K George Varghese
One of the most critical periods for the surgical patient is the immediate postoperative phase, covering the period of time from the end of the operation until the time when he regains consciousness. It is during this phase that the danger of aspiration, cardiac arrest, and circulatory or respiratory depression is greatest.
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The best method of removing the patient from the operating table to the recovery room bed generally is by placing him on a roller, thus protecting the patient’s and the attendants’ vertebral columns. The attending surgeon or the responsible assistant should accompany the patient to the recovery room with a recovery room note made on the patient’s chart and written post- operative orders.Once the patient is inside the recovery room he / she should be laid in a position to permit the drainage of saliva or blood and to prevent the aspiration of the same. Use humidified oxygen by mask, catheter or other appliance, if desired. (A Po2, of less than 40, Pco2 greater
than 65 with an arterial pH of under 7.25 are absolute indications, in most cases, for respiratory assistance.) Intermittent positive pressure breathing apparatus may be desired to assist in the ventilation of the patient.
The patient is kept in the recovery till he/ she recovers from the effects of an anesthesia and later shifted to the postoperative intensive care or ward with the permission of the anesthetist. Before the patient is send to the
postoperative intensive care or ward the case record should be completed with- (a) operative notes, (b) postoperative instructions and (c) postoperative orders of drugs as detailed below:
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It summarize all events that has occurred during and immediately after the surgery till the patient is transferred from the operation theatre to the recovery room. It consists of Anesthesiologist’s Notes and Surgeon’s Notes. The former is written from the induction of anesthesia, continues during the procedure till the recovery of the patient from anesthesia. Usually the anesthesiologist or the assistant does the writing. The surgeon’s note is written by the surgeon. It abridge all activities that has occurred during the surgery. The following points should be included in the surgeons note:
• Date
• Name of the operation
• Name of surgeons and anesthesiologists • Type and duration of anesthesia used • Preoperative Diagnosis
• Postoperative Diagnosis
• Summary of the procedure- Incision, operative procedure in brief, operative findings, discussion of any complications, type and location of drains, type of suture and suturing method, description of pathology specimen and whether it has been send
for frozen section or routine histopathological examination.
• Amount and type of fluids including blood transfusion. • Patient’s condition on leaving the OT
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The following points should be included in the postoperative instructions:
• When the oral hemostatic packs can be removed/ watch for bleeding
• When the patient can begin oral intake • The type of diet (liquid or semi solid) • Wound care- e.g. oral hygiene measures
• Patient handling and positioning e.g. avoid pressure on elevated zygoma, so patient to be placed for reco- very on the opposite side face down.
• Patient to be made to lie on one side (tonsillectomy position) to permit draining of saliva or blood, till the consciousness is fully regained
• Periodic/½ hourly recording of BP, pulse, respiration and temperature. Pulse oximeter to be connected to observe the oxygen saturation
• Care of the suction drain/urinary catheter
• Ice packs or cold compresses to desired areas, if indicated. (The application of bilateral flat ice packs over the sites of osteotomies or third molar extractions is useful in reducing postoperative edema, pain and bleeding).
• Regular observation of eyes particularly where zygomatico-orbital surgery is performed
• Contact names and numbers in the event of queries or emergency.
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• Patient’s own regular medication, e.g. salbutamol inhaler, antihypertensive medication, etc. In diabetic patients insulin to be restarted based on postoperative blood report
• Analgesics, e.g. parenteral narcotics or oral NSAID/
narcotic combinations
• Antiemetics, e.g. 10 mg metoclopramide IM or 12.5 mg phenergan IM, especially where narcotics are prescribed
• Antibiotics (IV or oral) as required
• Sedatives, e.g. diazepam 10 mg orally at night as required, since many patients find it difficult to sleep in the strange hospital environment
• Ranitdine (50 mg IM/IV or 150 mg orally BD) or Antacids—may be useful for patients stressed by major surgery or trauma. When steroids are given ranitidine should be given to prevent gastric irritation • Steroids are commenced in theatre and continued postoperatively to help minimize swelling after major surgery, e.g. Ing. Dexona 8 mg IV TID/BD in the first day and tapered in the subsequent days before stopping.(Instead of steroids, enzyme preparations like serratiopeptidase also may be given)
• Intravenous fluids will be required following major surgery where oral intake may be compromized for a few days. For minor oral surgery, IV fluids given at the start of the operation may be all that is required, unless the patient is vomiting. In such cases intravenous fluids should continue until vomiting ceases (see Chapter 13 on IV fluid therapy).
