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Surgery > Post-Op Care and Complications > Flashcards

Post-Op Care and Complications Flashcards

1
Q

What are the phases of postop care?

A

Post anesthetic observation
Intermediate phase: hospitalization period
Convalescent phase

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2
Q

What are the components of post anesthetic observation?

A

Immediate post op
Recovery room (PACU)

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3
Q

What is considered the convalescent phase?

A

Time from hospital discharge to full recovery

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4
Q

Who is the main provider in the immediate postop period?

A

Anesthesiologist

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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

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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

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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

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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
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9
Q

Who must dictate the operative report?

A

The surgeon

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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

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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

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12
Q

When does epitheliazation of the wound occur?

A

During first 48 hours

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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

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14
Q

Stages of healing

A

Inflammatory phase
Epitheliazation phase: forms scab
Maturation phase

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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

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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

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17
Q

Pulmonary function depression postop is worse in which populations?

A

Elderly patients
Smokers
Obesity
Pre-existing lung disease

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18
Q

What is the most common pulmonary risk postop?

A

Atelectasis, minimize risk via incentive spirometry and early mobilization

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19
Q

What are pulmonary risks in addition to atelectasis?

A

Pulmonary edema
Pneumonia
Respiratory failure
PE

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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

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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

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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

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23
Q

You must obtain ——– before giving blood!

A

informed consent

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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

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25
Q

If a patient has cardiac, pulmonary, or cerebrovascular disease, when would you give a blood transfusion?

A

Hgb <7 (in any patient) or <8 with c, p, or c disease

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26
Q

How much blood is given and what type is most common?

A

1 unit of RBCs increase Hg by 1 g/dL and Hct by 3%
MC - packed RBCs

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27
Q

How is adequate pain control assessed?

A

Pain scales/pain assessment

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28
Q

Why is adequate pain control important?

A

Reduce hospital stay
Improve mobility
Increase patient satisfaction

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29
Q

Goal for pain control

A

Adequate pain control with minimal side effects

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30
Q

what is mc used for postop pain control?

A

Opioids IV or PCA
Morphine, hydromorphone, fentanyl, meperidine

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31
Q

what non-opioids can be used for postop pain control

A

ketorolac (NSAID)
tylenol
celecoxib (celebrex)
gabapentin

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32
Q

how should pain control be given generally?

A

IV/PCA for first 48 hours, then switch to oral

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33
Q

How can opioids be given?

A

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

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34
Q

how are non-opioids often given post op?

A

In conjunction with opioids to reduce opioid requirements

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35
Q

_______ pain therapy is key!

A

multimodal

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36
Q

alternatives/adjuncts to opioids

A

local anesthesia: intraoperative injection, patches, pain-ball
spinal/epidural
nerve blocks
adjuvant therapy

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37
Q

when would spinal/epidural be given?

A

> 5 rib fractures

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38
Q

when would nerve blocks be given?

A

ORIF
external fixation
hemiarthroplasty of extremities

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39
Q

what adjuvant therapy can be used?

A

muscle relaxants
anxiolytics

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40
Q

after abdominal surgery, what will likely be present?

A

Diminished peristalsis

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41
Q

what may be necessary to help with GI tract symptoms after surgery?

A

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

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42
Q

what is used for DVT prophylaxis post-op?

A

medications - most commonly lovenox or SQ heparin
Compression stockings/SCDs
early ambulation

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43
Q

what score can be used to predict likelihood of DVT?

A

pauda prediction score

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44
Q

what are the 5 ws postop

A

wind
walking
water
wound
wonder drugs

refers to postop complications

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45
Q

what falls under wind

A

alectasis/pneumonia
suspect if see fever 24-48 h post op and order cxr

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46
Q

what falls under water

A

uti
suspect if fever 3-5 days post op and order UA with culture

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47
Q

what falls under walking

A

DVT –> PE
If fever 7-10 days post op suspect and perform venous doppler/CT scan PE protocol

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48
Q

What falls under wonder drugs

A

Medications or blood products
If fever at anytime post op consider, this is diagnosis of exclusion

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49
Q

If a fever 5-7 days post op with abscess, what should you consider?

A

Organ or space abscess as well as incision site and do a CT scan

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50
Q

What is the general rule for fever postop?

A

Identify source of fever. Treat accordingly. Consult as needed

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51
Q

When would you see post op bacteremia?

A

Within 24 hours; perform blood culture x 2 at two sites

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52
Q

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)?

A

Atelectasis

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53
Q

What is atelectasis?

A

Collapse of the bronchioles
Caused by shallow breathing and failure to hyperinflate the lungs

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54
Q

What are risk factors for atelectasis?

A

Smokers, COPD (already have loss of elastic recoil)
Increased secretions which can lead to obstructions
Elderly - loss of elastic recoil

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55
Q

What are complications of atelectasis?

A

Decreased oxygenation of blood
Infection of atelectasis segment
If atelectasis persists for >72 h pneumonia will develop

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56
Q

Clinical presentation of atelectasis

A

Fever
Tachypnea
Tachycardia
Hypoxemia - after 48 hours postop

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57
Q

Exam findings for atelectasis

A

Diminished breath sounds at bases

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58
Q

What will CXR of atelectasis show?

A

Changes consistent with atelectasis

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59
Q

Treatment for atelectasis

A

Deep breathing exercises/incentive spirometry
Chest percussion, bronchodilators
Bronchoscopy

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60
Q

Prevention of atelectasis

A

Early mobilization
Incentive spirometry

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61
Q

Causes of pneumonia

A

Aspiration
Atelectasis
Underlying pulmonary disease/smoking
Increased pulmonary secretions
Diminished defense mechanisms postoperatively
Impaired cough reflex, loss of ciliary coordination

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62
Q

Clinical manifestations of pneumonia

A

Tends to occur within 3-5 days postop
Fever
Tachypnea
Shortness of breath
Increased respiratory secretions

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63
Q

Exam of pneumonia

A

Auscultatory crackles or diminished breath breath sounds
Dullness to percussion if consolidation present

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64
Q

Labs for pneumonia

A

Leukocytosis

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65
Q

Imaging for pneumonia

A

Infiltrates or consolidation on CXR

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66
Q

Treatment of pneumonia

A

Obtain sputum culture, begin empiric abx treatment
Postop hospital acquired pneumonia with no other risk factors or known resistance: rocephin, unasyn, levofloxacin, ertapenem

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67
Q

What is the most common cause of pulmonary related post op death?

A

pneumonia

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68
Q

what antibiotics should be used for pneumonia if concerns for resistant organisms or coverage for pseudomonas? MRSA?

A

zosyn, cefepime, imipenem
MRSA: vancomycin, linezolid

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69
Q

a small effusion is common after _____

A

abdominal/thoracic surgery

70
Q

what do more significant pleural effusions present with?

A

atelectasis and pneumonia

71
Q

signs/symptoms of pleural effusion

A

cough
SOB
chest pain
fever

72
Q

exam of pleural effusion

A

dullness to percussion
decreased tactile fremitus
asymmetrical chest expansion (delayed expansion on side of effusion)

73
Q

treatment of pleural effusion

A

small and causing no respiratory compromise - do nothing
causing respiratory compromise or associated with pneumonia - drain

74
Q

what is the greatest risk of pneumothorax related to surgery?

A

Subclavian central line or after surgery where diaphragm may be punctured

75
Q

clinical presentation of pneumothorax

A

sudden shortness of breath
chest pain/tightness
hypoxia
tachycardia
tachypnea

76
Q

what is present on exam of pneumothorax

A

unequal breath sounds
hyperresonance with percussion
decreased wall expansion

77
Q

what is the treatment of pneumothorax

A

thoracostomy

78
Q

what causes a UTI post operatively?

A

bladder catheterization/instrumentation
risk increases with prolonged catheterization (>2 days)

79
Q

most common organism to cause a uti

A

e coli

80
Q

s/sx of uti

A

dysuria
hematuria
frequency
fever/n/v
malodorous urine

81
Q

diagnosis of uti

A

urinalysis with culture

82
Q

treatment of postop uti

A

ciprofloxacin, rocephin

cippingon that rose for your uti

83
Q

when do utis commonly cause post-op fever?

A

after 48 hours

84
Q

risk factors for urinary retention

A

pelvic/perineal surgery
spinal anesthesia
over distension of urinary bladder (not catheterized)
h/o BPH/prostate tumor

85
Q

s/sx of urinary retention

A

oliguria/anuria
abdominal/pelvic pain discomfort

86
Q

exam findings of urinary retention

A

palpation of lower abdomen may demonstrate distended bladder

87
Q

diagnosis of urinary retention

A

bladder scan with PVR >400 mL

88
Q

treatment of urinary retention

A

bladder catheterization (Foley)

89
Q

possible post op wound complications

A

hematoma
seroma
wound dehiscence
surgical site infection

90
Q

what is a hematoma

A

collection of blood caused by inadequate hemostasis

91
Q

risk factors for hematoma

A

anticoagulants
coagulopathies
marked post-op HTN
vigorous coughing/surgery

92
Q

Clinical appearance of hematoma

A

Swelling
Discoloration
Bruising
Pain/discomfort
Blood leaking through incision

93
Q

Treatment of post op hematoma

A

Small hematomas may resorb on own
Compression dressing
Evacuation of hematoma, ligation of bleeding vessels

94
Q

Common sites of hematoma

A

Breast
Joints
Thyroid

95
Q

Complications of hematoma

A

Compress nearby structures
Reduced perfusion to site
Infections

96
Q

Most serious complications of hematoma

A

Neck: cut off air supply
Spine: compress spinal cord

97
Q

Prevention of hematoma

A

Stop anticoagulants
Drain placement intraoperatively

98
Q

What is a seroma

A

Collection of serous fluid typically from lymphatics caused by transection of lymphatics

99
Q

Clinical appearance of seroma

A

Swelling
Discomfort
Leakage of serous fluid from incision

100
Q

Common sites of seroma

A

Axilla and breast
Inguinal region

101
Q

Treatment of seroma

A

Needle aspiration, compression dressings
If recurrent or severe = surgical wound exploration

102
Q

Complications of seroma

A

Compression of nearby structures
Delay wound healing
Increase risk of infection

103
Q

What is wound dehiscence?

A

Complete or partial disruption of any or all layers of incision

104
Q

What is evisceration?

A

Rupture of all layers exposing internal organs

105
Q

Most common site of wound dehiscence

A

abdominal

106
Q

risk factors for wound dehiscence

A

Age >60
DM
Immunosuppression
Liver diagnosis
Sepsis
Cancer
Obesity
Inadequacy of closure
Increased intra-abdominal pressure
Infection

107
Q

Clinical presentation of wound dehiscence

A

Between post op day 5-8
Increased drainage from incision or sudden opening
Absence of healing ridge by day 5

108
Q

Treatment of wound dehiscence

A

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
Q

What causes wound infection?

A

Bacterial contamination during or after surgery, MC with staph aureus

110
Q

Types of SSIs

A

Superficial: skin and subcutaneous tissues
Deep: fascia, muscles, tissues
Organ/open space

111
Q

What is a clean surgical wound?

A

No hollow viscus entered
no inflammation/infection
no breaks in aseptic technique
primary wound closure
non-traumatic surgery

112
Q

what is a clean-contaminated surgical wound?

A

hollow viscus entered by controlled
no inflammation/infection
minor break in aseptic technique
primary wound closure

113
Q

what is a contaminated wound?

A

uncontrolled spillage from viscus
inflammation/infection apparent
traumatic wounds
major break in aseptic technique

114
Q

what is a dirty wound

A

untreated, uncontrolled spillage from viscus
pus in operative wound
open dirty traumatic wound

115
Q

SSI host risk factors

A

DM
hypoxemia
immunosuppressive drugs
cigarette smoking
malnutrition
poor skin hygiene/contaminated or infected wounds

116
Q

SSI infection risk factors

A

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
Q

s/sx of SSI

A

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
Q

management and treatment of ssi

A

culture
abx
surgical debridement

119
Q

prevention of ssi

A

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
Q

most common antibiotics for prevention of ssi

A

cefazolin (ancef)
ceftriaxone (rocephin)
cefoxitin (mefoxin)

three foxes ssigh with their violins

121
Q

what abx would you add to prevent SSI with a patient who is having colorectal or appendix surgery?

A

metronidazole (flagyl) or clindamycin

122
Q

gi complications of surgery

A

stress gastritis
n/v
gastric dilation
bowel obstruction
fecal impaction
postoperative pancreatitis
postoperative hepatic dysfunction
postoperative cholecystitis
c. diff colitis

123
Q

this is normal for the first 24-72 hours after surgery

A

functional postop ileus

124
Q

what usually causes bowel obstruction after surgery?

A

adhesions/blockage
usually later in post op phase
early postop obstruction mc with colorectal surgery
intussusception common cause in postop peds patients

125
Q

what diagnostic can show bowel obstruction and what does it show?

A

KUB XR: dilation above area of obstruction for bowel obstruction

126
Q

s/sx of ileus and obstruction

A

abdominal distention
abdominal pain
absence of flatus
n/v: bilious emesis

127
Q

exam for ileus and obstruction

A

protuberant tense abdomen
tympanic abdomen to percussion
lack of bowel sounds after 2 min, high pitch tinkering intermittent sounds

128
Q

treatment of ileus and obstruction

A

NG tube decompression
bowel rest/NPO
possibly need for adhesiolysis

129
Q

who more commonly gets fecal impact and what is the typical cause?

