Secondary specialized medical education. Prevention of complications in the early and late postoperative period

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Postoperative complication is a new pathological condition, not typical for the normal course of the postoperative period and not a consequence of the progression of the underlying disease. It is important to distinguish complications from operational reactions, which are a natural reaction of the patient's body to illness and operational aggression. Postoperative complications, in contrast to postoperative reactions, dramatically reduce the quality of treatment, delay recovery, and endanger the patient's life. Allocate early (from 6-10% and up to 30% with prolonged and extensive operations) and late complications.
In the occurrence of postoperative complications, each of the six components is important: the patient, the disease, the operator, the method, the environment, and chance.
Complications may be:
- the development of disorders caused by the underlying disease;
- violations of the functions of vital systems (respiratory, cardiovascular, liver, kidneys), caused by concomitant diseases;
- consequences of defects in the execution of the operation or the use of vicious methods.
The features of a hospital infection and the system of patient care in a given hospital, schemes for the prevention of certain conditions, dietary policy, and the selection of medical and nursing staff are important.
You can not discount the elements of chance, and maybe fate. Every surgeon who has been practicing for a long time does not lose sight of the absolutely absurd and incredible complications that do not leave individual patients alone, overlap each other and often end in death in the postoperative period.
Nevertheless, the features of the pathological process, homeostasis disorders, infection, tactical, technical and organizational errors of doctors, the level of technical support - this is a typical set of reasons that require competent prevention and adequate treatment at an early stage in any clinic and hospital.
Postoperative complications are prone to progression and recurrence and often lead to other complications. There are no mild postoperative complications. In most cases, repeated interventions are required.
The frequency of postoperative complications is about 10% (V. I. Struchkov, 1981), while the proportion of infectious ones is 80%. (hospital strains (!), immunodeficiency). The risk increases with emergency as well as long-term operations. The factor of the duration of the operation is one of the leading factors in the development of purulent complications - a marker of trauma and technical problems.
Technical errors: inadequate access, unreliable hemostasis, invasiveness, accidental (unnoticed) damage to other organs, inability to delimit the field when opening a hollow organ, leaving foreign bodies, inadequate interventions, “tricks” in the performance of operations, defects in sutures, inadequate drainage, defects in postoperative reference.

THE CLINIC OF NORMAL POSTOPERATIVE PERIOD AFTER ABDOMINAL SURGERY includes surgical aggression superimposed on the initial state of the patient. A surgical operation is a non-physiological effect, in connection with which the entire body, its individual systems and organs are overloaded. The body copes with operational aggression with open classical access within 3-4 days. In this case, the pain subsides and is felt only during movements and palpation. Feeling better. The temperature decreases from subfebrile or febrile numbers. Increased movement activity. The tongue is wet. The abdomen becomes soft, intestinal motility is restored by 3-4 days. On the 3rd day before the passage of intestinal gases and feces, moderate bloating and soreness may be noted with some deterioration in well-being. Slight pain remains only in the area of ​​the operated organ with deep palpation.
Laboratory indicators: in proportion to the operational blood loss, a decrease in hemoglobin (up to 110 g/l) and erythrocytes (4 1012 l), an increase in leukocytes (9-12 109 l) with a shift of up to 8-10% of stab leukocytes is recorded. Biochemical indicators are either within the normal range, or in the case of their initial disturbances with a tendency to normalization. Recovery slows down in patients operated on an emergency basis for initial purulent-inflammatory diseases or massive bleeding. They are more pronounced phenomena of intoxication or anemia. Due to the unpreparedness of the intestines on the 2nd day, bloating can be a problem.

PREVENTION OF POSTOPERATIVE COMPLICATIONS.
There are no strict criteria for the portability of surgery in borderline conditions. The goal of prevention is to reduce risk as much as possible.
General principles:
1) systemic fight against nosocomial infection;
2) reduction of preoperative (if up to 1 day - 1.2% of suppuration, up to 1 week - 2%, 2 weeks and more - 3.5% - Kruse, Furd, 1980) and postoperative stay;
3) preparation in terms of strengthening specific and non-specific resistance, nutritional status;
4) identification of foci of infection in the body, including dormant in old postoperative scars (trial provocation with dry heat, UHF helps);
5) prophylactic use of antibiotics before and during operations;
6) high-quality suture material;
7) professional education of surgeons;
8) early diagnosis and the most complete examination - each patient with abdominal pain should be examined by a surgeon;
9) timely detection and surgical sanitation, adequate therapeutic treatment - a good state social policy;
10) participation in the postoperative treatment of the operating surgeon;
11) timely relief of postoperative reactions (for example, intestinal paresis);
12) uniform schemes of operational actions and postoperative management in the clinic (dressings, diet, activation);
13) reasonable implementation of the concept of “active management of the postoperative period” (early getting up, exercise therapy and early nutrition).

GENERAL CLINIC OF POSTOPERATIVE COMPLICATIONS. There are no asymptomatic complications. In each case there are specific signs. However, there are also common ones. They are mainly associated with ongoing intoxication, and are manifested by a change in appearance and a deterioration in well-being. The look is disturbing, the eyes are sunken, the facial features are pointed. Characterized by dry tongue, tachycardia, lack of peristalsis. Signs of ongoing intoxication syndrome: fever, sweating, chills, decreased diuresis. Sharply intensifying pains in the abdomen, and against the background of their blunted perception, is a sign of an abdominal postoperative catastrophe. Symptoms of peritoneal irritation.
Nausea, vomiting and hiccups are not typical for the normal postoperative period.
With the gradual development of complications, the most constant symptom is progressive intestinal paresis.
A sign of collapse is extremely alarming - it can be a sign of internal bleeding, suture failure, acute expansion of the stomach, as well as myocardial infarction, anaphylactic shock, pulmonary embolism.
Action Methodology if a postoperative complication is suspected:
- assessment of the level of intoxication syndrome (pulse, dry mouth, laboratory parameters) in dynamics (taking into account ongoing detoxification);
- extended bandaging of the surgical wound with probing (under conditions of sufficient anesthesia);
- directed and exploratory instrumental examination (ultrasound, X-ray diagnostics, NMR).

WOUND COMPLICATIONS. Any wound heals according to biological laws. In the first hours, the wound channel is filled with a loose blood clot. The inflammatory exudate contains a large amount of protein. On the second day, fibrin begins to undergo organization - the wound sticks together. In the same period, the phenomenon of wound contraction develops, which consists in a uniform concentric contraction of the edges of the wound. On the 3rd-4th day, the edges of the wound are connected by a delicate layer of connective tissue from fibrocytes and delicate collagen fibers. From 7-9 days, we can talk about the beginning of scar formation, which lasts 2-3 months. Clinically, uncomplicated wound healing is characterized by the rapid disappearance of pain and hyperemia, the absence of a temperature reaction.
Alternative-exudative processes are aggravated by rough manipulations in the wound, drying (dry lining), significant electrocoagulation with tissue charring, infection with the contents of the intestine, abscess, etc.). Biologically, microflora is needed, as it contributes to the rapid cleansing of the wound. The critical level of bacterial contamination is 105 microbial bodies per 1 g of wound tissue. Rapid reproduction of microorganisms occurs after 6-8 hours from the operation. In the wound, hermetically closed with sutures for 3-4 days, the exudative process spreads in depth along the interstitial pressure gradient. Under conditions of infection, the wound heals through granulation tissue, which transforms into scar tissue. The growth of granulations slows down in anemia and hypoproteinemia, diabetes mellitus, shock, tuberculosis, beriberi, and malignant tumors.
Patients with pronounced cellular tissue are prone to wound complications with its increased trauma.
There is a strict sequence of complications.
Bleeding external and internal 1-2 days.
Hematoma- 2-4 days.
Inflammatory infiltrate(8 - 14%) - 3-6 days. The tissues are impregnated with serous or serofibrinous transudate (prolonged hydration phase). The boundaries of the infiltrate - 5-10 cm from the edges of the wound. Clinic: pain and a feeling of heaviness in the wound, subfebrile fever with rises up to 38 °. moderate leukocytosis. Locally: swelling of the edges and hyperemia, local hyperthermia. Palpation compaction.
Treatment - wound probing, exudate evacuation, removal of some of the sutures to reduce tissue pressure. Alcohol compresses, heat, rest, physiotherapy, x-ray therapy (rarely).
Suppuration of the wound(2-4%) - 6-7 days. As a rule, due to a scanned hematoma, and then an infiltrate. Rarely unresponsiveness of the patient with a particularly virulent infection, but then it occurs very quickly.
Clinic: hectic fever, profuse sweat, chills, headache. The wound area swells, hyperemic, painful. With the subaponeurotic location of the abscess due to irritation of the peritoneum, there may be dynamic obstruction and then differential diagnosis with postoperative peritonitis is relevant.
With an anaerobic or other virulent infection, the purulent process can proceed rapidly, manifesting itself 2-3 days after the operation. Severe intoxication and local reaction. Emphysema of the perivulnar area.
Treatment. Removal of stitches. In the cavity of the abscess, pockets and streaks open. The wound is cleaned from non-viable tissues (washing) and drained. If an anaerobic process is suspected (tissues have a lifeless appearance with a purulent-necrotic coating of a dirty gray color, the muscle tissue is dull, gas is released) - a mandatory wide excision of all affected tissues. With a wide distribution - additional incisions.
Yellow or white pus, odorless - staphylococcus aureus, Escherichia coli; green - green streptococcus; dirty gray with a fetid odor - putrefactive flora; blue-green - Pseudomonas aeruginosa; raspberry with a putrid odor - anaerobic infection. In the process of treatment, the flora changes to the hospital.
With a putrefactive wound infection, there is abundant hemorrhagic exudate and fetid gas, gray tissues with necrosis.
As granulations develop and the exudative phase stops, either the imposition of secondary sutures (tightening the edges with a patch), or the transition to ointment dressings (in cases of extensive wounds).

POSTOPERATIVE PERITONITIS. Occurs after any operations on the organs of the abdominal cavity and retroperitoneal space. it new a qualitatively different form of the disease. It is essential to distinguish postoperative peritonitis from progressive, ongoing, or indolent peritonitis, in which the first operation does not (and sometimes cannot) solve all problems.
Etiopathogenesis. Three groups of reasons:
- medical errors of technical and tactical plan (50-80%);
- deep metabolic disorders leading to insufficiency of immunobiological mechanisms and defective regeneration;
- rare, casuistic reasons.
In practice, often: insufficient delimitation of the abdominal cavity from enteral infection, unsystematic revision, careless hemostasis (modern technique: “tweezers-scissors-coagulation”), lack of sanitation of the abdominal cavity at the end of the operation (dry and wet sanitation, toilet pockets and sinuses of the abdominal cavity) . The problem of insolvency of gastrointestinal anastomoses is relevant, including due to technical defects (prevention in maintaining sufficient blood supply, wide contact of the peritoneum without trapping the mucosa, infrequent sutures).
Classification postoperative peritonitis.
By genesis (V. V. Zhebrovsky, K. D. Toskin, 1990):

• primary - infection of the abdominal cavity during surgery or in the near future after it (perforation of acute ulcers, necrosis of the wall of the abdominal organ with an incorrect assessment of viability, unnoticed intraoperative damage);
• secondary peritonitis - as a result of other postoperative complications (failure of sutures, abscess rupture, with intractable paralytic ileus, eventration).

According to the clinical course (V. S. Savelyev et al., 1986): fulminant, acute, sluggish.
By prevalence: local, general
By type of microflora: mixed, colibacillary, anaerobic, diplococcal, Pseudomonas aeruginosa.
By type of exudate: serous-fibrinous, serous-hemorrhagic, fibrinous-purulent, purulent, bile, fecal.
Clinic. There is no universal clinical picture of postoperative peritonitis. The problem is that the patient is already in a serious condition, has a surgical disease, has undergone surgical aggression, and is being intensively treated with medications, including antibiotics, hormones, and drugs. It is impossible in all cases to focus on the pain syndrome and the tension of the muscles of the anterior abdominal wall. Therefore, diagnosis should be carried out at the level of microsymptoms.
Clinically two options:
1) acute deterioration against the background of a relatively favorable course (soft abdomen, good physical activity, but fever is possible). The later peritonitis occurs, the better it is to diagnose;
2) a progressive severe course against the background of ongoing intoxication.
Signs of peritonitis:
- direct (defense), - are not always detected against the background of intoxication, hypoergy and intensive treatment;
- indirect (!) - violation of homeostasis (tachycardia, hypotension), impaired motility of the stomach and intestines (not decreasing reflux through the intestines), preservation or aggravation of the intoxication syndrome, despite intensive treatment.
As a rule, the clinic of recurrent intestinal paresis and the progressive development of the systemic inflammatory response syndrome, accompanied by multiple organ failure, is the leading one.
No asymptomatic postoperative peritonitis. Diagnostic principles:

• dominant of the surgeon's clinical thinking;
• comparison of the predicted normal course of the postoperative period in this patient and the existing one;
• progression or preservation of intoxication syndrome with intensive detoxification.

