Post-Op Flashcards
(150 cards)
1
Q
Post-op complications depend on
A
Sx performed Baseline health of pt - Body Habitus - Tobacco, drug and alcohol use - Comorbid conditions (heart / lung dz, DM) - Medications (steroids, chemo, immunosuppressants) Elective, urgent of emergent nature Nutritional status
2
Q
Pre-op Preparation
A
Possible complications vs. probabl outcomes Pre-op abx therapy Fluid resuscitation Electrolyte abnormalities Nutritional optimization
3
Q
Complications which could occur Days 1-5, post op
A
Acute cerebreovascular event Acute MI Pyrexia due to atelectiasis Post-op Urinary retention (1-7 days) Renal Impairment / failure (1-7 days)
4
Q
Complications which could occur Days 1-7, post op
A
Post-op Urinary retention
Renal Impairment / failure
Delirium tremens (5-10 days)
5
Q
Complications which could occur Days 5-10, post op
A
Delirium tremens
6
Q
Complications which could occur Days 7-10, post op
A
Chest/wound/urinary infection
Secondary hemorrhage
Delirium tremens (5-10 days)
7
Q
Complications which could occur Days 10-14, post op
A
DVT / PE
Wound dehiscence
8
Q
Post-op fever - Infectious
A
Abscess Acalculous cholecystitis Bacteremia Decubitus ulcers Device-related infections Empyema Endocarditis Fungal sepsis Hepatitis Meningitis Osteomyelitis Pseudomembraneous Colitis Parotitis Perineal infections Peritonits PHarygitis Pneumonia Retained foreign body Sinusitis Soft tissue infection Traceobraonchitis UTI
9
Q
Post-op fever - Noninfectious
A
Acute hepatic necrosis Adrenal insufficiency Allergic reaction Atelectasis Dehydration Drug reaction Head injury Hepatoma Hyperthroidism Lymphoma MI Pancreatitis Pheochromocytoma PE Retroperitoneal hematoma Solid organ hematoma Subarachnoid hemorrhage Systemic inflammatory response syndrome Thrombophlebitis Transfusion reaction Withdrawal syndromes Wound infection
10
Q
The 5 W’s of a post-op fever
A
Wind (Lungs) Water (Urinary Tract) Walking (DVT / PE) Wound Wonder about Drugs
11
Q
Post-op fever - In general
A
2/3 of pts have fever after sx; only 1/3 have an infection
First 48-72h post-op - atelectasis is often the cause
Fever 5-8 days post-op is more worrisome
Pt’s s/s typically indicate the cause
Don’t jump to Tylenol for post-op fever - find the cause and tx appropriately
12
Q
Wind - In general
A
Pre-op pulmonary eval - identify pre-existing conditions (COPD, asthma, smoking, CHF, obesity, etc)
Sx and incapacitation causes
- Loss of functional residual capacity
- Vital capacity may be reduced up to 50%
Narcotics inhibit repiratory drive
25% of post-op deaths are due to pulmonary complications
Aggressive pulmonary toilet, SMI and IS
Eval includes CBC, CXR and ABGs
13
Q
Atelectasis
A
Collapse or incomplete expansion of part of the lung
Most common post-op fever in the first 48h
Responds to aggressive pulmonary toilet
14
Q
Pneumonia
A
HCAP
Aspiration is the leading cause
Higher fever than atelectasis
Pts on ventilator are at a higher risk
Typically pts have fever, cough, leukocytosis and CXR infiltrates
Sputum and blood cultures
Abx should cover Gram negative - start broad then narrow down
15
Q
Aspiration pneumonia
A
Inhalation of regurgitated gastric contents
16
Q
Aspiration pneumonitis
A
Inhalation of oropharyngeal secretions colonized by bacteria
More common in the right lung
17
Q
Aspiration pneumonia and aspiration pneumonitis
A
Elderly or pts with altered sensorium are more susceptible
Pts will have a cough, typically have wheezing and dyspnea
CXR, blood and sputum cultures
Secure the airway - frequently involves intubation
Empiric abx therapy that covers Gram negative bacteria
18
Q
Pulmonary Edema
A
Fluid overload and chronic renal failure
Kerley B lines - more localized to bases
Diuretics and supplemental oxygen
19
Q
ARDS - causes
A
Septic shock Drug OD Acute pancreatitis Aspiration Smoke inhalation Near-drowning
20
Q
ARDS - in general
A
Bilateral
Widespread
Confluent alveolar consolidation often with air bronchograms
Typically lacks cardiomegaly
21
Q
Which dz state typically produces a pleural effusion that is transudative?
