Post-Op Care and Complications Flashcards
(172 cards)
1
Q
What are the phases of postop care?
A
Post anesthetic observation
Intermediate phase: hospitalization period
Convalescent phase
2
Q
What are the components of post anesthetic observation?
A
Immediate post op
Recovery room (PACU)
3
Q
What is considered the convalescent phase?
A
Time from hospital discharge to full recovery
4
Q
Who is the main provider in the immediate postop period?
A
Anesthesiologist
5
Q
What is the focus of the immediate postop period?
A
Cardiopulmonary recovery, neurologic function, and pain control
Monitor VS, EKG, I&O, mental status, and pain
6
Q
How soon are patients usually ready to discharge from recovery room?
A
Within an hour or 2
unstable/intubated patients are transferred to ICU
7
Q
What happens during the transition from immediate to intermediate period?
A
Discharge from recovery room and transfer to hospital floor
Admit orders
Postop note
Operative report
8
Q
I’m assuming we don’t need to memorize the components of a admit order/post-op note but I’m not sure
A
9
Q
Who must dictate the operative report?
A
The surgeon
10
Q
what is the role of the PA in regards to the post op note/procedure note?
A
may provide brief op note at physician request
Orders can be given by PA but physician must cosign
11
Q
What is wound care during the intermediate phase?
A
Leave initial sterile dressings on for 48 hours and change if become saturated under sterile technique
Include wound check instructions in orders
Monitor for infection
Sutures/staples removed within 5-10 days and steri-strips applied
Keep incision dry for first few days, showering ok
12
Q
When does epitheliazation of the wound occur?
A
During first 48 hours
13
Q
How soon can sutures or staples be removed from the face? Abdomen? Extremities?
A
Face: 3-5 days
Abdomen: 8-10 days
Extremities: 10-14 days
14
Q
Stages of healing
A
Inflammatory phase
Epitheliazation phase: forms scab
Maturation phase
15
Q
How are drains managed in the intermediate phase?
A
Orders include how often to check drains and record output
Look for signs of infection, appearance of drain output
Typically removed in 3-5 days, once output diminishes
16
Q
How does pulmonary function change postop?
A
Remains markedly diminished for 12-14 hours postop
Slowly increases over next 5-7 days
Returns to baseline after 7 days
17
Q
Pulmonary function depression postop is worse in which populations?
A
Elderly patients
Smokers
Obesity
Pre-existing lung disease
18
Q
What is the most common pulmonary risk postop?
A
Atelectasis, minimize risk via incentive spirometry and early mobilization
19
Q
What are pulmonary risks in addition to atelectasis?
A
Pulmonary edema
Pneumonia
Respiratory failure
PE
20
Q
What factors determine fluid replacement during the intermediate phase?
A
Maintenance requirements: extra needs d/t fever, D/V, burns
Losses resulting from drains, operative blood/fluid loss
Third space losses
21
Q
What is the rule for maintenance fluids?
A
4:2:1 rule
4x10 for the first 10 kg
2x10 for the second 10 kg
1xremain kg
Fluid needs over first 24 hours postop are greater
22
Q
How is blood loss monitored in the intermediate phase?
A
H&H
In trauma/ICU patients, serial labs
Stable post op patients am labs
23
Q
You must obtain ——– before giving blood!
A
informed consent
24
Q
what hemoglobin level is typically tolerated by asymptomatic patients with normal medical history? What are normal values?
A
9-10 g/dL
Male: 14-17 g/dL
Female: 12-15 g/dL
25
If a patient has cardiac, pulmonary, or cerebrovascular disease, when would you give a blood transfusion?
Hgb <7 (in any patient) or <8 with c, p, or c disease
26
How much blood is given and what type is most common?
1 unit of RBCs increase Hg by 1 g/dL and Hct by 3%
MC - packed RBCs
27
How is adequate pain control assessed?
Pain scales/pain assessment
28
Why is adequate pain control important?
Reduce hospital stay
Improve mobility
Increase patient satisfaction
29
Goal for pain control
Adequate pain control with minimal side effects
30
what is mc used for postop pain control?