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Once the patient leaves the OT, depending on the condition of the patient he/she may be kept in the recovery room for short while and then shifted to the intensive care room or the postoperative ward. Postoperative care is simple in healthy patients who have undergone minor oral surgery, but becomes complex after major surgery and in medically compromized patients.
During the First 24 Hours
While the patient is in the recovery room/intensive care room or in the postoperative ward following points should be evaluated and recorded at periodic intervals until the patient is stable:
• Level of consciousness
• Skin warmth and color
• Vital signs-blood pressure, pulse rate, respiratory rate and temperature(every 30 minutes to 1 hour). Following major surgery oxygenation monitored continuously by pulse oximeter
• Fluid input and output- blood, IV fluids, urine out put. If the patient is catheterized, a 30 to 50 ml urine per hour output
• Physical examination: coronary—rate and rhythm, pulmonary- clear to auscultation and air entry adequate or not, abdomen—bowel sounds, whether distended or not
• Condition of extremities
• Bleeding from operative site- either intraorally or soaking of dressing
• Care of nasoendotracheal tube—frequent suctioning to avoid tube blockage
• Care of urinary catheters and nasogastric tube when placed
• Survey of nurse’s notes
• Consultation with the anesthesiologist or other specialist when ever required
The results of the duty doctor’s interaction with the patient postoperatively should be the guideline in outlining the further course of action. Even the most
minor complaints of the patient should not be dismissed without proper examination.
During the Subsequent Days (Postoperative rounds)
Patients should be visited by the house officer/medical officer on duty at least twice daily. The patient’s progress in terms of surgical wound healing and general physical and mental well-being must be carefully monitored and recorded:
• Examination of the surgical wound (including donor site)—the wound must be inspected daily while patient remains in hospital. Check for significant pain, bleeding, discharge or wound dehiscence
• Intravenous fluid administration should be evaluated daily with the objective of stopping IV fluids as soon as the patient is able to take adequate amounts of fluids by mouth. It is recommended that the IV access is changed every 2 to 3 days to minimize the risk
of infection and phlebitis. The hydration status of the patient may be monitored with daily urea and electrolyte tests or, in intensive care units, using a central venous pressure line and urinary catheters. If fluid overload occurs, sit the patient upright, slow the infusion and give a diuretic such as 40 mg frusemide
• Dressings—are often removed 24 to 48 hours after surgery. They are replaced with non-adhesive dressings only if there is an open wound or copious discharge, or if the wound is constantly irritated by clothing
• Drain tubes—check amount of drainage in the previous 24 hours. Make sure vacuum drains are still functioning. Remove drains when there is little or no drainage (usually 1 to 3 days). Drains kept in too long can result in ascending infection
• Suture removal—for extraoral wounds (e.g. coronal incision, chest flap, etc.) may be undertaken on a progressive basis, e.g. alternate suture or staple may be removed on day 5th day and the rest on the 7th day.
• Ensure that there are clear instructions to nursing staff about when to stop parenteral administration of drugs and to commence oral intake.
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Postoperostoperostoperostoperostoperativativativative Complicationsative Complicationse Complicationse Complicationse Complications
Acute Ventilatory Failure
This is the most urgent of all postoperative complication. The common causes are obstructions by secretions, foreign bodies, local trauma, or swelling. Ventilatory failure can be eliminated or bypassed immediately by intubation or tracheostomy. The position of the patient’s head and neck may be the cause of a serious obstruction of the upper airway in the unconscious patient. Narcotics and sedatives should be administered with extreme caution in the restless patient until it is certain that the restlesness is not related to cerebral hypoxia rather than pain. Strict asepsis is absolutely essential especially with respect to the suction catheter, in any patient with tracheal intubation. Sterile catheters used by individuals wearing sterile gloves should be mandatory. This prevent the entry of pathogenic organisms in the tracheobronchial
tree. Emergency tracheostomy has thus become justifiable only when tracheal intubation is not possible. If the endotracheal tube has to be kept for longer periods, then tracheostomy is preferable.
