special subjects
Surgery
After Surgery
After the operation is completed, the person is taken to a recovery room to be closely watched for about 1 or 2 hours while the anesthesia wears off. The care team makes sure the person is able to breathe, is not at risk of choking, and has drugs to control pain. The care team also evaluates whether the person is able to think clearly. Most people feel groggy when awakening, particularly after major surgery. Some people are nauseated for a short while. Some people feel cold. Depending on the nature of the surgery and the type of anesthesia, a person may go home directly from the recovery room or be admitted to the hospital, sometimes in an Types of units (ICU). A person being sent home must be Thinking clearly Breathing normally Able to drink fluids Able to urinate Able to walk Free of severe pain People who had anesthesia or who have been given sedatives and then discharged need to be accompanied home by someone else and are not permitted to drive themselves. The operative site should be free of bleeding and unexpected swelling. People who are admitted to the hospital after surgery may awaken to find many tubes and devices in and on them. For example, there may be a breathing tube in the throat, adhesive pads on the chest to monitor the heartbeat, a tube in the bladder, a device attached to a finger to measure the level of oxygen in the blood, a dressing on the operative site, a tube in the nose or mouth, and one or more tubes in the veins. is expected after most operations and can almost always be relieved. Drugs that relieve pain (analgesics) can be given by vein (intravenously), by mouth, or by injection into the muscle or can be applied to the skin as a patch. If Local anesthesia and regional anesthesia was used, the plastic tube used to give the anesthetic may be left in the person's back. Opioid analgesics, such as is critical for healing and minimizing the chance of infection. Nutritional needs increase after major surgery. If surgery makes eating impossible for more than a week, an alternative source of nutrition may be needed. People whose digestive tracts are functioning but who are otherwise unable to eat may be given nutrients through a tube placed into the stomach. Such a tube may be passed through the nose, mouth, or an incision in the abdominal wall. Rarely, people who have had surgery of the digestive tract and cannot eat for extended periods may be given nutrients through a catheter inserted in one of the body’s large veins ( Intravenous Feeding ). Complications such as fever, blood clots, wound problems, confusion, difficulty urinating or defecating, muscle loss, and a deterioration in fitness (called deconditioning) can develop during the days after surgery. Feverthat develops during the days or weeks after surgery has several common causes, including the following: Infections at the operative site Lung problems such as Overview of Pneumonia or collapsed lung tissue (called Overview of Urinary Tract Infections (UTIs) (UTIs) Blood clots in the legs ( Deep Vein Thrombosis (DVT) [DVTs]) or lungs ( Infections of devices, tubes, or drains that have been implanted Drugs may sometimes cause fever. Another possible cause is inflammation in response to the trauma of an operation. The risk of infections at the operative site, DVTs, and UTIs can be decreased by meticulous care after surgery. The risk of pneumonia and atelectasis may be decreased by periodically breathing forcefully in and out of a handheld device (incentive spirometry) and coughing as needed. in the legs or pelvic veins (DVTs) occasionally develop after surgery, particularly if people lie immobile during and after surgery or have had surgery on their leg, pelvis, or both. The clots can dislodge and travel through the bloodstream to the lungs, where they can block blood from circulating through the lungs (causing Pulmonary Embolism (PE) ). As a result, the oxygen supply to the rest of the body may be decreased, and sometimes blood pressure may fall. For operations that make blood clots particularly likely and for people who are likely to have to lie still without much movement, doctors give drugs that keep blood from clotting (anticoagulants), such as low-molecular-weightheparin, or put compression stockings on the person's legs to improve blood circulation. However, anticoagulants may not be recommended for operations in which these drugs may substantially increase bleeding. People should begin moving their limbs and walking as soon as it is safe for them to do so. Wound complicationsmay include infection and separation of the wound edges (dehiscence). To decrease the risk of infection, doctors put a dressing on the surgical incision after surgery. The dressing placed in the operating room is typically left on for 24 to 48 hours unless signs of infection (such as increasing pain, swelling, and drainage) develop. The dressing includes a sterile bandage and usually includes an antibiotic ointment. The bandage keeps bacteria away from the incision and absorbs fluids that ooze from the incision. Because these fluids can encourage bacteria to grow and infect the incision, the dressing is changed often, usually twice daily. The wound and any drainage tubes, sutures, or skin staples are examined whenever the dressing is