Postoperative Care & Complications Flashcards
(164 cards)
1
Q
What are the three postoperative phases
A
Immediate postoperative phase: Post anesthetic
Intermediate postoperative phase: Hospitalization period
Convalescent phase: From hospital discharge to full recovery
2
Q
Immediate postoperative period
A
Patient is transferred from operating room to either PACU or ICU to monitor.
Discharged from PACU when cardio, pulmonary, & neurologic function is back to baseline (~1-3 hours after operation)
3
Q
Immediate postoperative period: Monitoring
A
Vital signs, central venous pressure, intake & output, Intracranial pressure (in cranial surgery), pulses (vascular surgery)
4
Q
Immediate postoperative period: Respiratory orders
A
Intubated: Vent settings, CXR to check tube placement
Extubated: Supplemental oxygen PRN, IS, deep breathing, out of bed if no limitations.
5
Q
Immediate postoperative period: Position in bed
A
Elevate head of bed: Indicate minimal degrees of elevation
Elevate designated extremity
Specialty mattress for pressure relief if indicated
6
Q
Immediate postoperative period: activity orders
A
Bed rest: Consider DVT prophylaxis such as anticoagulant or sequential compression device (SCD):
Up in chair
Ambulate: Nursing &physical therapy
7
Q
Immediate postoperative period: diet
A
NPO vs clear liquids vs regular vs speciality diet
8
Q
Immediate postoperative period: Fluids and electrolytes
A
Fluids: Maintenance needs and replacement of losses
Electrolytes: Replace GI loss
9
Q
Immediate postoperative period: Drainage tubes
A
Specify type, amount of suction, irrigation fluid & frequency if indicated, and
Site care
10
Q
Immediate postoperative period: Medications
A
Analgesics: minimize in geriatric patients
Gastric acid suppression (selective use)
Deep vein thrombosis prophylaxis
Anxiolytic (selective use): use only when absolutely necessary and avoid in geriatric patients.
Hypnotics: lower dose in geriatric patients.
Antibiotics when indicated
Antipyretic prn
Stool softeners
Previous medications when indicated
11
Q
Immediate postoperative period: Laboratory testing
A
Depends on the patient and operation performed:
Significant blood loss: CBC
Significant fluids administered: BMP
Diabetic patient: Glucose checks q2-4h
12
Q
When is a CXR indicated postoperatively?
A
If patient is intubated, s/p central venous catheter placement, s/p tracheostomy, s/p cardiothoracic surgery.
13
Q
Intermediate postoperative period: Wound care
A
Sterile dressing should be applied in the OR.
Unless complications should remove dressing after 2 days (using aseptic technique –> gloves worn and wash hands before and after) to see if would edges have epithelialized.
Remove earlier if: Open wound Original dressing is wet Suspect infection: fever and increasing pain
14
Q
Intermediate postoperative period: suture/staple removal
A
Face wounds: remove sutures at post op day 2-3 & steri-strip
Most other wound closures: Remove sutures or staples by post-op day 5-7 and steri-strip wound ???? Slide 18
15
Q
When might wounds require more time prior to suture or staple removal?
A
Incisions that cross a crease line Incisions closed under tension Some incisions on extremities, especially incisions on feet Incisions in debilitated patients Scalp incisions
16
Q
What is the purpose of drain placement post op?
A
To evacuate fluid (pus, blood, serum) and air (from pleural cavity)
17
Q
Where should a drain be brought out?
A
Through a separative incision in order to prevent increasing the risk of wound infection.
18
Q
Intermediate postoperative period: Drain management
A
Use aseptic technique
Remove drain as soon as it is no longer useful
19
Q
What are the different types of drains?
A
Open, closed, and sump
20
Q
Open drains
A
eg Penrose
Increase rate of infection in surgical wounds. Use only in wounds already infected
21
Q
Closed drains
A
Connect to suction device
22
Q
Sump drains
A
Connect to suction device
Airflow system keeps lumen open. Useful when drainage is likely to plug other types of drains.
23
Q
What is the process of removing large bore drains?
A
After infection is controlled and large bore drain is to be removed:
consider slowly withdrawing drain over several days, progressively replace drain with smaller catheters as it closes.