The basis of diagnosis are: persistent intestinal paresis, endogenous intoxication that does not decrease (fever, dry tongue), a tendency to hypotension, tachycardia, decreased diuresis, development and progression of renal and hepatic insufficiency.
An obligatory stage is an extended revision of the wound with its probing.
The next stage of diagnosis is the exclusion of other sources of intoxication: broncho-pulmonary process, gluteal abscesses, etc. X-ray (free gas in the abdominal cavity, be careful!), Ultrasound of the abdominal cavity (presence of fluid in the abdominal cavity), and endoscopy.
Treatment. Conservative treatment gives 100% lethality. The key is relaparotomy followed by intensive detoxification and, in some cases, repeated sanitation.
The operation should be as radical as possible, but correspond to the vital capabilities of the patient - individual surgery.
General principles: suction of exudate, removal of the source, postoperative lavage, drainage of the intestine. Sometimes, if circumstances permit, you can limit yourself to a minimum. The latter is possible with early diagnosis and accurate determination of the degree of damage.
For example, in case of peritonitis caused by failure of the gastrointestinal anastomosis during distal resections of the stomach, N. I. Kanshin (1999) recommends, in the absence of a pronounced purulent process in the anastomosis area, reinforcing sutures (cover with Tachocomb) and along the anastomosis transverse through perforated drainage (permanent aspiration with suction of air and periodic washings), and insert a probe for decompression and enteral nutrition into the outlet loop through the anastomosis. With a significant defect in the anastomosis and severe peritonitis, a double-lumen tube is inserted into the afferent loop with fixation to the edge of the defect, covered with an omentum, and an jejunostomy is applied at a distance of 50 cm.
Important peritoneal detoxification - up to 10-15 liters of heated solution, as well as intestinal decompression: transnasal up to 4-6 days or through intestinal fistula.
A variant of a suspended compression enterostomy for peritonitis according to N.I. Kanshin: a Petzer catheter with a cut bottom of its socket is inserted through the minimum enterotomy opening and is crimped with a purse-string suture. The catheter is brought out through the puncture of the abdominal wall, pressing the intestine to the peritoneum, and is fixed in a predetermined position with a tightly dressed rubber bar until compression.
If peritonitis occurs after endovideoscopic interventions, then re-intervention can also be performed endovideoscopically or from a mini-access (the professionalism of the operator is very important, which, however, is also essential in classical reoperations).

POSTOPERATIVE INTRA-ABDOMINAL ABSCESSES. There may be intraperitoneal, retroperitoneal and abdominal abscesses. They are localized in bags, pockets, canals and sinuses of the abdominal cavity, cellular spaces of retroperitoneal tissue, as well as in the liver, spleen, pancreas. Predisposing factors are the neglect of acute surgical diseases, insufficient sanitation, sluggish peritonitis, irrational and inefficient drainage of the abdominal cavity.
Clinic. On the 3rd-10th day, deterioration of the general condition, pain, fever, tachycardia. There are phenomena of intestinal motor insufficiency: bloating, inadequacy of the effect during intestinal stimulation, pronounced reflux through the gastric tube. Dominant of active search and clinical diagnostics. The key is to palpate to look for even minimal soreness and infiltration, starting from the postoperative wound, along the anterior, lateral and posterior walls, ending along the intercostal spaces. Hope for the universal help of ultrasound, CT, NMR cannot be absolute.
Subdiaphragmatic abscesses. Persistent vomiting is an important manifestation. The key symptom is Grekov's - pain when pressed with fingers in the lower intercostal spaces above the abscess. Also important are Kryukov's symptom - pain when pressing on the costal arches and Yaure's symptom - balloting of the liver.
Informative x-ray examination in a vertical position (gas bubble above the liquid level, immobility of the dome of the diaphragm, concomitant pleurisy).
Treatment. With right-sided localization, high subdiaphragmatic abscesses are opened with resection of the 10th rib according to A.V. Melnikov (1921), the posterior ones with resection of the 12th rib according to Oksner, and the anterior ones according to Clermont.
Interintestinal abscesses occur with a combination of clinical septic process and intestinal obstruction (diamic and mechanical). Diagnosis is predominantly clinical. The beginning of treatment is conservative (at the stage of infiltration). Old technique: X-ray therapy. With an increase in the septic state, an autopsy is more often from a median relaparotomy. The use of puncture and catheterization under ultrasound guidance is promising.

POSTOPERATIVE INTESTINAL OBSTRUCTION. Allocate early (before discharge) and late (after discharge).
Talk about early adhesive obstruction should only be after a period of restoration of normal function of the gastrointestinal tract and at least one normal bowel movement.
Causes of early mechanical obstruction.

• adhesions in violation of the integrity of the serous cover (mechanical, chemical, thermal trauma, purulent-destructive process in the peritoneal cavity, talc, gauze);
• obstruction due to anastomosis, compression of the loop by infiltrate (by the type of “double-barrel”);
• obstruction due to the unsuccessful location of tampons and drains (compression from the outside, torsions);
• obstruction due to technical defects in the execution of the operation (defects in the imposition of anastomoses, picking up in a ligature when suturing a laparotomic wound of the intestinal wall).

Clinic. Violation of the passage of intestinal contents with gas retention and defecation further 4 days after surgery, persisting bloating, increased amount of discharge through the gastric tube.
Diagnostics. It is important to differentiate early ileus due to proper adhesions, for example, stimulated by tampons, from involvement of the intestine in an inflammatory infiltrate, as well as from intestinal paresis due to a septic process in the abdomen. It is difficult to notice the transition from dynamic to mechanical. The critical time for making a surgical decision is 4 days.
Great help in X-ray method.
Separately, there is a high obstruction during interventions on the stomach and duodenum (acute anastomositis after resections of the stomach, obstruction of the duodenum after suturing perforated ulcers, compression in the head of the pancreas), which manifests itself as a significant discharge along the gastric tube. The modern way out is to conduct gastroscopy with bougienage of the narrowed area and holding a nutrient probe below the narrowing site, the usefulness and safety of which were proven back in the 80s by V. L. Poluektov.
Surgical intervention should be complemented by nasoenteric intubation, colonic decompression with an anorectal tube, and anal sphincter divulsion.
Adequate intensive care.

POSTOPERATIVE PANCREATITIS develops after operations on the bile ducts and pancreas, stomach, after splenectomy, papillotomy, removal of the large intestine, when there is direct or functional contact with the pancreas.
Occurs 2-5 days after surgery. Manifested by dull pain in the epigastric region, bloating, gas retention. Amylazemia and amylasuria explain the cause of the deterioration. The emergence of psychotic disorders old doctors attributed, first of all, to postoperative pancreatitis.
The key is active drug prophylaxis with antienzymatic drugs and sandostatin in patients with the interventions indicated above, in which a pancreas reaction can be predicted.
In the treatment, the same actions are valid as in other forms of pancreatitis with the priority of intensive care and antibiotic therapy.

POSTOPERATIVE MYOCARDIAL INFARCTION. The occurrence of peri- and postoperative infarction is real with the following risk factors (Weitz and Goldman, 1987): heart failure; within the previous 6 months; unstable angina; ventricular extrasystole with a frequency of more than 5 per minute; frequent atrial extrasystoles or more complex arrhythmias; age over 70 years; the emergency nature of the operation; hemodynamically significant aortic stenosis; general severe condition. The combination of any three of the first six indicates a 50% chance of perioperative myocardial infarction, pulmonary edema, ventricular tachycardia, or death of the patient. Each of the last three factors individually increases the risk of these complications by 1%, and any combination of two of the last three increases the risk to 5-15%.
A heart attack usually develops in the first six days after surgery. It is important to record the ECG on days 1, 3 and 6 after surgery.

POSTOPERATIVE DEEP VEIN THROMBOSIS OF THE LEGS. About 80% of cases of deep vein thrombosis after surgery have no clinical manifestations (Planes et al., 1996). The most dangerous is thrombosis of the muscular veins of the lower leg due to: 1) turning off the central mechanism of outflow of blood from the legs in bed patients - the muscular-venous pump of the lower leg; 2) a high frequency of silent ectasias of the tibial and muscle veins of the leg; 3) subclinical manifestations; 4) the absence of leg edema due to the preserved outflow of blood from the limb.
Important: prevention in the broad and narrow terms; identification of risk groups; daily palpation of the calf muscles as a standard for postoperative monitoring.

POSTOPERATIVE PNEUMONIA - the most severe of the bronchopulmonary complications . Causes: aspiration, microembolism, stagnation, toxicoseptic state, heart attack, prolonged standing of the gastric and intestinal probes, prolonged mechanical ventilation. It is predominantly small-focal in nature and is localized in the lower sections.
Clinic: exacerbation of fever not associated with wound findings, chest pain when breathing; cough, flushed face. It starts as tracheobronchitis. Appears for 2-3 days.
Three variants of the course (N. P. Putov, G. B. Fedoseev, 1984): 1) a clear picture of acute pneumonia; 2) with prevalence of the phenomena of bronchitis; 3) an erased picture.
Indicators of severe prognosis in nosocomial pneumonia (S. V. Yakovlev, M. P. Suvorova, 1998): age over 65 years; IVL for more than 2 days; the severity of the underlying disease (head injury, coma, stroke); severe concomitant diseases (diabetes mellitus, chronic obstructive pulmonary disease, alcoholism and liver cirrhosis, malignant tumors); bacteremia; polymicrobial or problematic (P. Aeruginosa, Acinnetobacter spp., fungi) infection; previous ineffective antibiotic therapy.
In the complex of treatment, antibacterial treatment is important, taking into account the characteristics of the nosocomial infection of the medical institution and operational control of bronchial patency (bronchoscopy).

POSTOPERATIVE PAROTITIS - acute inflammation of the parotid salivary gland. More often in patients of elderly and senile age, with diabetes mellitus. Contribute to carious teeth, decreased function of the salivary glands due to dehydration, in the absence of chewing, prolonged standing of the probes, leading to the multiplication of microbial flora in the oral cavity.
Clinic. On the 4th - 8th day, pain, swelling, hyperemia in the parotid areas occur with the development or aggravation of a septic condition. In addition, dry mouth, difficulty opening the mouth.
Prevention: sanitation of the oral cavity, rinsing the mouth, removing plaque from the tongue, chewing sour.
Treatment: local (compresses, dry heat, rinsing) and general (antibacterial therapy, detoxification). If suppuration occurs, open with two incisions parallel to the vertical part of the lower jaw and along the zygomatic arch (work digitally on the gland).

The postoperative period begins immediately after the end of the operation and ends with the recovery of the patient. It is divided into 3 parts:

early - 3-5 days

late - 2-3 weeks

long-term (rehabilitation) - usually from 3 weeks to 2-3 months

Main taskspostoperative period are:

Prevention and treatment of postoperative complications.

Acceleration of regeneration processes.

Rehabilitation of patients.

The early postoperative period is the time when the patient's body is primarily affected by surgical trauma, the effects of anesthesia and a forced position.

The early postoperative period may be uncomplicated and complicated.

In the uncomplicated course of the postoperative period, the reactive changes that occur in the body are usually moderately expressed and last for 2-3 days. At the same time, fever up to 37.0-37.5 ° C is noted, inhibition of the central nervous system is observed, there may be moderate leukocytosis and anemia. Therefore, the main task is to correct changes in the body, control the functional state of the main organs and systems.

Therapy for an uncomplicated postoperative period is as follows:

pain management;

the correct position in bed (Fovler's position - the head end is raised);

wearing a bandage;

prevention and treatment of respiratory failure;

correction of water and electrolyte metabolism;

balanced diet;

control of the function of the excretory system.

The main complications of the early postoperative period.