changed, sometimes more often. Occasionally, infection develops despite the best wound care. An infected site becomes increasingly painful 1 or more days after surgery and can become red and warm or drain pus or fluid. Fever can develop. If any of these symptoms develop, the doctor should be seen as soon as possible. Delirium None Difficulty urinating and difficulty defecating(constipation) are common after surgery. Factors that contribute can include use of drugs with anticholinergic effects or opioids, bowel surgery, inactivity, and not eating or drinking. Urine flow may become completely blocked, stretching the bladder. Blockage can lead to urinary tract infections. Sometimes pressing on the lower abdomen while trying to urinate relieves the blockage, but often a catheter needs to be inserted into the bladder. The catheter may be left in place or may be removed as soon as the bladder is emptied. Frequently sitting up may help prevent blockage. People who do not have a bladder blockage may be givenbethanecholby mouth to stimulate the bladder to contract. People who develop constipation are given smaller doses of opioids (pain relievers) and other drugs that cause constipation and begin walking as soon as possible. Unless their surgery involved the intestinal tract, people who develop constipation can also be given laxatives that stimulate the intestines, such asbisacodyl,senna, or cascara. Stool softeners such asdocusatedo not help. and strength occur in all people who need bed rest for a long time. With complete bed rest, young adults lose about 1% of muscle per day, but older people lose up to 5% per day because they have lower levels of growth hormone, which is responsible for maintaining muscle tissue. Adequate amounts of muscle are important for recovery. Thus, people should sit up in bed, move, stand, and exercise as soon as and as much as is safe for them. People who are not receiving proper nutrition are at increased risk of sarcopenia. People are encouraged to eat and drink. If they are not able to eat and drink by themselves, Tube Feeding or, rarely, Before leaving the hospital, people are responsible for Scheduling a follow-up visit with the doctor Knowing what drugs to take Knowing what activities to avoid or limit Examples of activities that may need to be avoided temporarily include climbing stairs, driving a car, lifting heavy objects, and having sexual intercourse. A person should know what symptoms necessitate contacting the doctor before the scheduled follow-up visit. Resuming normal activity during recovery from surgery should occur gradually. Some people need Overview of Rehabilitation , which involves special exercises and activities, to improve strength and flexibility. For example, rehabilitation after hip replacement surgery can involve learning ways to walk, stretch, and exercise. In the mid-1900s, surgeons often hesitated to do even simple operations on people over age 50. Times have changed. Now, more than one third of all operations in the United States are done on people aged 65 or over. However, age does increase the risk of complications during and after surgery. For example, older people are much more likely than younger people to develop Delirium after surgery. They are also more likely to have serious complications from bed rest, which may occur after surgery. These complications include Blood clots Loss of muscle Pneumonia Urinary tract infections The risk of death during or after surgery also increases with age. More than three quarters of deaths in the period immediately after surgery occur in older people. Further, when emergency surgery is done or when surgery involves the chest or abdomen, the risk of death increases in all age groups, but much more so for the older age group. Although age itself is a risk factor, overall health and the presence of certain disorders increase Surgical Risk far more than age does. Having had a heart attack within 6 months of a surgical procedure greatly increases risk, as does poorly controlled heart failure. For example, Certain surgical procedures pose more risk than others. For example, surgery involving the abdomen or chest, removal of the prostate, and major surgery on a joint (such as hip replacement) rank high on the list of risky procedures. Many procedures that older people commonly undergo, such as cataract surgery and surgery on small joints, pose lower risk. If an older person is generally well, most operations, including ones considered to be higher risk, can be done safely. When the risks of surgery are high, they still may be outweighed by the potential benefits. For example, surgery that involves some risk of death, such as repair of a large aortic aneurysm, should be considered if the person is expected to live for another 8 to 10 years because such aneurysms increase the risk of death if they are not repaired. However, such surgery should probably be avoided if other illnesses limit life expectancy to only 1 to 2 years. When the risks of surgery are low, the low risk may be outweighed by a lack of benefit. For example, some people believe that the risk of even more minor procedures (for example, a skin graft of a pressure sore), which usually is very low, is still much too great to justify putting a person with advanced dementia through such an operation. 