Post-operative Complications

Question 1

fever within 24 hours post operation think?

Answer 1

• necrotizing wound infections (RARE)- Think clostridia or streptococcus
• pre-existing infection (i.e, ruptured appendicitis causing posst op fevers)

Question 2

fever within 24-72hrs think?

Answer 2

• UTI- usually catheter associated, goal to remove catheters by 48hrs post op per CMS guidelines
• Pneumonia- dx with CXR treat HCAP. be on alert for aspiration pneumonia
• IV related complications- look for physical signs of vein irritation

Question 3

• may present with fever, leukocytosis, increased secretions and pulmonary infiltrates on chest radiographs
• hypoxemia may develop, or the patient may require more supplemental oxygen to maintain the same oxyhemoglobin saturation
• respiratory distress, dyspnea, tachypnea, small tidal volumes and hypercapnia may also occur
• treat as HCAP

Answer 3

Post OP pneumonia

**postoperative pneumonia tends to occur wihtin five postoperative days*

Question 4

Fever 72hrs–> 1 week think?

Answer 4

• UTI (after catheter removed)
• pneumonia
• surgical site infection
• deep (surgical space) abscess
• anastomatic leak
• prosthetic leak
• prosthetic infection
• acalculous cholecystitis
• parotitis
• c-diff diarrhea
• line infection

also think DVT/PE, drug fever

Question 5

• s/sx: unilateral extremity pain, edema, erythema or warmth. Calf tenderness (Homan’s sign)
• dx: venous doppler
• TX: anticoagulation ASAP, consider IVC filter depending on size of clost
• keep alert for surgical bleeding (you are anticoagulating a patient who just had surgery)

Answer 5

DVT

Question 6

• inability to fully expand the lungs after surgery; collapse of alveoli
• one ofthe most common post op issues, particularly after abdominal and thorcoabdominal surgery
• asymptomatic or sx of increaed work of breathing and hypoxemia
• becomes most severe during the second postoperative night and continues thorugh the fourth postoperative night

Answer 6

atelectasis

Question 7

• typical orgnaisms: skin flora (staph), or flora of site entered
• usually appearing 3-5 days post op
• diagnosis: clincal exam (wound erythema, fluctuance, odor, purulent drainage
• tx: usually bedside I & D (need to assess the depth of infection) - deep tissue involvement requires ongoing wound care and often prolonged antibiotic therapy

Answer 7

wound infection

Question 8

• dx: usual CT scan targeted at surgical site
• tx: dependent on surgical site and patient condition. Could involve bring back to OR, I&D, IR drain placement
• tx is highly institution and surgeon dependent

Answer 8

Deep surgical site infection

Question 9

• occurs POD 5-7
• intestinal anastomosis breaks down spilling enteric contents into the abdominal cavity
• causes peritonitis and sepsis (fever, leukocytosis, abdominal pain, hypotension, tachycardia, cardiac arrhythmias)
• requires emergent re-operation to fix the leak
• SICK PATIENT- significant associated mortality

Answer 9

Anastomotic Leak

Question 10

• any type of infection affecting prosthetic implant (joint, spine, surgical mesh, vascular graft)
• can require suppressive antibiotics versus return to OR for washout and removal of prosthetic implant with subsequent antibiotic therapy
• high associated morbidity/ mortality

Answer 10

prosthetic infection

Question 11

inflammation/infefction of the parotid gland from prolonged NPO/dry mouth. Associated with sialolithiasis.

• tx: antibiotics plus sour lozenges to stimulate saliva

Answer 11

Parotitis

Question 12

• acute gallbladder infection from prolonged NPO status/ acute illness
• requires cholecystectomy or cholecystomy tube

Answer 12

acalculous cholecystitis

Question 13

post op causes of hypotension?

Answer 13

• hypovolemia d/t bleeding or dehydration
• sepsis d/t underlying problem (IE perforated viscous)
• cardiogenic shock d/t post op MI, fluid overload, arrhythmias, tamponade
• medication effect- anesthesia, opioids, benzos, epidural analgesia

Question 14

Causes of oliguria

Answer 14

• Prerenal: decreased renal blood flow d/t decreased blood volume (dehydration), decreased cardiac output. Usually modest oliguria and normal creatinine
• renal: occurs from prolonged or uncorrected prerenal OR nephrotoxic meds/contrast dye. THInk ATN
• Postrenal: think obstructive uropathy or ureteral injury

Question 15

• inability to completely void bladder volume
• risk factors: middle aged or older men, BPH, instrumented uretheral sphincter, perianal or rectal surgery, narcotics or decongestants
• monitor: measure voided outuput, bladder scan (portable ultrasound) if no void > 6hr, straight cath and record residual volume
• tx: straight cath every 6hrs or sooner if uncomfortable

Answer 15

Urinary retention

Question 16

• non-mechanical (neurogenic) obstruction
• due to inflammation, manipulation, peritonitis
• distended, hypoactive BS, no flatus, abd films show dilated bowel; generally does not cause pain!!
• tx: back off an oral (can often do liquid diet or light eating despite mild ileus) if n/v-may need NG, provide IV fluids
• consider mechanical obtruction if not relieving in 3-4 days

Answer 16

Ileus