A - CHF
B - RA
C - Lung cancer
D - Pancreatitis
A
A
22
Q
UTI - in general
A
UTIs associated with catheters are the leading cause of secondary healthcare-associated bacteremia
Approximately 20% of hospital-acquired bacteremia cases arise from the urinary tract
UTI is more common in pts who have undergone a GU procedure and in those who have chronic, indwelling catheters
23
Q
C.A.U.T.I. to prevent CAUTI
A
Catheter removal Aseptic insertion Use regular assessments Training for catheter care Incontinence care planning
24
Q
C.A.U.T.I. to prevent CAUTI
A
Catheter removal Aseptic inserUTI - tion Use regular assessments Training for catheter care Incontinence care planning
25
UTI - RF
Females
Elderly
DM
Duration of catherization
26
UTI - s/s
Fever is the most common symptom
Flank or suprapubic pain
CVA tenderness
Cloudy or foul smelling urine
27
UTI - dx
Cath urine specimen is most reliable - straight cath
| Can culture bag/foley tip
28
UTI - tx
Empiric broad-spectrum abx until culture results
29
Urinary retention
Most commonly it is a reversible abnormality of the trigone and detrusor muscles
- BPH and low pelvic operations will increase risk of urinary retention
Bladder scan, straight cath, or leave foley catheter out
Rapaflo, flomax
30
Acute Renal Failure - "areas of failure"
Prerenal - secondary to hypotension, NSAIDs and Gram negative sepsis
Renal - damage to kidneys
Postrenal - outflow obstruction
31
Acute Renal Failure - Contrast
Induced nephropathy is on the rise with incrased use of contrast studies
32
Acute Renal Failure - prevention
Avoid hypovolemia, hypotension, and nephrotoxic meds
33
Acute Renal Failure - rise in Cr
Decrease in Cr clearance
| Decrease in urinary output
34
Acute Renal Failure - tx
```
management of fluids
Correct electrolyte abnormalities
Avoiding nephrotoxicity
Optimizing nutrition
Some pts require dialysis
```
35
A 41yo M presents with acute onset right flank pain. The pain is intermittent and now radiates into his right tesicale. He is afrebrile. Which of the following is the most likely dx?
A - Incarcerated inguinal hernia
B - Appendicitis
C - Ureteral stone
D - Varicocele
C
36
Which of the following is indicated by the presence of broad waxy casts on UA?
D
37
Walking - In general
To ward off DVT / PE
More common after oncologic, pelvic, orthopedic, and neurosx - procedures that directly or indirectly cause venous stasis
38
Walking - RF
```
Type and extent of sx
Trauma
Duration of hospital stay
Hx of previous VTE or cancer
Immobility
Recent sepsis
Presence of a central venous access device
PG or the postpartum period
Inherited or acquired hypercoaguable states
```
39
Virchow's Triad
Stasis
Endothelial injury
Hypercoagulable state
40
DVT - Prevention
Prevention is key
| Post-op anticoagulation (lovenox), early ambulation and sequential compression devices (SCDs)
41
DVT - s/s
Unilateral edema, erythema and tenderness
Positive Homan's sign
May include SOB
Legs may look a little different
42
DVT - Dx
Venous US
43
DVT - Tx
```
Therapeutic anticoagulation (Eliquis, Xarelto, etc.)
Compression stockings
```
44
PE - in general
Remains the most common preventable cause of hospital death
| Responsible for approximately 150-200,000 deaths per year in the US
45
PE - s/s
```
Sudden dyspnea
Tachypnea
Hemoptysis
Tachycardia
Acute RV Dysfunction
Pleuritic CP
Leg swelling
4th heart sound
Inspiratory crackles
```
46
PE - Eval
```
VQ Scan
CT PE Protocol (CT angiogram
EKG
ECHO
Venous Doppler
CXR
ABG
D-Dimer (cannot be excluded with D-Dimer)
```
47
PE - Therapeutic anticoagulation
Heparin - Full strength for 6 months
48
Wound - in general
Bacterial contamination of the sx site
| Typically develop 5-6 days post-op
49
Wound - most common pathogens
Staph aureus
| Coagulase - negative staph
50
Wound - Most common GI operation pathogens
Enterobacter species
E. coli
Group D enterococcus
51
Wound - Prevention
Bowel Prep
Pre-op abx +/- redosing
Drain placement in deep wounds or wounds with large flaps
52
Wounds - Pt Factors
```
Ascites
Chronic inflammation
Undernutrition obesity
DM
Extremes of age
Hypercholesterolemia
Hypoxemia
Peripheral vascular dz
Post-op anemia
Previous site of irradiation
Recent operation
Remote infection
Skin carriage of staph
Skin dz in the area of infection
Immunosuppression
```
53
Wounds - Environmental factors
```
Contaminated meds
Inadequate disinfection / sterilization
Inadequate skin antisepsis
Inadequate ventilation
Presence of a foreign body
```
54
Wounds - Tx factors
```
Drains
Emergency procedure
Inadequate abx coverage
Pre-op hospitalization
Prolonged operation
```
55
Wound infection - S/s
```
Tenderness
Erythmatous
Edematous +/- drainage
Leukocytosis
Fever
Occasional fluctuance
```
56
Wound infection - tx
Open the wound and pack / dress
If cellulitis - abx - heavy use can increase risk of C.diff
If purulence from below fascia - drainage vs. operative exploration at site of infection
57
Seroma - in general
Collection of liquefied fat, serum and lymphatic fluid under the incision
Typically thin, yellow or serosanguinous drainage
58
Seroma - exam
Localized swelling, pressure / pain
59
Seroma - tx
Open the areas to wound and allow it to drain
| Pack wound or leave open
60
Seroma - Prevention
Surgical drains help to prevent these (JP drains)
| Can become infected - wet to dry dressing changes
61
Hematoma - in general
Abnormal collection of blood
| Typically caused by inadequate hemostasis, lack of clotting factors or coagulopathy (asa, plavix, etc.)
62
Hematoma - Exam
Localized soft-tissue swelling to skin breakdown
63
Hematoma - Complications
Depednind on location of hematoma
- Ileus
- Compartment syndrome
- Airway compromise
64
Hematoma - Prevention
Hold anticoagulation pre-op
| Identify clotting d/o
65
Hematoma - Intraoperative hemostasis
Cautery
Suture control of hemorrhage
Pro-clotting materials
66
Hematoma - tx
Typically resorbed but can be drained or sx evacuated
67
Dehiscence - In general
Wound failure and separation of abdominal layers
1-3% of pts with an abdominal operation - obesity increases the risk
Acute, large volume of clear or light pink colored drainage precedes dehiscence -in 25% of cases
68
Dehiscence - Common causes
```
Deep wound infection (most common)
Technical error in closure
Age
Steroid use
Malnutrition
Radiation or chemo
DM
```
69
Dehiscence - Tx
Pack the wound, open with wet to dry dressing changes
| Wound VAC
70
Dehiscence - with evisceration
Requires operative intervention
| Abthera or temporary closure device
71
Dehiscence - wound cultures
Use with caution
| Blood cultures only if s/s of sepsis are present
72
Wonder about Drugs - in general
Chart review on what meds pt is taking
| Interactions with other meds and possible missing home meds
73
Medications that can cause fever
```
Anesthesia
Heparin
Abx
Anticonvulsants
Anti-inflammatories
Blood products / transfusions
Stopping home meds
```
74
Stevens-Johnson syndrome is most commonly linked to exposure of which of the following medications?
A - Levquin
B - Metformin
C - Dilantin
D - Cordarone
C
75
A pt currently taking coumadin presents with spontaneous nosebleeds. Labs demonstrate a PT = 45s and an INR = 6.9. Which of the following is the tx of choice?
A - Heparin
B - Salicylate
C - Vitamin K
D - Protamine sulfate
C
76
Post-op HTN - Common causes
```
Pain
Hypothermia
Hypoxia
Fluid overload
Discontinued home meds
```
77
Post-op HTN - More "serious" causes
Bleeding
Head trauma
Withdrawal
Pheochromocytoma
78
Post-op HTN - tx
slow steady reduction of pressure to avoid ischemia and hypoprofusion
79
Post-op MI - in general
STEMI vs. NSTEMI
Greatest risk in the first 48 h
Pre-op cardiac risk stratificaiton
80
Post-op MI - s/s
CP / tightness
Cyspnea
Tachycardia
Hypotension
81
Post-op MI - work-up
```
EKG
Troponins
CXR
ABG
Echo
```
82
Post-op MI - tx
Medical management
Cardiac catheterization
CABG
83
Post-op arrhythmias - in general
Brady / Tachy / Heart Block
Sinus tachycardia, A. Fib and Atrial flutter are most common tachyarrhythmias
Most are transient and benign, but can be precursor to hemodynamic compromise (sinus tach vs. Afib vs Afib with RVE)
84
Post-op arrhythmias - s/s
```
Palpitations
CP
Dyspnea
Dizziness /syncope
Hypotension
```
85
Post-op arrhythmias - work-up
EKG +/- echo
86
Post-op arrhythmias - tx
Rate control
Rhythm control
Possibly anticoagulation or cardioversion
87
Post-op heart failure -
Risk is the greatest in the first 24-48h after sx
88
Post-op heart failure - increased risk
CAD
HTN
Elderly
89
Post-op heart failure - S/s
Dypnea
Wheezing and rales
Tachycardia
Peripheral edema
90
Post-op heart failure - work-up
EKG
Echo
CXR
BNP
91
Post-op heart failure - tx
ACEI
| Diuretics
92
Which of the following coronary arteries is typically involved in a lateral wall MI?
