Post Op Cx

Question 1

What commonly causes respiratory complications?

Answer 1

• general anaesthesia
• post-op pain
• immobility

Question 2

Define the following terms

Hypoxia

Hypercapnia

Hypocapnia

T1RF

T2RF

Answer 2

• PaO2 <10.5kPa
• PaCO2 >6.5kPa
• PaCO2 < 3.5kPa
• PaO2 < 8.0kPa
• PaO2 < 8.0kPa, PaCO2 >6.0kPa

Question 3

What are the examples of respiratory complications?

Answer 3

• Chest infection
• COPD exacerbation

Question 4

What are the initial assessment and mx for pt c suspected respiratory complications

Answer 4

• Position: sit pt up
• Airways
  
  • give high flow O2 using tight fitting mask
• Breathing
  
  • check chest expansion
  • auscultate lungs bilaterally
  • If bronchospasm - nebulise 5mg salbutamol
  • Order CXR
• Circulation
  
  • assess circulation

Question 5

What features lead to the diagnosis of chest infection?

Answer 5

• Bedside
  
  • cough c purulent sputum
  • pyrexia
  • bronchial breathing
  • reduced air entry
• Lab
  
  • raised CRP, neutrophils
  • Sputum culture + for organism
• Imaging
  
  • CXR consolidation

Question 6

How to prevent chest infection post op?

Answer 6

• Active chest infection
  
  • Prevent surgery
• Cough, temp, clinicl signs of chest infection undergoing elective
  
  • deferred fortnight and reassess

Question 7

What are the RF for chest infections?

Answer 7

• Active smoker
• Stopped smoking within last 6 weeks
• COPD
• Obesity
• Prolonged ventilation
• Aspirating pt

Question 8

What are the supporting tx for chest infections?

Answer 8

• Physiotherapy
  
  • assist coughing
  • prevent mucus plugging
• Analgesia
  
  • allow pt to cough

Question 9

What are the definitive tx for chest infection?

Answer 9

• Braod spec antibiotic until organism sensitivities known
• Tx suspected aspiration pneumonia
• Humidify oxygen - prevent mucus plugging
• CPAP - improve basal collapse
• Hypoxic, tachypnic, tiring pt should be reviewd urgently

Question 10

What is the epidemiology of COPD?

Answer 10

• Moderate COPD
  
  • not associated c inc. post op cx
• Severe COPD + steroid use
  
  • associated c increase morbidity, mortaity after surgery

Question 11

What to ensure for Pt on preoperative B-agonist inhalers?

Answer 11

• Regular post-operative nebulizers

Question 12

What are the causes of post-op chest pain?

List them according to these headings

Dull,central ache

Central pain radiating to back

Pain on movement

Pleuritic pain

Answer 12

• Dull,central ache
  
  • MI
  • Gastric distention
• Central pain radiating to back
  
  • Thoracic aneurysm/dissection
  • PUD, oesophagitis, panreatitis
• Pain on movement
  • MSK pain
  • Chest drains
• Pleuritic
  
  • Chest infection
  • Pneumothorax
  • Haemothorax, pleural effusion, empyema
  • Chest drain in situ
  • PE

Question 13

What is oliguria an anuria?

Answer 13

• oliguria
  
  • UO <0.5ml/kg/h
• anuria
  
  • no UO

Question 14

What does UO indicate?

What does UO indirectly measure?

Answer 14

• GFR
  
  • influenced by renal plasma flow and renal perfusion
• Renal and blood flow function

Question 15

What are the initial mx for oliguria?

Answer 15

• Check Foley catheter
  
  • catheter may be obstructed, bypassing or malpositioned
  • Flush 60ml saline. If unable to draw back this amount - change to new catheter

Question 16

How would you mx oliguric pt with loop diuretics?

Answer 16

• If pt is adequately filled, MAP normal
  
  • 20mg furosemide IV
  • if no response, give further 40mg IV
• If urine produced after furosemide concentrated
  
  • pt inadequately filled

Question 17

What are the Cx of oliguria?

Answer 17

• Pulmonary & cerebral oedema
• CCF
• Hyperkalaemia
• Acidosis

Question 18

What type of pt will commonly get acute urinary retention post operatively?

Answer 18

• elderly males after abdominal, pelvic or groin surgery and after anticholinergics

Question 19

What are the clinical features of acute urinary retention?

Answer 19

• Suprapubic discomfort
• inability to initiate micturition
• Hx of prostatic disease
• Percussable bladder

Question 20

How would you Mx acute urinary retention?

Answer 20

• Conservative
  
  • Analgesia
  • tx constipation
  • mobilise
  • warm baths
  • restart tamsulosin
• Definitive
  
  • insert urinrary catheter

Question 21

What are the types of gastrointestinal complications post op?

Answer 21

• Paralytic ileus
• Post op mechanical small bowel obstruction
• N&V
• D&C
• Anastomotic leakage

Question 22

What are the causes of constipation?

Answer 22

• Lack of privacy
• immobility
• pain from wounds
• anal fissure
• dehydration
• poor nutrition
• low fibre
• opiates
• spinal anaesthesia

Question 24

What are the tx for post op constipation?

Answer 24

• Bulking agents
• Stool softeners
  
  • sodium docusate 30-60mg od PO
• Osmotic agents
  
  • lactulose 5-10ml bd
• Stimulants
  
  • senna one table bd PO

Question 25

What are the common causes of post op diarrhoea

Answer 25

* resolving ileus/obstruction * Antibiotic related diarrhoea * C.diff * pseudomembranous colitis

Question 26

What are the cx of post op N&V?

Answer 26

* increase bleeding * incisional hernias * aspiration pneumonia * dec. absorption of oral medication * poor nutrition * hypokalaemia

Question 27

What causes post op N&V?

Answer 27

* Anaesthetic agents * opiods * spinal anaesthesia * gastric dilation from CPAP * bowel obstruction * gastric refulx * peptic ulceration * constipation * sepsis * hyponatraemia * antibiotics * NSAIDs

Question 28

What are the common causes of confusion post op?

Answer 28

* Medication * benzos, opiates, anticonvulsant * Stroke * Hypoxia, hypercapnia * shock * sepsis * alcohol withdrawal * metabolic distrubances * low - glucose, Na, pH * high- Ca, creatinine, urea

Question 29

What are the clincial features of post op confusion?

Answer 29

* Obvious signs * disoriented * uncooperative * hallucinating * Subtle signs * inactivity * quietness * slow thinking * labile mood

Question 30

How would you mx post op confusion?

Answer 30

* If pt pose danger to themselves or others * First line: sedate c Haloperidol 2.5mg PO, IM or IV * 2.5-5mg midazolam if still disturbed * Be aware of sedating hypoxic or hypotensive - can trigger cardiorespiratory arrest * Assess & tx hypoxia and hypotension * Reassess drug chart * stop opiates and benzos * Assess metabolic status * correct low glucose/Na * Perform neurological examination - exclude stroke