Clinical - Post-op Complications Flashcards
(32 cards)
1
Q
Initial treatment for acute MI
A
- Morphine
- Oxygen
- Nitrates
- Aspirin
- Inform cardiology to plan for reperfusion
2
Q
Risk factors for acute MI
A
- Smoking
- Hypercholesterolaemia
- DM
- HTN
3
Q
What is a silent MI
A
Painless infarct, common in diabetics and the elderly
4
Q
Complications of acute MI
A
- Rhythm disorder
- Heart failure
- Circulatory failure
- VTE
- Pericarditis
- Free wall rupture
- Papillary muscle rupture
- Dressler’s syndrome
5
Q
Outline the approach to the unwell surgical patient
A
- A-E
- Focused history and examination
- Chart review
- Review of available results
- Decide and plan
- Stable = daily management plan
- Unstable = definitive treatment and diagnosis
6
Q
Outline the infective causes of post-op pyrexia by day
A
- Any = line infection
- 1-2 = respiratory source
- 3-5 = respiratory or urinary source
- 5-7 = surgical site infection or abscess/collection
7
Q
Non-infective causes of post-op pyrexia
A
- Iatrogenic = drugs
- VTE
- Prostehtic implantation
- Physiological
- Unknown origin
8
Q
Describe why post-op patients get atelectasis
A
- GA gases irritate the respiratory mucosa and increase mucous secretion
- Muscle relaxants reduce post-op respiratory effort
- Ventilation risks barotrauma and alveolar collapse
- Laparoscopy splints diaphragm to reduce air entry at bases
9
Q
Outline the SIRS criteria
A
Two or more of:
- Pyrexia >38 or <36
- Tachycardia >90
- Tachypnoea >20
- WBC >12 or <4
- Acutely altered mental state
- BM >6.6
10
Q
What is the sepsis 6 and where is it derived?
A
Derived from the ‘surviving sepsis campaign’. It aims to improve survival rates by optimising treatment given in the first 6 hours.
- High flow O2
- Blood cultures
- Lactate
- IV antibiotics
- IV fluids
- Urine output
11
Q
Define septic shock
A
Refractory hypotension in the presence of invasive infection
12
Q
Define sepsis
A
SIRS + documented source of infection
13
Q
Define severe sepsis
A
Sepsis + altered organ perfusion or dysfunction
14
Q
How can you judge you have achieved adequate fluid resuscitation
A
- CVP between 5-10cmH2O
- Urine output >30ml/hr
15
Q
How would you approach a confused patient assessment?
A
- Work with the nurses to try verbal de-escalation techniques to move the patient to a safe place
- Perform clinical assessment using A-E structure to ensure the patient is stable
- Attempt to take a history. Assess her capacity and decide whether a formal MCA/DOLS is required
- Discuss with the nurses to establish whether this is new confusion.
- Review the medical notes, drug chart, anaesthetic chart to establish a potential cause
- Perform some basic bedside tests including BM and urine dip to exclude reversible causes
- Examine the patients for lines, catheters, etc. that could present a source of infection
- Take a blood panes
- Decide whether CXR is required
- D/W NOK
- D/W Registrar
16
Q
Outline the KDIGO AKI criteria
A
- An abrupt reduction in kidney function with creatinine rise >26
- A percentage increase in creatinine >50%
- A reduction in urine output of <0.5ml/kg/hr for >6 hours
17
Q
What are the 5 golden rules of renal failure in a surgical patient
A
- Kidneys can’t function without adequate perfusion
- Renal perfusion is dependent on adequate blood pressure
- A surgical patient with poor urine output usually requires more fluid
- Absolute anuria is usually due to obstruction
- Poor urine output in a surgical patient is not a furosemide deficiency
18
Q
What are the common causes of renal failure? (structure this)
A
- Pre-renal: Hypovolaemia, sepsis, low CO
- Intrinsic: ATN, ischaemic injury, nephrotoxic injury, abdominal compartment syndrome, hepatorenal syndrome
- Post-renal: bladder outflow obstruction, bilateral ureteric obstruction
19
Q
What is Acute Tubular Necrosis?
A
Renal failure resulting from injury to the tubular epithelial cells, there are two types:
- Ischaemic injury - following any cause of shock resulting in a fall in renal perfusion
- Nephrotoxic injury - from drugs, toxins, myoglobin (from rhabdomyolysis)
20
Q
How can Pre-renal AKI be differentiated from ATN?
A
- Pre-renal = the concentrating ability of the tubular system is retained, producing urine with high osmolarity, high urea, high creatinine, and low sodium
- ATN = low osmolar urine with high sodium and low urea/creatinine
21
Q
How would you approach the assessment of a patient in AKI?
A
- I would adopt a CCrISP protocol and adopt an A-E approach
- I would treat any life threatening issues if they arose
- I would take a focused history focusing on potential causes of AKI including nephrotoxic drugs and look for symptoms of fluid overload such as PND
- I would perform a focused examination of their fluid status, abdomen, and catheter
- I would review the patients drug, observation, and fluid balance charts
- I would perform basic bedside tests including urine dip and ECG (if hyperkalaemic)
- I would take a blood panel
- I would arrange a renal USS
- I would arrange a CXR to exclude pulmonary oedema
- I would look for reversible causes and act urgently to:
- Restore and maintain renal perfusion
- Relieve any obstruction
- Oxygenate the tubules
- Remove/avoid toxins
- Identify and treat underlying cause - I would alert my SpR and the medical SpR if required
22
Q
List the reversible causes of post-op AF
A
- Electrolyte abnormalities
- Hypoxia - PE
- Hypotension
- Hypervolaemia
- Infection
- Severe anaemia
- Hyperthyroidism
- Pulmonary oedema
23
Q
List the risk factors for post-op AF (structure this)
A
- Patient factors:
- Age
- Male gender
- Current smoker
- ASA 3 or 4
- CCF
- COPD
- IHD
- Structural or valvular heart disease
- DM - Surgical factors:
- Abdominal and vascular surgery
- Intra-operative hypotension >10 minutes
24
Q
List the complications of AF
A
- Stroke
- TIA
- Heart failure
- Increased risk of mortality
25
What is the most common cause of wound dehiscence?
Infection
26
Risk factors for wound dehiscence (structure this)
```
Pre-operative:
- Immunosuppression
- Jaundice
- Vitamin C deficiency
- Malnutrition
- Steroid use
- Previous surgery
- DM
- Smoking
Intraoperative:
- Surgical technique
- Increased bowel handling
Postoperative:
- Chronic cough
```
27
Signs of wound dehiscence
- Pink fluid sign = produced by peritoneal exudate tinged with blood and is a precursor to complete dehiscence
- Open wound, visible fat and fascia
28
How would you manage wound dehiscence?
```
Resuscitation:
1. IV access
2. IVF
3. Analgesia
Early Treatment:
1. Cover any exposed viscera with saline soaked dressings
2. Give IV antibiotic cover
```
29
How is wound dehiscence definitively managed?
Superficial:
- Continue regular wound lavage and dressings
- For large defects consider VAC therapy
Complete:
- Resuturing in theatre
- Laparostomy
30
Risk factors for anastomotic leak
```
Technique:
- Tension
- Poor anatomical blood supply
Local Factors:
- Obstruction
- Ischaemia
- Peritonitis
Systemic:
- Shock
- Age
- Malnutrition
- Immunosuppression
```
31
How should anastomotic leak be definitively managed?
- Collection showing localised leak = US-guided drainage
- Major leak = re-operation with exteriorisation of suitable ends of small and large bowel (ITU and nutrition team should be involved)
32
How would you manage a suspected intestinal fistula
1. CCriSP protocol
2. SNAP Protocol:
- Sepsis = obtain adequate drainage
- Nutrition = provide nutritional support
- Anatomy = delineate using imaging (CT with contrast)
- Procedure = ultimately aim for repair but delay until patient is well enough
