8 - Post-op Flashcards
Asepcts of ensuring patient safety:
QA/QI
Communication (hand-off, time-out, consents)
Documentation of care
Reporting complications (M and M)
Patient feedback (surveys)
Surgical complications
Bleeding Anesthetic/medications reactions Infection Injury to surrounding structures Poor cosmetic outcome Retained foreign body (sponges, instruments) Recurrence
How to prevent retained foreign bodies
Increased communication with team members
X-ray and wand prior to leaving OR
Ensure accurate instrument / sponge count
Radiopaque line on sponges
Post-op complications at 0-48 hrs
Resp and card issues
Failure of ventilation
Aspiration
Sudden cardiac event
HOTN
Post-op complications 48hrs to 30 days
Localized - UTI, pneumonia
Systemic - SIRS, MODS
PROBABLE TEST QUESTION
What is atelectasis?
Collapsed alveoli -> decreased gas exchange -> one of the MC complications of general anesthesia
Causes of atelectasis
Pain inhibits cough, deep breath
hypoventilation
Retained secretions
Low tidal volume
Presentation of atelectasis
Low-grade fever
Decreased breath sounds
Basilar rales
Seen on CXR
How to prevent atelectasis
Stop smoking prior to surgery
Post-op - incentive spirometry, deep breathing, ambulate, pain management
Txt for atelectasis
Chest physiotherapy (percussion, postural drainage)
Naso-tracheal suctioning
Therapeutic bronchoscopy
Presentation of pneumonia
Fever
Cough (productive)
Leukocytosis
CXR - infiltrate, consolidation
Txt for pneumonia
ABX
Aggressive pulm toilet
Intubation (maintain PCO2 35-45, SpO2 > 95%)
Prevention of VAP
Elevate head of the bed
Ventilator liberation trials (daily) - see how they do off the vent
Don’t over-sedate
PUD prophylaxis
DVT prophylaxis
Aggressive oral hygiene
Causes of aspiration pneumonia
Vomiting 2/2 anesthesia, narcs, ileus/obstruction, meals before surgery, obese/pregnant, AMS
Prevention of aspiration pneumonia
NPO at least 6 hrs prior to surgery
NGT
Cricoid pressure / avoid insufflating the stomach
Management of aspiration pneumonia
Suction immediately
Bronchial hygiene
ABX
Mechanical ventilation
Causes of pulmonary edema
Volume overload
CHF
Renal failure
Management of pulmonary edema
Close monitoring of fluid status
Sit up
Diuretics PRN
Consider / rule out PE and MI
Low threshold for intubation and mechanical ventilation
ARDS
Non-cardiogenic pulmonary edema
Interstitial - doesn’t respond to diuretics
Not 2/2 HF or fluid overload
Inflammatory process - 3rd-spaced fluid
Txt of ARDS?
Mechanical ventilation
Moderate PEEP settings 10-15cm (>15cm considered high)
Lower tidal volumes 5-7ml/kg IBW vs traditional 10-15ml/kg IBW
Maintain FiO2 <60% to avoid O2 toxicity
Increase the expiration time (more alveoli open)
Airway pressure release ventilation - full inspirations, little pulsing expirations (possibly works better than prone)
Central lines good for:
More caustic meds, ABX, blood
Monitoring hemodynamics (Swan Ganz, Vigeleo)
Easy to draw blood
Easy access
Complications of central line
Infection
PTX
Hematoma
Sterile technique critical
Fat emboli associated with:
Long bone / pelvic fx
Fat globules move into pulmonary capillary bed
Petechial rash
Normal d-dimer
Supportive care
Don’t forget to r/o PE / MI
Risk factors for PE
Malignancy Pregnancy Immobilization Nephrotic syndrome Blood dyscrasia (hypercoagulable)
Presentation of PE
Hypoxia
Tachypnea
Signs of DVT
PE workup
Low pulse ox Hypoxemia Hypocarbia D-dimer Cardiac isoenzymes and BNP to r/o MI and CHF
Imaging for PE workup
CXR limited
Spiral CT with PE protocol
VQ if pregnant or renal problems
Pulmonary angiogram - good but requires a central line
Txt for PE:
O2, IV access
Anticoag - heparin or SQ LMWH
Oral warfarin x 3-6 mos (INR 2-3)
Oral Xa inhibitors to replace warfarin
Inferior Vena Cava Filter - Christmas ornament
Virchow’s triad
Venous stasis
Endothelial injury
Hypercoagulability
Risk factors for DVT
Malignancy Elderly Pregnancy OCP use Post-partum Prolonged immobility Surgery stuff
