1. Post Op Complications

Question 1

List some risk factors for post-operative complications.

What does post-operative care involve?

What are some general complications of surgery?

Answer 1

Poor nutritional state (e.g. cancer), inflammatory state, organ failure, compromised immunity, vascular disease, elderly, smoking (COPD? penumonia risk), DM (bad wound healing), obesity, dementia. Bleeding (e.g. on warfarin - put on LMWH preop), antiplatelets)

Monitoring (vital signs, fluid balance), wounds, stomas, drains, monitoring blood results (FBC, WCC, plts, U+E), medication (VTE prophylaxis, abx, analgesia), nutrition, enhanced recovery, physiotherapy.

Haemorrhage, SIRS (systemic inflammatory response syndrome), VTE, wound complications and surgical site infections.

Question 2

Describe 3 different types of scores used to assess patients.

Shock can cause hypoperfusion leading to end organ damage. Briefly describe 4 main types of shock.

Answer 2

1) PARS - patient at risk score
2) MEWS - modified early warning score: resp rate, temp, systolic BP, pulse rate, AVPU score
3) NEWS - national early warning score: resp rate, O₂ sat, temp, systolic BP, pulse rate, level of consciousness, AVPU score. 5 or more linked to increased liklihood of death/admission to ICU
Allow early recognition of deteriorating patient, quantifies change in obs, empowers ward staff to call for help, early recognition reduces deaths!

• *1) Hypovolaemic** - bleeding
• *2) Cadiogenic** - MI/CCF
• *3) Obstructive** - tamponade/PE/tension pneumothorax
• *4) Distributive** - sepsis/anaphylaxis

Question 3

Distinguish between the following:

1. SIRS (systemic inflammatory response syndrome)
2. Sepsis
3. Severe sepsis
4. Septic shock

Answer 3

1) SIRS: at least 2 of these needed to meet criteria for SIRS:

• *Temp** ≥38^oC or <36^oC
• *HR** >90/min
• *Resp rate** >20/min or PaCO₂ <32mmHg
• *WWC** >12.0 x 10⁹/L or <4.0 x 10⁹/L

2) Sepsis: SIRS + infection

3) Sepsis associated with organ dysfunction, systemic hypoperfusion, or hypotension
4) Sepsis with arterial hypotension despite adequate fluid replacement. NB. 4 clases of shock with worsening blood loss, HR, resp rate, systolic BP and urine output

Question 4

What is the sepsis 6?

Case 1
61yo male, 3 days post anterior resection for large rectal tumour. Struggling with breathing. MEWS score = 5.
A: patent
B: RR-25, sats 87, chest- scattered creps at bases
C: HR 110 regular, BP 125/80
D: GCS 15, BM 7, T 37.3
E: no rashes/haemorrhage, soft abdomen, mildly tender, BS +, R calf swollen, red and tender, not wearing TEDs. No clexane (LMWH) prescribed. ABG (on 15L): pH 7.48, pO₂ 10, pCO₂ 5, lactate 1.6

How would you immediately manage this patient?

What does the ABG show?

What can you see on the ECG and CXR below?

How would this case be treated?

Answer 4

Give 3: high flow O₂, IV abx, IV fluids (challenge, tend to give cyrstalloid e.g. Hartmann’s)
Take 3: blood (culture, before abx!), blood (lactate), urine output

O₂, access, bloods (FBC - Hb, plts, WCC, U+E, troponin), ABG (resp distress status), ECG, portable CXR, call for help.

ABG: respiratory alkalosis (with metabolic compensation?). Hypoxic despite being on O₂. Hyperventing…

ECG: 120bpm - sinus tachycardia. High take off in V2

CXR: looks normal…

Definitive tx: LMWH (tx dose)
CTPA (has contrast so need to know renal function) or V/Q
Find source - USS leg vessels
If massibe PE, may need embolectomy; if small and not central just LWMH tx

Question 5

Case 2
48yo male, recent colectomy with an ileo-rectal anastomosis complicated by an anastomotic leak. He’s being treated via TPN (method of feeting that bypasses GI tract - fluids given into vein to provide most nutrients). His central line was replaced today.
A: self maintained
B: RR 24, SaO2 92% (RA), decreased air entry R on auscultation
C: HR 98, BP 145/92, warm peripheries with good urine output
D: GCS 15
E: 37.2

What can you see on his CXR?