I. Complications from the wound:

bleeding,

development of wound infection

divergence of seams (eventeration).

Bleeding- the most formidable complication, sometimes threatening the life of the patient and requiring a second operation. In the postoperative period, to prevent bleeding, an ice pack or a load of sand is placed on the wound. For timely diagnosis, monitor the pulse rate, blood pressure, red blood counts.

Development of a wound infection can proceed in the form of the formation of infiltrates, suppuration of the wound or the development of a more formidable complication - sepsis. Therefore, it is necessary to bandage the patients the next day after the operation. To remove the dressing material, which is always wet with sanious wound discharge, treat the edges of the wound with an antiseptic and put a protective aseptic bandage. After that, the bandage is changed every 3 days when it gets wet. According to the indications, UHF therapy is prescribed for the area of ​​surgical intervention (infiltrates) or antibiotic therapy. It is necessary to monitor the portal functioning of the drains.

Divergence of seams (eventeration) most dangerous after abdominal surgery. It may be associated with technical errors in suturing the wound (the edges of the peritoneum or aponeurosis are closely captured into the suture), as well as with a significant increase in intra-abdominal pressure (with peritonitis, pneumonia with severe cough syndrome) or with the development of infection in the wound. To prevent the divergence of the seams during repeated operations and at a high risk of developing this complication, suturing the wound of the anterior abdominal wall with buttons or tubes is used.

II. The main complications from the nervous system: in the early postoperative period are pain, shock, sleep and mental disorders.

The elimination of pain in the postoperative period is given exceptionally great importance. Painful sensations can reflexively lead to disruption of the cardiovascular system, respiratory organs, gastrointestinal tract, and urinary organs.

The fight against pain is carried out by the appointment of analgesics (promedol, omnopon, morphine). It must be emphasized that the unreasonable long-term use of drugs of this group can lead to the emergence of a painful addiction to them - drug addiction. This is especially true in our time. In the clinic, in addition to analgesics, long-term epidural anesthesia is used. It is especially effective after operations on the abdominal organs; within 5-6 days, it makes it possible to drastically reduce pain in the area of ​​operation and to eliminate a pair of intestines as soon as possible (1% trimecaine solution, 2% lidocaine solution).

Elimination of pain, the fight against intoxication and excessive excitation of the neuropsychic sphere are the prevention of such complications from the nervous system as postoperative sleep and mental disorders. Postoperative psychoses often develop in weakened, malnourished patients (homeless people, drug addicts). It must be emphasized that patients with postoperative psychosis need constant supervision. Treatment is carried out in conjunction with a psychiatrist.

Consider an example: A patient with destructive pancreatitis developed psychosis in the early postoperative period. He jumped out of the emergency room window.

III. Complications from the cardiovascular system can occur primarily, as a result of weakness of cardiac activity, and secondarily, as a result of the development of shock, anemia, severe intoxication.

The development of these complications is usually associated with concomitant diseases, so their prevention is largely determined by the treatment of concomitant pathology. The rational use of cardiac glycosides, glucocorticoids, sometimes vasopressants (dopamine), compensation for blood loss, full blood oxygenation, the fight against intoxication and other measures taken into account the individual characteristics of each patient make it possible in most cases to cope with this severe complication of the postoperative period.

An important issue is the prevention of thromboembolic complications, the most common of which is pulmonary embolism- a serious complication, which is one of the frequent causes of deaths in the early postoperative period. The development of thrombosis after surgery is due to slow blood flow (especially in the veins of the lower extremities and small pelvis), increased blood viscosity, impaired water and electrolyte balance, unstable hemodynamics, and activation of the coagulation system due to intraoperative tissue damage. The risk of pulmonary embolism is especially high in elderly obese patients with concomitant pathology of the cardiovascular system, the presence of varicose veins of the lower extremities and a history of thrombophlebitis.

Principles of prevention of thromboembolic complications:

early activation of patients, their active management in the postoperative period;

exposure to a possible source (for example, treatment of thrombophlebitis);

ensuring stable dynamics (control of blood pressure, pulse);

correction of water and electrolyte balance with a tendency to hemodilution;

the use of antiplatelet agents and other agents that improve the rheological properties of blood (rheopolyglucin, trental, neoton);

the use of direct anticoagulants (heparin, fraxiparin, streptokinase) and indirect action (sinkumar, pelentan, aescusin, phenylin, dicoumarin, neodicoumarin);

bandaging of the lower extremities in patients with varicose veins.

IV. Postoperative respiratory complications the most common are tracheobronchitis, pneumonia, atelectasis, pleurisy. But the most formidable complication is development of acute respiratory failure, associated primarily with the effects of anesthesia.

That's why the main measures for the prevention and treatment of respiratory complications are:

early activation of patients,

adequate position in bed with a raised head end

(Fowler position),

breathing exercises,

combating hypoventilation of the lungs and improving the drainage function of the tracheobronchial tree (inhalation with humidified oxygen,

banks, mustard plasters, massage, physiotherapy),

liquefaction of sputum and the use of expectorants,

prescribing antibiotics and sulfa drugs, taking into account sensitivity,

sanitation of the tracheobronchial tree in seriously ill patients (through an endotracheal tube with prolonged mechanical ventilation or through a microtracheostomy with spontaneous breathing)

Analysis of inhalers and oxygen system.

V. Complications from the abdominal cavity in the postoperative period are quite severe and varied. Among them, a special place is occupied by peritonitis, adhesive intestinal obstruction, paresis of the gastrointestinal tract. Attention is drawn to the collection of information in the study of the abdominal cavity: examination of the tongue, examination, palpation, percussion, auscultation of the abdomen; digital examination of the rectum. Emphasis is placed on the particular importance in the diagnosis of peritonitis of such symptoms as hiccups, vomiting, dry tongue, tension of the muscles of the anterior abdominal wall, bloating, weakening or absence of peristalsis, the presence of free fluid in the abdominal cavity, the appearance of Shchetkin-Blumberg's symptom.

The most common complication is the development paralytic ileus (intestinal paresis). Intestinal paresis significantly disrupts the processes of digestion, and not only them. An increase in intra-abdominal pressure leads to a high standing of the diaphragm, impaired ventilation of the lungs and heart activity; in addition, there is a redistribution of fluid in the body, the absorption of toxic substances from the intestinal lumen with the development of severe intoxication of the body.

Basics of prevention of intestinal paresisassigned to operations:

respect for fabrics;

minimal infection of the abdominal cavity (use of tampons);

careful hemostasis;

novocaine blockade of the root of the mesentery at the end of the operation.

Principles of prevention and control of paresis after surgery:

early activation of patients wearing a bandage;

rational diet (small convenient portions);

adequate drainage of the stomach;

introduction of a gas outlet tube;

stimulation of motility of the gastrointestinal tract (prozerin 0.05% - 1.0 ml subcutaneously; 40-60 ml of a hypertonic solution in / in slowly drip; cerucal 2.0 ml / m; cleansing or hypertonic enema);

2-sided novocaine pararenal blockade or epidural blockade;

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POSTOPERATIVE PERIOD

INTRODUCTION

The foundation for the success of surgical treatment is laid at the stage of preoperative preparation, when the patient is preparing for the upcoming surgical injury and during the surgical intervention. If the patient turned out to be unprepared for surgical aggression, if mistakes were made during the operation, complications arose and were not eliminated, then in most cases it is not necessary to count on a favorable outcome. However, even with a brilliantly performed surgical intervention, the treatment does not end. The patient needs comprehensive attention, care and treatment aimed at correcting impaired functions. Inattention, inadequate treatment, untimely diagnosis of emerging complications can negate all the efforts expended. Therefore, the treatment of the patient in the postoperative period is an important stage in the treatment of surgical patients.

POSTOPERATIVE PERIOD

The postoperative period is the time from the end of surgery to the moment when the outcome of surgical treatment is determined. There are three possible outcomes - recovery of the patient with the restoration of working capacity, recovery with the acquisition of disability and death. Thus, the results of surgical treatment can be favorable and unfavorable. Unfortunately, in some diseases, in order to save a person's life, surgeons must remove vital organs or body parts. The patient recovers as a result of treatment, but he cannot fully carry out labor activity. In such cases, a disability group is given.

The postoperative period is divided into:

· Early - from the end of the operation to 3-5 days.

Late - from 4-6 days before discharge from the hospital.

· Remote - from the moment of discharge from the hospital to the restoration of working capacity or the receipt of a disability group.

Significance and main tasks of the postoperative period.

The value of the postoperative period is great. At this time, firstly, all the omissions of the preoperative period and defects in surgical intervention appear, and secondly, the quality of treatment and care determines the speed of the patient's recovery.

The main tasks of the postoperative period are:

1. maintenance of protective and compensatory reactions of the body;

2. correction of functional disorders caused by the pathological process and surgical trauma.

3. stimulation of tissue regeneration;

4. prevention of development and timely diagnosis of postoperative complications. The duration of the postoperative period in each case is different and depends on the initial state of the patient, the nature of the disease, the volume of surgical intervention.

There are uncomplicated and complicated postoperative period.

UNCOMPLICATED POSTOPERATIVE PERIOD

postoperative complication pathological trauma

In the previous lecture, it was pointed out that the surgical intervention itself causes the development of "operational stress", various functional, biochemical, immunological and other changes. In fact, in the early postoperative period, a special pathological condition is formed, which the famous French surgeon Rene Leriche called "postoperative disease". Later, many surgeons paid great attention to the study of this condition and the development of methods to combat this "disease".

Of course, not a single person in the postoperative period can be called healthy, since processes that are not characteristic of the norm occur in the body. At the same time, with a smooth course, the "readiness" of the patient's body for changes characteristic of surgical intervention allows you to quickly eliminate them and restore normal function, therefore, calling this condition a disease is not entirely correct. It is more justified to speak of postoperative illness in cases where protective reactions are weakly expressed and various complications develop. In this regard, with an uncomplicated course, it is better to talk about the postoperative state.

Phases of the postoperative period.

There are three phases in the postoperative period:

The catabolic phase

phase of reverse development;

anabolic phase.

The catabolic phase lasts an average of 3-7 days. The severity and duration of it depends on the degree of functional disorders caused by the underlying and concomitant pathology, the trauma of surgical intervention. The catabolic phase is a protective reaction of the body, providing an increase in the body's resistance by accelerating energy and plastic processes. This phase is characterized by an increase in energy consumption due to hyperventilation, increased blood circulation, increased liver and kidney function. The source of energy is tissue catabolic processes. Carbohydrate and fat reserves are mobilized, and in case of their insufficiency, structural proteins are used.

This phase is characterized by certain neuroendocrine reactions. The sympathetic-adrenal system, hypothalamus and pituitary gland are activated, the flow of catecholamines, glucocorticoids, aldesterone, ACTH into the blood increases. There is an increased synthesis of angiotensin and renin.

Neurohumoral shifts cause a change in vascular tone, vasospasm develops. Accordingly, microcirculation in the tissues is disturbed, which leads to impaired tissue respiration and hypoxia, and metabolic acidosis develops. In turn, this exacerbates microcirculation disorders. The water-electrolyte balance is disturbed, the fluid passes from the vessels into the interstitial spaces, there is a thickening of the blood and stasis. Due to tissue hypoxia, redox reactions are disturbed, anaerobic glycolysis prevails over aerobic. In the blood, against the background of a decrease in insulin, the content of glucose increases.

In the catabolic phase, there is an increase in protein breakdown, and not only connective tissue and muscle proteins are lost, but also enzymatic proteins. Loss of protein during extensive operations can be 30-40 grams per day. Proteins of the liver, plasma, gastrointestinal tract break down faster, striated muscles slower. Loss of protein increases with blood loss, purulent complications. If the patient had hypoproteinemia, then the loss of protein in the postoperative period is quite dangerous.

Changes characteristic of the catabolic phase are exacerbated in the event of complications.

Phase of reverse development. The transition from the catabolic phase to the anabolic phase occurs gradually through the reverse development phase. It starts on 3-7 days and lasts 3-5 days. It is characterized by a decrease in catabolic and an increase in anabolic processes. The following processes take place in the body. There are changes in the neuroendocrine system. The activity of the sympathetic-adrenal system decreases and the influence of the parasympathetic system begins to predominate. The level of somatotropic hormone, insulin, androgens increases. The water-electrolyte balance is restored. There is an accumulation of potassium, which is involved in the synthesis of proteins and glycogen.

