Pre & Postoperative

care
& complications

Omar Salah
 Contents
Prevention of complications
Routine preoperative Evaluation
Clinical Predictors of Increased Risk for peri-
operative Cardiac Complications
Physical status scale: American Society of
Anesthesiologists
High risk group
Postoperative complications
 Prevention of complications

- Pre-op care:
- Stop smoking
- Loss of weight
- Control of chronic disease
- Prophylactic antibiotics
- Respiratory exercise
- Correction of any bleeding tendency
- Good surgical technique
 Prevention of complications

- Post-op care:
- Early mobilization
- Respiratory Care
- Fluids and electrolytes needs
 Routine preoperative
Evaluation
History:
Respiratory diseases, smoking,
CVS disease including DVT,
Bleeding diathesis,
Hypertension, diabetes,
Previous general anesthesia, drugs and alcohol
intake.
Indication for surgery
Allergy
 Routine preoperative
Evaluation
Clinical Examination:
Weight, height and body mass index
Vital signs : blood pressure, pulse (rate and
regularity), respiratory rate
Cardiac
Pulmonary
Other pertinent exam
 Routine preoperative
Evaluation
Laboratory tests:
Complete blood count
Kidney function tests
Liver function tests
Urinalysis
Prothrombin time, and partial thromboplastin
time,
Blood group
 Routine preoperative
Evaluation
Radiology :
Chest Xray
ECG
Clinical Predictors of Increased Risk for
peri-operative Cardiac Complications
MAJOR
Recent myocardial infarction (within 30 days)
Unstable or severe angina
De-compensated congestive heart failure
Significant arrhythmias (high-grade) atrio-ventricular block,
symptomatic ventricular arrhythmias with underlying heart
disease, supra-ventricular arrhythmias with uncontrolled
rate)
Severe valvular disease
Intermediate
Mild angina
Prior myocardial infarction by history or
electrocardiogram
Compensated or prior congestive heart failure
Diabetes mellitus Renal insufficiency

MINOR
Advanced age
Abnormal electrocardiogram rhythm other than sinus (e.g.,
atrial fibrillation)
Poor functional capacity
History of stroke
Uncontrolled hypertension (e.g., diastolic blood pressure
>10 mm Hg)
Physical status scale: American
Society of Anesthesiologists
ASA class Physical state
1 A normally healthy individual
2 Pt. with mild to moderate disturbances
controlled DM or Hypertension
3 severe systemic disease not incapacitating
Heart dis. with limited exercise
tolerance, Uncontrolled
hypertension or DM
 Physical status scale (ASA)
4. Incapacitating systemic dis. That is a constant
threat to life with or without
surgery eg. CCF & severe angina.
5. A moribund patient who is not expected to live and
where surgery is performed as a last resort e.g.
ruptured aortic aneurysm
6. A pt. Who requires an emergency surgery
 High risk group
Elderly patients
Respiratory disease and smokers
Cardiovascular diseases
Obese patient
Diabetes
Jaundice
Chronic drug medication
Bleeding tendency
 Elderly patient
Due to limited mobility
Intercurrent illness
Diminished cardiac, respiratory and renal
reserve
Higher postoperative wound infection
Longer hospital care
DVT and delirium.
 Respiratory dis. & smoking
Obstructive airway disease increase the risk
of post-op pulmonary complications and
require careful pre-op evaluation.
Blood gas analysis
Spirometry
Exercise tolerance test
Sputum cultureActive
 Resp. & Smoking
Breathing exercise.
Physiotherapy
Salbutamol nebulizer
Cessation of smoking: Due to Viscid
secretions and impaired clearance of mucus
Pulmonary collapse & infection results
 Obese patients
Increased risk of
Resp. complications
DVT
Wound Infections & Dehiscence
Limited mobility & hypertension
Difficult operation
Encourage weight reduction
 FREQUENCY OF POSTOPERATIVE COMPLICATIONS

