- Early - usually develop in the first 7 days after surgery;
- Late - develop through different periods after discharge from the hospital
From the side of the wound:
1. Bleeding from a wound
2. Suppuration of the wound
3. Event
4. Incisional hernia
5. Ligature fistulas
From the side of the operated organ (anatomical region):
- Failure of the anastomotic sutures (stomach, intestine, bronchus, etc.).
- Bleeding.
- Formation of strictures, cysts, fistulas (internal or external).
- Paresis and paralysis.
- Purulent complications (abscesses, phlegmon, peritonitis, pleural empyema, etc.).
From other organs and systems:
- On the part of the CVS - acute coronary insufficiency, myocardial infarction, thrombosis and thrombophlebitis, pulmonary embolism;
- From the side of the central nervous system - acute cerebrovascular accident (stroke), paresis and paralysis;
- Acute renal, liver failure.
- Pneumonia.
Postoperative complications can be presented as a diagram
Nursing begins immediately after the end of the operation. If the operation was performed under general anesthesia, an anesthesiologist gives permission for transportation. With local anesthesia, the patient is moved to a gurney after the operation, either independently or with the help of staff, after which he is transported to the recovery room or to the ward in the surgical department.
Sick bed must be prepared by the time of his arrival from the operating room: covered with fresh linen, heated with heating pads, there must be no folds on the sheets. The nurse should know in what position the patient should be after the operation. Usually patients lie on their backs. Sometimes, after surgery on the organs of the abdominal and thoracic cavities, patients lie in the Fowler position (a half-sitting position on the back with limbs bent at the knee joints).
Patients operated on under anesthesia are transported to the intensive care unit on the bed of the same unit. Transfer from the operating table to the functional bed is carried out under the supervision of an anesthesiologist. The unconscious patient is carefully lifted from the operating table and transferred to the bed, while sharp bending of the spine (possible dislocation of the vertebrae) and drooping of the limbs (possible dislocations) should be avoided. It is also necessary to ensure that the bandage from the postoperative wound is not torn off and the drainage tubes are not removed. At the time of transferring the patient to the bed and transportation, there may be signs of respiratory and cardiac disorders, therefore, the accompaniment of the anesthesiologist and nurse-anesthetist necessarily ... Until the patient regains consciousness, he is laid horizontally, his head is turned on the side (prevention of aspiration of gastric contents into the bronchi - the nurse should be able to use an electric suction to help the patient with vomiting). Cover with a warm blanket.
To provide the body with oxygen better, humidified oxygen is supplied through a special device. To reduce the bleeding of the operated tissues, an ice pack is placed on the wound area for 2 hours or a load (usually a sealed oilcloth bag with sand). Drainage tubes are attached to the system to collect the contents of the wound or cavity.
In the first 2 hours, the patient is in a horizontal position on his back or with the head end lowered, since in this position the blood supply to the brain is better provided.
During operations under spinal anesthesia, the horizontal position remains for 4-6 hours due to the risk of orthostatic hypotension.
After the patient regains consciousness, a pillow is placed under his head, and the hips and knees are raised to reduce blood stagnation in the calf muscles (prevention of thrombosis).
The optimal position in bed after surgery may vary, depending on the nature and area of the surgery. For example, patients who have undergone surgery on the abdominal organs, after they regain consciousness, are put to bed with their heads slightly raised and their legs slightly bent at the knees and hip joints.
Prolonged stay of the patient in bed is not desirable, due to the high risk of complications caused by physical inactivity. Therefore, all factors that impede his mobility (drains, prolonged intravenous infusions) must be taken into account in time. This is especially true for elderly and senile patients.
There are no clear criteria determining the timing of the patient's getting out of bed. Most patients are allowed to get up 2-3 days after surgery, but the introduction of modern technology into medical practice is changing a lot. After laparoscopic cholecystectomy, it is allowed to get up in the evening, and many patients are discharged for outpatient treatment the very next day. Getting up early increases confidence in a favorable outcome of the operation, reduces the frequency and severity of postoperative complications, especially respiratory and deep vein thrombosis.
Even before the operation, it is necessary to teach the patient how to get out of bed. In the evening or the next morning, the patient should already sit on the edge of the bed, clear his throat, move his legs, while in bed he should change his body position as often as possible, make active movements with his legs. At the beginning, the patient is turned on his side, to the side of the wound, with bent hips and knees, while the knees are on the edge of the bed; the doctor or nurse helps the patient to sit up. Then, after making several deep breaths and exhalations, the patient clears his throat, stands on the floor, taking 10-12 steps around the bed, and goes back to bed. If the patient's condition does not worsen, then the patient should be activated in accordance with his own feelings and the instructions of the doctor.
Sitting in a bed or chair is not recommended because of the risk of slowing venous blood flow and the occurrence of thrombosis in the deep veins of the lower extremities, which in turn can cause sudden death due to thrombus rupture and pulmonary embolism.
For the timely detection of this complication, it is necessary to daily measure the circumference of the limb, palpate the calf muscles in the projection of the neurovascular bundle. The appearance of signs of deep vein thrombosis (edema, cyanosis of the skin, an increase in the volume of the limb) is an indication for special diagnostic methods (ultrasound Doppler, phlebography). Especially often deep vein thrombosis occurs after traumatological and orthopedic operations, as well as in patients with obesity, cancer, diabetes mellitus. The restoration of impaired water-electrolyte metabolism, the prophylactic use of direct anticoagulants (heparin and its derivatives), early activation of the patient, bandaging of the lower extremities with elastic bandages before the operation and in the first 10-12 days after it contribute to the reduction of the risk of thrombosis in the postoperative period.
Failure to comply with the general rules of postoperative management and delayed correction of changes in homeostasis developing at this time lead to the development of postoperative complications, i.e. to the development of postoperative illness.
In this case, the localization of the pathological process, as a postoperative complication, can be different and involve different organs and systems of the body. Knowledge of these complications allows timely identification and treatment of them.
All complications arising in the postoperative period can be divided into three large groups:
Complications in the organs and systems on which the surgery was performed (complications of the main moment of the operation);
Complications in organs that were not directly influenced by surgery;
Complications from the surgical wound.
Complications of the first group arise as a result of technical and tactical errors made by the surgeon during the operation. The main cause of these complications is usually the surgeon's irresponsible attitude towards their work. Less often, the cause of these complications is an overestimation of the patient's body's ability to transfer those changes in the organs that occur after the operation. But these reasons can also be attributed to the surgeon - before the operation, he must anticipate the possibility of these complications.
Complications of the first group include: secondary bleeding, the development of purulent processes in the area of surgery and in the postoperative wound, impaired organ function after intervention on them (impaired patency of the gastrointestinal tract, biliary tract).
Usually, the occurrence of these complications requires a second surgical intervention, which is often performed in difficult conditions and quite often leads to death.
Continuous improvement of the surgical technique, a thorough assessment of the physiological state of the patient's organs and systems before the operation, the attitude to any stage of the operation as the most important - will always be a reliable guarantor in the prevention of these complications.
To complications of the second group relate:
1) about complications from the nervous system patient: sleep disturbance, mental disorders (up to the development of postoperative psychosis).
2) respiratory complications: postoperative pneumonia, bronchitis, lung atelectasis, pleurisy, accompanied by the development of respiratory failure.
The most common reason for the development of these complications is poor management of anesthesia, as well as failure to comply with basic measures in the early postoperative period, such as early activation of patients, early therapeutic respiratory gymnastics, and the release of mucus from the airways.
3) Complications from the organs of the cardiovascular system can be both primary, when heart failure occurs due to a disease of the heart itself, and secondary, when heart failure occurs against the background of a severe pathological process developing in the postoperative period in other organs (severe purulent intoxication, postoperative blood loss, etc.). Monitoring cardiac activity in the postoperative period, combating those pathological processes that can lead to the development of heart failure, and their timely treatment will improve the patient's condition and remove him from this complication.