Aspiration of Gastric Contents or Blood
Aspiration of gastric contents or blood during the induction or recovery from anesthesia can lead to significant pulmonary ventilatory problems. Restlessness, tachycardia, tachypnea, and occasionally cyanosis should alert the surgeon to this possibility. Physical examination of the chest, auscultation of the breath sounds, and an upright chest film can be used to confirm the diagnosis almost invariably. By early recognition and prompt removal of foreign material, from the tracheobronchial tree, secondary sequelae may be reduced or avoided. The prophylactic use of corticosteroids every 6 hours and significant doses of broad-spectrum antibiotic agents supplemented by adequate ventilation therapy are indicated. These complications can be avoided often by ascertaining that the stomach is empty prior to surgery. Intubating the patient in the head down position and maintaining the patient on his side or in a head down position during the period of unconsciousness will reduce the instance of aspiration. The use of cuffed endotracheal tubes is recommended, yet the cuff cannot be relied on entirely, because it may be improperly inflated or may leak enough air to permit the passage of blood or gastric contents into the trachea.
Edema of the Airway
This can occur after either oral or nasal intubation. This problem is more likely to occur in infants and children because of the peculiar anatomy of the subglottal trachea. The attending surgeon and others responsible for the care of the patient must be on constant alert for evidences of sudden or gradual obstruction of the airway. The judicious use of glucocorticoids, ultrasonic nebulizers with oxygen therapy, and, reintubation or a tracheostomy are measures that must be available in the postoperative armamentarium. Tracheostorny in the infant is an extremely dangerous procedure and is to be avoided whenever possible because of serious longterm complications. Bag and mask or mouth-to-mouth
respiration will force air through a laryngospasrn in almost every case.
Epistaxis
Epistaxis after nasal intubation may be reduced or controlled with preoperative and postoperative nasal vasoconstrictor agents (0.25% phenylephrine solution), elevation of the patient’s head, sedation, and, if necessary, judicious and gentle packing of the bleeding site with well-lubricated ¼ - or ½, inch gauze. Should these measures fail, it may be necessary to insert a posterior nasal pack.
Sore Throat or Pharyngitis
This is not an uncommon complication after intubation, and the possibility of this uncomfortable situation should be explained to the patient preoperatively. The early use of a cool mist vaporizer or ultrasonic nebulizer, as well as oral troches containing a topical anesthetic agent, (if the patient is not allergic to the topical anesthetic), is successful in reducing postoperative complaints of this type. The uncomfortable symptoms usually disappear within 8 to 12 hours after intubation. If they should worsen, the surgeon should be alerted to the possibility of pharyngeal mucosal tears and infection, which subsequently may extend into the pharyngeal spaces or mediastinum.
Postoperative Nausea and Vomiting
It can occur during normal recovery from general anesthesia. When protracted nausea and vomiting occur in the postoperative period, the possibility of something of a more serious nature should be suspected. Unrelieved, acute gastric dilatation may be lethal within 1 to 2 hours if not relieved. Tachycardia and hypotension are often associated with this. The dilated epigastrium extends into the left thoracic cavity. Elevation of the left diaphragm and radiographic evidence of a large gastric bubble are highly suggestive. Certain authors advice use of gastric suction in cases of protracted nausea and vomiting. Insertion of a nasogastric tube prior to extubation is recommended. The nasogastric tube is then attached to a low pressure suction apparatus. This will
facilitate the emptying of the stomach of swallowed blood or secretions and thereby reduce the chance of vomiting in the postoperative perod. In the absence of intestinal obstruction and electrolyte imbalance, the maintenance of continuous gastric suction should restore the stomach to functional tone within 36 to 48 hours. Because of the usual loss of potassium and sodium salts during surgery, these elements must be replaced along with the proper fluids to restore the body’s chemical balance. Other causes of postoperative nausea and vomiting are: ileus, cardiac failure, uremia, gastric atony, infections and drugs that have emetic tendencies. The occurrence of projectile vomiting indicates the need for a neurological evaluation for the presence of increased intracranial pressure.
