Post Op Complications Lecture Flashcards by Cassidy Ruocco

Endogenous pyrogen release:
IL-1
IL-6
TNF alpha
Interferon

Fever

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At what temp do we start to worry post op?

38 C

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Inflam stimulus
Atelectasis
Surg site infection
Nosocomial pneumonia
UTI
Drug fever
DVT

Causes of post op fever

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What are the 5 Ws of fever?

*W**ind
*W**ater
*W**alking
*W**ound
*W**onder drugs

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Wind (atelectasis) is usually seen on post op day ____?

POD 1-2

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True or False…

up to 90% of general anesthesia pts get atelectasis

True

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Causes:

*compressive** (positional)
*absorptive** (pain with deep inspiration)
*combo of absorptive + surfactant dysfxn** (anesthesia, ventilator associated)

Atlectasis (wind)

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atelectasis usually resolves within..

48 hours

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if atelectasis remains unresolved, what can develop after 72 hours?

pneumonia

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How can you prevent atelectasis/pneumonia?

Incentive spirometer
Mobility

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What is the “Water” cause of post op fever?

POD 3-5

UTI

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What is the “Walking” cause of post op fever?

POD 4-6

DVT

(MC in pelvic, general, ortho surg)

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Walking on post op day 1
Pneumatic compression
Antiembolsim stockings
LMWH or UFH
Warfarin
Aspirin

DVT prophylaxis

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Wound (infection) cause of fever typically occurs on post op day….

5-7

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Wonder drugs (drugs can cause fever) typically occurs on post op day..

(FYI in OB/GYN, the final W is womb)

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Atelectasis
Pulmonary edema
Alveolar hypoventilation
Aspiration
Pneumonia

..all causes of?

Respiratory failure

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Fever
SOB
Gradual decrease in O2 sat
Cough

Pneumonia

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Ambulation
Cough
Incentive spirometry

all ways to prevent..?

Pneumonia

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Auscultation
CXR
WBC

..used to dx what?

Pneumonia

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Tx of post op pneumonia?

Chest PT
Antibiotics

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Ventilator tubing
ET tube
Humidification fluid

all can cause?

Ventilator associated pneumonia

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gm neg pseudomonas serratia
gm pos MRSA

common pathogens of ventilator associated pneumonitis

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How can you prevent ventilator associated pneumonitis?

Aseptic technique
Avoid prolonged intubation

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Immobility
Hypercoaguable secondary to surg
Tobacco use
Estrogen
Increase age and comorbities

Risk factors for VTE

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is a D-Dimer useful in post-op patients?

How do you diagnose a VTE?

venous doppler

2 kinds of PE?

Clinically significant Non clinically significant

Sudden SOB Pleuritic CP Fever Sudden hypoxemia Tachycardia Cough/hemoptysis

Dx via: Chest CT Angiogram VQ scan

Post op arrhythmias: Atrial tachycardia Atrial fibrillation Ventricular arrhythmias ..MC after what type of surgeries?

Cardiac Thoracic

Hypoxia Hypovolemia Hyperthermia Electrolyte imbalance Hypoglycemia HTN Infection Meds

causes of post op arrhythmias

MC cause of morbidity and mortality after non cardiac surgeries?

Typically occurs **within 5 days of surgery** Post op ischemia on EKG is ominous sign\* May occur with arrhythmia

signs: HF, unexplained SOB, tachycardia, hypotension may no present with typical CP Tx: consult with surgeon

Post op MI

Dyspnea Hypoxemia w normal CO2 tension CXR with increased vascular markings

Heart failure/pulmonary edema

Reduce preload (diuretics) Possibly digitalis Inotropic support Invasive monitoring if in shock Ventilatory support as needed

Post op HF tx

Manipulation of heart and aorta Particulate release from ECMO ..early or late perioperative stroke?

Early

Emboli from Afib Supply/demand MI Coagulopathy ..early or late perioperative stroke?