This phase continues, but to a lesser extent, increased consumption of energy and plastic materials (proteins, fats, carbohydrates). At the same time, active synthesis of proteins, glycogen, and then fats begins. Gradually, this leads to the normalization of protein metabolism, the nitrogen balance becomes positive. Anabolic processes gradually begin to prevail over catabolic ones.

The anabolic phase lasts 2-5 weeks, its duration depends on the initial state of the patient, the severity of the operation, the severity and duration of the catabolic phase.

The anabolic phase is characterized by the restoration of changes that occurred in the catabolic phase.

The parasympathetic system is activated and the activity of growth hormone and androgens increases. The latter stimulate the synthesis of proteins. Growth hormone activates the transport of amino acids from the intercellular spaces into the cell, and androgens enhance the synthesis of proteins in the liver, kidneys, and myocardium. There is also an increased synthesis of fats and glycogen used up during surgery and in the catabolic phase. The restoration of glycogen stores occurs due to the anti-insulin action of somatotropic hormone. An increase in protein accelerates reparative processes, growth and development of connective tissue.

The anabolic phase ends with a complete recovery of the body.

CLINICAL COURSE OF THE UNCOMPLICATED POSTOPERATIVE PERIOD

Any surgical intervention causes the same type of pathophysiological changes in the body of patients, which have their own clinical manifestations. The severity and nature of these manifestations depends on the invasiveness of the surgical intervention and the protective reactions of the body.

It was mentioned above that the early, late and remote postoperative periods are distinguished. The early period corresponds to the catabolic phase, the late period corresponds to the reverse development phase and the anabolic phase.

Of course, a clinically abrupt transition from one phase to another cannot be identified. In addition, some changes may not fit into the above scheme at all. Let us dwell on the most typical manifestations.

Early period The catabolic phase is characterized by the following changes.

The cardiovascular system. At first, there is pallor of the skin, increased heart rate (20-30%), a moderate increase in arterial pressure and a moderate decrease in central venous pressure.

Respiratory system. Initially, breathing becomes more frequent with a decrease in its depth (superficial). The vital capacity of the lungs decreases by 30-50%, which reduces ventilation. Disturbances in the respiratory system can be aggravated by pain and impaired drainage function of the bronchi. During operations on the abdominal organs, the high standing of the domes of the diaphragm and intestinal paresis have an adverse effect.

Nervous system. The state of the nervous system on the first day is largely determined by the residual effect of anesthesia. Patients are usually inhibited, drowsy, indifferent to the environment, calm. As the effect of the drugs used in anesthesia decreases, the pain syndrome increases. There may be anxiety, agitation, or vice versa, a depressed state. Patients sometimes become capricious. Psychoemotional reactions are especially pronounced in patients of senile age. More pronounced changes may occur with the development of complications.

Gastrointestinal tract. Gastrointestinal tract disorders occur during operations on the abdominal organs. Dryness of the tongue is noted. This is a manifestation of fluid loss and disturbance of water and electrolyte balance. There is a gray coating on the tongue. Nausea and vomiting in the first day is mainly due to the action of narcotic drugs. There is intestinal paresis. Normal peristalsis is restored in 3-4 days. During this time, there may be congestion in the stomach. Clinically, it is manifested by heaviness in the epigastrium, heartburn, nausea, hiccups, and vomiting. When peristalsis is restored, stagnation is eliminated. Peristalsis is restored gradually. At first, individual peristaltic noises can be heard, then it appears periodically. A characteristic sign of the restoration of peristalsis is the restoration of gas discharge. Liver dysfunction is manifested by dysproteinemia, an increase in urea content.

urinary system. In the early days, there may be a decrease in diuresis. This is due to water and electrolyte disturbances and an increase in the content of aldosterone, an antidiuretic hormone.

Violation of carbohydrate metabolism. Hyperglycemia is noted in the blood, the sugar level can rise by 36.5-80% compared to the initial, preoperative level. Hyperglycemia usually lasts 3-4 days, and the amount of sugar in the blood gradually normalizes on its own. Violation of carbohydrate metabolism after surgery leads to the appearance of acetonuria, this phenomenon V. A. Opel called "small, surgical diabetes."

Violations of water-electrolyte metabolism and acid-base state. In the first days, hypovolemia is observed, which is manifested by thirst, dryness of mucous membranes and skin, a decrease in central venous pressure, a decrease in urine volume, and an increase in its specific gravity. The amount of chlorides in the blood decreases. A decrease in their level in the blood by 10-30% is not clinically manifested. There may be hyperkalemia. In the first days, acid-base disturbances (KJS) may occur, acidosis is noted in the blood. Clinically, acidosis is manifested by nausea, dizziness, vomiting, intestinal paresis with gas retention, headache, and insomnia. The development of acidosis is not a serious complication.

Temperature. In the first days, patients have a temperature of 37-38 C. Sometimes there may be rises to higher numbers.

In the peripheral blood, moderate leukocytosis, anemia and hypercoagulability are noted. An increase in neutrophils, predominantly segmented, is characteristic, an increase in ESR.

Wound. Clinical signs correspond to the phase of inflammation. Patients report moderate pain. The edges of the wound are moderately edematous, may be somewhat hyperemic. The pain syndrome disappears by 3-4 days. The late period can capture the final period of the reverse development phase and the initial anabolic one. Signs of the transition of the catabolic phase to the phase of reverse development is the disappearance of the pain syndrome. During this period, patients become active, take care of themselves. Temperature normalizes. Integuments acquire the usual color and elasticity. Pulse, arterial and central venous pressure are normalized. Breathing is restored, its frequency and depth correspond to normal indicators. The function of the gastrointestinal tract is normalized, patients have an appetite. Diuresis and biochemical parameters characterizing liver function are restored. Signs of inflammation disappear from the side of the wound. On palpation, it is practically painless, the edges are not edematous and not hyperemic. Gradually, the patient's condition improves. Blood counts are normalized - leukocytosis disappears, ESR decreases.

MANAGEMENT OF PATIENTS IN THE POSTOPERATIVE PERIOD

The specific tasks of managing patients in the uncomplicated period are careful monitoring of functional changes in the body after surgery, their correction, prevention, timely diagnosis and treatment of possible complications. It should immediately be emphasized that postoperative complications may be due to defects in the management of patients in the postoperative period. They can be avoided. To do this, in the postoperative period, it is necessary to carry out a number of activities that will allow the patient to more easily cope with the disorders that develop after surgery. The complex of the carried-out actions includes leaving, supervision and treatment.

Patients after surgery are admitted to the surgical department or intensive care unit. The question of the location of the patient is decided depending on the invasiveness of the operation, the type of anesthesia, the nature of the course of anesthesia and surgical intervention. Patients after low-traumatic and light-traumatic operations are usually in the surgical department. In moderately traumatic and traumatic operations, there is always a need for intensive care, so patients are placed in the intensive care unit.

Transportation from the operating room to the ward is carried out in a supine position on a stretcher. It should be adapted for convenient shifting of the patient.

In the first hours (days) after the operation, the position of the patient should correspond to the nature of the surgical intervention performed (usual lying position, Fowler's position, position with the head end of the bed raised, etc.). The bed should be equipped with devices that make it easier for the patient to move (tires, trapezoids, reins, tables). The patient should be activated as soon as possible. In the first days, it is necessary to force the patient to make active movements, the volume of which should correspond to the nature of the surgical intervention. It is better to attract exercise therapy instructors. For all types of surgical interventions, there are special gymnastic complexes. Patients should be encouraged to walk as early as possible. The active method of managing patients contributes to a more rapid restoration of the functions of almost all systems and to avoid the development of some complications.

Nursing issues were discussed in the course "Nursing Surgical Patients". It should only be noted that hygiene measures are important for the prevention of a number of complications. It is necessary to make a timely change of contaminated underwear and bed linen, treatment of the skin, mucous membranes.

Observation in the postoperative period. Observation of patients in the first hours after surgery.

In the first hours after the operation, it is necessary to carry out especially careful monitoring of patients. During this period, serious complications can develop with a breakdown in the functions of vital organs, complications of anesthesia may appear.

Conduct clinical and monitoring observation. In the first hours after the operation, the recovery of consciousness is monitored, the pulse rate and rhythm, blood pressure, and respiratory rate are constantly recorded. If necessary, perform an ECG or carry out constant monitoring control. Measure CVP. Particular care should be taken to avoid obstruction of the airways due to vomiting or regurgitation. Of the laboratory methods used to determine the level of hemoglobin, hematocrit, electrolytes, acid-base state.

In the future, multiple examinations of patients are carried out in order to be able to assess its condition in dynamics.

Neuropsychic state. Assess the consciousness and behavior of the patient. Emergence of excitement, oppression, hallucinations, delirium is possible.

The condition of the skin and mucous membranes. They monitor the color of the skin (pallor, cyanosis, jaundice), evaluate its turgor, and detect local swelling.

The state of the cardiovascular system. Determine the pulse rate, filling, rhythm, measure the level of arterial, and if necessary, central venous pressure. Evaluate the nature of heart sounds, the presence of noise.

The state of the respiratory system. Assess the frequency, depth, rhythm of breathing, auscultation and percussion of the lungs.

The state of the digestive system. Assess the condition of the tongue (dryness, presence and color of plaque). When examining the abdomen, it is determined whether there is swelling, whether the anterior abdominal wall is involved in the act of breathing. Palpation evaluates the tension of the abdominal wall, the presence of symptoms of peritoneal irritation (Shchetkin-Blumberg symptom). Ascultatively determine the presence of peristaltic noises. They find out if gases are leaving, whether there was a chair.

Urinary system. Determine the daily diuresis, the rate of urination by permanent urinary catheter, hourly diuresis. Find out if there are urinary disorders.

Body temperature. The temperature is measured twice a day.

Wound monitoring. The first dressing is carried out the next day. Assess the color of the skin around the wound, swelling, degree of pain. In the presence of drains installed in the wound or cavities, the volume of discharge is measured and its nature is assessed (serous, hemorrhagic, purulent).

Laboratory research. Patients perform general, biochemical blood tests, general urinalysis, coagulogram, determine indicators of the acid-base state, bcc, blood electrolytes.

Examination of the patient must be carried out repeatedly. The data of the examination and special studies are entered into the medical history, and in the case of a patient being treated in the intensive care unit, into a special card. Particular attention should be paid to elderly and senile patients. The body of people in this age group requires significantly greater efforts and a longer period of time to restore impaired organ functions; they most often have complications.

On the basis of clinical, instrumental and laboratory studies, a conclusion is made about the nature of the course of the postoperative period, and the treatment is corrected.

TREATMENT IN THE UNCOMPLICATED POSTOPERATIVE PERIOD

With lightly traumatic surgical interventions that took place without intraoperative complications and with adequate anesthesia, the body is able, thanks to compensatory reactions, to overcome the consequences of a single injury on its own. Patients who have undergone moderately traumatic and traumatic operations require intensive postoperative treatment. Otherwise, compensatory mechanisms become immediately untenable or change so much that they become pathological. It should always be remembered that the end of the surgical intervention does not mean the patient is cured of the underlying surgical disease, and in the postoperative period it is necessary to treat pathological disorders caused by the disease. For effective prevention of a number of complications, special treatment is necessary.

Thus, treatment in the postoperative period includes:

1. correction of functional disorders caused by surgery;

2. correction of violations caused by underlying and concomitant diseases;

3. prevention of the development of postoperative complications.

Intensive care in the postoperative period should include:

1. normalization of neuropsychic activity;

2. normalization of breathing;

3. normalization of hemodynamics and microcirculation;

4. normalization of water-electrolyte balance and acid-base state;

5. carrying out detoxification;

6. correction of the blood coagulation system;

7. normalization of the functioning of the excretory system;

8. providing a balanced diet;

9. restoration of the functions of the organs on which the surgical intervention was performed.

3. Normalization of neuropsychic activity.

An important diagnostic criterion for the course of the postoperative period is the state of consciousness. In the next few hours after surgical interventions performed under general anesthesia, the recovery of the patient's consciousness is monitored. There may be a slowdown in postanesthesia awakening due to three reasons:

An overdose of anesthetic;

Increased sensitivity of brain regions to the action of an anesthetic;

Slow metabolism and excretion of the anesthetic substance from the body.

In cases of slowing postanesthesia awakening, there is no need to take measures to speed up this process. In a severe initial condition of the patient, a very traumatic operation, it is advisable to use the method of prolonged postoperative sleep.

