Postoperative care

• Post operation care


  Supervision by adequately trained and experienced personnel is continued during the recovery period
• Complications in post anaesthetic unit


  • Major complications
  • Minor complications
• Post operative pain management

  Pain is an extraordinary complex sensation which is difficult to define and equally difficult to measure in an accurate objective manner
• Many problems associated with anaesthesia and surgery may occur in the immediate post operation period
• Systems affected


  • CNS
  • CVS
  • RS
  • GIT
• CNS


  1. Consciousness may not return for several minutes after the end of GA and may be impaired for a longer period of time

  2. Excitement and confusion may occur during recovery and may result in injury

  3. Pain may be severe if long – acting analgesic have not been given during surgery

  4. Risk of aspiration

  5. Patient airway must be maintained
• CVS


  1. Hypotension

  2. Hypertension may occur as a result of increase sympathoadrenal activity after restoration of consciousness, especially if analgesia is inadequate
• RS


  1. Hypoventilation occurs commonly, usually as a result of residual effects of anaesthetic drug or – incomplete antagonism of neuromuscular blocking drugs

  2. Hypoxemia may result from hypoventilation, ventilation/perfusion imbalance or increased 02 consumption produced by restlessness or shivering
• GIT


  Nausea and vomiting are common in the immediate post operative period
• Staff, Equipment and Monitoring in the Recovery Room/Ward


  • Trained and experienced Nurses
  • One nurse with each patient at all times
  • Anaesthetist designated to be available immediately to treat complication detected by the nursing staff
  • Patient nursed in a bed if a prolonged stay is envisaged
  • Patient more commonly on a trolley (tiltable)
  • Suction apparatus, including catheters
  • O2 supply with appropriate face masks
  • Sphygmomanometer must be available for each patient
  • Anaesthetic machine
  • A range of laryngoscope
  • Tracheal tubes, bougies
  • IV cannular, fluids, emergence drugs
  • ECG monitors and defibrillator
  • Facility for cricothyroid cannulation eg minitracheostomy set or For formal tracheostomy
  • A wide range of drugs should be stored in the recovery area for the treatment of common complications and also emergence events
• Criteria for discharge to surgical ward


  • Consciousness has returned fully and a patent airway can be maintained
  • Ventilation is adequate and stable
  • The CVS is stable
  • Excessive surgical blood loss has stopped
• High dependency unit or ICU


  Recovery chart must be filled and patient scored accordingly
• Causes of delayed recovery of consciousness


  • Volatile anaesthetic with high blood/gas solubility coefficient
  • Barbiturates, particularly if large total doses have been given
  • Benzodiazepines
  • Opioids with long duration of action including large doses of fentanyl
• Timing of drug use

  • Delayed recovery may occur of a long – acting iv anaesthetic or analgesic drug has been given towards the end of the procedure or if volatile agents have been continued until the end of the surgery
  • The presence of pain speeds recovery of consciousness
• Other causes of delayed recovery

  • Hypoglycaemia
  • Hyperglycaemia
  • Cerebral pathology
• Other causes of delayed recovery


  • Hypoxaemia
  • Hypercapnia PaCO2 exceeds 9 –10 kpa
  • Hypotension
  • Hypothermia
  • Hypoosmolar or TURP syndrome
  • Hypothyroidism
  • Hepatic or renal failure
• Causes of confusion and agitation


  • Uses of hyoscine or Atropine – in elderly patient
  • Emergence delirium – ketamine or etomidate
  • A lightly sedated, conscious pt with inadequate antagonism of NM blocking drugs may appear to the inexperienced observer to be agitated and confused movement are uncoordinated
• Causes of confusion and agitation - RS


  • Upper airway obstruction
  • Tongue, larygospasm, oedema, foreign body tumour
  • Bronchospasm
• Causes of confusion and agitation - CVS


  • Shunting, retension of secretions and under ventilation of lung because of pain
  • Hypoventilaton
  • Diffusion defects, fluid or interstitial oedema by over transfusion or LV dx may cause hypoxaemia
  • Diffusion hypoxia after nitrous oxide anaesthesia
  • Hypoxemia
• Causes of hypertension


  • Pain
  • Pre – existing hypertension
  • Hypoxeamia
  • Hypercapnia
  • Administration of vasopressor drugs
  • After aortic surgery as a result of partly increased of plasma concentraton of renin
• Deep venous thrombosis


  • Changes in the composition of blood
  • Damage to walls of blood vessel
  • Decrease blood flows
• Risk factors for deep venous thrombosis


  • Extensive trauma
  • Infection
  • Heart failure
  • Blood dyscrasias
  • Malignancy
  • Metabolic disorders
  • Commoner after hip pelvic and abdominal surgery
  • There is a well established association between spontaneous DVT and oestrogen and DVT may occur in women into take the oral contraceptive
• Other complications


  • Haematoma formation is probably the commonest complicate of IV injection resulted form
  • Inadequate pressure at the injection site after removal of the needle
  • Phlebitis thrombosis or thrombophlebitis may occur after the use of some iv Induction agents
• Causes of nausea and vomiting


  • More common in abdominal procedures
  • Middle ear surgery is associated with high incidence presumably b/c of the proximity of the vestibular apparatus
  • Strabismus correction is associated with more vomiting than other occular procedures
  • Dilation of the cervix may also cause post up emesis
• Other complications


  • Headache
  • Sore throat
  • Hoarseness of voice
  • Laryngeal granulomata
  • Dental trauma
  • Ocular complication
  • Muscle
  • Suxamethonium pains
• Post operative pain


  • Pain is an extraordinary complex sensation which is difficult to define and equally difficult to measure in an accurate objective manner
  • It has been defined as the sensory appreciation of afferent nociceptive stimulation which elicit an effective components
  • It may be represented as a venn diagram
  • The sensation of pain differs among individual patient
  • The emotional component may vary according to the patient's
  • The rational component varies with the patient's previous experience, insight and motivation
  • Post of pain differs from other types of pain in that it is usually transitory
  • With progressive improvement over a relatively short time-course
  • Pain on joint = sharp pain
  • Abdominal surgery = a continuous dull nauseating ache and sharper pain induced by coughing and movement) which responds poorly to morphine
• Opioid side effects


  • Ventilator depression
  • Nausea and vomiting
  • Papillary constriction
  • Biliary spasm
  • Urine retention
  • Tolerance
  • Physical dependence
• Post operative pain management


  • Moderate analgesics
  • Diahydrocadeine 50mg 4hly
  • Bolus IV opioid
  • Sublingual buprenorphine
  • Oral route: not used in the immediate post op period
  • Rectal route
  • Transdermal ; Fentanyl (B/c of the high lipid of solubility and high potency of fentanyl