If ileus, uremia, gastric atony, and hypokalemia can be eliminated as possible causes of the nausea and vomiting, then a suitable phenothiazine is indicated for the control of nausea and vomiting.
Generally, it is wise to avoid all oral fluids and medications until the patient is reacting well and bowel sounds are present. Until this status has been reached, medications, fluids, and nutrients may be supplied by the parenteral route. When intraoral surgery has been carried out, good hemostasis to prevent ingestion of blood from the surgical wound is needed. Oral medications usually are tolerated more successfully if taken with foods; this dilutes any irritant effect on the gastric mucosa.
Edema
Edema in the oral surgery patient may have many causes, the most common being physical trauma, infection, increased venous pressure, and decreased lymphatic flow. Other less likely causes are decreased arterial blood flow, decreased intravascular oncotic pressure, excessive sodium retention, and cardiac failure and immobility. This undesirable postoperative complication may be reduced by maintaining the operating table in such a position that the field of surgery is elevated above the level of the heart, by maintaining good hemostasis through careful handling of tissues, by the judicious administration of corticosteroids preope- ratively, and by the cooling, and compression of the area of surgery during the immediate postoperative period.
Postoperative Fever
The most common causes of postoperative fever are wound infection, urinary tract infection, pulmonary complications, thrombophlebitis, and increased osmo- larity because of lack of water or salt excess. Bacteremia or septicemia secondary to acute thrombophlebitis complicating a continuous intravenous infusion has become a prominent cause of “third-day surgical fever.” The careless use of intravenous catheters for the administration of drugs, and the tendency to leave them in as long as possible is to be avoided. When continuous intravenous solutions are required over a period of days, a change of the intravenous setup at 24- to 48-hour intervals, is recommended with a change in venipuncture site. Less common causes of postoperative fever are drug reactions, central neurological disturbances and bacterial enterocolitis. It is needless to say that elective surgery should be postponed in a patient who is febrile until recovery has been established. This does not mean that surgery has to be postponed when it may represent a crucial diagnostic maneuver to establish the process causing the fever. An oral body temperature of 100° F. in the immediate postoperative period or fever that persists for more than 6 hours, must prompt the surgeon to consider certain specific problems that often complicate recovery.
To determine the cause of the postoperative fever, the following procedures should begin immediately: 1. The patient’s entire clinical status should be carefully
appraised with particular reference to the state of hydration, the relationship of the febrile course to any of the medications being used, and the possibility of a hypersensitivity phenomenon having occurred in the patient’s past medical history.
2. Examination of the wounds, and cultures should be performed if there is evidence of infection. 3. Clinical evaluation of the lungs and urinary tract and
appropriate studies of the urine and sputum with cultures when indicated should be done. Gram stain examination of the sputum or urine may also be useful.
4. Blood cultures should be obtained whenever there is the slightest suggestion of sepsis, bacteremia, or peripheral vascular collapse of unexplained cause.
5. Chest radiographs should be taken if pulmonary embolism or infection is suspected.
6. ECG and liver function test. Management—depends on the cause:
• Symptomatic—external body cooling and NSAID’s • Local measures—drain pus or hematoma, remove necrotic tissues or foreign bodies, remove infected IV cannulas and catheters
• Systemic measures—antibiotics, medical treatment of myocardial infarction or thyroid crisis, treatment of pulmonary embolus.
It should be recalled that fever as a sign of postoperative infection may be absent or markedly depressed if the patient has been placed on corticosteroid drugs.
Shock
Shock is an acute circulatory failure with inadequate or inappropriately distributed tissue perfusion resulting in generalized cellular hypoxia. Shock in the postoperative patient may be related to hypoxia, hypercarbia (inadequate ventilation), coronary insufficiency, arrhy- thmia, or electrolyte imbalance. Other causes may be