Fighting pain. An important element in the normalization of neuropsychic activity is the fight against pain. Any person is afraid and tries to avoid pain, so pain in the postoperative period can contribute to the disruption of neuropsychic activity. In addition, pain syndrome leads to dysfunction of the respiratory system, cardiovascular system, etc. etc. In this regard, the issues of anesthesia are in the first place among the therapeutic measures in the postoperative period. The ideal option is when the patient does not experience pain.

The intensity of pain in the postoperative period depends on the trauma of the operation and the state of the patient's neuropsychic sphere. Pain appears after surgical interventions performed under local anesthesia, usually after 1-1.5 hours, under general anesthesia - after the restoration of consciousness. Traditionally, the main role in the relief of pain is given to the use of pharmacological drugs. Of course, this is fair. However, simple activities can help reduce pain. These include - giving a certain position to the patient in bed, wearing various bandages. Relaxing the muscles and protecting them from sharp painful movements allows you to somewhat reduce the pain reaction.

From pharmacological agents, narcotic and non-narcotic analgesics, sedatives are used. After traumatic surgical interventions, narcotic analgesics (promedol, morphine, etc.) are prescribed for 2-3 days. Non-narcotic analgesics (analgin, baralgin, etc.) are used after low-traumatic operations for 2-3 days or they are switched to their use 3-4 days after traumatic operations, canceling narcotic analgesics. Sedative drugs (seduxen, relanium, etc.) are used to increase the threshold of pain sensitivity. In some cases, the use of narcotic analgesics such as morphine, promedol is insufficient, in addition, they have an adverse effect, depress the respiratory center and contribute to the occurrence of complications from the respiratory system. In such cases, narcotic drugs are used that do not depress breathing and cardiac activity (fentanyl, dipidolor). For adequate pain relief in the postoperative period, especially after major traumatic operations, prolonged epidural anesthesia should be used.

Normalization of breathing. Normal gas exchange in the lungs is one of the main conditions for life support. Therefore, the normalization of breathing is an important element of treatment in the postoperative period. To correct respiratory disorders in the postoperative period, pathogenetic and substitution therapy is carried out. The first involves measures to ensure the patency of the respiratory tract and improve pulmonary blood flow. The second is to ensure an adequate supply of oxygen.

pathogenic therapy.

1. Relief of pain syndrome. Pain in the postoperative period leads to a decrease in chest excursion, therefore, to normalize breathing, it is necessary to achieve adequate pain relief. Methods for dealing with pain are outlined above. Attention should be paid only to the fact that elderly patients should not be prescribed morphine derivatives, since they depress the respiratory center.

2. Relief of bronchospasm, removal of sputum. For this, patients are prescribed inhalations with medicinal herbs (chamomile, sage, eucalyptus leaf). If necessary, especially in the first hours, after long-term surgical interventions, the respiratory tract is sanitized using suction.

3. Increasing the airiness of the respiratory zone. Patients are prescribed breathing exercises, physiotherapy exercises, chest massage, inflating rubber balloons.

replacement therapy.

1. Auxiliary artificial ventilation. It is used after long, traumatic surgical interventions performed under intubation anesthesia. In such cases, the patient is not transferred to spontaneous breathing, but prolonged artificial ventilation of the lungs is carried out for several hours.

2. Oxygen therapy. The patient is inhaled with humidified oxygen, for this purpose special catheters are used, inserted into the nasal passages.

Normalization of hemodynamics. The cardiovascular system has very powerful compensatory capabilities. However, they are not unlimited. Concomitant diseases of the cardiovascular system, intoxication, surgical blood loss, developing metabolic disorders and changes in water-electrolyte and acid-base conditions cause pathological processes in the myocardium, lead to impaired hemodynamics and microcirculation. Therefore, the main type of prevention and correction of disorders in the functioning of the cardiovascular system is the timely preventive replenishment and maintenance of circulating blood volume. For this, infusion therapy is carried out, including crystalloid solutions, volumetrically and rheologically active plasma substitutes (polyglucin, rheopolyglucin, albumin, etc.), and in case of blood loss, erythrocyte mass. Infusion therapy is carried out under the control of hemodynamic parameters.

If the patient in the preoperative period had any pathology on the part of the cardiovascular system, then appropriate treatment is carried out, including cardiotonic drugs, antihypertensive drugs, etc. etc.

Normalization of water-electrolyte balance and acid-base state. The degree of violation of the water-electrolyte balance and acid-base state depends primarily on the nature of their violation in the preoperative period and the severity of the surgical intervention. In low-traumatic operations, the body is able to compensate for the developing changes itself. After traumatic operations, it becomes necessary to carry out their correction.

Treatment of shifts in water-electrolyte balance and acid-base state is carried out under the control of the content of basic ions (K, Na, Ca), fluid loss, kidney function. Patients undergo infusion therapy, including crystalloid and colloid blood-substituting solutions. The volume of infusion is determined taking into account the daily needs of the body and fluid loss.

To correct the level of basic ions, ionic solutions are administered intravenously. In the uncomplicated period, the patient should receive at least 3 g of potassium. In cases of hypokalemia, the dose is increased. The lack of sodium ions is compensated by the introduction of NaCl solutions. To correct metabolic acidosis, sodium bicarbonate solutions are administered. The criterion for the adequacy of the treatment is sufficient diuresis.

Carrying out detoxification. The degree of intoxication in the postoperative period depends on the nature of the pathological process and the invasiveness of the surgical intervention. For the purpose of detoxification, transfusion-infusion therapy is used, and, according to indications, the method of forced diuresis and methods of extracorporeal detoxification.

Correction of the blood coagulation system. Observed in the postoperative period, it can cause the development of thromboembolic complications. Therefore, patients are taking measures to correct the blood coagulation system. They include infusion-transfusion therapy aimed at improving the rheological properties of blood and creating hemodilution. It is advisable to prescribe direct anticoagulants (heparin) in prophylactic doses (up to 5 thousand units every 6-8 hours).

Normalization of the functioning of the excretory system. It is impossible to achieve correction of many of the above functions in the postoperative period without ensuring the normal functioning of the excretory system. An obligatory element of the management of patients is the control of diuresis, and in the event of the development of disorders, their treatment. Therapeutic measures include, if necessary, stimulation of urination (prescription of diuretics), and in case of urination disorders, ensuring its free excretion.

Providing a balanced diet. Patients in the postoperative period require the supply of energy and plastic materials to ensure the vital activity of the body. Usually there are no problems with the provision of nutrition if the patient can eat himself. After operations on the organs of the abdominal cavity, retroperitoneal space, as a result of the development of dysfunction of the gastrointestinal tract, normal food intake is not possible. Patients should receive parenteral nutrition for several days. For this purpose, patients undergo transfusion-infusion therapy, including solutions of carbohydrates, protein preparations and fat emulsions. Parenteral nutrition should be balanced, provide the energy needs of the body and the supply of a sufficient amount of plastic substances. Enteral nutrition is switched to after the restoration of motility of the gastrointestinal tract. At the beginning, the most easily digestible food is prescribed, then the food is gradually expanded in composition and volume. In some cases, it is necessary to use parenteral and enteral nutrition at the same time, since the patient cannot meet his needs due to self-feeding.

It is customary to distinguish between complete, partial and mixed parenteral nutrition.

Complete - this is the provision of nutrition only by parenteral administration of substances.

Partial is when some separate, most suffering types of exchange are satisfied at the expense of it. Mixed parenteral nutrition is when it supplements inadequate enteral nutrition.

Restoration of the functions of organs on which surgery was performed. An obligatory element of treatment in the postoperative period is the implementation of measures aimed at restoring the function of the organs on which the surgical intervention was performed. Considering that most often we have to deal with patients operated on the abdominal organs, we will consider therapeutic measures that help restore the function of the gastrointestinal tract.

In small operations, intestinal peristalsis is restored independently during the first day. After moderately traumatic and traumatic surgical interventions, peristalsis appears for 2-3 days, then gases begin to leave. Treatment should be aimed at preventing paresis of the gastrointestinal tract. Patients produce aspiration of the contents of the stomach, in the initial period of restoration of peristalsis, to facilitate the discharge of gases, gas outlet tubes and cleansing enemas are used. After the restoration of peristalsis, the patient begins to eat on his own. The task of the doctor during this period is to ensure proper nutrition in terms of frequency of intake, composition and consistency.

COMPLICATED POSTOPERATIVE PERIOD

For timely diagnosis of postoperative complications, one can focus on the following clinical manifestations of disorders of the organs and systems.

1. Central nervous system. Disturbances of consciousness, inhibited state, delirium, hallucinations, motor, speech excitation.

2. Skin and mucous membranes, subcutaneous tissue. The appearance of severe pallor, acrocyanosis, cold sticky sweat, dry mucous membranes, swelling, decreased turgor.

3. Cardiovascular system. The pulse rate is more than 120 beats / min. Rhythm of heart contractions - the appearance of various arrhythmias. Blood pressure - decrease in systolic blood pressure to 80 mm Hg. Art. and below, as well as an increase to 200 mm Hg. Central venous pressure - a decrease below 50 mm of water. Art. and an increase of more than 110 mm. water. Art. The appearance of edema in the lower extremities.

4. Respiratory organs. The number of breaths is more than 28 in 1 min. Shortening of percussion sound, dull or boxed sound during percussion of the chest, absence of respiratory noises in the area of ​​dullness, the appearance of wheezing of a different nature. 5. Urinary organs. Decreased urination (less than 10 ml/h), anuria. Lack of spontaneous urination. 6. Gastrointestinal tract. Severe bloating and pain, a sharp tension in the muscles of the anterior abdominal wall, a positive Shchetkin-Blumberg symptom, stagnation of the stomach contents, vomiting, hiccups, absence of peristaltic intestinal noises, non-excretion of gases for more than 3 days, tarry stools, admixture of blood in the feces.

7. Operational wound. Soaking the bandage with blood, pus, bile, intestinal contents. Pain in the wound for more than 3 days, hyperemia, swelling of the edges. Divergence of the edges of the wound with prolapse of the abdominal organs into the wound (eventration). Isolation by drainage of blood, intestinal contents, bile.

8. Temperature reaction. Preservation of elevated temperature for more than 3-4 days.

The appearance of the above signs should serve as the basis for a thorough examination in order to determine the cause and diagnose developing complications.

In the case of complications, they speak of a complicated postoperative period.

The main factors contributing to the development of complications:

the impact of surgical trauma;

The effect of anesthesia

the presence of a postoperative wound;

forced position.

The reasons for the development of complications can also be functional disorders caused by the underlying pathological process, as well as concomitant diseases. The impact on the body of an operating injury, anesthesia can exacerbate the disorders that existed before the operation and lead to an exacerbation of chronic diseases.

Depending on the time of occurrence, early and late complications are distinguished. Early complications occur within the first 48 hours after surgery. Late complications include those occurring 48 hours after the end of the operation. Complications are also divided according to the organs and systems in which they develop.

Distinguish:

1) complications in organs that were not directly affected by surgery;

2) complications in the organs and systems on which surgery was performed;

3) complications from the surgical wound.

Complications from the neuropsychic sphere. Among the complications from the neuropsychic sphere, neurological and mental disorders are distinguished.

The reasons for the development of neurological disorders are a violation of cerebral circulation, compression of the nerve trunks with an incorrect long-term position of the patient during surgery, damage to the nerve structures during regional anesthesia. Violations of cerebral circulation proceed according to the type of ischemic stroke (insufficiency of cerebral circulation). They are clinically manifested by cerebral symptoms and the appearance of focal symptoms (impaired sensitivity and movement in certain parts of the body). Neurological complications that develop during regional anesthesia methods are covered in the corresponding lecture. Damage to the peripheral nerves can occur as a result of improper laying of the patient on the operating table. As a result of prolonged compression of the nerve trunks or plexuses, neuritis, plexitis develop, which are manifested by impaired sensitivity and motor activity in the innervated zone. So, with an incorrect position of the head and arm, the brachial plexus is compressed between the clavicle and the 1st rib. Treatment of acute disorders of cerebral circulation, plexitis, neuritis is carried out in conjunction with neuropathologists.

