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Surgery > Post Op Fever, Wound Infection And Surgical Nutrition > Flashcards

Post Op Fever, Wound Infection And Surgical Nutrition Flashcards

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1
Q

Day 1 of Post-op fever

A

M/C cause: Atelectasis
Prevention:
1. Chest physiotherapy: Incentive spirometer
2. Pain control
3. Steam inhalation
4. Cessation of smoking (4-6 weeks prior to surgery)

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2
Q

Day 2-3 of Post-op fever

A
  1. Superficial thrombophlebitis
  2. UTI: M/C hospital acquired infections
  3. Pneumonia
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3
Q

Day 4-5 of Post-op fever

A
  1. Surgical site infection
  2. Deep venous thrombosis
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4
Q

Day 6 of Post-op fever

A

Burst abdomen/Abdominal wound dehiscence

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5
Q

Day >=7 of Post-op fever

A

Intra-abdominal abscess/collection

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6
Q

What is Surgical site infection?

A

Wound infection within 30 days of surgery
Post implantation: Within 1 year of surgery

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7
Q

Types of scoring systems for SSI

A
  1. ASEPSIS score
  2. Southampton wound score
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8
Q

ASEPSIS score for SSI

A

Additional treatment
Serous discharge
Erythema
Purulent exudate
Separation of deep tissues
Isolation of bacteria
Prolonged Stay >14 days

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9
Q

Southampton wound score for SSI

A

0: Normal healing
I: Normal healing + mild bruising/erythema
II: Erythema + other inflammatory signs
III: Clear discharge
IV: Pus discharge
V: Deep/severe wound infection +/- tissue breakdown

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10
Q

DVT prophylaxis

A

Pneumatic compression stockings

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11
Q

Patients factors predisposing to Burst abdomen

A
  1. Chronic cough
  2. Constipation
  3. Infection/obesity
  4. Immunocompromised
  5. Malnourished
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12
Q

C/F of Burst abdomen

A

Salmon fluid/Serous fluid sign (Large quantity of clear fluid oozes out of wound)

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12
Q

What is Burst abdomen?

A

Rectus sheath wound opens up: Bowel exposed out

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12
Q

Management of Burst abdomen

A

In emergency: Urobag or bogota bag laparoscopy
Definitive: Rectus sheath resuturing

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13
Q

Surgery factors predisposing to burst abdomen

A
  1. Midline incision > Transverse
  2. Emergency > Elective
  3. Continuous sutures > Interrupted
  4. Large bite > Short bite
  5. Short thread > Long thread
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14
Q

M/C site of Intra-abdominal abscess

A

Pelvis/Pouch of Douglas

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15
Q

M/C site of Intra-abdominal abscess in Supine patient

A

Morrison’s/Hepatorenal pouch

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16
Q

C/F of Intra abdominal pouch

A

Fever + chills and rigors
Pelvic abscess: Presents with pelvic diarrhoea (Repeated episodes of loose stools + mucus)

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17
Q

Management of Intra abdominal abscess

A

IOC: CECT
Drainage with pigtail catheter under imaging guidance

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18
Q

Examples of Clean wound

A

Clean incised wound:
1. Thyroid surgery
2. Breast surgery
3. Knee replacement
4. Uncomplicated inguinal hernia surgery

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19
Q

Types of Wounds

A
  1. Clean wound
  2. Clean contaminated wound
  3. Contaminated wounds
  4. Dirty wound
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20
Q

Examples of Clean contaminated wounds

A

GI/GU system but there is no inflammation:
1. Elective/interval cholecystectomy
2. Elective appendectomy
3. Urinary stone removal when no UTI
4. LSCS
5. Bowel surgery, if bowel is prepared
6. Laparoscopic abdominal hysterectomy

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21
Q

Examples of Contaminated wounds

A

GI/GU system but there is non purulent inflammation:

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22
Q

Examples of Contaminated wounds

A

GI/GU system but there is non purulent inflammation:
1. Emergency/interval cholecystectomy
2. Emergency appendectomy
3. If bowel is opened while operating a case of intestinal obstruction
4. Breach in sterile protocol: Open cardiac massage