One of the manifestations of vascular insufficiency in the postoperative period is the development of thrombosis, the causes of which are considered to be a slowdown in blood flow, an increase in blood coagulability and a violation of the walls of blood vessels, which is often associated with infection.
Thrombosis is more often observed in elderly and senile patients, as well as in patients with oncological processes and diseases of the venous system (varicose veins, chronic thrombophlebitis).
Usually thrombosis develops in the venous vessels of the lower extremities and is manifested by pain, edema and cyanosis of the skin of the lower extremities, an increase in body temperature. However, these classic symptoms of the disease are rarely found. More often, thrombosis of the veins of the lower extremities is manifested by pain in the muscles of the lower leg, which increases during walking and on palpation of the muscles, sometimes there are swelling of the feet.
Venous thrombosis of the lower extremities is often the cause of such a formidable postoperative complication as embolism of small branches of the pulmonary artery, renal vessels.
Prevention of vascular complications developing in the postoperative period should begin in the preoperative period. To do this, examine the blood coagulation system, if necessary, conduct a course of anticoagulant therapy, bandage the lower extremities before surgery in patients with varicose veins. It must be continued both during the operation (respect for tissues and blood vessels) and in the postoperative period - early activation of the patient (early getting up) and the introduction of a sufficient amount of fluid into the patient's body.
The use of anticoagulants is of great importance for the prevention and treatment of developed thrombotic processes. As already noted, anticoagulant therapy should be started in the preoperative period and continued after the operation. In this case, it is always necessary to remember the need to control the blood coagulation system. Otherwise, an equally formidable complication may develop - bleeding.
4) Complications from the organs of the gastrointestinal tract
are more often functional in nature. These complications include the development of dynamic obstruction of the gastrointestinal tract, which occurs after laparotomy. Its clinical manifestations are belching, hiccups, vomiting, and bloating (intestinal paresis). However, it should be noted that dynamic disorders of the function of the organs of the gastrointestinal tract can occur with a developing pathological process in the abdominal cavity - postoperative peritonitis, which may be caused by a technical error made during the operation (incompetence of the sutures on the wounds of the gastrointestinal tract). In addition, obstruction of the gastrointestinal tract can be associated with mechanical reasons (torsion of the intestinal loop, improperly formed interintestinal anastomosis).
Therefore, before deciding on therapeutic measures when signs of dysfunction of the organs of the gastrointestinal tract appear, it is necessary to exclude pathological processes in the abdominal cavity, and only then begin treatment aimed at normalizing the function of these organs. This treatment includes stimulation therapy, gastric tube insertion, insertion of a gas tube into the rectum, a cleansing enema, use of special bowel stimulants, and active standing.
In some cases, the postoperative period may be complicated by the appearance of diarrhea in the patient, which has a different origin.
According to etiological factors, the following types of postoperative diarrhea are distinguished:
a) achilic diarrhea arising after extensive resections of the stomach;
b) diarrhea from shortening the length of the small intestine;
c) neuroreflex diarrhea in patients with a labile nervous system;
d) diarrhea of infectious origin (enteritis, exacerbation of chronic bowel disease);
e) septic diarrhea arising from the development of severe intoxication of the patient's body.
Any disorder of bowel function in the postoperative period, especially diarrhea, sharply worsens the patient's condition, leads his body to exhaustion, to dehydration, and reduces the immunobiological defense of the body. Therefore, the fight against this complication, which should be carried out taking into account the etiological factor, is of great importance for the patient.
5) Complications from the urinary organs not so often occur in the postoperative period, due to the active behavior of patients after surgery. These complications include: a delay in the production of urine by the kidneys - anuria, a delay in urination - ischuria, the development of inflammatory processes in the renal parenchyma and in the wall of the bladder.
Postoperative anuria is most often of a neuro-reflex nature. However, it is sometimes associated with the development of infectious postoperative complications. With anuria, the bladder is empty, there is no urge to urinate, the general condition of the patient is severe.
Ishuria usually occurs after operations on the pelvic organs (genitals, rectum). The bladder fills with urine, and urination does not occur or occurs in small portions (paradoxical ischuria). Treatment of complications arising in the kidneys and urinary tract should be carried out depending on the factor that caused them.
The third group of postoperative complications is associated with an operating wound. They arise as a result of violations of technical techniques during the operation and in case of non-observance of the rules of asepsis. These complications include: bleeding, the formation of hematomas, inflammatory infiltrates, suppuration of the surgical wound with the formation of an abscess or phlegmon, dehiscence of the edges of the wound with prolapse of internal organs (eventration).
Bleeding can be caused by:
1) slipping of the ligature from the blood vessel;
2) bleeding not completely stopped during the operation;
3) the development of a purulent process in the wound - erosive bleeding.
The inflammatory process in a postoperative wound has an infectious etiology (an infection enters the wound as a result of a violation of the rules of asepsis).
The divergence of the edges of the operating wound with the eventration of organs most often occurs as a result of the development of an inflammatory process in the wound. However, this can be facilitated by a violation of the regeneration process in the tissues of the wound, due to the underlying disease (cancer, vitamin deficiency, anemia, etc.).
Prevention of complications of the third group should begin in the preoperative period, continue during the operation (adherence to asepsis, respect for the tissues of the wound, prevention of the development of the inflammatory process in the area of surgery) and in the postoperative period - the use of antiseptics.
Particular attention should be paid to the postoperative period in elderly and senile patients. These patients have a kind of "readiness for complications." The organism of old patients, brought out of its usual state by an operational trauma, requires much more effort and time to restore functional disorders than is the case in young people.
Postoperative period I
Postoperative period
Disorders of the central mechanisms of respiration regulation, arising, as a rule, due to depression of the respiratory center under the influence of anesthetic and narcotic drugs used during the operation, can lead to acute respiratory disorders in the nearest P. of the item. Intensive therapy of acute respiratory disorders of central origin is based on artificial ventilation (ALV), the methods and options of which depend on the nature and severity of respiratory disorders. Disturbances in the peripheral mechanisms of respiration regulation, often associated with residual muscle relaxation or recurarization, can lead to a rare violation of gas exchange and cardiac arrest. In addition, these disorders are possible in patients with myasthenia gravis, myopathies and other peripheral breathing disorders. It consists in maintaining gas exchange by mask ventilation or re-intubation of the trachea and transfer to mechanical ventilation until muscle tone is completely restored and adequate spontaneous breathing. Severe breathing disorders can be caused by atelectasis of the lungs, pneumonia and pulmonary embolism. With the appearance of clinical signs of atelectasis and X-ray confirmation of the diagnosis, it is necessary to eliminate, first of all, the cause of atelectasis. With compression atelectasis, this is achieved by draining the pleural cavity with the creation of a vacuum. With obstructive atelectasis, therapeutic bronchoscopy is performed with sanitation of the tracheobronchial tree. If necessary, the patient is transferred to mechanical ventilation. The complex of therapeutic measures includes the use of aerosol forms of bronchodilators, percussion and vibration chest, postural. One of the serious problems of intensive care of patients with respiratory failure is the question of the need for mechanical ventilation. Respiratory rate of more than 35 in 1 serves as guidelines for solving it. min, Stange test less than 15 with, pO 2 below 60 mm rt. st... despite inhalation of 50% oxygen mixture, hemoglobin with oxygen less than 70%, pCO 2 less than 30 mm rt. st... ... vital capacity of the lungs is less than 40-50%. The defining criterion for the use of mechanical ventilation in the treatment of respiratory failure is the increase in respiratory failure and insufficient effectiveness of the therapy. In early P. p. .
