Many postoperative problems can be avoided if patients fully understand the nature of the proposed procedure, the potential

side effects of the operation, and the role they must play in their own postoperative care. Facilitating such understanding not only helps prevent potential problems but also increases patients overall satisfaction with the process of outpatient surgery.

Postoperative care begins in the recovery room and continues throughout the recovery period. Critical concerns are airway clearance, pain control, and mental status. Other important concerns are preventing urinary retention, constipation, deep venous thrombosis, and BP variability (high or low). For patients with diabetes, plasma glucose levels are monitored closely by finger-stick testing every 1 to 4 h until patients are awake and eating, because better glycemic control improves outcome. Patients who have procedures done in a day-surgery center usually require only a few hours of care by health care professionals before they are discharged to go home. If postanesthesia or postoperative complications occur within these hours, the patient must be admitted to the hospital. Patients who are admitted to the hospital may require days or weeks of postoperative care by hospital staff before they are discharged.

Assessment of the patient's airway patency (openness of the airway), vital signs, and level of consciousness are the first priorities upon admission to the PACU. The following is a list of other assessment categories: Surgical site (intact dressings with no signs of overt bleeding) Patency (proper opening) of drainage tubes/drains Body temperature (hypothermia/hyperthermia) Patency/rate of intravenous (IV) fluids Circulation/sensation in extremities after vascular or orthopedic surgery Level of sensation after regional anesthesia Pain status Nausea/vomiting Depending on the type of surgery and the patient's condition, the patient may be admitted to either a general surgical floor or the intensive care unite. Since the patient may still be sedated from anesthesia, safety is a primary goal. The patient's call light should be in the hand and side rails up. Patients in a day surgery setting are either discharged from the PACU to the unit, or are directly discharged home after they have urinated, gotten out of bed, and tolerated a small amount of oral intake.

After the hospitalized patient transfers from the PACU. Vital signs, respiratory status, pain status, the incision, and any drainage tubes should be monitored every one to two hours for at least the first eight hours. Fluid intake and urine output should be monitored every one to two hours. If the patient does not have a urinary catheter, the bladder should be assessed for distension, and the patient monitored for inability to urinate. Oral hygiene Controlling pain is crucial so that the patient may perform coughing, deep breathing exercises, and may be able to turn in bed, sit up, and, eventually, walk.

After the initial 24 hours, vital signs can be monitored every four to eight hours if the patient is stable. The incision and dressing should be monitored for the amount of drainage and signs of infection. Specific follow up should be done each for each

Activity and position in bed Observation (V. Signs , fluid chart{in and out put, dressing ,drains and blood sugar if need) Diet if any Pain relief Medication Wound care Follow-up of investigations or treatments Emergency contacts, including surgeon and acute care facility

Postoperative complications can be subdivided into complications related to surgery and anesthesia. Anesthetic complications are those which are related to the anesthesia, including hypoventilation, and changes in the level of consciousness. Post-operative complications related to surgery may either be general or specific to the type of surgery undertaken. Common general post-operative complications include hemorrhage , pneumonia , UTI ,atelectasis, wound infection, DVT and pulmonary embolism myocardial infarction , Anaphylaxis.

Occur in up to 15% of general anaesthetic and major surgery and include: sore throat Atelectasis (alveolar collapse):

Pneumonia Aspiration pneumonitis :Sterile inflammation of the lungs from inhaling gastric contents

Predisposed by preexisting pulmonary problem or poor inraoperative anesthetic management Caused when airways become obstructed, usually by bronchial secretions. Most cases are mild and may go unnoticed Symptoms are mild tachypnoea, tachycardia and low-grade fever

Non-starved patient undergoing emergency surgery is particularly at risk Mortality is nearly 50% and requires urgent treatment with bronchial suction, positive pressure ventilation, prophylactic antibiotics and IV steroids

Urinary retention: common immediate postoperative complication that can often be dealt with conservatively with adequate analgesia. If this fails may need catheterization. UTI: very common, especially in women. Acute renal failure

May be caused by antibiotics, obstructive jaundice or surgery to the aorta Presents as low urine output despite of adequate hydration

Primary Reactionary : This occurs within 48 hours of surgery and is due to the rise in blood pressure, Slipped ligiture .During surgery blood pressure is low because of the anesthetic medications. The rise in blood pressure opens up the divided blood vessels. These blood vessels were not bleeding at completion of surgery. Secondary post-operative haemorrhage occurs several days after surgery and is usually due to infection damaging vessels at the operation site. Treat infection and consider exploratory surgery.

