Companion to Clinical Training Guidelines

on Principles of Surgical Management

PERI - OPERATIVE
CARE

KB Galketiya (MBBS, MS, FRCS, FCSSL)

Senior Lecturer
Department of Surgery, Faculty of Medicine
These notes were compiled from the final year ward classes.

I expect medical students who attend the ward classes to use this as a guide
during their clinical training.

These notes, hopefully, will provide a frame work to build up knowledge by

further reading and not an alternative to standard text books.

KB Galketiya

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 Contents

01. Post-Operative Care ........................................................ 3

02. Prevention of Post-Operative Infections. ......................... 6

03. SOB After Surgery .......................................................... 8

04. Sudden Onset Hypotension After Surgery....................... 9

05. Post-Operative Low Urine Output ................................. 10

06. Post-Operative Fever (Following Clean Surgery) ......... 11

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 01. Post-Operative Care
Aim - quick and safe recovery.
Involves
1. Monitoring
2. Pain management
3. Feeding
4. Iv fluids & Hydration
5. Temperature chart
6. Scientific wound management
7. Management of drains
8. Infection prevention
9. Early mobilization
10.Discharge advice and follow up plan

Monitoring
Type
➢ Continuous
➢ Intermittent
Continuous monitoring is done for all patients done under GA until full
recovered; done in theatre recovery unit (observe how it’s done).
This is continued for
▪ Major surgeries
▪ Patient co-morbidities (especially respiratory/ cardiac)
▪ Per-operative complications
Need ICU/ HDU
Find out parameters monitored and methods of monitoring.

Pain relief
Makes patient psychologically comfortable and allows early mobilization
Find methods of pain relief from your patients

Feeding
Depends on
➢ GA or regional anaesthesia
➢ GI or non-GI surgery

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 ▪ Non-GI surgery with regional anaesthesia (Eg: hernia repair/
varicose) can be fed very early(immediate post-op)
▪ Non-GI surgery done under GA-once fully recovered from GA
(there is no rule as 6 hours post-op)
▪ GI surgery
❖ Factors to consider
✓ Whether patient is thirsty
✓ Vomiting-yes or no
✓ NG aspirate
✓ Opening of bowels-this indicate good bowel
functioning but is not an essential criterion to start
liquids
✓ Examination findings-abdomen has to be not
distended, soft and no undue tenderness.
✓ Level of anastomosis-upper GI/ small intestine/ large
bowel
❖ It is best for the surgeon to decide when to feed
❖ Currently its thought for small intestinal and colonic
anastomoses if other factors are all right early feeding is
safe. For oesophageal/ gastric anatomoses its debatable.
❖ Introduce fluids (may be 30 ml/hr) initially and gradually
increase daily and then soft solids
❖ If feeding is delayed IV fluids are essential
Read about what fluid and how much to prescribe and
electrolyte replacement
❖ If feeding has to be delayed beyond 2-3days consider
alternate forms of enteral or parenteral nutrition

Urine output
After major operations reducing UOP is an early warning sign

Minimizing post-operative infections

Refer the note on this.

Temperature chart
Fever indicates onset of infection (refer the note on post-op fever)

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Early mobilization
➢ Need adequate pain relief for this
➢ Some advantages
• Reduces respiratory complications/ DVT
• Patient feels satisfied
• Learn from your patients for different surgeries how they are
mobilized

Scientific wound care

From your patients find out
➢ After clean surgeries unless there is wound discharge or fever dressings
are left undisturbed until suture removal (from your patients find out day
of suture removal for different surgeries)
➢ Infected wound need frequent dressing changing
➢ Generally, patients are advised to bathe after suture removal even though
there is no harm of bathing early with sutures on. However patients are
often reluctant to bathe with sutures due to fear of infections (a myth). If
the sutures are sub-cuticular, the preferred way they may bathe early.

Management of drains (including urinary catheter/ NG tubes)

Drains should be removed early as the function is served.
Find from your patients about this.

Follow up
➢ Inform patient about current health/ diagnosis card
➢ Is follow up necessary or no
➢ Where to be followed up-at your institute or refer
➢ Inform patient Eg: need of checking histopathology
➢ Discharge advice regarding food/ bathing/ suture removal/ travelling/
driving/ weight lifting etc.

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 02. Prevention of Post-Operative Infections.
Pre op measures
1. Reduce hospital stay. (Day case for minor surgery.)
2. Control co morbidities (diabetes mellitus)
3. Prevent chest infection
• COPD- pre op nebulize with optimal drugs
• Smoking stop 6weeks before
• Chest physiotherapy for major surgery
• Treat dental caries
4. Proper and adequate nutrition/ hydration.
5. Look for active infections and treat and delay elective surgeries
6. Ask patient to bath day prior
7. Limited shaving preferably just before surgery

Per-operative
1. Use well designed operating theatre.
2. Wear clean clear cloths, masks, and caps.
3. Operating team should scrub, wear sterile gown gloves.
4. Start prophylactic antibiotics with induction when indicated.
5. Clean and drape the site with antiseptic. Eg; povidine iodine.
6. Use sterile equipment/ suture material/ linen
7. Follow correct surgical technique - Eg: less bleeding, shorter time as
possible
8. Avoid spillage. If it happens do lavarge.
9. Use absorbable suture material of smaller sizes if possible.
10.Use drains only when required. Always use closed drains.