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23
Examples of Dirty wound
Pus present: 1. All abscesses 2. Peritonitis/Fecal contamination 3. Any neglected traumatic wound > 6 hours
24
When are prophylactic antibiotics given before surgery?
Given 30-60 minutes before surgery Prolonged surgery: Repeat dose after 4 hours
25
Indicator of poor prognosis for weight after a surgery
Unintentional weight loss of >10% in 3 months
26
Assessment of Nutrition for surgery
Fat: Skin fold thickness Muscle mass: Mid arm circumference
27
Indicator of poor outcome in Surgical nutrition
Low albumin, BMI <15
28
Malnutrition Universal Screening Tool (MUST)
BMI score + Weight loss score + Acute disease effect score = Overall risk of malnutrition
29
Types of Nutrition
1. Enteral (Oral/gut) 2. Parenteral (IV route)
30
Which is a better method and why?
Enteral: 1. More physiological 2. Prevents translocation of gut bacteria
31
Best route for Enteral nutrition
Oral
32
If oral not possible, enteral nutrition given by
Based on duration of requirement: 1. If > 3 weeks: > Gastric emptying good: Feeding gastrostomy > Poor: Feeding jejunostomy 2. If < 3 weeks: > Gastric emptying good: NG tube > Poor: Nasojejunal tube
33
How to check NG tube position?
1. Clinical methods: > Aspirating gastric contents > Pushing air f/b Auscultation in epigastrium 2. Imaging: Chest X ray
34
Techniques for Gastrotomy and Jejunostomy
1. Open techniques: > Stamm method > Witzel technique 2. Percutaneous endoscopic gastronomy (PEG) 3. Radiologically inserted gastronomy (RIG): Done when endoscopy is not possible
35
Tube related complications of Enteral nutrition
1. Blockage 2. Migration 3. Leak
36
Feeding regime related complications of Enteral nutrition
1. Osmotic diarrhoea (Sugar rich fluids) 2. Over feeding (Inc in risk of aspiration)
37
Best route of Parenteral nutrition
Central line
38
Indications of Parenteral nutrition
1. Prolonged paralytic ileus (>72 hours) 2. Short bowel syndrome (<200 cm small intestine) 3. High output fecal fistula (>500 cc/24 hours) 4. Acute episodes of inflammatory bowel ds 5. Acute severe pancreatitis (Initial phase only)
39
Veins chosen for Central line
1. Subclavian vein 2. Internal jugular vein 3. Femoral vein
40
M/C vein used in TPN
Subclavian vein
41
M/C used vein overall for Central line
Internal jugular vein
42
Vein with least risk of thrombosis and infection for Central line
Subclavian vein Max: Femoral vein
43
Vein with least risk of pneumothorax for Central vein
Femoral vein Max: Subclavian vein
44
Catheter tip position
In SVC Just above the Right atrium
45
Contents of TPN
Protein:Fat:Carbohydrate = 20:30:50
46
Infusion rate of TPN
1-2 litres/24 hours
47
TPN solution modifications in Respiratory failure
Dec carbohydrates (Dec osmolar) Dec quantity
48
TPN solution modifications in Renal failure
Inc carbohydrate Dec quantity
49
Daily monitoring of Patients on Feeding regimes
1. Pulse, BP and temperature 2. Body weight (Inc: Earliest sign of overfeeding) 3. Input/output chart 4. Type of nutrition given
50
Biochemical measures monitored of patients on feeding regimes
Initially daily Later once/twice a week 1. Na, K, urea and creatinine 2. Blood glucose 3. Magnesium and phosphate 4. Liver function tests 5. CRP
51
Central line related complications of TPN
1. Pneumothorax 2. Arrhythmias 3. Thrombosis 4. Air embolism 5. Migration 6. Catheter related sepsis (M/C central line complication)
52
Feeding regime related complications of TPN
1. Hyperglycemia (M/C) 2. Excess weight gain 3. Cholestasis (Withhold TPN) 4. Micronutrient deficiency (M/C: Zn def) 5. Refeeding syndrome
53
What is Catheter related sepsis?
On fluid administration -> Fever + chills and rigors Investigations: Cultures from catheter tip, peripheral line and central line Management: Remove catheter if it is the source
54
What is Refeeding syndrome?
Large quantities of nutrition given to chronically malnourished
55
Metabolic derangements in Refeeding syndrome
1. Dec in K 2. Dec in Ca 3. Dec in PO4: Main driver 4. Dec in Mg 5. Fluid overload
56
Patients at risk of developing Refeeding syndrome
>= 1 factor: 1. BMI <16 kg/m2 2. Unintentional weight loss >15% within last 3-6 months 3. Little/no nutrition intake for >10 days 4. Dec K/PO4/Mg prior to feeding
57
Prevention of Refeeding syndrome
1. Inc feeds gradually (Initially 10 kcal/kg/day -> Full feeds in 4-7 days) 2. Strict electrolyte levels monitoring 3. Thiamine supplementation
58
Liver dysfunction in TPN Just study
Long term TPN use -> 25% liver derangement Fatty liver (M/C): 1. Children (M/C) 2. Modified using lipid free solutions Intestinal Failure Associated Liver Disease (IFALD): Small no of patients
59
Main cause of death in Refeeding syndrome
1. CHF 2. Arrhythmias

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