Wound infection: most common form is Non specific : Minor( superficial ) wound infection occurring within the first week presenting as localized pain, redness and slight discharge usually caused by skin staphylococci. But no constitutional symptom Cellulites and abscesses( deep wound infection ):

Most present within first week but can be seen as late as third post-operative week, even after leaving hospital Present with pyrexia and spreading cellulites or abscess

Gas gangrene is uncommon and life-threatening.

Specific:

Surgical site spicific

Affects about 2% of mid-line laparotomy wounds. Serious complication with a mortality of up to 30%. Due to patient related healing factors versus failure of wound closure technique . Usually occurs between 7 and 10 days postoperatively. Often heralded by serosanguinous discharge from wound.

Major cause of complications and death after surgery. DVT is very commonly related to grade of surgery. Many cases are silent Present as swelling of leg, tenderness of calf muscle and increased warmth with calf pain on passive dorsiflexion of foot. Diagnosis is by Duplex ultrasound. Pulmonary embolism PE:
3

Classically presents with sudden dyspnoea and cardiovascular collapse with pleuritic chest pain, pleural rub and haemoptysis. However, smaller PEs are more common and present with confusion, breathlessness and chest pain Diagnosis is by ventilation/perfusion scanning and/or pulmonary angiography or dynamic CT

Anastomotic leakage or breakdown: causing low output versus high output fistula or
generalized peritonitis Intestinal obstruction

Delayed return of function (Paralytic ileus) Early mechanical obstruction: may be caused by twisted or trapped loop of bowel or adhesions occurring approximately 1 week after surgery.. Late mechanical obstruction: adhesions can organize and persist or stenosed site of anastomosis

Tissue damage may occur during many types of surgery, e.g Facial nerve damage during parotidectomy Impotence following prostate surgery or rectal surgery Recurrent laryngeal nerve damage during thyroidectomy Common bile duct injury during cholysistectomy

There is also a risk of injury while being transported and handled in the theatre under general anaesthetic. These include injuries due to falls from trolley, damage to diseased bones and joints during positioning, nerve palsies, and diathermy burns.

Immediate: Primary haemorrhage Basal atelectasis:acute myocardial infarction ,pulmonary embolism . Shock: blood loss or septicaemia. Low urine output Early: Acute confusion : exclude dehydration and sepsis Nausea and vomiting: analgesia or anaesthetic-related; paralytic ileus Fever Secondary haemorrhage: often as a result of infection Pneomonia Wound or anastomosis dehiscence Deep vein thrombosis (DVT) Acute urinary retention (UTI) Post-operative wound infection Bowel obstruction due to fibrinous adhesions Paralytic Ileus Late: Bowel obstruction due to fibrous adhesions Incisional hernia Persistent sinus Recurrence of reason for surgery, e.g. malignancy

Within 2 days :

Mild fever (Common) Tissue damage and necrosis Haematoma Persistent fever (T >38 C) Atelectasis: Specific infections related to the surgery eg :UTI post-urological surgery Blood transfusion Drug reaction

3-5 Days :

Bronchopneumonia UTI Sepsis (Wound infection ,abscess formation, e.g. subphrenic or pelvic, depending on the surgery involved ) DVT Specific complications related to surgery, e.g. bowel anastomosis breakdown, fistula formation Wound infection Distant sites of infection, e.g. UTI DVT, (PE)

After 5 days:

Bleeding Fever (usually > 101 F [38.3 C]) Persistent uncontrolled pain Persistent nausea and vomiting Excessive drainage from incision or the drain Urinary retention

Discharge Followup