Answer 5

• *Pneumothorax on R**.
• NB. if tracheal deviation to L = tension pneumothorax -> can lead to obstructive shock because mediastinum compressed -> occlusion of pulmonary vasculature, aortic arch etc.*

Question 6

Case 3
60yo male, gastric bypass operation 2 days ago. Sats drop to 92%.
A: self maintained
B: RR 26, sats 92% (RA), bibasal reduced air entry L>R, shallow breathing
C: HR 87, BP 140/82, adequate urine output
D: GCS 15
E: 38^oC, wound NAD
Abdomen soft but tender RUQ, BMI 40kg/m, chart review - switched from PCA to oral analgesia.

What does the CXR show?

Answer 6

Pleural effusion?

Question 7

Case 4
65yo female underwent anterior resection (rectum joined to sigmoid/further down) 4 days ago. She is now spiking temperature and confused. Abdomen is generally tender and distended. Not opened bowels post-op but has passed small amount of fluids.

A: self maintainted
B: RR 16, sats 98% (RA)
C: HR 110, BP 90/55, CRT <3s, U/O <0.5mls/kg/hr
D: GCS 15 (E4 V5 M6)

What can you deduce from the ABG and X-rays?

What is your management plan?

Answer 7

ABG: metabolic acidosis (O₂ and CO₂ ok)

X-rays: massively dilated large bowel (L), pneumoperitoneum (R) (pneumatosis in the abdominal cavity)

Management: strong abx - tazocin and gent, sliding scale (insulin), fluids b/c very acidotic.
If big anastomotic leak needs theatre -> laparotomy, wash out and remove dead bowel. If small, CT guided drain.

Question 8

Case 5
66yo male undergoes elective femoropopliteal bypass for intermittant claudication. The operation is complicated by significant blood loss. Hb dropped from 13-9.

A: self-maintained
B: RR 21, SaO₂ 91% (5L O₂), good air entry bilaterally
C: cold peripherally, CRT 5s, HR 115, BP 105/62, U/O 8ml last hour
D: GCS 15
E: T 35.9, clammy

What does the ECG show?

What are some causes of cardiogenic shock?

Answer 8

ECG: inferiorlateral STEMI?

• *Acute MI:** acute mitral regurg (papillary rupture), ventricular septal rupture, arrhythmia
• *CCF:** ischaemia, valvular disease (regurgitation, stenosis), cardiomyopathy
• *Arrhythmia** - metabolic disturbances
• *Infection** (infective endocarditis)
• *Cardiac depression in sepsis**

Question 9

Case 6
40yo female underwent sigmoid colectomy with formation of a colostomy for sigmoid cancer. She presents to the GP as she’s worried she has recurrent cancer. She noticed a large lump around the stoma site.
A: self maintained
B: RR 15, SaO₂ 100%, good air entry bilaterally
C: warm peripherally, HR 62, BP 145/68
D: GCS 15
E: T 36.9

What are some differential diagnoses for the lump?

Answer 9

Skin irritation, prolapse, retraction, obstruction, necrosis.

Question 10

Case 7
54yo obese male with diabetes undergoes open Whipple’s procedure. Day 5 post-op a sero-sanguinous fluid is noted to be discharging from the wound.

What is Whipple’s procedure?

What might be happening?

Answer 10

Whipple procedure — removes head of the pancreas, first part of duodenum, gallbladder and bile duct.

Question 11

What is Hartman’s operation?

What would you suspect if a post-op patient had abdominal pain and urea much higher than creatinine?

List some acute, intermediate and longterm post-op complications.

Answer 11

Surgical resection of rectosigmoid colon with closure of anorectal stump and formation of an end colostomy. Used to treat colon cancer or inflammation (diverticulus, proctitis etc.) [Pic]

GI bleed

Acute: haemorrgage, anaphylaxis, respiratory depression from analgesia, MI, bradycardia
Intermediate: infection (LRT/atelectasis), UTI, cellulitis/wound infection, osteomyelitis, prosthesis), ileus (non-mechanical obstruction in bowel, tx = NG tube), anastamotic leak, DVT/PE
Longterm: DVT/PE, 2^o bleeding, stoma problems (retraction, prolapse), rejection of transplanted ogans