Chapter 9.1.3 Postoperative care

Communicate to the family the outcome of the operation, any problems encountered during the procedure and the expected postoperative course.

Immediately after surgery

Ensure that the child recovers safely from the anaesthesia. The patient should be kept on the ward or recovery area where she or he can be adequately monitored, with clear orders to:

  • monitor the airway, breathing and circulation
  • observe vital signs: temperature, pulse (see Table 30), respiratory rate and blood pressure (with the correct size of cuff, Table 30).  Observations should be made more often if there is a change from a normal to an abnormal value.
  • monitor oxygen saturation (normal, > 94%) after a general anaesthetic. Give oxygen if required.
  • Observe the patient closely until the effect of the anaesthetic has worn off.

 

Fluid management

Postoperatively, children commonly require more than maintenance fluid. Children who have undergone abdominal operations typically require 150% of baseline requirements and even larger amounts if peritonitis is present. The preferred IV fluids are Ringer’s lactate with 5% glucose, normal saline with 5% glucose or half-normal saline with 5% glucose. Note that normal saline and Ringer’s lactate do not contain glucose and are therefore a risk in hypoglycaemia; large amounts of 5% glucose contain no sodium and can produce hyponatraemia and cerebral oedema (see Annex 4).

Monitor fluid status closely.

  • Record inputs and outputs (IV fluids, nasogastric drainage, vomit, urine drain outputs) every 4–6 h.

Urine output is the most sensitive indicator of fluid status in a child:

  • Normal urine output: infants, 1–2 ml/kg per h; children, 1 ml/kg per h

If urinary retention is suspected, pass a urinary catheter. This also allows hourly measurements of urine output, which can be valuable for severely ill children. Suspect urinary retention if the bladder is palpable or the child is unable to void urine.

Pain control

Have a plan for postoperative pain management.

  • Mild pain

Give paracetamol (10–15 mg/kg every 4–6 h) by mouth or rectally. Oral paracetamol can be given several hours before the operation or rectally at the completion of surgery.

  • Severe pain

Give IV narcotic analgesics (IM injections are painful)

    • Morphine sulfate, 0.05–0.1 mg/kg IV every 2–4 h

Nutrition

Many surgical conditions increase caloric needs or prevent adequate nutritional intake. Many children with surgical problems present in a debilitated state. Poor nutrition adversely affects their response to injury and delays wound healing.

  • Feed children as soon as possible after surgery.
  • Provide a high-calorie diet containing adequate protein and vitamin supplements.
  • Consider feeding by nasogastric tube for children whose oral intake is poor.
  • Monitor the child’s weight.

Prevention of complications

  • Encourage early mobilization:
    • deep breathing and coughing
    • active daily exercise
  • Move joints passively
    • muscular strengthening
    • provide walking aids, such as canes, crutches and walkers, with instructions for their use
  • Prevent skin breakdown and pressure sores:
    • Turn the patient frequently.
    • Keep urine and faeces off skin.

Common postoperative problems

  • Tachycardia (raised pulse rate, see Table 30) may be caused by pain, hypovolaemia, anaemia, fever, hypoglycaemia or infection.
    • Examine the child.
    • Review the child’s pre-operative and intra-operative care.
    • Monitor the response to pain medication, boluses of IV fluids, oxygen and IV transfusions, when appropriate.
  • Bradycardia in a child should be considered a sign of hypoxia until proven otherwise.
  • Fever

May be due to tissue injury, wound infection, pneumonia, internal abscess, urinary tract infection (from indwelling catheters), phlebitis (from an IV catheter site) or other concomitant infection (e.g. malaria).

    • See section 9.3.6 for information on the diagnosis and treatment of wound infections.
  • Low urine output may be due to hypovolaemia, urinary retention or renal failure; usually due to inadequate fluid resuscitation.
    • Examine the child.
    • Review the child’s fluid record.
    • If hypovolaemia is suspected, give normal saline (10–20ml/kg) and repeat once (total highest safe level, 40 ml/kg; watch closely after first 20 ml/ kg for circulatory fluid overload), as needed.
    • If urinary retention is suspected (the child is uncomfortable and has a full bladder on physical examination), pass a urinary catheter.
  • Wound abscess
    • If there is pus or fluid, open and drain the wound. Remove infected skin or subcutaneous sutures, and debride the wound. Do not remove fascial sutures.
    • If there is an abscess without cellulitis, antibiotics are not required.
    • Place a damp, sterile normal saline dressing in the wound, and change the dressing every 24 h.
    • If the infection is superficial and does not involve deep tissues, monitor for development of an abscess and give antibiotics:
    • Give ampicillin (25–50mg/kg IM or IV four times a day) and metronidazole (10 mg/kg three times a day) before and for 3–5 days after the operation.
    • If the infection is deep, involves muscles and is causing necrosis (necrotiz- ing fasciitis), give antibiotics until necrotic tissue has been removed and the patient is fever-free for 48 h.
    • Give ampicillin (25–50mg/kg IM or IV four times a day) plus gentamicin (7.5 mg/kg IM or IV once a day) and metronidazole (10 mg/kg three times a day).