Post-Op Care and Complications

Question 1

post-operative care and complications

Answer 1

• LOSS OF BLOOD, TAKE BACK, ATELECTASIS, HYPOTENSION
• Rounds: happen every day early in the morning for each patient that is admitted
• Ex) if you did a mastectomy on the gen surg side and then reconstruction on plastic surg side, then both of those teams would round together

Question 2

wound complications: cellulitis, subcutanous abscess

Answer 2

• šCellulitis
  
  • šTissue center with blood supply
  • šWill resolve with antibiotics
• šSubcutaneous abscess
  
  • šNecrotic center without blood supply
  • šPus
  • šWill not heal unless pus is drained
• Cellulitis is on the top and subcut abscess is on the bottom
• The subcut abscess wont heal unless the pus is drained
• One of the complications that the pt is signing on to is these two – any time you cut skin you risk infection
• Wound cultures will be sent off to microbiology
• SSTI MCC is staph and strep

Question 3

wound complications: seroma

Answer 3

• šSeroma
  
  • šLymphatic fluid with liquefied fat under incision
  • šConcern in breast surgery/ventral hernia repairs/Axillary and groin dissection
  • šEdema
  • šClear or yellow liquid from incision
  • šNo erythema or acute pain
• šPrevention
  
  • šClose subcutaneous layers to avoid dead space
  • šUse drains and don’t remove prematurely
• When you take something out, there is a potential space where fluid can accumulate
• Presents with swelling – you can tell there’s fluid under there. No redness, no infection
• This is a problem because the seroma fluid can become painful and open the incision
• Seroma tx is kind of surgeon dependent
• Jackson pratt drain is there to collect the serous fluid
• If the drain comes out too early, the pt can develop a seroma
• How to treat a seroma: you can aspirate

Question 4

wound complications: hematoma

Answer 4

• šHematoma
  
  • šmost common surgical complication due to lack of coagulation of vessels during surgery
  • šRisk when patient is anti-coagulated with heparin or patient is an aspirin user
  • šHematoma increases risk of infection
  • šNeck hematomas can compromise airways
  • šIf expanding, take back to surgery may be necessary

Question 5

wound/incisional infection signs and sxs

Answer 5

• Signs and Symptoms:
  
  • fever
  • N/V/D possibly
  • erythema
  • edema
  • exudate (fluid/pus at incision site)

Question 6

wound management

Answer 6

• šDressing over closed wounds should be removed on 3rd postop day if dry
• šDressing that are wet, should be removed and the wound inspected for drainage, redness
• šSutures/staples are removed POD #5
• šSutures over creases and on extremities are left in for 2 wks
• šSutures should be removed immediately if signs of infection are present
• šLook at wound dressing – dry and intact (d/i)
• šTake off dressing – no erythema, edema, exudate (e/e/e)
• šIf pus or fluid draining - culture
• šBlisters are caused by tape or steristrips that are too tight
• šRedness and itchiness is allergy to tape or use of adhesive (mastisol/benzoin)
• šTreatment is remove offending agent and use of hydrocortisone 1% cream and benadryl cream if itchy

Question 7

Post op fever

Answer 7

• šMost febrile patient are not infected
• šMost infected patients are not febrile
• šMost common cause is atelectasis
• šFever that starts on POD #5 is surgical infection
• šFever that lasts 5 days post op is surgical infection
• THE TIMING WILL GUIDE YOU AS TO CAUSE
• 5 Ws: wind, water, wound, walking, wonder – causes of postop fever
• 39 degrees on any postop day: FEVER
• Immediate fever: occurs immediately after surgery or within hours on postop day 0 or 1 (postop day 0 = day of surgery). Sources: malignant hyperthermia (high grade), catheter in the presence of a bladder infection, bacteremia, cdiff
• Acute fever: this is where wind, water, etc. come in: atelectasis (collapse of alveoli - theyre not breathing as deeply (intubation for long time, lying supine, etc.)
• Surgical causes:
  
  • Injury to bowel with bowel leak
    
    • fever
    • tachycardia
    • hypotensive
    • low u/o (urinary output)
    • abd tenderness out-of-proportion to procedure vs abd ttp app to proc
  • Treatment: surgical intervention

