Day Care Surgery & Post-Op Complications, Bed Sores😊

Day Care Surgery

ERAS Protocol

Preoperative

• Counselling.

• Avoid mechanical bowel prep (due to I/V fluid/electrolyte imbalance).

• Permitted prior to Sx:
• Solids up to 6 hours.
• Clear carbohydrate rich liquids up to 2 hours (carbohydrate loading).

• (Incentive Spirometry before Sx)

Intra-operative

• Surgical approach: Minimally invasive.

• Keep patient warm.

• Nausea + vomiting prophylaxis (≥ 2 classes of meds).

Post-operative

• Bupivacaine infiltration.

• Use NSAIDs, avoid opioids.

• Within 24 hours:
• Discontinue IV fluids.
• Start with liquids f/b regular diet.
• Ambulate.

• Avoid drains/Plan early removal.

Post-Op Fever and Wound Infection

Causes of Post-Op Fever

• Wonder drugs (drug reactions → anytime), Wind (Atelectasis → 1 - 3 days), Water (UTI → 3 - 4 days), Walking (DVT → 4-5 days), Wound (wound infection - 7 days)

Day 1: 

• M/C cause → Atelectasis.

• Prevention:
• Chest physiotherapy (Incentive spirometry).
• To be used from 2 days before surgery onwards

• Pain control.
• Steam inhalation.
• Cessation of smoking (4-6 weeks pre-op).

Day 2-3:

• UTI (m/c hospital acquired infections),

• Superficial thrombophlebitis, 

• Pneumonia.

Day 4-5:

• Deep venous Thrombosis (DVT)

• Surgical site infection

Day 6: 

• Burst abdomen/abdominal wound dehiscence

Day ≥ 7: 

• Intra-abdominal abscess/collection

Air Embolism

• Air sucked into vein: 50-100 cc.

• Clinical scenarios 
• Sudden desaturation:
• During thyroid/head & neck surgery (vein nicked).
• While operating in sitting position.

• Suspected air embolism Mx: 
• Durant's position (Left lateral, Right side up) + legs up.

• Significance:
• Air in right heart → easy aspiration (image guided).

Surgical Site Infection (SSI)

• Wound infection within 30 days of surgery.

• Post implantation: 
• Within 1 year of surgery.

Southampton wound score: 

• Grade 0: Normal healing

• Grade I: Normal healing + mild bruising/erythema

• Grade II: Erythema + other inflammatory signs

• Grade III: Clear discharge

• Grade IV: Pus discharge

• Grade V: Deep/severe wound infection + tissue breakdown

ASEPSIS Score: 

• Additional treatment

• Serous discharge

• Erythema

• Purulent exudate

• Separation of deep tissues

• Isolation of bacteria → wound swab

• S → Prolonged Stay > 14 days.

Which of the following is not taken into consideration in ASEPSIS wound scoring?
A. Wound swab from the site
B. Serous discharge
C. Erythema
D. Induration

DVT Prophylaxis

• Pneumatic compression stockings (no numbering).

• Military Anti-shock garment (numbering ⊕).

Burst Abdomen

• Rectus sheath wound opens → Bowel exposed.

• 6 days Post Op

• C/P: 
• Salmon fluid/Serous fluid sign (large clear fluid).
• Copious sero-sanguinous discharge

• Mx:
• Emergency → Urobog/Bogata bag laparostomy.
• Definitive → Rectus sheath resuturing.

Factors Predisposing to Burst Abdomen

• Patient factors:
• Chronic cough,
• Constipation,
• Infection/obesity,
• Immunocompromised,
• Malnourished.

• Surgery factors:
• Midline incision > Transverse.
• Emergency > Elective.
• Continuous sutures > Interrupted.
• Large bite > Short bite 
• [ideal: 0.5 cm]
• Short thread > Long thread 
• [minimum 4 times length preferred]

Intra-abdominal Abscess

• Pelvis/Pouch of Douglas (POD).
• M/C site overall.
• M/C site ambulatory

• Morrison's/hepatorenal pouch.
• M/C site supine

• Fever on POD 9

• Presentation: 
• Fever + chills & rigors.
• Pelvic abscess → Pelvic diarrhoea (repeated loose stools + mucus).

• LOC: 
• CECT.

• Mx:
• Drainage with pigtail catheter under imaging guidance.

Types of Wound & SSI

• Clean wound 
• (e.g., Thyroid Sx, Knee replacement, Breast Sx, Uncomplicated inguinal hernia, CABG)
• With ABX prophylaxis: 1-2%.
• No prophylactic ABX role (unless implant/mesh placed).