acute hemodynamic disturbances can be caused by volemic, vascular or heart failure. The causes of postoperative hypovolemia are manifold, but the main ones are unrecovered during surgery or ongoing internal or external. The most accurate assessment of the state of hemodynamics is provided by comparing the central venous pressure (CVP) with the pulse and, the prevention of postoperative hypovolemia is the full replacement of blood loss and circulating blood volume (BCC), adequate pain relief during the operation, careful during surgery, ensuring adequate gas exchange and correction of violations metabolism both during the operation and in early P. of the item. The leading place in intensive therapy of hypovolemia is taken, aimed at replenishing the volume of circulating fluid. Vascular insufficiency develops as a result of toxic, neurogenic, toxic-septic or allergic shock. In modern conditions, cases of anaphylactic and septic shock have become more frequent in P. of the item. with anaphylactic shock (anaphylactic shock) consists of intubation and mechanical ventilation, the use of adrenaline, glucocorticoids, calcium preparations, antihistamines. Heart failure
is a consequence of cardiac (, angina pectoris, surgery) and extracardiac (toxicoseptic myocardium) causes. Its therapy is aimed at eliminating pathogenetic factors and includes the use of cardiotonic drugs, coronary artery disease, anticoagulants, electrical impulse cardiac stimulation, assisted artificial circulation. In case of cardiac arrest, they resort to cardiopulmonary resuscitation. P.'s course of the item to a certain extent depends on the nature of the surgical intervention, the existing intraoperative complications, the presence of concomitant diseases, the patient's age. With a favorable course of P. the item in the first 2-3 days can be increased to 38 °, and the difference between the evening and morning temperatures does not exceed 0.5-0.6 °. The pains gradually subside by the 3rd day. The heart rate in the first 2-3 days remains in the range of 80-90 beats per 1 min, CVP and blood pressure are at the level of preoperative values, the next day after the operation, there is only a slight increase in sinus rhythm. After operations under endotracheal anesthesia, the next day, the patient coughs up a small amount of mucous sputum, breathing remains vesicular, single dry sputum can be heard, disappearing after coughing up sputum. the skin and visible mucous membranes do not undergo any changes in comparison with their color before the operation. remains moist, may be overlaid with a whitish bloom. corresponds to 40-50 ml / h, there are no pathological changes in the urine. After operations on the abdominal organs, it remains symmetrical, intestinal murmurs are sluggish on the 1-3rd day. Moderate is allowed on the 3-4th day of P. of the item after stimulation, cleansing. The first postoperative revision is carried out the next day after the operation. At the same time, the edges of the wound are not hyperemic, not edematous, the sutures do not cut into the skin, and the wound is moderate on palpation. and hematocrit (if there was no bleeding during the operation) remain at baseline. On the 1-3rd day, there may be moderate leukocytosis with a slight shift of the formula to the left, relative, an increase in ESR. In the first 1-3 days, slight hyperglycemia is observed, but sugar in the urine is not detected. A slight decrease in the level of the albumin-globulin coefficient is possible. Elderly and senile persons in early P. of the item are characterized by the absence of an increase in body temperature; more pronounced and fluctuations in blood pressure, moderate (up to 20 in
1 min) and a large amount of sputum in the first postoperative days, sluggish tract. the wound heals more slowly, often occurs, eventration and other complications. Possible. In connection with the tendency to shorten the patient's stay in the hospital, the outpatient surgeon has to observe and treat some groups of patients from the 3rd to 6th day after the operation. For the general surgeon on an outpatient basis, the most important are the main complications of P. of the item, which can arise after operations on the organs of the abdominal cavity and chest. There are many risk factors for the development of postoperative complications: concomitant diseases, long-term, duration of the operation, etc. During the outpatient examination of the patient and in the preoperative period in the hospital, these factors should be taken into account and appropriate corrective therapy should be carried out. With all the variety of postoperative complications, the following signs can be distinguished, which should alert the doctor in assessing the course of P. p. Increased body temperature from 3-4 or 6-7 days, as well as high temperature (up to 39 ° and above ) from the first day after the operation, testify to the dysfunctional course of P., the item hectic from the 7-12th day speaks of a severe purulent complication. A sign of trouble is pain in the area of the operation, which does not subside by the 3rd day, but begins to increase. Severe pains from the first day of P. of the item should also alert the doctor. The reasons for the intensification or renewal of pain in the operation area are diverse: from superficial suppuration to intra-abdominal catastrophe. The expressed tachycardia from the first hours of P. of the item or its sudden appearance on the 3rd-8th day indicates a developed complication. A sudden drop in blood pressure and at the same time an increase or decrease in CVP are signs of a severe postoperative complication. On the ECG, with many complications, characteristic changes are recorded: signs of overload of the left or right ventricle, various arrhythmias. The causes of hemodynamic disturbances are manifold: heart disease, bleeding, etc. The appearance of shortness of breath is always alarming, especially on the 3-6th day of P. of the item. The causes of shortness of breath in P. of the item can be pneumonia, septic shock, pleural empyema, pulmonary edema, etc. The doctor should be alerted by sudden unmotivated shortness of breath, characteristic of thromboembolism pulmonary arteries. Cyanosis, pallor, marbled skin, purple, blue spots are signs of postoperative complications. The appearance of jaundice of the skin and often indicates severe purulent complications and developing liver failure. Oligoanuria and testify to the most difficult postoperative situation - renal failure. A decrease in hemoglobin and hematocrit is a consequence of unreplenished surgical blood loss or postoperative bleeding. A slow decrease in hemoglobin and the number of erythrocytes indicates inhibition of toxic erythropoiesis. , lymphopenia or the emergence of leukocytosis again after the normalization of the blood count is characteristic of complications of an inflammatory nature. A number of blood biochemical parameters may indicate operational complications. So, an increase in the level of blood and urine is observed with postoperative pancreatitis (but it is possible with parotitis, as well as high intestinal obstruction); transaminases - with exacerbation of hepatitis, myocardial infarction, liver; bilirubin in the blood - with hepatitis, obstructive jaundice, pylephlebitis; urea and creatinine in the blood - with the development of acute renal failure. The main complications of the postoperative period... Suppuration of the surgical wound is most often caused by aerobic flora, but often the causative agent is anaerobic non-clostridial. Complication usually manifests itself on the 5-8th day of P. p., It can also occur after discharge from the hospital, but the rapid development of suppuration is also possible on the 2-3rd day. With suppuration of the operating wound, the body temperature, as a rule, rises again and is usually of a character. Moderate leukocytosis is noted, with anaerobic non-clostridial flora - severe lymphopenia, toxic granularity of neutrophils. Diuresis, as a rule, is not impaired. Local signs of wound suppuration are swelling in the area of seams, skin, sharp pain on palpation. However, if suppuration is localized under the aponeurosis and has not spread to the subcutaneous tissue, these signs, with the exception of pain on palpation, may not be. In elderly and senile patients, general and local signs of suppuration are often erased, and the prevalence of the process, at the same time, can be large. Treatment consists in diluting the edges of the wound, debridement and drainage, dressing with antiseptics. When granulations appear, ointments are prescribed, secondary sutures are applied. After careful excision of purulent-necrotic tissues, it is possible to suture with drainage and further flow-drop washing of the wound with various antiseptics with constant active aspiration. For large wounds, surgical necrectomy (full or partial) is complemented by laser, X-ray or ultrasound treatment of the wound surface, followed by the use of aseptic dressings and the imposition of secondary sutures. If suppuration of a postoperative wound is found when a patient visits a surgeon in a polyclinic, then with superficial suppuration in the subcutaneous tissue, treatment on an outpatient basis is possible. If suppuration in deep-lying tissues is suspected, hospitalization in a purulent department is necessary, because in these cases, more complex surgical intervention is required. At present, the danger of clostridial and non-clostridial infections (see Anaerobic infection), in which signs of shock, high body temperature, hemolysis, growing, subcutaneous crepitus, can be found, is becoming increasingly important in P. of the item. At the slightest suspicion of anaerobic infection, urgent hospitalization is indicated. In the hospital, the wound is immediately widened, non-viable tissues are excised, intensive antibiotic therapy is started (penicillin - up to 40,000,000 or more per day intravenously, metronidazole - 1 G per day, clindamycin intramuscularly at 300-600 mg every 6-8 h), carry out serotherapy, carry out hyperbaric oxygenation (Hyperbaric oxygenation). Due to inadequate hemostasis during the operation or other reasons, hematomas may occur that are located under the skin, under the aponeurosis or intermuscularly. Deep hematomas in the retroperitoneal tissue, in the pelvic and other areas are also possible. In this case, the patient is worried about pain in the area of the operation, upon examination of which there is a swelling, and after 2-3 days - in the skin around the wound. Small hematomas may not show up clinically. When a hematoma appears, the wound is opened, its contents are evacuated, hemostasis is carried out, the wound cavity is treated with antiseptic solutions and the wound is sutured with the use of any preventive measures for possible subsequent suppuration. Therapy of psychosis consists in the treatment of the underlying disease in combination with the use of antipsychotics (see. Antipsychotics),
antidepressants (Antidepressants) and tranquilizers (Tranquilizers). almost always favorable, but worsens when states of dullness are replaced by intermediate syndromes. Thrombophlebitis most often occurs in the superficial vein system that was used during or after surgery for fluid therapy. As a rule, superficial veins of the upper extremities are not dangerous and are stopped after local treatment, including immobilization of the extremity, application of compresses, heparin ointment, etc. Superficial thrombophlebitis of the lower extremities can cause deep phlebitis with a threat of pulmonary embolism. Therefore, in the preoperative period, it is necessary to take into account the data of the coagulogram and such factors as a history of thrombophlebitis, complicated, disorders of fat metabolism, vascular disease, lower extremities. In these cases, the limbs are bandaged, measures are taken to combat anemia, hypoproteinemia and hypovolemia, and to normalize arterial and venous circulation. In order to prevent thrombus formation in P. of the item, along with adequate restoration of homeostasis in patients with risk factors, it is advisable to prescribe direct and indirect action. One of the possible complications of P. of the item - pulmonary arteries. The most common is the pulmonary artery (pulmonary embolism), less often fatty and air embolism.
The volume of intensive care for pulmonary embolism depends on the nature of the complication. With a lightning-fast form, resuscitation measures are necessary (trachea, mechanical ventilation, closed). Under appropriate conditions, it is possible to carry out emergency thromboembolectomy with mandatory massage of both lungs or catheterization embolectomy followed by anticoagulant therapy against the background of mechanical ventilation. With partial embolism of the branches of the pulmonary arteries with a gradually developing clinical picture, fibrinolytic and anticoagulant therapy is indicated. The clinical picture of postoperative peritonitis is diverse: abdominal pain, tachycardia, gastrointestinal tract, not relieved by conservative measures, changes in the blood count. The outcome of treatment fully depends on timely diagnosis. Relaparotomy is performed, the source of peritonitis is eliminated, the abdominal cavity is sanitized, adequately drained, and nasointestinal intestinal intubation is performed. Eventration, as a rule, is a consequence of other complications - paresis of the gastrointestinal tract, peritonitis, etc. Postoperative pneumonia can occur after severe operations on the abdominal organs, especially in elderly and senile people. In order to prevent it, inhalations, cans, breathing exercises, etc. are prescribed. Postoperative pleura can develop not only after operations on the lungs and mediastinum, but also after operations on the abdominal organs. In diagnostics, the chest has a leading place. Outpatient management of patients after neurosurgical operations... Patients after neurosurgical operations usually require long-term outpatient observation and treatment for the purpose of psychological, social and labor rehabilitation. After surgery for traumatic brain injury (Traumatic brain injury), complete or partial impaired cerebral functions are possible. However, in some patients with traumatic arachnoiditis and arachnoencephalitis, hydrocephalus, epilepsy, various psychoorganic and autonomic syndromes, the development of cicatricial adhesions and atrophic processes, disorders of hemo- and liquorodynamics, inflammatory reactions, and immune deficiency are observed. After removal of intracranial hematomas, hygromas, foci of brain crush, etc. conduct anticonvulsant therapy under the control of electroencephalography (electroencephalography). In order to prevent epileptic seizures developing after severe traumatic brain injury in about 1/3 of patients, drugs containing phenobarbital (pagluferal = 1, 2, 3, gluferal, etc.) are prescribed for 1-2 years. In case of epileptic seizures resulting from traumatic brain injury, therapy is selected individually, taking into account the nature and frequency of epileptic seizures, their dynamics, age and general condition of the patient. Various combinations of barbiturates, tranquilizers, nootropics, anticonvulsants and sedatives are used. To compensate for impaired brain functions and accelerate recovery, vasoactive (Cavinton, Sermion, Stugeron, Theonicol, etc.) and nootropic (Piracetam, Encephabol, Aminalon, etc.) drugs are used in alternating two-month courses (at intervals of 1-2 months) for 2- 3 years old. It is advisable to supplement this basic therapy with means that affect tissue metabolism: amino acids (cerebrolysin, glutamic acid, etc.), biogenic stimulants (aloe, etc.), enzymes (lidaza, lekozyme, etc.). According to the indications on an outpatient basis, various cerebral syndromes are treated - intracranial hypertension (intracranial hypertension), intracranial hypotension (see Intracranial pressure), cephalgic, vestibular (see Vestibular symptom complex), asthenic (see Asthenic syndrome), hypothalamic (see Asthenic syndrome), hypothalamic (see Intracranial pressure) (Hypothalamic syndromes)), etc., as well as focal - pyramidal (see Paralysis), cerebellar, subcortical, etc. In case of mental disorders, supervision of a psychiatrist is mandatory. After surgical treatment of pituitary adenoma (see.Pituitary adenoma), the patient, along with a neurosurgeon, neuropathologist and ophthalmologist, should be monitored, since after surgery often develops (hypothyroidism, insipidus, etc.), requiring hormone replacement therapy. After transnazosphenoidal or transcranial removal of prolactotropic adenoma of the pituitary gland and an increase in prolactin concentration in men, sexual activity decreases, hypogonadism develops, in women, infertility and lactorrhea. After 3-5 months after treatment with parlodel, patients can recover full and come (during which parlodel is not used). With the development of panhypopituitarism in P. of the item, substitution therapy is carried out continuously for many years, tk. its termination can lead to a sharp deterioration in the condition of patients and even to death. With hypocorticism, ACTH is prescribed, with hypothyroidism, it is used. With diabetes insipidus, the use of adiurecrine is mandatory. Substitution therapy for hypogonadism is not always used; in this case, the consultation of a neurosurgeon is necessary. After discharge from the hospital of patients operated on for benign extracerebral tumors (meningiomas, neuromas), therapy is prescribed to accelerate the normalization of brain functions (vasoactive, metabolic, vitamin preparations, exercise therapy). In order to prevent possible epileptic seizures, small doses of anticonvulsants (usually) are exchanged for a long time. To resolve the syndrome of intracranial hypertension that often remains after surgery (especially with pronounced congestive nipples of the optic nerves), dehydrating drugs (furosemide, diacarb, etc.) are used, recommending their intake 2-3 times a week for several months. With the involvement of speech therapists, psychiatrists and other specialists, targeted treatment is carried out to eliminate the deficit and correct certain brain functions (speech, vision, hearing, etc.). In case of intracerebral tumors, taking into account the degree of their malignancy and the volume of surgical intervention, outpatient treatment for individual indications includes courses of radiation therapy, hormonal, immune and other drugs in various combinations. In the outpatient management of patients who have undergone transcranial and endonasal operations for arterial, arteriovenous aneurysms and other vascular malformations of the brain, special attention is paid to the prevention and treatment of ischemic brain lesions. Prescribe drugs that normalize cerebral vessels (aminophylline, no-shpa, papaverine, etc.), microcirculation (trental, komplamin, sermion, cavinton), brain (piracetam, encephabol, etc.). Similar therapy is indicated for extra-intracranial anastomoses. With pronounced epileptic readiness, according to clinical data and the results of electroencephalography, preventive anticonvulsant therapy is performed. Patients who have undergone stereotaxic surgery for parkinsonism are often additionally shown long-term neurotransmitter therapy (levodopa, nakom, madopar, etc.), as well as anticholinergic drugs (cyclodol and its analogs, tropacin, etc.). After operations on the spinal cord, a long, often long-term treatment is carried out, taking into account the nature, level and severity of the lesion, the radical nature of the surgical intervention and the leading clinical syndromes. Prescribed to improve blood circulation, metabolism and trophism of the spinal cord. In case of gross destruction of the spinal cord substance and its persistent edema, proteolysis inhibitors (contrical, gordox, etc.) and dehydrating agents () are used. They pay attention to the prevention and treatment of trophic disorders, primarily bedsores (bedsores). Given the high incidence of chronic sepsis with gross injuries of the spinal cord, on an outpatient basis, it may appear for a course of antibacterial and antiseptic therapy. Many patients who have undergone spinal cord surgery require correction of pelvic dysfunction. Often long-term use of bladder catheterization or continuous, as well as tidal systems. It is necessary to strictly observe measures for the prevention of outbreaks of uroinfection (thorough toilet of the genitals, rinsing the urinary tract with a solution of furacilin, etc.). With the development of urethritis, cystitis, pyelitis, pyelonephritis, antibiotics and antiseptics (derivatives of nitrofuran and naphthyridine) are prescribed. For spastic para- and tetraparesis and plegias, antispastic drugs (baclofen, midocalm, etc.) are used, for flaccid paresis and paralysis - anticholinesterase drugs, as well as exercise therapy and massage. After operations for spinal cord injuries, general, segmental and local physiotherapy and balneotherapy are