Question 8

atelectasis

Answer 8

• šThe most common cause of post op fever!
• šAppears in first 48hr post-op
• šCauses 90% of febrile episodes in first 48hr post-op
• šRisk factors:
  
  • šElderly
  • šOverweight
  • šSmokers
  • šHx of respiratory dz
• Symptoms:
  
  • šFever
  • šTachypnea
  • šTachycardia
• Signs:
  
  • none or
  • elevation of diaphragm
  • scattered rales
  • decreased breath sounds

Question 9

pulmonary aspiration

Answer 9

• šAspiration of secretions and gastric contents
  
  • šDue to relaxation of sphincters from anesthetic drugs or
  • šInsertion of ET and NG tubes
• šRisk factors:
  
  • GERD
  • Eating before surgery
  • Pregnant women – high intra-abdominal pressure and decreased gastric motility
  • Small bowel or colon obstruction
• Usually minimum of 4-5 hrs before surgery is when we limit food intake
• šSIGNS & SYMPTOMS:
  
  • šBasilar rales
  • šHypoxia
  • šTachypnea
• PREVENTION:
  
  • pre-op fasting
  • patient positioning
  • careful intubation and extubation
  • H2 blocker or PPI before intubation- reducing acidity of stomach contents thus preventing chemical pneumonitis

Question 10

pneumonia

Answer 10

• šMost common cause of pulmonary complications leading to death after surgery
• šPolymicrobial with predominance of gram negative bacteria
• šCauses:
  
  • šAspiration
  • šAtelectasis
  • šCopious secretions
• šSIGNS AND SYMPTOMS:
  
  • šFever
  • šTachypnea
  • šIncreased secretions
  • šCXR confirms consolidation
• šTREATMENT:
  
  • šCulture sputum and treat with ABXš

Question 11

respiratory management

Answer 11

• šTo prevent atelectasis, aspiration and pneumonia
  
  • šEncourage coughing
  • šFrequent change in position
  • šGet out of bed!
  • šI/S incentive spirometer
  • šDeep breathing
  • Breathing, movement, aeration prevents atelectasis and aspiration
• TO PREVENT PULMONARY EMBOLISM:
  
  • šElastic compression stocking (TEDS)
  • šSequential pneumatic device (SCD)
  • šHeparin for high risk patients

Question 12

pulmonary embolism

Answer 12

• šRISK FACTORS:
  
  • šObesity
  • š Age
  • šLengthy operative procedure
  • šBirth control pills
  • šMalignancy
  • šTrauma
  • šImmobilization
  • šParalysis
  • šIBS, Crohn’s
  • šChronic heart dz
  • šCoagulation disorders
• Longer surgery is roughly 5-6 hrs
• šSIGNS AND SYMPTOMS:
  
  • Cough
  • Dyspnea
  • Pleuritic chest pain
  • Apprehension!
  • Tachypnea
  • Tachycardia
  • P02 less than 70
• DIAGNOSTIC TESTS:
  
  • Ventilation/perfusion scan
  • vCT angiogram
• TREATMENT:
  
  • šHigh dose Heparin

Question 14

Urinary retention

Answer 14

• Common in patients with hernia repair surgery
• With patients that are given spinals or epidurals
• Signs and Symptoms:
  
  • pain and fullness over bladder with distension
  • unable to void after 6 hours
• Treatment:
  
  • Bladder scan
  • if residual is greater than 500 cc, patient is catheterized

Question 15

Ileus

Answer 15

• šAfter abdominal surgery, the colon ceases to function for a period of time 3-5 days due to:
  
  • bowel manipulation
  • intra-abd infection
  • pancreatitis
  • pneumonia
  • peritonitis
  • narcoticsš

Question 16

Ileus due to bowel manipulation

Answer 16

• SIGNS AND SYMPTOMS:
  
  • šAbd distension
  • šN/V
  • šObstipation (failure to pass gas and stool)
  • šAbd pain
• TREATMENT:
  
  • šFull liquid diet until 1st BM
  • šPatience
• SIGNS OF RESOLVEMENT:
  
  • šFlatulence
  • šSharp, colicky pain