Late

Advanced age Non-elective surgery Female sex EF \<40% Vascular disease DM Creatinine \>2mg/dl or dialysis

Pt dependent risk factors

Acute mechanical failure of the wound closure

Dehiscience

Mechanical force Tissue ischemia due to tight suturing Poor suturing technique Local infection ..causes of?

wound dehiscience

True or False... 14-16% of all infections in hospitalized pts are post op wound infections

True

Most post op wound infections require...

surgical debridement

Is induration a normal sign with a wound?

YES

Redness Swelling Localized heat Increased pain Dehiscience Tachycardia Fever (late)

signs of infection

Non abdominal surgeries No gross contamination ..which classification?

Clean

Elective GI surgeries Lightly contaminated ..which classification?

Clean contaminated

"Spill" during elective surgery Perforated gastric ulcer ..which classification?

Contaminated

Intestinal infarction Intra abdominal abscess drainage ..which classification?

Contaminated

Infected Intestinal infarction Intrabdominal abscess drainage ..which classification?

Dirty

Source: pt skin OR environment surgical team contaminant: gm +

Clean wound infection

Limit pre-op hosp Pre-op shower Chlorhexadine bath Hair removal Avoidance of adhesive drapes Decrease OP time

Ways to prevent infections

Decreased suture material Decreased cautery Drains

Procedural infxn prevention

**Endogenous colonization** Polymicrobial contaminant - frequently gm neg - anaerobes

Clean contaminated

Source: **gross contamination** polymicrobial contamination

Contaminated wound infection

Abx must be present at time of contamination!! ## Footnote **give pre op abx \<60 min of incision re dose 4-6 hours later \< 3 post op doses**

Contaminated wound infxn

Should you give long term abx for contaminated wound infections?

Source: **established post op infection** polymicrobial

Dirty wound infection or intra-abdominal abscess

Spore forming gm + anaerobic bacillus ## Footnote **carriage by 20-50% of adults in hospitals and LTC**

C dif

Associated with abx, **esp clindamycin and fluoroquinolones**

C dif

Fecal/oral transmission Spores resistant to heat, acid, alcohol, and abx **sporilates in the presence of waterless hand wash** (must be washed down the drain)

c dif

PO metronidazole PO vanco (NO IV) PO vanco plus IV metro

C dif

MC nosocomial infection

UTI

Preexisting urinary tract contamination Urine retention Instrumentation

UTI risk factors

5% of catheter pts will develop bacteriuria within 48 hours of palcement but only \_\_% will develop a UTI

Dysuria and mild fever

Cystitis

Hydration Bladder drainage Specific abx

UTI tx

**Temporary paralysis of a portion of the bowels** typically follows abdominal surgery may accompany any abdominal infxn or trauma risk with any surgery

post op ileus

N/V Vague abdominal symptoms ``` dx: abdominal X ray Clinical impressiong (**quiet bowel sounds**) ```

Paralytic ileus

Tx: NPO NG tube IVF/nutrition (D5 IV) Support \*do no jump right to TPN

Paralytic ileus

**Hypermetabolic condition of muscle** Muscle necrosis and Rhabdomyolysis may occur Potentially fatal Associated w autosomal dominant mutations

Malignant hyperthermia

Malignant hyperthermia triggers?

Extreme stress Anasethetic agents

Abrupt increase in ETCO2 Possible massester rigidity Increased body temp (may be delayed up to 36 hrs) Tachycardia Cyanosis Muscle rigigity

Malignant hyperthermi

True or False... With malignant hyperthermia, an increased body temp may be delayed up to 36 hours after trigger

True

Compartment syndrome Rhabdo Acidosis (resp and metabolic) Arrhythmias/sudden cardiac arrest

Malignant hyperthermia late effects

Check family hx Muscle biopsy with stimulated contaction studies

Ways to prevent malignant hyperthermia

Discontinue triggering agent Dantroline Cooling blankets (without shivering) Renal support Search for occult compartment syndrome Respiratory support

Malignant hyperthermia tx