Opioids IV or PCA
Morphine, hydromorphone, fentanyl, meperidine
31
what non-opioids can be used for postop pain control
ketorolac (NSAID)
tylenol
celecoxib (celebrex)
gabapentin
32
how should pain control be given generally?
IV/PCA for first 48 hours, then switch to oral
33
How can opioids be given?
Bolus IV, continuous IV or PCA
start low, go slow
Orders for IV and PO provided PRN
if patients tolerate PO can have PO
IV can be used for break through pain control PRN or for pt who are NPO
34
how are non-opioids often given post op?
In conjunction with opioids to reduce opioid requirements
35
_______ pain therapy is key!
multimodal
36
alternatives/adjuncts to opioids
local anesthesia: intraoperative injection, patches, pain-ball
spinal/epidural
nerve blocks
adjuvant therapy
37
when would spinal/epidural be given?
>5 rib fractures
38
when would nerve blocks be given?
ORIF
external fixation
hemiarthroplasty of extremities
39
what adjuvant therapy can be used?
muscle relaxants
anxiolytics
40
after abdominal surgery, what will likely be present?
Diminished peristalsis
41
what may be necessary to help with GI tract symptoms after surgery?
NG tube for ileus if N/V, hypoactive or high pitched bs and distention
bowel regimen for constipation
GI prophylaxis with PPI or H2 blocker for stress ulcer
antiemetics with zofran or phenergan
42
what is used for DVT prophylaxis post-op?
medications - most commonly lovenox or SQ heparin
Compression stockings/SCDs
early ambulation
43
what score can be used to predict likelihood of DVT?
pauda prediction score
44
what are the 5 ws postop
wind
walking
water
wound
wonder drugs
refers to postop complications
45
what falls under wind
alectasis/pneumonia
suspect if see fever 24-48 h post op and order cxr
46
what falls under water
uti
suspect if fever 3-5 days post op and order UA with culture
47
what falls under walking
DVT --> PE
If fever 7-10 days post op suspect and perform venous doppler/CT scan PE protocol
48
What falls under wonder drugs
Medications or blood products
If fever at anytime post op consider, this is diagnosis of exclusion
49
If a fever 5-7 days post op with abscess, what should you consider?
Organ or space abscess as well as incision site and do a CT scan
50
What is the general rule for fever postop?
Identify source of fever. Treat accordingly. Consult as needed
51
When would you see post op bacteremia?
Within 24 hours; perform blood culture x 2 at two sites
52
What is the most common postoperative pulmonary complication and the most common cause of fever in the first 24-48 hours after surgery (occurs in up to 25% of patients post abdominal surgery)?
Atelectasis
53
What is atelectasis?
Collapse of the bronchioles
Caused by shallow breathing and failure to hyperinflate the lungs
54
What are risk factors for atelectasis?
Smokers, COPD (already have loss of elastic recoil)
Increased secretions which can lead to obstructions
Elderly - loss of elastic recoil
55
What are complications of atelectasis?
Decreased oxygenation of blood
Infection of atelectasis segment
If atelectasis persists for >72 h pneumonia will develop
56
Clinical presentation of atelectasis
Fever
Tachypnea
Tachycardia
Hypoxemia - after 48 hours postop
57
Exam findings for atelectasis
Diminished breath sounds at bases
58
What will CXR of atelectasis show?
Changes consistent with atelectasis
59
Treatment for atelectasis
Deep breathing exercises/incentive spirometry
Chest percussion, bronchodilators
Bronchoscopy
60
Prevention of atelectasis
Early mobilization
Incentive spirometry
61
Causes of pneumonia
Aspiration
Atelectasis
Underlying pulmonary disease/smoking
Increased pulmonary secretions
Diminished defense mechanisms postoperatively
Impaired cough reflex, loss of ciliary coordination
62
Clinical manifestations of pneumonia
Tends to occur within 3-5 days postop
Fever
Tachypnea
Shortness of breath
Increased respiratory secretions
63
Exam of pneumonia
Auscultatory crackles or diminished breath breath sounds
Dullness to percussion if consolidation present
64
Labs for pneumonia
Leukocytosis
65
Imaging for pneumonia
Infiltrates or consolidation on CXR
66
Treatment of pneumonia
Obtain sputum culture, begin empiric abx treatment
Postop hospital acquired pneumonia with no other risk factors or known resistance: rocephin, unasyn, levofloxacin, ertapenem
67
What is the most common cause of pulmonary related post op death?