widely used. Transcutaneous electrical stimulation is successfully used (including with the use of implanted electrodes), which helps to accelerate reparative processes and restore the conduction of the spinal cord. After operations on the spinal and cranial nerves and plexuses (stitching, etc.) on an outpatient basis, many months or many years of rehabilitation treatment is carried out, preferably under the control of thermal imaging. In various combinations, drugs are used that improve (proserin, galantamine, oxazil, dibazol, etc.) and trophism of damaged peripheral nerves (groups B, E, aloe, FiBS, vitreous, anabolic agents, etc.). With pronounced cicatricial processes, lidaza is used, etc. Various options for electrical stimulation, physiotherapy and balneotherapy, exercise therapy, massage, as well as early labor rehabilitation are widely used. Outpatient management of patients after eye surgery should ensure the continuity of treatment in accordance with the surgeon's recommendations. The first time a patient visits an ophthalmologist in the first week after discharge from the hospital. Therapeutic tactics in relation to patients who have undergone surgery on the appendages of the eye - after removing the stitches from the skin of the eyelids and conjunctiva, is to monitor the operating wound. After abdominal operations on the eyeball, the patient is actively observed, i.e. appoints the timing of repeated examinations and monitors the correctness of the implementation of medical procedures. After antiglaucomatous operations with a fistulosing effect and a pronounced filtration cushion in early P. of the item on an outpatient basis, the syndrome of a small anterior chamber can develop
with hypotension due to cilichoroidal detachment, diagnosed with ophthalmic illumination or with ultrasound echography, if there are significant changes in the optical media of the eye or is very narrow not amenable to expansion. In this case, the cilichoroidal detachment is accompanied by a sluggish iridocyclitis, which can lead to the formation of posterior synechiae, blockade of the internal operating fistula by the root of the iris or processes of the ciliary body with a secondary increase in intraocular pressure. can lead to the progression of cataracts or its swelling. In this regard, therapeutic tactics on an outpatient basis should be aimed at reducing subconjunctival filtration by applying a pressure bandage to the operated with a dense cotton roll on the upper eyelid and treating Iridocyclitis. Shallow anterior chamber syndrome can develop after intracapsular cataract extraction, accompanied by an increase in intraocular pressure as a result of the difficulty in transferring moisture from the posterior chamber to the anterior chamber. The tactics of an outpatient eye doctor should be aimed, on the one hand, at reducing the production of intraocular fluid (diacarb, 50% glycerol solution), on the other hand, at eliminating the iridovitreal block by prescribing mydriatics or laser peripheral iridectomy. The lack of a positive effect in the treatment of small anterior chamber syndrome with hypotension and hypertension is an indication for hospitalization. The tactics of managing patients with aphakia after extracapsular cataract extraction and patients with intracapsular pseudophakia are identical (in contrast to pupillary pseudophakia). With indications (), it is possible to achieve maximum mydriasis without the risk of dislocation and dislocation of the artificial lens from the capsule pockets. After cataract extraction, it is advisable not to remove the supramid sutures for 3 months. During this time, a smooth operating room is formed, tissue edema disappears, decreases or completely disappears. Continuous is not removed, it dissolves within several years. Interrupted sutures, if their ends are not tucked in, are removed after 3 months. The indication for removing stitches is the presence of astigmatism 2.5-3.0 diopters and more. After removing the stitches, the patient is prescribed instillation into the eye of a 20% sodium sulfacyl solution 3 times a day for 2-3 days or other drugs, depending on tolerance. Continuous suture after penetrating keratoplasty is not removed from 3 months to 1 year. After penetrating keratoplasty, the long-term treatment prescribed by the surgeon is monitored by an outpatient eye doctor. Among the complications in the distant P. of the item, a graft or an infectious process, most often a herpes-viral infection, which is accompanied by edema of the graft, iridocyclitis, neovascularization, can develop. Examinations of patients after operations for retinal detachment are performed on an outpatient basis after 2 weeks, 3 months, 6 months, 1 year, and when complaints of photopsies appear, visual impairment. With a relapse of retinal detachment, the patient is sent to. The same tactics of managing patients is followed after vitreoectomy for hemophthalmos. Patients who have undergone surgery for retinal detachment and vitrectomy should be warned about adherence to a special regimen that excludes low head tilts, weight lifting; colds accompanied by cough, acute holding of breath, for example, should be avoided. After operations on the eyeball, all patients should follow a diet that excludes the intake of spicy, fried, salty foods and alcoholic beverages. Outpatient management of patients after abdominal surgery. After operations on the organs of the abdominal cavity, P. of the item can be complicated by the formation of fistulas of the gastrointestinal tract. for patients with artificially formed or naturally occurring fistulas is an integral part of their treatment. Fistulas of the stomach and esophagus are characterized by the release of food masses, saliva and gastric juice, for fistulas of the small intestine - liquid or mushy intestinal chyme, depending on the level of the fistula (high or low small intestinal). Colonic fistula discharge -. From the fistulas of the rectum, mucopurulent is secreted, from the fistulas of the gallbladder or bile ducts - bile, from the fistulas of the pancreas - light transparent pancreatic. The amount of discharge from the fistula varies depending on the nature of the food, time of day and other reasons, reaching 1.5 l and more. With long-term external fistulas, their discharge macerates the skin. Monitoring patients with fistulas of the gastrointestinal tract includes an assessment of their general condition (, the adequacy of behavior, etc.). It is necessary to control the color of the skin, the appearance of hemorrhages on it and the mucous membranes (with liver failure), determine the size of the abdomen (with intestinal obstruction), liver, spleen, the protective reaction of the muscles of the anterior abdominal wall (with peritonitis). At each dressing, the skin around the fistula is cleaned with a soft gauze cloth, washed with warm water and soap, rinsed thoroughly and gently patted dry with a soft towel. Then it is treated with sterile petroleum jelly, Lassar paste or synthomycin emulsion. To isolate the skin in the fistula area, elastic cellulose-based adhesive films, soft linings, plasters and activated carbon filters are used. These devices prevent skin and uncontrolled escape of gases from the fistula. An important condition for care is discharge from the fistula in order to avoid contact of the discharge with the skin, underwear and bedding. For this purpose, a number of devices are used to drain the fistula with the discharge of discharge from it (bile, pancreatic juice, urine - into a bottle, feces - into a colostomy bag). From artificial external bile fistulas, more than 0.5 l bile, which is filtered through several layers of gauze, is diluted with any liquid and given to the patient during meals. Otherwise, severe disorders of homeostasis are possible. Drains introduced into the bile ducts must be flushed daily (with saline or furacilin) so that they are not encrusted with bile salts. After 3-6 months, these drains must be replaced with X-ray control of their location in the ducts. When caring for artificial intestinal fistulas (ileo- and colostomas) formed for therapeutic purposes, self-adhesive or colostomy bags attached to a special belt are used. The selection of colostomy bags is made individually, taking into account a number of factors (the location of the ileo- or colostomy, its diameter, the state of the surrounding tissues). Enteral (tube) through in order to meet the needs of the patient's body in plastic and energetic substances is of great importance. It is considered as one of the types of additional artificial nutrition (along with parenteral), which is used in combination with other types of therapeutic nutrition (see.