• Clean contaminated wounds 
• (GIT/GU without inflammation, e.g., Elective/interval cholecystectomy, Elective appendectomy, Urinary stone removal (no UTI), LSCS, TURP, Laparoscopic abdominal hysterectomy, Bowel surgery (if prepared))
• With ABX prophylaxis: 3%.
• Without ABX prophylaxis: 6-9%.

• Contaminated wounds 
• (GIT/GU with non-purulent inflammation, e.g., Emergency appendectomy, Bowel opened in obstruction, Breach sterile protocol - Open cardiac massage):
• With ABX prophylaxis: 6%.
• Without ABX prophylaxis: 20%.

• Dirty wound 
• (Pus present, e.g., All abscesses, Peritonitis/Fecal contamination, Neglected traumatic wound > 6 hours):
• With ABX prophylaxis: 7-8%.
• Without ABX prophylaxis: 30-40%.

Note

• Elective OT list:
• Clean cases (e.g., Implant insertion) posted first.

Prevention of Wound Infection

Hand Hygiene/ Steps of Hand Washing

• Steps: Wet hands → Soap → Rub palms → Right palm over left dorsum (interlaced) → Palms to palm (interlaced) → Backs of fingers to opposing palms → Rotational rubbing of thumbs → Rotational rubbing of clasped fingers → Rinse → Dry → Use towel to turn off faucet.

• Areas missed:
• Thumb,
• Inter digital areas,
• Finger tips.

• 5 moments:
• "2 Before":
• Before touching patient.
• Before clean/aseptic procedure.
• "3 After":
• After body fluid exposure.
• After touching patient.
• After touching patient's surroundings.

• Soap and water/sanitizer:
• C/I for sanitizer:
• After toilet visit.
• Visibly soiled hands.

Essential PPE:

• Gown, Gloves, Mask, Goggles, Face shield

Step	Sequence
1. Donning (Putting on PPE)	Gown → Mask → Goggles/Face Shield → Gloves
2. Doffing (Removing PPE)	Gloves → Goggles/Face Shield → Gown → Mask

Parts Preparation

• Hair clipper:
• Used to trim hair (prior to surgery).

• Avoid shaving (→ ↑ Infection rates).

Cleaning Body Part

• Agent used:
• Betadine/Alcohol.

• Area cleaned:
• Abdominal Sx:
• Males: Nipples to mid thigh;
• Females: Inframammary fold to mid thigh.
• Limb Sx:
• Till 1 joint up.

• Direction:
• Abdomen: Midline to lateral.
• Limbs: Lateral to medial.
• Circumferentially outwards from incision site/midline.

• Followed by Sponge disposal.

Prophylactic Antibiotics

• Given 30-60 minutes before Sx.

• Prolonged Sx → Repeat dose after 4 hours.

Other Measures

• Prevent hypothermia.

• Prevent blood loss → Achieve proper hemostasis.

Bed Sores

 

Features

• Pressure >30 mmHg leads to bed sore

• M/c site: Ischium > greater trochanter > sacrum

Risk Factors

• Prolonged immobilization

• Malnutrition

• Maceration of the area

Prevention

• Frequent position change: 10 minutes every 2 hours

• Use air/water mattress to offload weight

Staging of Pressure Sores

• Stage 1: Non-blanchable erythema, no epidermal breach

• Stage 2: Partial thickness skin loss involving epidermis & dermis

• Stage 3: Full thickness skin loss extending into subcutaneous tissue

• Stage 4: Full thickness skin loss involving muscle, bone, tendon or joint

Management

• Grade I/II: Keep dry + offloading + Hydrocolloid dressing

• Grade II/III: Debridement + VAC dressing

• Grade IV: Debridement + VAC/flap

Vacuum Assisted Closure (VAC)

• AKA negative pressure dressing:
• -120 to -125 mmHg

• Hastens healing

Mechanism of Action

• Macrodeformation
• Negative pressure pulls wound edges together
• Reduces wound size
• Decreases dead space

• Microdeformation
• Sponge pores transmit mechanical forces to cells
• Stimulates cell proliferation, angiogenesis, granulation tissue formation

• Edema Reduction
• Removes excess interstitial fluid
• Decreases tissue pressure
• Improves blood flow

• Exudate & Bacterial Load Removal
• Continuous suction clears wound exudate
• Reduces bacterial colonization
• Decreases infection risk

• Enhanced Perfusion
• Negative pressure increases local blood flow
• Improves oxygen & nutrient delivery

• Moist Healing Environment
• Prevents wound desiccation
• Promotes faster healing

Uses:

• Chronic non-healing wounds

• Venous ulcers without slough

• Burn wounds without eschar

• Bed sores after debridement

• Diabetic ulcers without osteomyelitis

Types: