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Flashcards in Post-operative complications Deck (28):
1

Potential complications

1. Respiratory failure->heart and lungs
2. Wound failure->check wound site
3. Confusion->orientation
4. Pyrexia->vitals
5. Deep vein thrombosis->painful calves, mobilising, DVT prophylaxis
6. Oliguria->urine output
7. Hyponatremia->bloods
8. Hypernatremia
9.Hypo/hyperkalemia
10. Hemorrhage
11. Vomiting

2

Causes of respiratory failure

1. Pulmonary embolism
2. Acute lung injury/ARDS
3. Abdominal distension
4. Opiate overdose

3

Potential wound failures

1. Discharge of fluid
(serous, blood, serosanguinous,
infected fluid)
2. Collection of fluid
(blood, pus, seroma--> large incision in SC or lymphatic damage-->lift skin off tissues and impede wound healing
3. Disruption of the wound

4

Risk factors for wound breakdown

1. General
DM
Immunosuppression
Malignancy
Malnutrition
2. Local
Wound closure
Infection
Foreign body
Mechanical stress

5

Serous versus serosnguinous from wound

1. serous may be little significance
2. Serosanguinous--> 5-8 days post may be due to dehiscience
with evisceration. Sterile dressing
consider taking back to surgery

6

Causes of post-operative confusion

1. Hypoxia->pneumonia, PE, cariac
2. Sepsis
3. Drug withdrawal, drug effects
4. Metabolic/electrolyte
5. Urinary retention

7

Management of confusion

1. Study charts
2. Co-morbidities
3. Drug/alcohol
4. History and examine
5. Consider oxygen
Consider ABG, FBC/UEC/LFTs,
blood/urine culture, CXR, echo?
6. May need sedation->midazolam, haloperidol

8

Define normal temperature

A normal temperature is 36.5-37.5

9

What considerations with post-op pyrexia

1. Type of fever
2. Procedure
3. Temporal relationship

10

Fever within 24 hours

1. ATELECTASIS
2. Metabolic response

11

Fever days 5-7

Usually infection
Pulmonary can
Consider: infection of the wound, operative site or urinary tract
Cannula and DVT!

12

Fever >7 days post op

Abscess
Also remember--> drugs, transfusion, brainstem as cause of
+temperature

13

Causes of oliguria

Diminished output

most commonly hypovolemia
2. Intra-renal (ATN)
3. Post renal failure: Need accurate matching input and output
Most ensure not in acute urinary retention

14

Common causes of oliguria in terms of procedure and ileus

1. Underestimating fluid loss in procedure
2. Ileus->fluid becomes sequestered in the gut

15

Cause of hyponatremia and management

1. Mostly dilutional
2. +ADH

Fluid restriction 2L until diuresis settles

16

Causes of hypernatremia and management

Usually secondary to
reduced water intake
1. Administer water by mouth or
IV dextrose
2. Max reduction 10mmol/L in 24
hours redution/L dextrose= sodium concentration/ (TBW +1)

17

Types of hemorrhage related to surgery

Localised
1. Primary-
within procedure
2. Reactionary- w/i
24 hours of procedure,
most commonly from
poorly ligated blood vessel
3. Secondary 7-10 days
after operation-->most often erosion of vessel from spreading infetion, intraperitoneal bleeding, GIT hemorrhage, disordered hemostasis

18

Causes of vomiting

1. Drugs->immediate
2. Gut atony->self limiting
3. If >7 days->consider mechanical course

19

Causes of post-op fever and timeframe

1. Wind
Pulmonary 1-3 days
Atelectasis, pneumonia
Exacerbate pre-existing
2. Water
UTI day 3-5
3. Wound
Infection day 5-8
4. Walk
Venous->DVT, PE, Thrombophlebitis
5. Wonder drugs
Any drug can cause

20

Timing of post-op fever to identify cause

1. Hours after POD 1
Inflammatory
Blood reaction
Malignant hyperthermia
2. POD 1-2
!Atelectasis
Early wound
Aspiration pneumonitis
Addisonian, thyroid storm
Transfusion reaction
3. POD 3-7
UTI
Surgical site infection
Septic thrombophlebitis
Leaked anastamosis
4. POD 8
Intra-abdo abscess
DVT/PE, drug fever
Cholecystitis, peri-rectal
abscess, URTI,
seroma/hematoma/biloma that's
infected
C dif colitis, Endocarditis

21

Immediate post-operative management

1. Pain and other medications
a. analgesia,
b. antibiotics
(prophylactic or therapeutic),
c. sedatives,
d. antiemetics and
e. anticoagulants/DVT prophylaxis-->
ensure charted and being
administered where relevant
2. Monitoring
vitals, (may include cVP),
Fluid input and output
Normal fluids noted
If fluid shifts/renal reduce-->
catheter and review hourly
Check UEC, CRP, eGFR, haem regularly
3. Mobilisation
as early/much as can (not in
epidural catheter,
multiple injuries)
Physio--> help flow, reduce
DVT risks
4. Communication
5. Respiratory
6. Fluid balance
7. Gut function
8. Drain and catheter care

22

Respiratory considerations

1. Control of pain
2. Regular hyperinflation with inhalation spirometry
3. Early mobilisation

23

Gut function considerations

1. Gastric dilitation: 2-3 days post-->massive fluid secretion, risk of regurg and aspiration
Insert NGT and decompress
2. Paralytic ileus: first post op
following peritonitis or 5 days post. Abdominal distention and vomiting
a. Oral fluid restriction
b. IV replacement
c. Most resolve spontaneousl
d. May consider pro-kinetic agents
3. Pseudo-obstruction:
elderly who has surgery
for fractures NOF
a. If not resolving spontaneously,
colonoscopic decompression

24

Principles of fluid balance

1. Correct abnormalities
2. Provide the daily requirements
3. Replace any abnormal/ongoing losses

25

Daily requirements

basic requirements
45-60% TBW
2/3 intracellular
1/3 plasma water
(25% of extracellular fluid) and
interstitial
fluid (75% of extracellular fluid).
Na and potassium daily
requirements:
100–150 mmol and 60–90 mmol-->will balance loss in urine
Daily requirement for
maintenence 2-3L:
Loss: 1500 mL in the urine and about 500 mL from the skin, lungs and stool

26

What do you need to do prior to potassium supplementation

Need to ensure kidneys are functioning

27

Approximting losses from gastric, duodenal, diarrhea, upper GI, lower

Gastric--> +chloride,
sodium, small potassium
Duodenal/biliary/
pancreat/jejuno/feces--> mostly
Na, Cl and bicarb
Diarrhea--> Na, Cl, potassium and
bicarb
Upper GI-->acid lost (metabolic
alkalosis)
Lower-->sodium and bicarb

28

Management of wound dishiscience and evisceration of the ward after laparotomy

1. Assume defect involvles whole of the wound
2. Put guts in abdomen, sterile dressing
3. IV cannula, IV antibiotics, IVF
4. Get senior help
5. Let theatre know
6. Analgesia