Parenteral nutrition). In connection with the exclusion of some parts of the digestive tract from the digestion processes, it is necessary to draw up a balanced diet, in which the average consumption for an adult is assumed to be 80-100 G squirrel, 80-100 G fat, 400-500 G carbohydrates and the corresponding amount of vitamins, macro- and microelements. Specially developed enteral mixtures (enpits), meat and vegetable dietary canned food are used. Enteral nutrition is carried out through a nasogastric tube, or a tube inserted through a gastrostomy or jejunostomy tube. For these purposes, use soft plastic, rubber or silicone tubes with an outer diameter of up to 3-5 mm... The probes have an olive at the end, which facilitates their passage and installation in the initial part of the jejunum. Enteral nutrition can also be carried out through a tube temporarily inserted into the lumen of an organ (stomach, small intestine) and removed after feeding. Tube feeding can be carried out by the fractional method or by drip. The intensity of the intake of food mixtures should be determined taking into account the patient's condition and stool frequency. When carrying out enteral nutrition through a fistula, in order to avoid regurgitation of the food mass, the probe is inserted into the intestinal lumen for at least 40-50 cm using an obturator. Outpatient management of patients after orthopedic and traumatological operations should be carried out taking into account the postoperative management of patients in the hospital and depends on the nature of the disease or the musculoskeletal system for which it was undertaken, on the method and characteristics of the operation performed in a particular patient. The success of outpatient management of patients depends entirely on the continuity of the treatment process, begun in a hospital setting. After orthopedic and traumatological operations, patients can be discharged from the hospital without external immobilization, in various types of plaster bandages (see Plaster technique), distraction-compression (distraction-compression devices) can be applied to the limbs, patients can use various orthopedic products after the operation (tire-sleeve devices, insoles, instep supports, etc.). In many cases, after operations for diseases and injuries of the lower extremities or pelvis, patients use crutches. On an outpatient basis, the attending physician should continue to monitor the state of the postoperative scar in order not to miss superficial or deep suppuration. It can be caused by the formation of late hematomas due to unstable fixation of fragments with metal structures (see Osteosynthesis), loosening of parts of the endoprosthesis when it is not firmly fixed in (see Endoprosthetics).
Rejection of the allograft due to immunological incompatibility (see Bone grafting), endogenous with damage to the area of operation by hematogenous or lymphogenous pathways, ligature fistulas can also be the reasons for late suppuration in the area of the postoperative scar. Late suppuration may be accompanied by arterial or venous bleeding caused by purulent fusion (arrosion) of a blood vessel, as well as a pressure ulcer of the vessel wall under the pressure of a part of a metal structure protruding from the bone during submerged osteosynthesis or a needle of a compression-distraction apparatus. With late suppuration and bleeding, patients need emergency hospitalization. On an outpatient basis, restorative treatment, begun in a hospital, continues, which consists in physiotherapy exercises for joints free from immobilization (see Physical therapy), gypsum and ideomotor gymnastics. The latter consists in contraction and relaxation of the muscles of the limb, immobilized with a plaster cast, as well as imaginary movements in the joints fixed by external immobilization (extension) in order to prevent muscle atrophy, improve blood circulation and bone regeneration processes in the area of operation. Physiotherapy continues to stimulate muscles, improve microcirculation in the operation area, prevent neurodystrophic syndromes, stimulate callus formation, and prevent joint stiffness. The complex of rehabilitation treatment on an outpatient basis also includes those aimed at restoring movements in the extremities necessary for servicing oneself in everyday life (on the stairs, using city transport), as well as general and professional working capacity. in P., the item is usually not used, with the exception of hydrokinesis therapy, which is especially effective in restoring movements after joint operations. After spinal surgery (without spinal cord injury), patients often use semi-rigid or rigid removable corsets. Therefore, on an outpatient basis, it is necessary to monitor the correctness of their use, the integrity of the corsets. During sleep and rest, patients should use a hard bed. On an outpatient basis, physical therapy continues, aimed at strengthening the muscles of the back, manual and underwater massage. Patients must strictly adhere to the orthopedic regimen prescribed in the hospital, which consists in unloading the spine. After surgery on the bones of the extremities and pelvis, the doctor on an outpatient basis systematically monitors the condition of the patients and the timeliness of removing the plaster cast, if after the operation an external one was used, conducts the operation area after removing the plaster, and timely prescribes the development of joints freed from immobilization. It is also necessary to monitor the state of metal structures during immersion osteosynthesis, especially with intramedullary or transosseous insertion of a pin or screw, in order to timely detect possible migration, which is detected during X-ray examination. When metal structures migrate with the threat of skin perforation, patients need hospitalization. If an apparatus for external transosseous osteosynthesis is imposed on, the task of an outpatient doctor is to monitor the condition of the skin in the area where the wires are inserted, regular and timely, to monitor the stable fastening of the apparatus structures. If necessary, make additional fastening, tightening of individual nodes of the apparatus, with the beginning of the inflammatory process in the area of the needles - injecting soft tissues with antibiotic solutions. With deep suppuration of soft tissues, patients need a referral to a hospital to remove a wire in the area of suppuration and hold a new wire in an unaffected area, if necessary, to remount the apparatus. With complete consolidation of bone fragments after a fracture or orthopedic surgery, the device is removed on an outpatient basis. After orthopedic and traumatological operations on joints on an outpatient basis, physical therapy, hydrokinesis therapy, physiotherapy aimed at restoring mobility are performed. When using transarticular osteosynthesis to fix fragments in cases of intra-articular fractures, the fixing wire (or wires) is removed, the ends of which are usually located above the skin. This manipulation is carried out in terms of the nature of the joint damage. After operations on the knee joint, synovitis is often observed (see.Synovial bags), in connection with which the joint may be required with the evacuation of synovial fluid and the introduction of medications according to indications, incl. corticosteroids. In the formation of postoperative joint contractures, along with local treatment, general therapy is prescribed aimed at the prevention of cicatricial processes, para-articular ossification, normalization of the intra-articular environment, regeneration of hyaline cartilage (injections of the vitreous body, aloe, FIBS, lidase, rumalon, oral administration of non-steroidal anti-inflammatory drugs Brufen, Voltaren, etc.). After removing the plaster immobilization, persistent edema of the operated limb is often observed as a result of post-traumatic or postoperative lymphovenous insufficiency. In order to eliminate edema, manual massage or with the help of pneumatic massagers of various designs, compression of the limb with an elastic bandage or stocking, physiotherapeutic treatment aimed at improving venous outflow and lymph circulation are recommended. Outpatient management of patients after urological operations is determined by the functional characteristics of the organs of the genitourinary system, the nature of the disease and the type of surgery. for many urological diseases, it is an integral part of a comprehensive treatment aimed at preventing recurrence of