pneumonia
68
what antibiotics should be used for pneumonia if concerns for resistant organisms or coverage for pseudomonas? MRSA?
zosyn, cefepime, imipenem
MRSA: vancomycin, linezolid
69
a small effusion is common after _____
abdominal/thoracic surgery
70
what do more significant pleural effusions present with?
atelectasis and pneumonia
71
signs/symptoms of pleural effusion
cough
SOB
chest pain
fever
72
exam of pleural effusion
dullness to percussion
decreased tactile fremitus
asymmetrical chest expansion (delayed expansion on side of effusion)
73
treatment of pleural effusion
small and causing no respiratory compromise - do nothing
causing respiratory compromise or associated with pneumonia - drain
74
what is the greatest risk of pneumothorax related to surgery?
Subclavian central line or after surgery where diaphragm may be punctured
75
clinical presentation of pneumothorax
sudden shortness of breath
chest pain/tightness
hypoxia
tachycardia
tachypnea
76
what is present on exam of pneumothorax
unequal breath sounds
hyperresonance with percussion
decreased wall expansion
77
what is the treatment of pneumothorax
thoracostomy
78
what causes a UTI post operatively?
bladder catheterization/instrumentation
risk increases with prolonged catheterization (>2 days)
79
most common organism to cause a uti
e coli
80
s/sx of uti
dysuria
hematuria
frequency
fever/n/v
malodorous urine
81
diagnosis of uti
urinalysis with culture
82
treatment of postop uti
ciprofloxacin, rocephin
## Footnote
cippingon that rose for your uti
83
when do utis commonly cause post-op fever?
after 48 hours
84
risk factors for urinary retention
pelvic/perineal surgery
spinal anesthesia
over distension of urinary bladder (not catheterized)
h/o BPH/prostate tumor
85
s/sx of urinary retention
oliguria/anuria
abdominal/pelvic pain discomfort
86
exam findings of urinary retention
palpation of lower abdomen may demonstrate distended bladder
87
diagnosis of urinary retention
bladder scan with PVR >400 mL
88
treatment of urinary retention
bladder catheterization (Foley)
89
possible post op wound complications
hematoma
seroma
wound dehiscence
surgical site infection
90
what is a hematoma
collection of blood caused by inadequate hemostasis
91
risk factors for hematoma
anticoagulants
coagulopathies
marked post-op HTN
vigorous coughing/surgery
92
Clinical appearance of hematoma
Swelling
Discoloration
Bruising
Pain/discomfort
Blood leaking through incision
93
Treatment of post op hematoma
Small hematomas may resorb on own
Compression dressing
Evacuation of hematoma, ligation of bleeding vessels
94
Common sites of hematoma
Breast
Joints
Thyroid
95
Complications of hematoma
Compress nearby structures
Reduced perfusion to site
Infections
96
Most serious complications of hematoma
Neck: cut off air supply
Spine: compress spinal cord
97
Prevention of hematoma
Stop anticoagulants
Drain placement intraoperatively
98
What is a seroma
Collection of serous fluid typically from lymphatics caused by transection of lymphatics
99
Clinical appearance of seroma
Swelling
Discomfort
Leakage of serous fluid from incision
100
Common sites of seroma
Axilla and breast
Inguinal region
101
Treatment of seroma
Needle aspiration, compression dressings
If recurrent or severe = surgical wound exploration
102
Complications of seroma
Compression of nearby structures
Delay wound healing
Increase risk of infection
103
What is wound dehiscence?
Complete or partial disruption of any or all layers of incision
104
What is evisceration?
Rupture of all layers exposing internal organs
105
Most common site of wound dehiscence
abdominal
106
risk factors for wound dehiscence
Age >60
DM
Immunosuppression
Liver diagnosis
Sepsis
Cancer
Obesity
Inadequacy of closure
Increased intra-abdominal pressure
Infection
107
Clinical presentation of wound dehiscence
Between post op day 5-8
Increased drainage from incision or sudden opening
Absence of healing ridge by day 5
108
Treatment of wound dehiscence
Moist towels and binder until surgical consult - return to OR
Debridement and reclosure of fascia with skin loosely approximated to heal by secondary intetion
Small areas of dehiscence can be managed with meticulous wound care, not operative
109
What causes wound infection?
Bacterial contamination during or after surgery, MC with staph aureus
110
Types of SSIs
Superficial: skin and subcutaneous tissues
Deep: fascia, muscles, tissues
Organ/open space
111
What is a clean surgical wound?
No hollow viscus entered
no inflammation/infection
no breaks in aseptic technique
primary wound closure
non-traumatic surgery
112
what is a clean-contaminated surgical wound?
hollow viscus entered by controlled
no inflammation/infection
minor break in aseptic technique
primary wound closure
113
what is a contaminated wound?
uncontrolled spillage from viscus
inflammation/infection apparent
traumatic wounds
major break in aseptic technique
114
what is a dirty wound
untreated, uncontrolled spillage from viscus
pus in operative wound
open dirty traumatic wound
115
SSI host risk factors
DM
hypoxemia
immunosuppressive drugs
cigarette smoking
malnutrition
poor skin hygiene/contaminated or infected wounds
116
SSI infection risk factors
operative site shaving
poor sterile technique/contaminated instruments
inadequate skin prep
inadequate antimicrobial prophylaxis
prolonged hypotension
poor OR air quality
poor postop wound care
117
s/sx of SSI
usually start 5-6 days post-op (deep infections may as months)
fever
surgical site pain
edema
erythema
drainage
palpitation may elicit discharge
can lead to wound dehiscence
118
management and treatment of ssi
culture
abx
surgical debridement
119
prevention of ssi
good aseptic technique
incisions made without undue injury - good skin and subcutaneous tissue perfusion
good hemostasis
control of intraluminal contents/thorough irrigation if spillage
skin closure does not strangulate
leave no "dead space" when closing
antibiotic prophylaxis one dose 30 mins before incision and no longer than 24 hrs post op
120
most common antibiotics for prevention of ssi
cefazolin (ancef)
ceftriaxone (rocephin)
cefoxitin (mefoxin)
## Footnote
three foxes ssigh with their violins
121
what abx would you add to prevent SSI with a patient who is having colorectal or appendix surgery?
metronidazole (flagyl) or clindamycin
122
gi complications of surgery
stress gastritis
n/v
gastric dilation
bowel obstruction
fecal impaction
postoperative pancreatitis
postoperative hepatic dysfunction
postoperative cholecystitis
c. diff colitis
123
this is normal for the first 24-72 hours after surgery
functional postop ileus
124
what usually causes bowel obstruction after surgery?
adhesions/blockage
usually later in post op phase
early postop obstruction mc with colorectal surgery
intussusception common cause in postop peds patients
125
what diagnostic can show bowel obstruction and what does it show?
KUB XR: dilation above area of obstruction for bowel obstruction
126
s/sx of ileus and obstruction
abdominal distention
abdominal pain
absence of flatus
n/v: bilious emesis
127
exam for ileus and obstruction
protuberant tense abdomen
tympanic abdomen to percussion
lack of bowel sounds after 2 min, high pitch tinkering intermittent sounds
128
treatment of ileus and obstruction
NG tube decompression
bowel rest/NPO
possibly need for adhesiolysis
129
who more commonly gets fecal impact and what is the typical cause?
