Postoperative Surgical Care

Postoperative surgical care Wipusit Taesombat, MD Department of surgery Naresuan university hospital

Perioperative care should involve a continuous, linear knowledge of patient’s surgical and comorbid condition  All medical providers are involved in the management of a patient’s surgical disease 

Excellent surgical result   

Preoperative management Intraoperative management Postoperative management

Postoperative surgical care Prevention and awareness of postoperative complication  Early detection  Early treatment 

Postoperative surgical care Complication  Related to surgery  Related to anesthesia  Medical complication  …,etc

Postoperative surgical care Complication related to surgery  In general  Specific disease or procedure

Postoperative surgical care 

Specific disease or procedure -liver resection -pancreatic resection -thyroid surgery

Postoperative surgical care 

In general -wound complication -ileus -postoperative fever

Wound complication    

Seroma Hematoma Dehiscence Infection

Wound seroma Collection of liquefied fat, serum and lymphatic fluid under the incision  Clear, yellow fluid  Likely to occur when large skin flap are developed : mastectomy, ventral hernia repair  May become secondary infection 

Wound seroma Management  Placement of suction drain in wound  Repeat aspiration  Aware infection

Wound hematoma Abnormal collection of blood, usually in subcutaneous layer of recent incision  More potentially to infection 

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Management

Wound complication    

Seroma Hematoma Dehiscence Infection

Wound dehiscence Dehiscence : the separation of fascial layers early in postoperative course  Greatest concern because possibility of evisceration  Evisceration : protrusion of intestines out onto abdominal skin surface 

Management  Dehiscence -conservative treatment : wound care  Evisceration -surgical emergency

Wound infection 3 categories  Superficial : skin and subcutaneous layers  Deep : fascia and muscle  Organ space : internal organ 

Surgical site infection

Surgical wound classification : risk of wound infection    

Clean Clean-contaminated Contaminated Dirty

1-3% 5-8% 20-25% 30-40%

Wound infection Clinical presentation  present as erythema, tenderness, edema and occasionally drainage  common occur 5-6 days postoperatively

Wound infection Management  Depend on severity of infection

Postoperative surgical care 

In general -wound complication -ileus -postoperative fever

Ileus Diminish or absent of bowel movement (stomach, small and large bowel)  Clinically functional obstruction 

Ileus : Classification 

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Adynamic or paralytic ileus Bowel motility is diminished or absent because of inhibition of normal neuromuscular activity Spastic ileus : Lead poisoning, porphyria Bowel is tightly contracted without co-ordinated propulsive activity Ischemic ileus Result of low-flow or vascular occlusion (dying musculature)

Cause of paralytic ileus       

Operative bowel manipulation Intraabdominal infection Medication (narcotics) Electrolyte abnormality Intra/retroperitoneal hemorrhage Pneumonia …,etc

Ileus Duration  Stomach  Small intestine  Large intestine

48-72 hours 24 hours 3-5 days

Ileus Prolong duration of ileus, must find the underlying condition  May be difficult to distinguish from mechanical obstruction 

Ileus    

Prevention Intraoperative management Early ambulation Correct underlying condition

Postoperative fever A host of infectious or non infectious agents may cause postoperative fever  Temperature modulation is managed by anterior hypothalamus, which react to variety of systemic stimuli 

Postoperative fever Clinical presentation : persistent fever  First 48-72 hours  5-8 days postoperatively

Postoperative fever First 48-72 hours  surgical reaction -extent of surgery -usually BT < 38 c -usually spontaneous resolved

Postoperative fever First 48-72 hours  Atelectasis  Pre-existing infection  Clostridial or streptococcal wound infection (extremely uncommon)

Postoperative fever 5-8 days postoperatively

Five W’s  Wind (lung)  Wound  Water (urinary tract, phlebitis, catheter related)  Waste (lower GI tract : pseudomembranous colitis) Intraabdominal collection)  Wonder drug

 Preoperative

care  Intraoperative care  Postoperative care

 Excellent

surgical outcome