the disease and rehabilitation. In this case, the continuity of inpatient and outpatient treatment is important. For the prevention of exacerbations of the inflammatory process in the organs of the genitourinary system (pyelonephritis, cystitis, prostatitis, epididymo-orchitis, urethritis), continuous sequential intake of antibacterial and anti-inflammatory drugs is shown in accordance with the sensitivity of the microflora to them. Monitoring the effectiveness of treatment is carried out by regular examination of blood, urine, prostate secretions, seeding of ejaculate. When the infection is resistant to antibacterial drugs, multivitamins, nonspecific immunostimulants are used to increase the reactivity of the body. In case of urolithiasis caused by impaired salt metabolism or a chronic inflammatory process, after removal of calculi and restoration of urine passage, correction of metabolic disorders is necessary. After reconstructive surgeries on the urinary tract (plastic of the pelvic-ureteric segment, ureter, bladder and urethra), the main task of the immediate and distant postoperative period is to create favorable conditions for the formation of an anastomosis. For this purpose, in addition to antibacterial and anti-inflammatory drugs, agents are used to soften and resorb scar tissue (lidase) and physiotherapy. The appearance of clinical signs of impaired urine outflow after reconstructive surgery may indicate the development of stricture in the anastomotic area. For its timely detection, a regular follow-up examination is necessary, including X-ray, radiological and ultrasound methods. With an insignificant degree of narrowing of the urethra, the urethra can be carried out and the above complex of therapeutic measures can be prescribed. If a patient has chronic renal failure (Renal failure) in a distant P., it is necessary to monitor its course and the results of treatment by regular examination of biochemical blood parameters, drug correction of hyperazotemia and water-electrolyte disturbances. After palliative surgery and ensuring the outflow of urine through the drains (nephrostomy, pyelostomy, ureterostomy, cystostomy, urethral catheter), their function must be carefully monitored. Regular change of drains and rinsing of the drained organ with antiseptic solutions are important factors in the prevention of inflammatory complications from the genitourinary system. Outpatient management of patients after gynecological and obstetric operations is determined by the nature of gynecological pathology, the volume of the operation performed, the peculiarities of P.'s course of the item and its complications, concomitant extragenital diseases. A complex of rehabilitation measures is carried out, the duration of which depends on the speed of restoration of functions (menstrual, reproductive), complete stabilization of the general condition and gynecological status. Along with restorative treatment (and others), physiotherapy is carried out, in which the nature of the gynecological disease is taken into account. After surgery for tubal pregnancy, medicinal hydrotubation is performed (penicillin 300,000 - 500,000 U, hydrocortisone hemisuccinate 0.025 G, lidase 64 UE in 50 ml 0.25% novocaine solution) in combination with ultrasound therapy, vibration massage, zinc, in the future, spa treatment is prescribed. For the prevention of adhesions after operations for inflammatory formations, zinc electrophoresis is indicated, in a low frequency mode (50 Hz). For the prevention of recurrence of endometriosis, electrophoresis of zinc, iodine is performed, sinusoidal modulating currents, pulsed ultrasound are prescribed. The procedures are prescribed in 1-2 days. After operations on the uterine appendages for inflammatory formations, ectopic pregnancy, benign ovarian formations, after organ-preserving operations on the uterus and supravaginal amputation of the uterus in connection with myoma, patients remain disabled for an average of 30-40 days, after extirpation of the uterus - 40-60 days. Then, an examination of the ability to work is carried out and recommendations are made, if necessary, excluding contact with occupational hazards (vibration, exposure to chemicals, etc.). Patients remain on the dispensary for 1-2 years or more. Outpatient treatment after obstetric operations depends on the nature of the obstetric pathology that caused the operative delivery. After vaginal and abdominal operations (, fruit-destroying operations, manual examination of the uterine cavity,), postpartum women receive a duration of 70 days. Examination in the antenatal clinic is carried out immediately after discharge from the hospital, in the future, the frequency of examinations depends on the peculiarities of the course of the postoperative (postpartum) period. Before being removed from the dispensary for pregnancy (i.e., by the 70th day), it is carried out. If the reason for the operative delivery was extragenital, an examination by a therapist, according to the indications of other specialists, a clinical and laboratory examination is mandatory. A complex of rehabilitation measures is carried out, which includes restorative procedures, physiotherapy, taking into account the nature of somatic, obstetric pathology, peculiarities of P.'s course. In case of purulent-inflammatory complications, zinc electrophoresis is prescribed with diadynamic currents of low frequency, in a pulsed mode; postpartum women who have undergone with concomitant kidney pathology are shown with exposure to the kidney area, the collar zone according to Shcherbak, ultrasound in a pulsed mode. Since even during lactation it is possible 2-3 months after childbirth, contraception must be prescribed. Wounds and wound infection, ed. M.I. Kuzin and B.M. Kostyuchenok, M., 1981; Guide to Eye Surgery, ed. L.M. Krasnova, M., 1976; Guide to neurotraumatology, ed. A.I. Arutyunova, hours 1-2, M., 1978-1979; Sokov L.P. Course of traumatology and orthopedics, p. 18, M., 1985; Strugatsky V.M. Physical factors in obstetrics and gynecology, p. 190, M., 1981; Tkachenko S.S. , with. 17, L., 1987; Hartig V. Modern infusion therapy, trans. from English., M., 1982; Shmeleva V.V. , M., 1981; Yumashev G.S. , with. 127, M., 1983. the period of the patient's treatment from the moment of the end of the surgical operation to its fully determined outcome. 1. Small medical encyclopedia. - M .: Medical encyclopedia. 1991-96 2. First aid. - M .: Great Russian Encyclopedia. 1994 3. Encyclopedic Dictionary of Medical Terms. - M .: Soviet encyclopedia. - 1982-1984. The period of the patient's treatment from the moment of the end of the surgical operation to its fully determined outcome ... Comprehensive Medical Dictionary Arising after surgery; this term is used in relation to the patient's condition or to his treatment carried out during this period.
Before any operation, the patient's gastrointestinal tract must be cleaned. Bloating of the stomach and intestines, filled with gases and contents, after the operation impairs the blood supply to these organs, which contributes to the development of infection in the intestine with its penetration beyond the intestinal wall, and due to increased pressure, it can break the seams on the abdominal organs after the operation. In addition, bloating of the stomach and intestines dramatically impairs the function of the cardiovascular and pulmonary systems, which in turn impairs the blood supply to the abdominal organs. The contents of the hollow organs of the abdomen during operations on these organs can enter the free abdominal cavity, causing inflammation of the peritoneum (peritonitis). The presence of contents in the stomach, which is necessarily found when a tumor of the outlet of the stomach or ulcerative narrowing is blocked by a tumor, is dangerous because during induction of anesthesia it can get into the patient's mouth, and from there into the lungs and cause suffocation.
In patients without disturbing gastric evacuation, preparation of the upper digestive tract for surgery is limited to complete starvation on the day of surgery. In case of violations of evacuation from the stomach before the operation, the contents of the stomach are pumped out. To do this, use a thick gastric tube and a syringe to flush the cavities.
When food residues of a thick consistency and mucus accumulate, the stomach is washed - instead of a syringe, a large glass funnel is put on the end of the probe.
A large amount of gastric contents accumulates in patients with intestinal obstruction.