Elderly
Postoperative ileus, opioids, and reduced mobility
130
s/sx of fecal impaction
anorexi
obstipation
131
treatment of fecal impaction
manual removal
bowel regimen
132
when does pancreatitis and cholecystitis most commonly happen?
after biliary tract surgeries
pancreatitis: after ERCP, cholecystectomy
cholecystitis: after ERCP or upper GI procedures
more likely to develop into infected necrotizing pancreatitis and associated with higher mortality rate
133
s/sx of pancreatitis and cholecystitis
acute severe abdominal pain
n/v/d
fever
134
diagnosis of pancreatitis and cholecystitis postop
US/CT scan/MRI
elevated enzymes
leukocytosis
135
symptoms of post op hepatic injury
jaundice to liver failure with increased risk with surgery of the upper abdomen, biliary tract, and/or pancreas
136
what can cause jaundice post op
drugs
blood tranfusion reactions
damage to liver or liver resections
obstruction due to injury of bile ducts
137
treatment of post op hepatic injury
discontinuation of drug
discontinuation of blood transfusion, fluid replacement
GI consult for ERCP, stenting
138
what is the main risk associated with postoperative antibiotic use that can be transmitted person to person
c diff
139
s/sx of c.diff colitis
malodorous diarrhea
abdominal distention
pain
140
diagnosis of c. diff colitis
stool culture
141
treatment of c. diff colitis
abx
142
complication of c. diff colitis
toxic megacolon
143
prevention of c. diff colitis
contact precautions
144
cardiac complications postop
CVA
dysrhythmias
MI
DVT/thromboembolism
phlebitis/bacteremia
145
what typically causes CVA
prolonged ischemia/poor perfusion
highest risk surgery: CEA, open heart surgery
146
risk factors for CVA
elderly
patients with severe known atherosclerosis
severe hypotension during surgery
147
when are dysrhythmias common
during induction and during surgery , typically self-limiting
postop typically due to electrolyte disturbances, drug toxicity, may be first sign of MI
148
s/sx of dysrhythmias
often asymptomatic
may have CP
palpitations
dyspnea
149
risk factors for post op MI
duration and type of surgery
prolonged hypotension
prolonged hypoxemia
patients with known CAD, HTN, CHF, angina
150
s/sx of MI
CP
SOB
151
diagnosis of mi
EKG
Labs
152
Prevention of MI
stabilizing any underlying cardiovascular disorders prior to elective surgery
153
what causes phlebitis
needle or catheter introduced into the vein causing inflammation --> infection and thrombosis causing fever 72 hours after surgery
154
s/sx of phlebitis
induration
edema
tenderness
erythema
drainage
pronounced pain with infection
155
treatment of phlebitis
removal of catheter
warm compresses
NSAIDs
abx and excision of affected area of vein with suppurative phlebitis
156
prevention of phlebitis
good aseptic technique
rotation of insertion site
157
risk factors for DVT
fhx
obesity
immobility
trauma
surgery
smoking
oral contraceptives
age
158
s/sx of DVT
posterior calf pain
erythema
induration
tenderness
159
diagnosis and compications of dvt
diagnosis: venous doppler
compliations: embolism
160
treatment of dvt
anticoagulation therapy, filter
161
prevention of dvt
chemical/mechanical DVT prophylaxis
early mobilization
162
Virchow's triad
endothelial injury
hypercoagulability
venous stasis
163
what causes fat embolism?
tiny fat globules entering bloodstream through bone marrow, most common with orthopedic surgeries/long bone fractures
164
s/sx of fat embolism
mostly asymptomatic
onset 12-72 h after surgery
respiratory distress/hypoxemia
petechiae of axilla and chest
neurologic abnormalities
165
diagnosis of fat embolism
clinical
MRI can show emboli in brain
166
tx of fat embolism
symptomatic respiratory support
167
s/sx of pulmonary embolism
tachycardia
hypotension
tachypnea
hypoxia
chest pain
168
dx of pulmonary embolism
state CTA PE protocol
169
tx of PE
anticoagulation therapy
embolectomy
170
when should a patient be discharged post-op
afebrile for >24 h
controlled with PO medication
tolerating PO intake
voiding spontaneously
has had return of bowel function
hemodynamically stable
ambulatory
safe disposition
may require LTAC or SNF placement
171
what is the convalescent phase
begins once patient home
ongoing over weeks and months post op
length dependent on surgery
longer course of recovery with post op complications
longer in patient with significant comorbidities
172
what should happen during the convalescent phase?
close follow up with surgeon, typically at 2 weeks and sooner if issues
additional labs if indicated
follow up with PCP 2-4 weeks post discharge for continuity of care