Mental disorders. This type of complications most often occurs in patients with various mental disorders in the preoperative period (mental illness, alcoholism, drug addiction, psychoemotional disorders). The impact of anesthetics, other drugs, surgical trauma, intoxication lead to an exacerbation of mental disorders. They are divided into psychotic and neurotic. Patients may experience the following psychotic disorders - delirious and depressive syndromes. Delirious syndrome is manifested by impaired consciousness, loss of orientation in time and space, the appearance of visual and auditory hallucinations, motor excitation. Depressive syndrome is characterized by a decrease in mood, the appearance of isolation, alienation, and suicidal attempts are possible. Patients with such complications need to organize an individual fast and involve psychiatrists in the treatment. Tranquilizers, sleeping pills are prescribed. However, it should be noted that the appearance of mental disorders in the postoperative period may be a sign of severe intoxication of the body as a result of the development of purulent-septic complications. Faced with the onset of a psychotic disorder, it is necessary to exclude the development of a complication that can cause intoxication.

Neurotic disorders are observed in people with a labile psyche. Patients become quick-tempered, capricious, irritable, exaggerate their complaints. Patients in such situations are prescribed sedatives, general strengthening treatment is carried out. In severe cases, psychotherapists are involved.

Complications from the cardiovascular system In the postoperative period, complications from the cardiovascular system can be as follows: myocardial infarction, cardiac arrhythmias, acute cardiovascular failure, hypotension, thrombosis and vascular embolism, pulmonary embolism. The development of these complications is facilitated by blood loss, disturbances in water and electrolyte balance, hypercoagulability, intoxication, and exposure to anesthetics. The risk of their occurrence in individuals is especially high. who already had a pathology of the cardiovascular system before the operation, therefore, even before the operation, this category of patients should be identified as a risk group and treated together with therapists. The clinic of most of these complications is considered in the course of therapy.

Let us dwell on such a complication as pulmonary embolism. This is a very serious complication that can suddenly lead to a catastrophic death of the patient. The cause of thromboembolism is hypercoagulability, which leads to thrombus formation in the venous bed. The main source of dangerous blood clots are the vessels of the system of the inferior vena cava, less often they form in the right parts of the heart and in the system of the superior vena cava. The mechanism of development of thromboembolism is as follows. As a result of the development of hypercoagulation and impaired blood flow in the veins of the lower extremities (long stay in bed), floating thrombi are formed, which are not firmly fixed to the venous wall. In the event of separation of such a thrombus by the blood flow, it enters the right heart, and then into the pulmonary artery. Occlusion of the pulmonary vessels by a thrombus occurs and the blood flow in the lungs is disturbed, which leads to a violation of gas exchange. If large (lobar, segmental arteries) are occluded, death occurs within a few minutes.

Treatment of thromboembolism is a difficult task. Sometimes they simply do not even have time to carry out any therapeutic measures, so the main thing is prevention. To do this, the following activities are carried out in the postoperative period. Anticoagulants (heparin, fraxiparin) are prescribed in a prophylactic dose, antiplatelet agents and other agents that improve the rheological properties of the blood, correct the water and electrolyte balance (with a tendency to hemodilution), bandage the limbs with an elastic bandage, recommend patients to constantly move their feet, and if possible as quickly as possible allowed to walk. If venous thrombosis develops, it is treated, and when a floating thrombus is diagnosed, patients are shown implanting an anti-embolic cava filter into the inferior vena cava

Complications from the respiratory system in the postoperative period may be due to a violation of the central regulation of respiration, airway patency, and a decrease in the functioning surface of the lungs. As a result, the patient may develop acute respiratory failure.

Violations of the central regulation of respiration develop as a result of inhibition of the respiratory center by the action of anesthetics and narcotic drugs, muscle relaxants. This is manifested by hypoventilation (rare shallow breathing, retraction of the tongue) up to respiratory arrest. In such cases, prolonged artificial ventilation of the lungs is used until the normal activity of the respiratory center is restored. You can use respiratory analeptics (nalorfin, bimegrid, cordiamine).

Airway obstruction. In the first hours it may be due to vomiting, regurgitation, bronchospasm. Therefore, patients who have not left the state of narcotic sleep should be under the close supervision of medical staff. In later periods, the obstruction of patency is due to the development of inflammatory changes in the trachea, bronchi, as well as obstruction with sputum or blood. In order to prevent these complications, patients are prescribed inhalations, and if necessary, the bronchial tree is sanitized using suction and bronchoscopes.

The decrease in the functional surface of the lungs is due to the development of pneumonia, atelectasis, as well as circulatory disorders as a result of pulmonary embolism. Atelectasis (collapse of the alveoli) develops when the lumen of the bronchus is closed with sputum, blood, compression of the lung by exudate, blood, air. Bronchoscopy is used to treat atelectasis. In cases of compression of the lung with blood, air, exudate, the pleural cavity is punctured and air or fluid is removed from it.

Postoperative pneumonia in the postoperative period develops as a result of a long forced position of the patient during surgery, impaired lung ventilation during anesthesia, limitation of chest excursion due to pain. A certain role is played by the activation of microflora and a decrease in the body's defense reactions.

Pulmonary infarction develops as a result of impaired blood circulation in the lungs with pulmonary embolism. Prevention methods are discussed above.

Most often, complications develop in persons who had a pathology of the respiratory system before the operation. Therefore, prevention and treatment of respiratory failure should begin in the preoperative period. In the postoperative period, effective methods of prevention are the correct position of the patient in bed, adequate pain relief, early activation, breathing exercises, chest massage, balloon inflation, inhalation, prophylactic antibiotics. These activities contribute to the disclosure of collapsed alveoli, improve the drainage function of the bronchi.

Treatment of pneumonia, bronchitis is carried out according to the principles set forth in the course of therapy.

Complications from the urinary system Complications from the urinary system include: acute renal failure, acute inflammatory diseases, impaired urination.

Acute renal failure develops as a result of circulatory disorders (hypovolemia, shock), water and electrolyte disorders, intoxication. Impaired renal function is due to hypoxia of the parenchyma, leading to necrosis of the epithelium of the renal tubules. Symptoms of developing acute renal failure are: a decrease in diuresis up to anuria, a violation of the concentration ability of the kidneys, an increase in urea in the blood, and disorders of water and electrolyte balance. There is dryness of the skin, tongue, pronounced thirst, the temperature of the skin rises, its turgor decreases, the eyeballs become soft, the central venous pressure decreases, the pulse quickens. For the treatment of acute renal failure, complex conservative treatment is used, aimed at eliminating the factors that caused it, stimulating kidney function, and correcting metabolic disorders. In severe cases, it is necessary to use the device "artificial kidney".

Inflammatory diseases (pyelonephritis, cystitis, urethritis, etc.) are most often caused by an exacerbation of a chronic process, as a result of activation of the microflora and a decrease in the protective reactions of the body, and the development of urinary retention, often observed after surgery, contributes to this. They can also develop in cases of violation of the rules of asepsis when performing bladder catherization. Antibacterial drugs are prescribed for treatment.

Urinary retention (ischuria) is quite common after surgery. Most often, it is of a neuro-reflex nature and is due to the fact that the patient is not used to urinating lying down. It may also occur due to a reaction to pain in the wound and reflex tension of the abdominal muscles. Clinically, urinary retention is manifested by the urge to urinate with a full bladder. The bladder overflows with urine, and urination does not occur or occurs in small portions (paradoxical ischuria). The patient complains of pain above the pubis, an overflowing bladder is determined by percussion. In such situations, if there are no contraindications, the patient can be allowed to urinate while sitting or standing, prescribe painkillers, antispasmodics, put a warm heating pad on the suprapubic area, try to stimulate urination with the sound of flowing water. In case of ineffectiveness of the above measures, bladder catheterization is performed. If the patient cannot urinate on his own, the catheter should be used to urinate at least once every 12 hours. Sometimes, in order to avoid multiple catheterizations, patients are left with a permanent catheter for several days. This need arises in patients with prostate adenoma.

Complications from the digestive organs. In the postoperative period, complications from the organs of the gastrointestinal tract of a functional nature may develop. These include the development of dynamic obstruction (intestinal paresis), atony of the stomach. Intestinal paresis disrupts the processes of digestion, in addition, it causes an increase in intra-abdominal pressure, which leads to a high standing of the diaphragm, impaired lung ventilation and heart activity. Fluid accumulates in a non-functioning intestine, which leads to its redistribution in the body, which in turn causes water and electrolyte disorders. Toxic substances are absorbed from the intestinal lumen.

Clinically, paresis is manifested by belching, regurgitation, vomiting, bloating, and non-excretion of gases.

To eliminate these phenomena, patients aspirate the contents from the stomach, put gas tubes, perform cleansing and hypertonic enemas. With deep paresis, chemical or electrical stimulation of the intestine is carried out, drugs that stimulate peristalsis are prescribed (perinorm, cerucal, etc.). It should be noted that in some cases it is necessary to undertake long-term treatment in order to achieve the elimination of intestinal paresis. Therefore, the actions of the surgeon during the operation should be aimed at preventing postoperative paresis. To do this, it is necessary to carefully treat the tissues, avoid infection of the abdominal cavity, carry out thorough hemostasis, and when performing an operation directly on the small intestine, perform a novocaine blockade of the mesenteric root. An effective method of prevention, especially in traumatic operations, is epidural anesthesia, both during surgery and in the postoperative period.

Atony of the stomach (stump) develops after surgical interventions on it (selective proximal vagotomy, resection). It is caused by a violation of innervation and, as a result, motor skills. Clinically manifested by hiccups, vomiting, heaviness in the epigastrium. Treatment is aimed at restoring the normal tone of the gastric wall. They periodically aspirate the contents, sometimes leave a permanent nasogastric tube, prescribe drugs that stimulate motor skills (cerucal, perinorm). In such cases, electrical stimulation can be carried out using Endoton devices.

Faced with the clinical manifestations of impaired bowel function, one should always remember that they can be symptoms of more formidable complications (postoperative peritonitis, intestinal obstruction). Therefore, before deciding on therapeutic measures, it is necessary to exclude pathological processes in the abdominal cavity and only after that begin treatment aimed at normalizing the function of the stomach and intestines.

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Postoperative period I Postoperative period

Disorders of the central mechanisms of regulation of respiration, which occur, as a rule, as a result of depression of the respiratory center under the influence of anesthetic and narcotic drugs used during surgery, can lead to acute respiratory disorders in the nearest P. of the item. The intensive therapy of acute respiratory disorders of central origin is based on artificial lung ventilation (ALV), the methods and options of which depend on the nature and severity of respiratory disorders.

Violations of the peripheral mechanisms of respiratory 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 respiratory disorders of the peripheral type, which consists in maintaining gas exchange by mask ventilation or re-intubation of the trachea and transfer to mechanical ventilation until complete restoration of muscle tone and adequate spontaneous breathing.

Severe respiratory distress may be due to pulmonary atelectasis, pneumonia, and pulmonary embolism. With the appearance of clinical signs of atelectasis and radiological 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 a ventilator. The complex of therapeutic measures includes the use of aerosol forms of bronchodilators, percussion and vibration of the chest, postural.

One of the serious problems of intensive care of patients with respiratory failure is the question of the need for mechanical ventilation. Reference points in its solution are the respiratory rate of more than 35 in 1 min, Shtange 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 below 30 mm rt. st. . vital lung capacity - less than 40-50%. The determining criterion for the use of mechanical ventilation in the treatment of respiratory failure is the increase in respiratory failure and the lack of 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 diverse, but the main ones are unreplenished during surgery or ongoing internal or external. The most accurate assessment of the state of hemodynamics gives a comparison of central venous pressure (CVP) with pulse and, prevention of postoperative hypovolemia is the full compensation of blood loss and circulating blood volume (CBV), adequate pain relief during surgery, thorough surgical intervention, ensuring adequate gas exchange and correction of disorders metabolism, both during surgery and in early P. p. The leading place in the intensive care of hypovolemia is occupied by, 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 in P. of the item cases of anaphylactic and septic shock became frequent. in anaphylactic shock (Anaphylactic shock) consists in intubation and mechanical ventilation, the use of adrenaline, glucocorticoids, calcium preparations, antihistamines. Heart failure is a consequence of cardiac (, angina pectoris, operations on) and extracardiac (, myocardial toxicoseptic) causes. Its therapy is aimed at eliminating pathogenetic factors and includes the use of cardiotonic agents, coronary drugs, anticoagulants, electrical impulse pacing, and assisted artificial circulation. In cardiac arrest resort to cardiopulmonary resuscitation.

