative
• Remove interfering hair immediately before surgery by clipping or
depilatories; no perioperative shaving
• Use an antiseptic surgical scrub or alcohol-based hand antiseptic for
preoperative cleansing of the operative team members’ hands and
forearms
• Prepare the skin around the operative site with an antiseptic agent
based on chlorhexidine, alcohol, or iodine/ iodophors
• Administer prophylactic antibiotics for most clean-contaminated,
contaminated, and dirty procedures
• Administer prophylactic antibiotics within 1 hr before incision (2 hours
for Vancomycin and Fluoroquinolones)
• Use higher dosages of prophylactic antibiotics for morbidly obese
patients
• Use Vancomycin as a prophylactic agent only when there is a
significant MRSA infection risk
• Provide adequate ventilation, minimize operating room traffic, and
clean instruments and surfaces with approved disinfectants
• Avoid flash sterilization
Intraoperative
• Carefully handle tissue
• Eradicate dead space
• Adhere to standard principles of asepsis
• Avoid use of surgical drains unless absolutely necessary
• Leave contaminated or dirty-infected wounds open
• Redose prophylactic antibiotics with short half-lives intraoperatively if
operation is prolonged (for cefazolin if operation is > 3 hr) or if there is
extensive blood loss (>1500 mL)
• Maintain intraoperative normothermia
Postoperative
• Maintain serum glucose levels < 200 mg/dL on postoperative days 1
and 2
• Monitor wound infection
Diagnosis
• Superficial wound separations usually present 3 to 5 days after
surgery, with wound erythema and new drainage.
• A delay in evacuating inflammatory exudates from within
subcutaneous layer dead space can lead to fascial weakening and an
increased risk of fascial dehiscence.
• Fascial dehiscence generally presents within the first 10 days
postoperatively.
• Superficial disruption of the subcutaneous layer and extensive
leakage of peritoneal fluid or purulent drainage are indicative.
Superficial Wound Dehiscence
Treatment
• Wet to dry Dressing Changes.
• With initial wound management, all hematomas, seromas, or pus are
evacuated, and necrotic tissue is debrided.
• If needed, underlying infection is treated with antibiotics.
• Most abdominal wound infections that follow clean cases originate
from Staphylococcus aureus.
• In contrast, those after clean-contaminated cases have a greater
chance of being polymicrobial.
• Thus, antibiotic regimens that cover gram-positive and gram-negative
organisms are suitable.
• After evacuation, wounds are typically gently filled with fluffed out
gauze to provide continued wound drainage and access for additional
debridement.
• This dressing is usually removed daily and replaced with new moist
gauze. Solutions used in this dressing remove surface bacteria without
disrupting normal healing components.
• Thus, povidone iodine, iodophore gauze, dilute hydrogen peroxide, and
Daiken solution, which are cytotoxic to white blood cells, should play a
limited role in wound care .
• In very necrotic wounds, allowing gauze to dry and pulling tissue
adherent to the gauze with each change is acceptable.
• More frequent dressing changes are avoided as they lead to aggressive
debridement of vital tissues and slow wound healing
Negative pressure Wound Therapy.
• This is primarily used for acute wounds to minimize scarring or for chronic wounds
that have been resistant to other forms of wound care.
1.Wound retraction
2.Continuous wound cleaning
3.Stimulation of granulation tissue formation,
4.Reduction of interstitial edema
5. Removal of exudates.
These are the postulated mechanisms which help in negative pressure wound
therapy.
• The external forces create microdefects in individual cells that stimulate the
cellular repair process and lead to cell proliferation within the wound.
• The negative pressure generated by such devices provides three
woundcare actions
• (1) evacuates wound drainage to reduce bacterial colonization,
• (2) promotes release of cytokines that are helpful in wound healing
• (3) increases blood flow and oxygenation to tissues to uniformly
reduce wound size and improves angioneogenesis .
• The two most commonly used dressings are
• 1. Foam
• 2.Moistened non adherent cotton gauze.
• After the initial application, the dressing is typically changed within 48
hours and then two to three times a week thereafter.
• After the dressing is covered with an adhesive film dressing, a suction-
generating evacuation tube runs through the dressing to help draw
excessive exudates away from the wound and into a canister attached at
the other end.
• The vacuum pump offers either continuous or intermittent negative
pressure.
Delayed Primary Closure.

• Approximately 4 days after wound disruption and resolution of

subcutaneous infection, a superficial vertical mattress closure with
delayed-absorbable suture may be used to reapproximate tissue
edges .
• Depending on wound depth and patient tolerances, this can be
completed in the operating room or at the bedside using a local
anesthetic complemented by systemic analgesia
• Antifungal cream Topical cream used as treatment for superficial
fungal infections of the peri wound skin; contains 2% miconazole
nitrate.
• Calcium alginate :It is a solid that exchanges calcium ions for sodium
ions when it contacts any substance containing sodium such as wound
fluid. The resulting sodium alginate is a gel that is nonadhesive,
nonocclusive, and conformable to the wound bed. Indicated for
moderately or highly draining wounds.
Enzymatic debrider :Topical solution that breaks down
necrotic tissue by directly digesting the components of slough
or by dissolving the collagen that holds necrotic tissue to the
underlying wound bed.

Film: Thin, transparent polyurethane sheets coated on one

side with acrylic, hypoallergenic adhesive. The adhesive will
not stick to moist surfaces, and the film is impermeable to
fluids and bacteria, but semipermeable to oxygen and water
vapor. Indicated in superficial wounds with little or no
exudates
• Foam Polyurethane sheets containing open cells capable of holding
fluids and pulling them away from the wound bed. Foams provide
absorbency while keeping the wound moist. Indicated in moderately or
highly draining wounds.
• Gauze Woven or nonwoven cotton or synthetic blends.
• Hydrogel Formulated in sheets or gels. Glycerin-, saline-, or water-
based to hydrate the wound. Indicated in dry or minimally draining
wounds.
• Silver nitrate Used to treat overgrown granulation tissue.
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