Post-operative
1. Good pain relief for early mobilization.
2. Proper wound care.
3. Remove drains once function is served.
4. Chest physiotherapy if indicated.
5. Early discharging.
6. Antibiotics if indicated

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General measures
1. Hospital antibiotic policy.
2. Proper waste disposal.
3. Isolate infected patients.
4. Hand washing.

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 03. SOB After Surgery
may be
➢ Hypoxia
➢ Acidosis
➢ Hypercapnia

Approach
➢ Check air way and settle if at risk/ obstructed
➢ (recall how to do)
➢ Start oxygen by mask
➢ Call for help
➢ Do a quick respiratory system examination to find cause
➢ Consider intubation and ventilation if not improving
➢ Possible causes
• Hypoxia
▪ Pneumonia
▪ COPD
▪ Pulmonary embolism
▪ Pneumothorax (related or unrelated to procedure done)
▪ Heart failure,
▪ Diaphragmatic splinting (peritonitis/ bowel distension)
• Acidosis
▪ Sepsis
▪ Diabetic keto-acidosis
• Hypercapnia
▪ Air way obstruction – Eg: following head and neck surgery
▪ Sedation and respiratory depression
▪ (in above a severe hypoxia too results)
With a focused history and examination, a possible cause can be found
confirmed by appropriate investigations.

Treatment
➢ Support ventilation-O2 by mask up to ventilation as required
➢ Treat cause

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 04. Sudden Onset Hypotension After Surgery
Causes
➢ Haemorrhagic shock - commonest after surgery
➢ Cardiogenic shock
➢ Obstructive shock
Tension pneumothorax (related or unrelated to surgery)
Pulmonary embolism
➢ Distributive shock
Anaphylaxis
Sepsis

Action
➢ ABC and resuscitation
➢ Find type of shock by quick examination
Example of physical signs useful to distinguish one from another; pallor,
orthopnoea, JVP, fine basal crepts, abdominal distension in abdominal
surgery, increase drain out put
➢ CVP - high in cardiogenic shock/ obstructive shock
- low in hypovolaemic shock/ distributive shock
- it also will guide fluid resuscitation
➢ Treat according to cause
if bleeding; fluid/ blood resuscitation/ surgical intervention

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 05. Post-Operative Low Urine Output
Causes
➢ Pre-renal due to hypotension
➢ Renal (delay to pick pre-renal cause leading to acute renal failure/
existing renal disease/ per-operative causes)
➢ Post renal (acute retention/ blocked catheter)

Action
➢ Assessment of air way, breathing and circulation and appropriate support
➢ Check fluid balance chart - ?lack of adequate input
➢ Check catheter/ if no catheter, insert
➢ If low BP check cause for hypotension (cross ref - hypotension after
surgery)
• ? Lack of fluid intake
• ? Bleeding
• ? other cause for shock (cardiac/ sepsis etc.)
➢ Treat cause
• If pre-renal may need fluid/ blood resuscitation if its hypovolaemic
- may need surgical intervention if bleeding
• Use diuretics if fluid resuscitation is adequate (best to get CVP
guidance)
• Pre-renal due to other causes of shock need appropriate
management
▪ Cardiogenic-fluid restriction (CVP guided), cardiac support
▪ Sepsis-fluid resuscitation/ antibiotics/ inotropes/ intervention
if required; Eg- drainage of collections
➢ If renal failure established need fluid restriction and nephrology opinion
regarding dialysis

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06. Post-Operative Fever (Following Clean Surgery)
Day 1:- Atelectasis & tissue trauma.
Treatment: - Antipyretics
Mobilization
Chest physiotherapy
Day 4 - 5:-
Infection:
Possible sites
➢ Wound
➢ Chest
➢ Cannula site
➢ CV line
➢ urinary
➢ Deep infection depending on surgery
o Brain sx - Brain abscess
o Chest sx - Pyothorax
o Abdominal sx - Intra abdominal abscess
o Joint and bone surgeries-septic arthritis/ implant infection
➢ Rarely may be unrelated to surgery
The deep infections carry the worst prognosis as it may be
secondary to a surgical failure like anastomotic leak

Management:
➢ Take focused History
Eg- cough/ pleuritic pain in chest infection
feeling ill, vomiting, abd pain in intra-abd infections

➢ Focused examination to confirm

Eg- chest signs/ abdominal distension/ tenderness/ gas under
diaphragm
Inspect wound

➢ Appropriate investigations
Eg- CXR/ USS abdomen/ urine culture
FBC/ CRP will aid monitoring

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Treatment
➢ Supportive
➢ Specific
➢ Eg; Intraabdominal abscess-USS guided drainage/ consider re
opening if anastomotic leak is suspected
Wound infection-may need suture removal to drain out pus/
antibiotics

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