A - Right coronary A.
B - Circumflex A.
C - Left anterior descending A.
D - Left coronary A.
B
93
Which of the following conduction d/o increases the risk of intra-arterial clot formation?
A - Ventricular tachycardia
B - A. fib
C - Premature atrial contractions
D - Wolff-Parkinson-White syndrome
B
94
A 55yo presents with orthopnea and PND. On physical exam, jugular venous distention and pulmonary rales are noted. Which of the following laboratory tests would most likely be elevated in this pt?
A - Thyroid-stimulating hormone
B - Brain natriuretic peptide
C - Myoglobin
D - Renin
B
95
Thermal regulation complications - in general
Malignant hyperthermia occurs in 1:30,000-50,000 individuals
96
Thermal regulation complications - cause
An abnormal reaction to anesthetic which causes rapid release of CA2+
97
Thermal regulation complications - s/s
```
Cellular hypoxia
Lactic acidosis
Hypercapnia
Hypotension
Tachypnea
Arrhythmias
```
98
Thermal regulation complications - tx
Identify at risk individuals pre-op
Identify the problem in the OR and abort the procedure
Give dantrolene - muscle relaxant
Administer alternative anesthesia and stabilize pt
99
Endocrine complications - in general
Adrenal insufficiency
Hyperthyroid crisis
Hypothyroidism
SIADH
100
Endocrine complications - Adrenal insufficiency
```
Fatigue
Weakness
Abdominal pain
Diarrhea
Hyponatremia
Hypoglycemia
Ha
Visual disturbances
```
101
Endocrine complications - Hyperthyroid crisis
```
Nervousness
Fatigue
Palpitations
A.fib
Periorbitial edema
Proptosis
```
102
Endocrine complications - Hypothyroidism
Rarely to pts develop myxeda coma
103
Endocrine complications - SIADH
```
Anorexia
N / V
Obtundaiton
Seizures
Hyponatremia
```
104
GI Complications - Ileus and obstruction in general
Ileus and obstruction
Functional
Mechanical
105
GI Complications - Function obstruction
"Sleepy bowels"
| Caused by manipulation during sx, restricted oral intake and analgesics
106
GI Complications - mechanical
```
Early post-op SBO
Adhesions (>90%)
Abscess
Internal hernia
Intestinal ischemia or intussusception
```
107
GI Complications - S/s of Ileus and obstruction
```
Abdominal pain
Distention
N/V
Belching and hiccupping
Obstipation
```
108
GI Complications - Work-up of Ileus and obstruction
Abdominal XR - "Transition point"
109
GI Complications - tx of Ileus and obstruction
```
Correct electrolyte abnormalities
NGT decompression
Promotility meds
Reduction or elimination or narcotics
NPO / ice chips
Consider TPN or TF
```
110
Post -op GI bleeding - Differential
PUD
Mallory-Weiss Tear
Stress Ulcers
111
Post -op GI bleeding - s/s
Hematemesis
Hematochezia / Melana
Anemia
112
Post -op GI bleeding - Work-up
H and H
Bleeding scan
Colonscopy / EGD
113
Post -op GI bleeding - tx
PPI therapy and prophylaxis
| Transfusion as needed
114
Post-op C.diff Colitis - in general
```
Gram positive
Anaerobic
Spore forming bacillus
Can produce toxins A and B
Abx use precedes most cases
45-55% are sx pts
```
115
Post-op C.diff Colitis - s/s
Ranging from asymptomatic carriers to toxic megacolon
| Typically pts have profuse, watery diarrhea
116
Post-op C.diff Colitis - dx
Stool sample
117
Post-op C.diff Colitis - tx
```
Oral vancomycin (Gold standard)
Alternatives
- Vancomycin ememas or per stoma
- Fecal transplant
- TAC with ileostomy
```
118
Post-op C.diff Colitis - Pt related RF
```
Increasing age
Pre-existing renal dz
Pre-exisiting COPD
Impaired immune defense
Underlying malignancy
Underlying GI dz
```
119
Post-op C.diff Colitis - Tx-related RF
```
Pre-op bowel cleansing
Abx use
Immunosuppressive therapy
Sx
Prolonged hospital stay
```
120
Post-op C.diff Colitis - facility-related RF
ICU
Caregivers
Long-term facilities
121
GI Complications - in general
```
Ileus
Obstruction
GI Bleed
C. diff Colitis
Anastomotic leaks
Intestinal fistula
Stomal complications
Abdominal compartment syndorme
Ischemia / infarct
```
122
45 yo M presents wit abdominal pain, N/V. Exam demonstrates high-pitched bowel sounds and X-ray of the abdomen shows multiple air-fluid levels. What is the most likely dx?