Postoperative Complications
Frequency of Complication )%(Incidence
Infection 14.3
Wound 5.1
Pneumonia 3.6
Urinary tract 3.5
Systemic sepsis 2.1
Respiratory 9.5
Failure to wean from respirator in 48 hours 3.2
Unplanned intubation 2.4
Pulmonary embolus 0.3
Cardiac 4.5
Pulmonary edema 2.3
Cardiac arrest 1.5
Myocardial infarction 0.7
 Wound complications
Hematoma:- Due to
Imperfect hemostasis during operation, bleeding
tendencies, aspirin, heparin and warfarin.
Vigorous cough or straining may initiate bleeding
Clinically; swelling, discoloration of the wnd.
edges, discomfort, blood ooze from skin edges
 Hema-cont
Neck hematomas expand rapidly, deviate &
compress the trachea. It needs immediate
evacuation
Small hematomas may be absorbed but it
predisposes to wound infection
Evacuation under GA may be necessary
with ligation of bleeding and closure
 Seroma
Collection of fluid serum
Delays healing
Increases the risk of wnd infection
Often follow elevation of skin flaps that leeds to
lymphatic damage
Can be prevented by pressure dressing
Aspiration or incision and evacuation
Antibiotics cover.
 Wound Dehiscence
Partial or total disruption, it occurs between 5th-
8th.post op days, serosanguinous fluid or
evisceration
It is due to:
Systemic causes: Elderly, diabetics, jaundice,
cancer, immunocompromised, hypoproteinemia,
obesity, corticosteroids
 Wnd. dehiscence- cont.
Local causes:
1-In the wound:- Improper closure of anatomic
layers.- Devitalized tissues due to rough handling
- -Suture material, - Dead space, - FBs and - drains
2- Increased intra-abdominal pressure; ileus,
obesity , ascitis, and COPD
3-Infection: hematoma, seroma and FBs
 Wnd. Deh. cont
Management:
Prevention by proper preop. Preparation
Cover with moist sterile towels
Antibiotics
Closure under GA
If neglected it will led to incisional hernia
 Chronic pain
Due to:
Stitch abscess,
Granuloma,
Hernia,
Neuroma
 Respiratory complications
Most common single cause of morbidity
Second most common cause of death in
patients older than 60 y
It occurs more frequently in:
Upper abdo. & chest surg., emergency,
elderly, ch. Bronch. And asthma, smoking &
obesity
 Atelectasis
It is the most common pulm. Complications
It occurs within the first 48 h of surg. In about 25%
of pts. With abdo. Surg. & responsible for over 90%
of febrile episodes during that peroid
Pathogenesis:1- Obstruction: by secretions, blood
clots & malpositioning of endotracheal tube.
2- Non obstructive: closure of the bronchioles due to
shallow breathing
 Atelect. Cont.
Clinically manifested by fever, tachypnoea, tachycardia.
O/E Scattered rales, decreased air entry & elevation of the
diaphragm on that side.
. Prevenetd by preop. proper treatment of resp. disease, stop
smoking (6w), early mobilization,and encourage deep
breathe & cough in the postop period
. Managed by chest percussions and breathing exercises,
Nasotrach. Aspiration, broncho-dilators and mucolytics.
Usually recover uneventful
 Pulmonary Aspiration
Normally prevented by GO & Pharyngo-oesoph
sphincters
Predisposed by NG & endotrach tubes, depression
of the CNS by drugs, trauma, GO. Reflux,
intestinal obstruction, pregnancy & pt.
Positioning.
Minor degrees of aspn. Can be found in 15% of
abdo. Surg. & may occur during sleep and are well
tolerated
 pul. Aspn. cont

The magnitude of injury depends on: pH,

frequency & volume of aspirate.
Pathogen; chemical pneumonitis- oedema-
inflammation-infection. Obst. Of bronci or
bronchioles by large food particles atelect.
Prevention by preop. fasting ,proper positioning &
careful intubation
Treatment: Bronchoscopy, intubation, & suction
fluid resuscitation, hydrocortisone, antibiotics &
chest physioth.
 Post-op. pneumonia

The main cause of death after surg.