A cleansing enema is usually used to cleanse the lower intestines. A single enema or even two enemas (at night and in the morning) cannot effectively cleanse the intestines in a patient with chronic stool retention, therefore one of the main tasks of the preoperative period is to achieve a daily independent bowel movement in the patient. This is especially necessary for patients with a tendency to accumulate gases (flatulence) and suffering from chronic constipation. The correct diet can help to normalize bowel movements.
Skin preparation.
Microorganisms accumulate in the pores and folds of the skin, the entry of which into the wound should be excluded. This is the meaning of preparation for the operation of the patient's skin. Moreover, contaminated skin after surgery can become a site for the development of pyoinflammatory diseases, that is, a source of infection for the whole body.
On the eve of the operation, the patient is washed and the linen is changed. Especially thoroughly it is necessary to wash the places of accumulation of sweat and dirt (armpits, perineum, neck, feet, navel and all skin folds, very deep in obese patients).
The hair on the patient's head should be neatly trimmed; in men, the beard and mustache should be shaved off. Nails on hands and feet must be cut short. The nail polish must be washed off.
A more effective sanitization of the patient's body before surgery is undoubtedly a shower, which is easier for many patients.
Lying patients are first wiped in the bed with warm soapy water, after that - with alcohol, cologne, etc. An oilcloth should be placed on the bed. When rubbing with water, use a sponge. The nurse is obliged to examine the entire body of the patient and, if pustular or other inflammatory skin lesions are found, be sure to inform the doctor about it.
It is necessary to know the possible complications during the operation, how to prevent and treat them.
In the early postoperative period, complications can occur at different times. In the first 2 days after the operation, complications such as bleeding (internal or external), acute vascular failure (shock), acute heart failure, asphyxia, respiratory failure, complications of anesthesia, imbalance in water and electrolyte balance, decreased urination (oliguria, anuria) are possible , paresis of the stomach, intestines.
In the following days after the operation (3-8 days), the development of cardiovascular failure, pneumonia, thrombophlebitis, thromboembolism, acute hepatic-renal failure, wound suppuration is possible.
The causes of postoperative complications are associated with the underlying disease for which surgery was performed, with anesthesia and surgery, exacerbation of concomitant diseases. All complications can be divided into early and late.
Early complications can occur in the first hours and days after the operation, they are associated with the depressing effect of drugs on respiration and blood circulation, with uncompensated water-electrolyte disturbances. Drugs not eliminated from the body and undisturbed muscle relaxants lead to respiratory depression, up to and including stopping it. This is manifested by hypoventilation (rare shallow breathing, retraction of the tongue); development of apnea is possible.
Therefore, monitoring in the early postoperative period is very important. If breathing is impaired, it is necessary to immediately establish mechanical ventilation, if the tongue is retracted, use air ducts that restore the patency of the airways, if respiratory depression is caused by the continuing action of narcotic substances, you can use respiratory analeptics (nalorphine, bimegrid, cordiamine).
Bleeding is the most formidable complication of the postoperative period. It can be external (from the wound) and internal - hemorrhage in the cavity (chest, abdominal), in the tissue.
If conservative measures to stop bleeding are unsuccessful, a revision of the wound is indicated, a second operation is a relaparotomy.
In the first days after the operation, there may be disturbances in the water and electrolyte balance due to the underlying disease, in which there is a loss of water and electrolytes (intestinal obstruction), or blood loss.
It is necessary to immediately correct the deficiency of water and electrolytes by transfusing appropriate solutions (Ringer-Locke solution, potassium chloride, disol, chlorosalt). Transfusion must be carried out under the control of CVP, the amount of urine excreted and the level of blood electrolytes. Water and electrolyte disorders can also occur in the late period after surgery. In this case, constant correction of the electrolyte balance and transfer to parenteral nutrition are necessary.
In the early postoperative period, respiratory disorders associated with atelectasis of the lungs, pneumonia, bronchitis may occur. For the prevention of respiratory complications, early activation and adequate pain relief after surgery are important. All these | measures contribute to the disclosure of collapsed alveoli, improve drainage! bronchial function.
Complications from the cardiovascular system often occur against the background of uncompensated blood loss, disturbed water and electrolyte balance and require adequate correction.
Treatment in each case is individual (cardiac glycosides, antiarrhythmic drugs, coronary dilators). With pulmonary edema, ganglion blockers, diuretics, inhalation of oxygen with alcohol are used.
During operations on the organs of the gastrointestinal tract, one of the complications may be intestinal paresis (dynamic intestinal obstruction). It usually develops in the first 2-3 days after surgery. Its main signs: bloating, absence of peristaltic bowel sounds. For the prevention and treatment of paresis, intubation of the stomach and intestines, early activation, anesthesia, epidural anesthesia, perirenal blockade, proserin, pituitrin, diadynamic currents, etc. are used.
Violation of urination in the postoperative period may be due to a change in renal excretory function or the addition of inflammatory diseases - cystitis, urethritis, pyelonephritis. The delay in urination can also be of a reflex nature - it is caused by pain, spastic contraction of the abdominal muscles, pelvis, and sphincters of the bladder.
With urinary retention, pain relievers and antispastic agents are administered; on the area of the bladder, above the bosom, put a warm heating pad. If it is unsuccessful, urine is removed with a soft, if this fails, a rigid (metal) catheter. In extreme cases, when attempts to catheterize the bladder are unsuccessful, a suprapubic bladder fistula is applied.
Thromboembolic complications in the postoperative period are rare. The source of embolism is often the veins of the lower extremities, pelvis. A slowdown in blood flow, a change in the rheological properties of blood can lead to thrombosis. Prevention is activation, treatment of thrombophlebitis, bandaging of the lower extremities, correction of the blood coagulation system, which includes the use of heparin, the introduction of drugs that reduce the aggregation of blood cells (rheopolyglucin, analgin), daily transfusion of fluids in order to create moderate hemodilution.
The development of wound infection often occurs on the 3rd-10th day of the postoperative period. Pain in the wound, fever, thickening of tissues, inflammatory infiltration, hyperemia of the skin around the wound serve as an indication for its revision, partial or complete removal of stitches.
Subsequent treatment is carried out according to the principle of treating a purulent wound.
Pain syndrome in the postoperative period. The absence of pain after surgery largely determines the normal course of the postoperative period. In addition to psycho-emotional perception, pain syndrome leads to respiratory depression, reduces the cough impulse, promotes the release of catecholamines into the blood, against this background, tachycardia occurs, and blood pressure rises.
To relieve pain, you can use narcotic drugs that depress respiration and cardiac activity (fentanyl, lexir, dipidolor), srcotic analgesics (analgin), percutaneous electroanalgesia, long-term epidural anesthesia, acupuncture.
Prevention of postoperative infectious complications
Sources of microflora that cause postoperative inflammatory complications can be both outside the human body (exogenous infection) and in the body itself (endogenous infection). With a decrease in the number of bacteria trapped on the wound surface, the incidence of complications significantly decreases, although today the role of exogenous infection in the development of postoperative complications is not so significant due to the use of modern methods of asepsis.
Endogenous infection of the surgical wound occurs by contact, hematogenous and lymphogenous pathways. Prevention of postoperative inflammatory complications in this case consists in sanitizing the foci of infection, sparing surgical technique, creating an adequate concentration of antibacterial drugs in the blood and lymph, as well as influencing the inflammatory process in the surgical area in order to prevent the transition of aseptic inflammation to septic.
The targeted prophylactic use of antibiotics for the rehabilitation of the focus of surgical infection in preparation for the operation is determined by the localization of the focus of possible infection and the alleged pathogen. In inflammatory diseases of the respiratory tract, the use of macrolides is indicated. For chronic infection, the use of fluoroquinolones is advisable. For the general prevention of postoperative infectious complications in modern conditions, the most reasonable prescription of cephalosporins, aminoglycosides. Rational implementation of antibiotic prophylaxis reduces the incidence of postoperative complications.
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