A - Paralytic ileus
B - Small Bowel obstruction
C - Crohn's dz
D - Ulcerative Colitis
B
123
Which of the following findings is indicative of acute cholecystitis?
A - Cullen's
B - Chadwick's
C - Hegar's
D - Murphy's
D
124
Which of the following leads to Barrett's esophagus?
A - Pyloric stenosis
B - Mallory-Weiss Tear
C - Esophageal Stricture
D - Gastroesophageal Reflux dz
D
125
Bile Duct Injuries - in general
Most dreaded cholecystectomy complication
126
Biloma or Bile ascites - s/s
```
RUQ pain
Fever
Nausea
Distention
Drain with bilious output
Leukocytosis
```
127
Bile Duct Injuries - cause
Bile duct that has been clipped
| Can cause elevated LFTs
128
Bile Duct Injuries - strictures s/s
Cholangitis
Pain
Fever
Jaundice
129
Bile Duct Injuries - dx
CT
| ERCP
130
Bile Duct Injuries - Tx
Percutaneous drain
Sphincterotomy
Stenting
131
Neurologic complications - in general
```
Delirium
Psychosis
Delirium Tremens
Stroke
TIA
```
132
Delirium and Psychosis - in general
Acute confusion or mental status change
133
Delirium and Psychosis - s/s
```
Agitation
Uncooperative
Confused
Emotionally labile
Hallucinations
Disturbances of sleep-wake cycle
ICU Delirium
```
134
Delirium and Psychosis - causes
```
Loss of routine
Stress of dz
Fear of operation
Loss of control
Unfamiliar environment
Meds
Pain
Post-op anemia
Electrolyte imbalance
Sepsis
Catheterization
Extended anethesia
Infection
```
135
Delirium and Psychosis - RF
Elderly
Those with a substance abuse hx
Psychiatric d/o
Children
136
Delirium and Psychosis - tx
Minimizing meds
Optimizing fluids and nutrition
Early ambulation
137
Delirium Tremens
Acute alcohol w/d causing fever, tachycardia, agitation, seizures and psychosis
Prevention is key
Tx - Haldol and benzodiazepines
138
Stroke and TIA - RF
Elderly with CV dz
| Young with inherited thrombophilia
139
Stroke and TIA - s/s
Acute alteration in motor function
Alteration in mental status
Aphasia
140
Ischemic Stroke
Perioperative hypotension or cardioembolic
141
Hemorrhagic stroke
Typically related to anticoagulation therapy
142
Stroke and TIA - prevention
Managing BP and anticoagulation
143
Stroke and TIA - dx
Heat CT
144
Stroke and TIA - tx
Based on type of stroke
- TPA or anticoag
- HTN control
145
ENT complications - in general
Epistaxis
Acute hearing loss
Nosocomial Sinusitis
Parotitis
146
Epitaxis
Caused by
- Blood dyscrasias
- Excessive anticoagulation
- HTN
Tx - firm pressure or packing resolves the bleeding
147
Acute hearing loss
Unilateral loss - Obstruction or edema
Bilateral loss - typicall caused by ototoxic meds (aminoglycosides and diuretics)
148
Noscomial Sinusitis
Typically in the second week of hospitalization
Most often maxillary sinuses
More common with pts on ventilator
Commonly an incidental CT finding when eval for fever
149
Parotitis
More often elderly gentleman with poor oral hygiene, poor oral intake and decreased salivary production
Demonstrate edema and focal tenderness
Broad spectrum IV abx to cover staph infections
150
Lines and Drains
All "foreign" objects can get infected - PICC infections, CAUTI, etc.
Phlebitis from IV placement
Most of the time the removal of offending line/drain will resolve the issue
- If infection is present, then abx are required