Predesposed by Atelect.,aspiration, or copious
secretions associated with infections & prolonged
intubation
Causative bacteria: staph, pseudomonas, klebsiela
& G-ve bacilli.
Clinically; fever, tachycardia, tachypnoea, &
features of consolidation- CXR
Treated by breathing exercise & cough, antibiot.,
mucolytics & bronchdilators
 Deep vein thrombosis
It is associated with a high mortality rate
esp in the elderly.
The cause is usually multi factorial
Virchows triad;
1- Stasis can occur with venous insufficiency,
severe heart failure, prolonged bed rest or
immobility & surgery or fractures of the
pelvis or hip joint
 DVT Cont.
2-Endothelial vascular damage by cannulation
or irritation by chemicals
3- Hypercoagulable state either;
a-acquired e.g;
In cancers of the lung, pancreas, prostate,
breast & ovaries
b-inherited e.g;
Deficiency of antithrombin III.
Protein C & S
As a result of nephrotic synd., liver failure, & DIC.
4- Advanced age, obesity, CCP, multiparity, Infly
bowel dis.
 DVT. Cont.
It occurs most frequently in the calf veins &
spread to the proximal veins (25%) that can led to
venous insufficiency or fatal pul. Embolism
Clinically:
1-Pain in the thigh or calf, sometimes with oedema.
50% are asymptomatic
2- Hx of recent surgery,trauma, cancer, CCP, or
immobilization.
 DVT. Cont.
3- Homans sign positive in 50% of cases
4-Venous duplex U/S is diagnostic.
Prevention by elastic stocking with sequential
compression & low dose unfractionated
heparin or LMWH
Treatment: The primary treatment is by
systemic anticoagulation, initially with heparin
then continue with warfarin
 Fat embolism
It is relatively common but only rarely
causes symptoms.
Fat particles are present in the pulmonary
bed in 90% of long bone fractures.
Exogenous sources are; Bld. transfusion, IV.
Lipid in parenteral nut., or bone marrow
transplantn.
 Fat emb.
Fat emb. Syndrome: It occurs 12- 72 h after injury.
Neurologic dysfunctn.,
Respiratory insufficiency.
Petechiae of axilla, chest & arms
The findings of fat droplets in sputum & urine.
Treated by positive pressure ventn. & diuretics
until symptoms disappear
 Cardiac complications
To avoid compln.
Preexisted card. Dis. Should be properly evaluated
by a cardiologist.
Evaluatn. Of Lt. Vent. Ejection- fraction to
identify pts. at high risk.
ECG-monitoring
Ao. Stenosis limits the ability of the heart to
respond to increased demand.
Bleeding & hypo-proteinemia--- compn.
 Card. Compl.
Dysrhythemias; appear during the operation
& within 3/7 after surgery eg. Chest surg.
Supra vent. Dysrhythemia
Ventricular premature beats
Heart block.
 Postop. MI.
Precipitated by hypoxia & hypotension
Asymptomatic in 50% of cases
Chest pain & hypotension are the main
features
Monitor in CCU, ECG changes
Anticoagulants & O2 inhalation
 Card. Failure
Fluid overload in pts. With limited card. Reserve
Postop. MI, sepsis, multiple injuries.
Progressive dyspnoea & hypoxia Normal PCO2 &
decreased PaO2.
Diffuse congestion in CXR.
Treat in CCU; Dopamine is the best drug for
inotropic support, Diuretics, fluid restriction,
digoxin & respiratory support ventilation
 Peritoneal comp.
Hemoperitoneum: Bleeding is a common cause of
shock within 24h after surg. Mainly due to tech.
Problems.
Coagulopathy may play a role
Clinicaly; hypovolemia & shock
Increasing abdo. Girth
If persisted--- Re-operate; evacuate clots & ligate
bleeding vessels.

.
 Periton. Comp.
Complications of drains
Infection
Erosion of viscera
May cause leakage from anastomosis
Prevention by closed suction drains with
soft selastic tubes
 GI. complications
Gastric dilatation; massive distention of the
stomach by gas & fluid predisposed by
gastric outlet obstruction, drinking with
paralytic ileus, splenectomy & Anorexia
nervosa.
Distention--- increased pressure---
congested veins--- bleeding ischemia
necrosis.
 Gastric dilatation
Clinically -ill, hiccups,
-hypoK., alkalosis,
-collapse of the lower lobe of the Lt lung
may occur
Treated by: -NPO, NG tube,
-fluid and electrolytes replacement.
 GI.comp.
Bowel obstruction
Paralytic ileus
Mech. Obstn. Adhesions or hernias.
Treated by NG. Suction, fluid &electrolytes
corrections for few days.
If no response--- Surgery.
 Urinary complications
Urinary retention
Over distention of urinary bladder inhibit
contraction
Interference with the neural mechanism
Treated by:
catheterization if operation is taking 3h or more.&
to empty the bladder after retention. Look for
features of BPH.
 Urinary tract infection
Instrumentation, retention &
catheterization.
Clinically; dysuria, fever, flank & supra-
pubic tenderness
Diagnosis; urine analysis & culture.
Treatment; Hydration, antibiotics &
catheterization
 CNS comp.
CVA
Convulsions; in ulcerative colitis, & crohns
for unknown reasons
Psychosis post-op, mood disturbances,
delirium d. tremens in alcoholics
Sexual dysfunction, confusion, fear &
disorientation.
 Post- operative fever
It occurs in about 40% after major surgery,it
resolves without specific treatment in most
patients.
Within 48h--- atelectasis
After 2 days--- Wound infection, anastomatic
breakdown,& intra-abdo. Abscesses
After 1 w--- Allergy to drugs, transfusion reactions
& pelvic and abdo. Abscesses.
Temp. >38.5`C, CT abdo. & pelvis