The course of P. p. to a certain extent depends on the nature of the surgical intervention, the existing intraoperative complications, the presence of concomitant diseases, and the age of the patient. With a favorable course, P. p. in the first 2-3 days can be increased to 38 °, and the difference between evening and morning temperatures does not exceed 0.5-0.6 ° Pain gradually subsides by the 3rd day. The pulse rate in the first 2-3 days remains within 80-90 beats per 1 min, CVP and BP are at the level of preoperative values, on 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 ones can be heard, disappearing after coughing up sputum. skin and visible mucous membranes does not undergo any changes compared to their color before surgery. remains moist, may be overlaid with a whitish coating. corresponds to 40-50 ml/h There are no pathological changes in the urine. After operations on the abdominal organs remains symmetrical, bowel sounds are sluggish on the 1-3rd day. Moderate is resolved on the 3-4th day of P. p. 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, a moderate wound remains on palpation. and hematocrit (if there was no bleeding during surgery) remain at baseline. On the 1-3rd day, moderate leukocytosis can be observed with a slight shift of the formula to the left, relative, an increase in ESR. In the first 1-3 days there is a slight hyperglycemia, but sugar in the urine is not determined. A slight decrease in the level of albumin-globulin coefficient is possible.

In elderly and senile people in early P., the item is 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 reduce the time of the patient's stay in the hospital, the outpatient surgeon has to observe and treat some groups of patients already from the 3rd-6th day after the operation. For the general surgeon on an outpatient basis, the main complications of P. p., which can occur after operations on the abdominal cavity and chest, are most important. There are many risk factors for the development of postoperative complications:, concomitant diseases, long-term, duration of surgery, 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. ) from the first day after the operation indicate an unfavorable course of P. p. hectic from the 7-12th day indicates 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 grow. Severe pain from the first day of P. p. should also alert the doctor. The reasons for the increase or resumption of pain in the area of ​​operation are diverse: from superficial suppuration to intra-abdominal catastrophe.

Severe tachycardia from the first hours of P. p. or its sudden appearance on the 3-8th 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 disorders are diverse: heart disease, bleeding, etc.

The appearance of shortness of breath is always alarming, especially on the 3-6th day of P. p. The causes of shortness of breath in P. p. 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 yellowness of the skin and often indicates severe purulent complications and developing liver failure. Oligoanuria and indicate a severe 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 indicate the inhibition of erythropoiesis of toxic origin. , lymphopenia or the occurrence of leukocytosis again after normalization of the blood count is characteristic of inflammatory complications. A number of biochemical blood parameters may indicate operational complications. So, an increase in the level of blood and urine is observed with postoperative pancreatitis (but it is also possible with mumps, 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. The 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 already on the 2-3rd day. With suppuration of the surgical wound, the body temperature, as a rule, rises again and is usually of a character. Moderate leukocytosis is noted, with anaerobic non-clostridial flora - pronounced lymphopenia, toxic granularity of neutrophils. Diuresis, as a rule, is not disturbed.

Local signs of suppuration of the wound are swelling in the area of ​​​​sutures, 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, however, can be large.

Treatment consists in dilution of the edges of the wound, sanitation and drainage of it, dressings with antiseptics. When granulations appear, ointments are prescribed, secondary sutures are applied. After a thorough excision of purulent-necrotic tissues, suturing with drainage and further flow-drip washing of the wound with various antiseptics with constant active aspiration is possible. For extensive wounds, surgical necrectomy (complete or partial) is supplemented with laser, x-ray or ultrasound treatment of the wound surface, followed by the use of aseptic dressings and secondary sutures.

If suppuration of a postoperative wound is detected when a patient visits a surgeon in a clinic, then with superficial suppuration in the subcutaneous tissue, outpatient treatment is possible. If suppuration in deep-lying tissues is suspected, hospitalization in the purulent department is necessary, because in these cases, more complex surgical intervention is required.

Currently, the danger of clostridial and non-clostridial infection is becoming increasingly important in P. (see Anaerobic infection), in which signs of shock, high body temperature, hemolysis, and increasing, subcutaneous crepitus can be detected. At the slightest suspicion of an anaerobic infection, urgent hospitalization is indicated. In the hospital, the wound is immediately opened wide, 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, located under the skin, under the aponeurosis or intermuscularly. Deep hematomas are also possible in the retroperitoneal tissue, in the pelvic and other areas. At the same time, the patient is worried about pain in the area of ​​the operation, upon examination of which swelling is noted, and after 2-3 days - in the skin around the wound. Small hematomas may not be clinically manifested. 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 using any measures to prevent 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 benign, but worsens when states of obscuration of consciousness are replaced by intermediate syndromes.

Thrombophlebitis most often occurs in the superficial vein system, which was used during or after surgery for infusion therapy. As a rule, the superficial veins of the upper extremities are not dangerous and stop after local treatment, including immobilization of the limb, the use 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, diseases of the vessels, lower extremities. In these cases, limbs are bandaged, and measures are taken to combat anemia, hypoproteinemia and hypovolemia, and normalize arterial and venous circulation. In order to prevent thrombus formation in P. p., along with an 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. p. - pulmonary arteries. More common is the pulmonary artery (Pulmonary embolism), less often fat and air embolism. The volume of intensive care for pulmonary embolism depends on the nature of the complication. With a fulminant form, resuscitation is necessary (trachea, mechanical ventilation, closed). Under appropriate conditions, emergency thromboembolectomy with obligatory massage of both lungs or catheterization embolectomy followed by anticoagulant therapy against the background of mechanical ventilation is possible. With partial embolism of the branches of the pulmonary arteries with a gradually developing clinical picture, fibrinolytic and anticoagulant therapy are indicated.

The clinical picture of postoperative peritonitis is diverse: abdominal pain, tachycardia, gastrointestinal tract, not stopped 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 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 major operations on the abdominal organs, especially in elderly and senile patients. For the purpose of its prevention, inhalations, banks, 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 the diagnosis, the leading place is occupied by the chest.

Outpatient management of patients after neurosurgical operations. Patients after neurosurgical operations usually need long-term outpatient observation and treatment for the purpose of psychological, social and labor rehabilitation. After surgery for a craniocerebral (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 vegetative syndromes, the development of cicatricial adhesions and atrophic processes, hemodynamic and liquorodynamic disorders, inflammatory reactions, and immune failure are observed.

After removal of intracranial hematomas, hygromas, foci of crushing of the brain, etc. conduct anticonvulsant therapy under the control of electroencephalography (Electroencephalography). In order to prevent epileptic seizures that develop after a severe traumatic brain injury, approximately 1/3 of patients are prescribed drugs containing phenobarbital (pagluferal = 1, 2, 3, gluferal, etc.) for 1-2 years. In case of epileptic seizures resulting from a traumatic brain injury, therapy is selected individually, taking into account the nature and frequency of epileptic paroxysms, 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 speed up recovery, vasoactive (cavinton, sermion, stugeron, teonikol, etc.) and nootropic (piracetam, encephabol, aminalon, etc.) drugs are used in alternating two-month courses (with intervals of 1-2 months) for 2- 3 years. It is advisable to supplement this basic therapy with agents that affect tissue metabolism: amino acids (cerebrolysin, glutamic acid, etc.), biogenic stimulants (aloe, etc.), enzymes (lidase, lecozyme, etc.).

According to 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. Hypothalamic (Hypothalamic syndromes)) and others, as well as focal - pyramidal (see. Paralysis), cerebellar, subcortical, etc. In case of mental disorders, the 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 observed, since after surgery often develops (, hypothyroidism, insipidus, etc.), requiring hormone replacement therapy.

After transnasosphenoidal or transcranial removal of a prolactotropic pituitary adenoma and an increase in the concentration of prolactin in men, the sexual level decreases, hypogonadism develops, in women, infertility and lactorrhoea. 3-5 months after treatment with parlodel, patients can recover full-fledged and come on (during which parlodel is not used).

With the development of panhypopituitarism in P., substitution therapy is carried out continuously for many years, tk. stopping it can lead to a sharp deterioration in the condition of patients and even death. With hypocorticism, ACTH is prescribed; with hypothyroidism, they are used. In diabetes insipidus, the use of adiurecrin is mandatory. Replacement therapy for hypogonadism is not always used; in this case, consultation with a neurosurgeon is necessary.

After discharge from the hospital, patients operated on for benign extracerebral tumors (meningiomas, neurinomas) are prescribed therapy that accelerates the normalization of brain functions (vasoactive, metabolic, vitamin preparations, exercise therapy). In order to prevent possible epileptic seizures, small doses of anticonvulsants will be exchanged for a long time (usually). To resolve the syndrome of intracranial hypertension often remaining 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.).

For intracerebral tumors, taking into account the degree of their malignancy and the volume of surgical intervention, outpatient treatment according to individual indications includes courses of radiation therapy, hormonal, immune and other drugs in various combinations.

In 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 the cerebral vessels (eufillin, no-shpa, papaverine, etc.), microcirculation (trental, complamin, sermion, cavinton), brain (piracetam, encephabol, etc.). Similar therapy is indicated for extra-intracranial anastomoses. With severe epileptic readiness, according to clinical data and the results of electroencephalography, preventive anticonvulsant therapy is carried out.

Patients who have undergone stereotaxic surgery for parkinsonism are often additionally indicated for long-term neurotransmitter therapy (levodopa, nakom, madopar, etc.), as well as anticholinergic drugs (cyclodol and its analogues, tropacin, etc.).

After operations on the spinal cord, a long-term, often long-term treatment is carried out, taking into account the nature, level and severity of the lesion, the radicalness of the surgical intervention and the leading clinical syndromes. Assign, aimed at improving blood circulation, metabolism and trophism of the spinal cord. With gross destruction of the substance of the spinal cord and its persistent edema, proteolysis inhibitors (kontrykal, Gordox, etc.) and dehydrating agents () are used. They pay attention to the prevention and treatment of trophic disorders, especially bedsores (Decubituses). Considering the high incidence of chronic sepsis in severe spinal cord injuries, on an outpatient basis, there may be a course of antibacterial and antiseptic therapy.

Many patients who have undergone surgery on the spinal cord require correction of dysfunction of the pelvic organs. Often long-term use of bladder catheterization or permanent, as well as tidal systems. It is necessary to strictly observe measures to prevent outbreaks of uroinfection (careful toilet of the genital organs, washing 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 plegia, anti-spastic drugs (baclofen, mydocalm, 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 (including with the use of implanted electrodes) is successfully used, which accelerates reparative processes and restores the conduction of the spinal cord.

After operations on the spinal and cranial nerves and plexuses (, stapling, etc.), many months or many years of rehabilitation treatment is carried out on an outpatient basis, preferably under the control of thermal imaging. In various combinations, drugs are used that improve (prozerin, galantamine, oxazil, dibazol, etc.) and the trophism of damaged peripheral nerves (groups B, E, aloe, FiBS, vitreous, anabolic agents, etc.). With pronounced cicatricial processes, lidase is used, etc. Various options for electrical stimulation, physiotherapy and balneotherapy, exercise therapy, massage, and early labor rehabilitation are widely used.

Outpatient management of patients after eye surgery should ensure the continuity of treatment in accordance with the recommendations of the surgeon. The first time the patient visits an ophthalmologist in the first week after discharge from the hospital. Therapeutic tactics in relation to patients who underwent surgery on the appendages of the eye - after removing the sutures from the skin of the eyelids and conjunctiva, is to monitor the surgical wound. After abdominal operations on the eyeball, he actively observes the patient, i.e. appoints the terms of repeated examinations and controls the correctness of the implementation of medical procedures.

