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):
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
Pneumonia
Aspiration pneumonitis :Sterile inflammation of the lungs from
inhaling gastric contents
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 post-
operative 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
Specific:
Gas gangrene is uncommon and life-threatening.
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 post-
operatively.
Often heralded by serosanguinous discharge
from wound.

Major cause of complications and death after surgery.
DVT is very commonly related to grade of surgery.
3

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:
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
After 5 days:
Specific complications related to surgery, e.g. bowel anastomosis breakdown, fistula formation
Wound infection
Distant sites of infection, e.g. UTI
DVT, (PE)

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