A

Elderly
Postoperative ileus, opioids, and reduced mobility

130
Q

s/sx of fecal impaction

A

anorexi
obstipation

131
Q

treatment of fecal impaction

A

manual removal
bowel regimen

132
Q

when does pancreatitis and cholecystitis most commonly happen?

A

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
Q

s/sx of pancreatitis and cholecystitis

A

acute severe abdominal pain
n/v/d
fever

134
Q

diagnosis of pancreatitis and cholecystitis postop

A

US/CT scan/MRI
elevated enzymes
leukocytosis

135
Q

symptoms of post op hepatic injury

A

jaundice to liver failure with increased risk with surgery of the upper abdomen, biliary tract, and/or pancreas

136
Q

what can cause jaundice post op

A

drugs
blood tranfusion reactions
damage to liver or liver resections
obstruction due to injury of bile ducts

137
Q

treatment of post op hepatic injury

A

discontinuation of drug
discontinuation of blood transfusion, fluid replacement
GI consult for ERCP, stenting

138
Q

what is the main risk associated with postoperative antibiotic use that can be transmitted person to person

A

c diff

139
Q

s/sx of c.diff colitis

A

malodorous diarrhea
abdominal distention
pain

140
Q

diagnosis of c. diff colitis

A

stool culture

141
Q

treatment of c. diff colitis

A

abx

142
Q

complication of c. diff colitis

A

toxic megacolon

143
Q

prevention of c. diff colitis

A

contact precautions

144
Q

cardiac complications postop

A

CVA
dysrhythmias
MI
DVT/thromboembolism
phlebitis/bacteremia

145
Q

what typically causes CVA

A

prolonged ischemia/poor perfusion
highest risk surgery: CEA, open heart surgery

146
Q

risk factors for CVA

A

elderly
patients with severe known atherosclerosis
severe hypotension during surgery

147
Q

when are dysrhythmias common

A

during induction and during surgery , typically self-limiting
postop typically due to electrolyte disturbances, drug toxicity, may be first sign of MI

148
Q

s/sx of dysrhythmias

A

often asymptomatic
may have CP
palpitations
dyspnea

149
Q

risk factors for post op MI

A

duration and type of surgery
prolonged hypotension
prolonged hypoxemia
patients with known CAD, HTN, CHF, angina

150
Q

s/sx of MI

A

CP
SOB

151
Q

diagnosis of mi

A

EKG
Labs

152
Q

Prevention of MI

A

stabilizing any underlying cardiovascular disorders prior to elective surgery

153
Q

what causes phlebitis

A

needle or catheter introduced into the vein causing inflammation –> infection and thrombosis causing fever 72 hours after surgery

154
Q

s/sx of phlebitis

A

induration
edema
tenderness
erythema
drainage
pronounced pain with infection

155
Q

treatment of phlebitis

A

removal of catheter
warm compresses
NSAIDs
abx and excision of affected area of vein with suppurative phlebitis

156
Q

prevention of phlebitis

A

good aseptic technique
rotation of insertion site

157
Q

risk factors for DVT

A

fhx
obesity
immobility
trauma
surgery
smoking
oral contraceptives
age

158
Q

s/sx of DVT

A

posterior calf pain
erythema
induration
tenderness

159
Q

diagnosis and compications of dvt

A

diagnosis: venous doppler
compliations: embolism

160
Q

treatment of dvt

A

anticoagulation therapy, filter

161
Q

prevention of dvt

A

chemical/mechanical DVT prophylaxis
early mobilization

162
Q

Virchow’s triad

A

endothelial injury
hypercoagulability
venous stasis

163
Q

what causes fat embolism?

A

tiny fat globules entering bloodstream through bone marrow, most common with orthopedic surgeries/long bone fractures

164
Q

s/sx of fat embolism

A

mostly asymptomatic
onset 12-72 h after surgery
respiratory distress/hypoxemia
petechiae of axilla and chest
neurologic abnormalities

165
Q

diagnosis of fat embolism

A

clinical
MRI can show emboli in brain

166
Q

tx of fat embolism

A

symptomatic respiratory support

167
Q

s/sx of pulmonary embolism

A

tachycardia
hypotension
tachypnea
hypoxia
chest pain

168
Q

dx of pulmonary embolism

A

state CTA PE protocol

169
Q

tx of PE

A

anticoagulation therapy
embolectomy

170
Q

when should a patient be discharged post-op

A

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
Q

what is the convalescent phase

A

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
Q

what should happen during the convalescent phase?

A

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

Surgery (7 decks)

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