Management of a surgical patient Flashcards
(38 cards)
What does PPC stand for?
Post-op Pulmonary Complications
What can happen to the length of hospital stay (LOS) when a patient has PPC (Post-op Pulmonary Complications)?
Prolonged by 13-17 days
How does mortality rate differ after Post-op pulmonary complications (PPC)?
Mortality rate after 1 year:
- 45.9% (8.7% without)
Mortality rate after 5 years:
- 71.4% (41.1% without)
1/5 die within 30 days of major surgery (0.2-3% without)
What are risk factors of age in pre-op?
- Reduced physiological reserve
- Decreased elastic recoil
- Decreased chest wall compliance
- Decreased respiratory muscle strength
- Increased alveolar collapse
- > 70 y.o 3x risk
What can happen if the patient has lung disease pre-op?
- Increased reduction in FRC
- Potential cilia dysfunction
- Potential dysfunction of lung tissue/impaired gas exchange
- Potential existing retained secretions
- Severe COPD FEV<40% has 6x more complications
What can happen if the patient has heart failure pre-op?
- Potential worsening VQ mismatch
- Potential worsening hypoxaemia
What can happen if the patient has a neurological disorder pre-op?
- Increased risk respiratory failure
- Increased risk aspiration
What can happen if the patient has functional status pre-op?
- Lower functional reserves
- Further reduced mobility post-op increased risk VTE, pneumonia, etc.
What can happen if the patient has obesity pre-op?
- Increased reduction in FRC perioperatively
- Potential mobility issues post-op
What can happen if the patient has a smoking status pre-op?
- Cilia dysfunction
- Potential underlying lung disease
- 2x increased risk complications
What can happen if the patient has mechanical ventilation peri-op?
- Aspiration
- VQ mismatch
- Lack of independent airway protection/secretion clearance
- Ventilator-Induced Lung Injury (VILI)
What can happen if the patient has anaesthesia peri-op?
- Cilia impairment
- Risk bronchoconstriction
- Reduced surfactant production
- Reduced FRC (muscle tone, chest wall deformation)
What can happen if the patient has opioids in peri-op?
- Respiratory depression
- Hypoventilation
- Aspiration risk
What can happen in peri-op if the patient has emergency surgery?
- Lack of fasting - risk of aspiration
- Higher risk patient cohort
What can happen if the patient has lung deflation peri-op?
- Atelectasis of deflated lung
- Barotrauma of reinflation
What are the most important predictors of risk in a surgical site peri-op?
Most important predictor of risk:
- Aortic
- Thoracic
- Upper abdominal surgeries are high-risk
What can happen if the patient has surgical site peri-op?
- Distance of incision from diaphragm inversely proportional to the incidence of complications
- Intercostal muscle involvement
- Positions/restrictions
- Site of pain/inflammation
What can happen if the patient has pain post-op?
- Reduced thoracic expansion
- V/Q mismatch
- Reduced cough-risk retained secretions
- Reduced mobility
What can happen if the patient has reduced mobility in post-op?
Reduced FRC
What can happen if the patient has dehydration post-op?
- Increased viscosity of secretions
- Reduced sputum clearance
- Reduced mobility/repositioning
What are the aims of post-op physio management?
- Improve V/Q matching
- Restore FRC
- Maintain sputum clearance
- Restore mobility
What are some physio treatment options for post-op?
- Positioning
- Mobilise
- ACBT (splinted cough)
- Humidification
- Incentive spirometry, flutter devices
- Intermittent Positive Pressure Breathing (IPPB)
- CPAP –> BiPAP
- Manual hyperinflation, Suctioning
What are the contraindications & precautions for Intermittent Positive Pressure Breathing (IPPB), CPAP, MI-E?
- Vomiting
- Facial trauma / surgery
- Raised intracranial pressure
- Recent upper GI surgery (D/W consultant)
- Recent thoracic surgery (D/W consultant)
- Low GCS/impaired consciousness
- Undrained pneumothorax
- Large emphysematous bullae
- Open bronchopleural fistula
- Lung abscess
- Severe haemoptysis
- Ca Bronchus
- Active pulmonary tuberculosis
- Frank haemoptysis
Name some surgical incisions.
- Median sternotomy
- Right subcostal (open cholecystectomy)
- Horizontal transabdominal
- Appendicectomy
- Right inguinal (hernia repair)
- Bilateral subcostal with median extension (liver transplant)
- Left paramedian (laparotomy)
- Lower midline
- Suprapubic
- Lateral thoracotomy
- Limited thoracotomy
- Left transverse lumbar (nephrectomy)