After antiglaucomatous operations with a fistulosing effect and a pronounced filtration cushion in early P. p., on an outpatient basis, the Syndrome of the shallow anterior chamber may develop with hypotension due to cilichoroidal detachment, diagnosed by ophthalmic illumination or by ultrasound echography, if there are significant changes in the optical media of the eye or a very narrow non-expandable eye. At the same time, cilichoroidal detachment is accompanied by sluggish iridocyclitis, which can lead to the formation of posterior synechia, blockade of the internal surgical fistula by the root of the iris or processes of the ciliary body with a secondary increase in intraocular pressure. may lead to cataract progression or swelling. In this regard, outpatient therapeutic tactics should be aimed at reducing subconjunctival filtration by applying a pressure bandage with a dense cotton pad on the upper eyelid and treating Iridocyclitis a. Small anterior chamber syndrome may develop after intracapsular cataract extraction, accompanied by an increase in intraocular pressure as a result of difficulty in the transfer of moisture from the posterior chamber to the anterior chamber. The tactics of an outpatient ophthalmologist 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 is identical (in contrast to pupillary pseudophakia). When indicated (), it is possible to achieve maximum mydriasis without the risk of dislocation and dislocation of the artificial lens from the capsular pockets. After cataract extraction, supramid sutures should not be removed for 3 months. During this time, a smooth operating room is formed, tissue edema disappears, decreases or disappears completely. Continuous at the same time do not remove, it resolves within several years. Interrupted sutures, if their ends are not tucked in, are removed after 3 months. The indication for suture removal is the presence of astigmatism 2.5-3.0 diopter and more. After removing the sutures, the patient is prescribed for 2-3 days instillation into the eye of a 20% solution of sodium sulfacyl 3 times a day or other drugs, depending on tolerance. A 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 supervised by an outpatient eye doctor.

Among the complications in remote P., a graft or an infectious process, most often a herpes virus infection, may develop, which is accompanied by graft edema, iridocyclitis, and neovascularization.

Examinations of patients after surgery for retinal detachment are carried out on an outpatient basis after 2 weeks, 3 months, 6 months, 1 year, and when complaints of photopsy, visual impairment appear. In case of recurrence of retinal detachment, the patient is sent to. The same tactics of managing patients is observed after vitreectomy for hemophthalmos. Patients who have undergone surgery for retinal detachment and vitreectomy should be warned about the observance of a special regimen that excludes low head tilts, weight lifting; colds accompanied by coughing, acute breath holding, 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 abdominal organs, P. p. may 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. For fistulas of the stomach and esophagus, the release of food masses, saliva and gastric juice is characteristic, for fistulas of the small intestine - liquid or mushy intestinal chyme, depending on the level of the location of the fistula (high or low small intestine). Detachable colonic fistula -. From the fistulas of the rectum, mucopurulent is released, from the fistulas of the gallbladder or bile ducts - bile, from the fistulas of the pancreas - light transparent pancreatic. The amount of discharge from fistulas varies depending on the nature of food, time of day and other reasons, reaching 1.5 l and more. With long-term external fistulas, their discharge macerates the skin.

Observation of patients with fistulas of the gastrointestinal tract includes an assessment of their general condition (, 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, and 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 soapy water, 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 area of ​​the fistula, cellulose-based elastic adhesive films, soft pads, plasters and activated carbon filters are used. These devices prevent skin and uncontrolled release of gases from the fistula. An important condition for care is the discharge from the fistula in order to avoid contact of the discharge with the skin, underwear and bed linen. For this purpose, a number of devices are used for draining the fistula with the discharge of discharge from it (bile, pancreatic juice, urine into a bottle, feces into a colostomy bag). From artificial external biliary fistulas, more than 0.5 l bile, which is filtered through several layers of gauze, diluted with any liquid and given to the patient during a meal. Otherwise, severe violations of homeostasis are possible. Drainages introduced into the bile ducts must be washed daily (with saline or furatsilin) ​​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 colostomy) formed for therapeutic purposes, self-adhesive or attached to a special belt colostomy bags 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 condition of the surrounding tissues).

Of great importance is enteral (probe) through in order to meet the needs of the patient's body in plastic and energy substances. 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 Tube nutrition, parenteral nutrition).

In connection with the exclusion of some parts of the digestive tract from the processes of digestion, it is necessary to draw up a balanced diet, which assumes an average consumption of 80-100 G protein, 80-100 G fat, 400-500 G carbohydrates and the corresponding amount of vitamins, macro- and microelements. Specially designed enteral mixtures (enpitas), canned meat and vegetable diets are used.

Enteral nutrition is carried out through a nasogastric tube, or a tube inserted through a gastrostomy or jejunostomy. For these purposes, 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 section of the jejunum. Enteral nutrition can also be carried out through a tube temporarily inserted into the lumen of the organ (stomach, small intestine) and removed after feeding. Probe nutrition can be carried out by the fractional method or drip. The intensity of intake of food mixtures should be determined taking into account the condition of the patient and the frequency of stools. When conducting 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-traumatological operations should be carried out taking into account the postoperative management of patients in a hospital and depends on the nature of the disease or the musculoskeletal system, about 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 started in a hospital setting.

After orthopedic-traumatological operations, patients can be discharged from the hospital without external immobilization, in plaster casts of various types (see Plaster technique), a distraction-compression device (Distraction-compression apparatus) can be applied to the limbs, patients can use various orthopedic products after surgery (tire-sleeve devices, arch support insoles, 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 condition of the postoperative scar so as not to miss superficial or deep suppuration. It may be due to the formation of late hematomas due to unstable fixation of fragments with metal structures (see Osteosynthesis), loosening of parts of the endoprosthesis with insufficiently strong fixation in it (see Endoprosthetics). The causes of late suppuration in the area of ​​the postoperative scar can also be rejection of the allograft due to immunological incompatibility (see Bone grafting), endogenous with damage to the area of ​​operation by the hematogenous or lymphogenous route, ligature fistulas. Late suppuration may be accompanied by arterial or venous bleeding caused by purulent fusion (arrosion) of the blood vessel, as well as pressure ulcers of the vessel wall under pressure from the part of the metal structure protruding from the bone during submersible osteosynthesis or by the pin of the compression-distraction apparatus. With late suppuration and bleeding, patients need emergency hospitalization.

On an outpatient basis, rehabilitation treatment, begun in a hospital, continues, which consists in physiotherapy exercises for joints free from immobilization (see Therapeutic physical culture), plaster and ideomotor gymnastics. The latter consists in contraction and relaxation of the muscles of the limb, an immobilized 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 tissue regeneration processes in the area of ​​operation. Physiotherapeutic treatment continues, aimed at stimulating muscles, improving microcirculation in the surgical area, preventing neurodystrophic syndromes, stimulating callus formation, and preventing stiffness in the joints. The complex of rehabilitation treatment on an outpatient basis also includes, aimed at restoring the movements in the limbs necessary for servicing oneself at home (stairs, using public transport), as well as general and professional working capacity. in P. p. is usually not used, with the exception of hydrokinesitherapy, which is especially effective in restoring movements after operations on the joints.

After operations on the spine (without damage to the spinal cord), 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 corsets. During sleep and rest, patients should use a hard bed. On an outpatient basis, physiotherapy exercises aimed at strengthening the back muscles, manual and underwater massage, continue. Patients must strictly comply with the orthopedic regimen prescribed in the hospital, which consists in unloading the spine.

After surgery on the bones of the limbs and pelvis, the doctor on an outpatient basis systematically monitors the condition of patients and the timeliness of removing the plaster cast, if an external one was used after the operation, conducts the areas of operation 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 internal osteosynthesis, especially during intramedullary or transosseous insertion of a pin or screw, in order to timely identify possible migration, which is detected by X-ray examination. With the migration of metal structures with the threat of skin perforation, patients need hospitalization.

If a device for external transosseous osteosynthesis is applied, the task of the outpatient doctor is to monitor the condition of the skin in the area of ​​​​the introduction of the spokes, regular and timely, to monitor the stable fastening of the device structures. If necessary, additional fastening is carried out, individual nodes of the apparatus are pulled up, and with the onset of an inflammatory process in the region of the spokes, soft tissues are chipped with antibiotic solutions. With deep suppuration of soft tissues, patients need to be sent to a hospital to remove the needle in the area of ​​​​suppuration and insert a new needle in the unaffected area, if necessary, to remount the device. With complete consolidation of bone fragments after a fracture or orthopedic surgery, the device is removed on an outpatient basis.

After orthopedic-traumatological operations on the joints on an outpatient basis, physiotherapy exercises, hydrocolonotherapy, physiotherapy aimed at restoring mobility are carried out. When using transarticular osteosynthesis for fixing fragments in cases of intra-articular fractures, a fixing pin (or pins) is removed, the ends of which are usually located above the skin. This manipulation is carried out in time, due to the nature of the damage to the joint. After operations on the knee joint, synovitis is often observed (see Synovial bags), and therefore it may be necessary for the joint to be evacuated from the synovial fluid and administered according to the indications of drugs, incl. corticosteroids. In the formation of postoperative joint contractures, along with local treatment, a general therapy is prescribed aimed at the prevention of cicatricial processes, paraarticular ossification, normalization of the intraarticular environment, regeneration of hyaline cartilage (injections of the vitreous body, aloe, FiBS, lidase, rumalon, oral administration of non-steroidal anti-inflammatory drugs - indomethacin, brufen, voltaren, etc.). After removal of 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, physiotherapy 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 surgical intervention. in many urological diseases, it is an integral part of a comprehensive treatment aimed at preventing the recurrence of the disease and rehabilitation. At the same time, the continuity of inpatient and outpatient treatment is important.

To prevent exacerbations of the inflammatory process in the organs of the genitourinary system (pyelonephritis, cystitis, prostatitis, epididymo-orchitis, urethritis), a continuous sequential intake of antibacterial and anti-inflammatory drugs is indicated 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 secretion, seeding of ejaculate. When the infection is resistant to antibacterial drugs, multivitamins and nonspecific immunostimulants are used to increase the reactivity of the body.

In case of urolithiasis caused by a violation of salt metabolism or a chronic inflammatory process, after the removal of stones and the restoration of the passage of urine, correction of metabolic disorders is necessary.

After reconstructive operations on the urinary tract (plasty of the pelvic-ureteral segment, ureter, bladder and urethra), the main task of the immediate and long-term 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 that promote softening and resorption of scar tissue (lidase) and physiotherapy. The appearance of clinical signs of impaired urinary outflow after reconstructive operations may indicate the development of a stricture in the area of ​​the anastomosis. For its timely detection, regular follow-up examinations are necessary, including radiological and ultrasound methods. With a slight degree of narrowing of the urethra, it is possible to carry out the urethra and prescribe the above complex of therapeutic measures. If a patient has chronic renal failure (renal failure) in remote P., it is necessary to monitor its course and the results of treatment by regularly examining biochemical blood parameters, drug correction of hyperazotemia and water and electrolyte disorders.

After palliative surgery and ensuring the outflow of urine through drainage (nephrostomy, pyelostomy, ureterostomy, cystostomy, urethral catheter), their function must be carefully monitored. Regular change of drains and washing of the drained organ with antiseptic solutions are important factors in the prevention of inflammatory complications in 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 characteristics of the course of P. p. 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 general strengthening 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 IU, hydrocortisone hemisuccinate 0.025 G, lidases 64 UE in 50 ml 0.25% solution of novocaine) in combination with ultrasound therapy, vibration massage, zinc, further prescribed spa treatment. For the prevention of adhesions after operations for inflammatory formations, zinc electrophoresis is indicated, in a low frequency mode (50 Hz). To prevent the recurrence of endometriosis, electrophoresis of zinc, iodine is performed, sinusoidal modulating currents, pulsed ultrasound are prescribed. Procedures are appointed 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 due to fibroids, patients remain disabled for an average of 30-40 days, after extirpation of the uterus - 40-60 days. Then they conduct an examination of working capacity and give recommendations, if necessary, excluding contact with occupational hazards (vibration, exposure to chemicals, etc.). Patients remain in the dispensary for 1-2 years or more.

Outpatient treatment after obstetric surgery 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,) puerperas 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 characteristics of the course of the postoperative (postpartum) period. Before being removed from the dispensary for pregnancy (i.e., by the 70th day), they are carried out. If the cause of operative delivery was extragenital, an examination by a therapist is mandatory, according to indications - other specialists, a clinical and laboratory examination. A complex of rehabilitation measures is performed, which includes restorative procedures, physiotherapy, taking into account the nature of somatic, obstetric pathology, the characteristics of the course of P. p. In case of purulent-inflammatory complications, zinc electrophoresis is prescribed with diadynamic low-frequency currents, in a pulsed mode; puerperas who underwent with concomitant kidney pathology are indicated with an impact on 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, the appointment of contraception is mandatory. 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, part 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.

II Postoperative period

the period of treatment of the patient from 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 treatment of the patient from the end of the surgical operation to its fully determined outcome ... Big Medical Dictionary

Occurring after surgery; this term is used in relation to the condition of the patient or to his treatment carried out during this period.