24
Q
Intermediate postoperative period: Changes in pulmonary function following surgery
A
Decreased vital capacity
Decreased functional residual capacity –> both can lead to alveolar collapse and atelectasis
25
What are some common causes of pulmonary edema postoperatively?
Increased hydrostatic pressure (left ventricular failure and fluid overload)
Increased capillary permeability: Due to systemic sepsis or SIRS
Decreased plasma oncotic pressure
26
What patients are at increased risk for pulmonary complications?
Smokers
Those with underlying pulmonary disease (COPD)
Elderly
27
Intermediate postoperative period: Early respiratory failure (< 48 hours)
Associated with major operations and develops in short time span.
Chest or upper abdomen
Severe trauma
Preexisting lung disorder
28
Intermediate postoperative period: Late respiratory failure (> 48 hours postoperative)
Triggered by postoperative event:
Pulmonary embolism
Abdominal distension
Opioid overdose
29
What are signs of respiratory failure?
```
Tachypnea
Decreased tidal volume
PCO2 > 45 mm Hg
Po2 < 60 mm Hg
Low cardiac output
```
30
Respiratory failure treatment
1. Intubate and ventilate
| 2. Determine etiology
31
Respiratory failure prevention
Anticipate potential problems
Postoperative pulmonary care: IS, elevate head of bed, mobilize early if possible
Hypovolemia can lead to dry secretions and risk for pneumonia --> fluids, fluids, fluids!
Hypoventilation: avoid high FIO2 (with supplemental oxygen) because it removes stabilizing gas (nitrogen) for alveoli and causes over sedation. Control pain!
32
Intermediate postoperative period: Maintenance fluids
24 hrs = wt (kg) x 30
or
4 mL/kg/hr for 1st 10 kg
2 mL/kg/her for 2nd 10 kg
1 mL/kg/hr for every kg above 20 kg
33
Why do patients need maintenance fluids after surgery?
Systemic factors (fever, burns)
Loses from drains
Increased capillary permeability
34
Fluids: Dextrose 5% in H2O
50 g/ dL of glucose
| Given in the case of evaporative loss postoperatively
35
Fluids: Dextrose 5% & NaCl .45 %
50 g/dl of glucose + 77 meq/L of both Na and Cl.
36
Fluids: NaCl 0.9%
154 meq/L of Na and Cl
37
Fluids: NaCl 0.45%
77 meq/L of Na and Cl
38
Fluids: Lactated Ringers
103 meq/L of Na, 109 meq/L Cl, 28 meq/L of bicarb, and 4 meq/L of potassium.
Most commonly given as initial maintenance fluids and in the case of loss due to increased capillary permeability.
39
Fluids: Plasmalyte
140 meq/L of Na, 98 meq/L of Cl, 5 meq/L K, + magnesium, and buffers
40
Intermediate postoperative period: Potassium replacement
Usually potassium is not added to IV fluids for first 24 hours postop because levels may already be increased secondary to intraoperative trauma.
After 24 hours --> add 20 meq/L
41
When do you need to measure electrolyte levels postoperatively?
In patients requiring IV fluids for short postoperative period it is not indicated.
For complicated patients it may be needed daily in order to continue to evaluate fluid and electrolyte requirements.
42
What is in the process of evaluating fluid needs?
```
Vital signs
Mental status
I&O
Central pressure monitoring
Lab- acid-base status (ABG and BMP)
```
43
Intermediate postoperative period: postoperative ileus
S/p laparotomy peristalsis is decreased and slowly returns over 3-4 days.
Small intestine --> 24 h
stomach --> 48 h
large intestine --> 3-4 days
44
Intermediate postoperative period: Nasogastric tube indications
Esophageal & gastric resections
Marked ileus (bowel obstruction, diffuse peritonitis)
Acute gastric distension postoperative
45
Potential complications associated with nasogastric tube
Postoperative atelectasis
Postoperative pneumonia
Gastric reflux/ aspiration
46
When should you remove NG tubes?
When output is decreased
| Or when peristalsis is returned.
47
Intermediate postoperative period: hyperglycemia
Monitor blood sugar and maintain in appropraite range (140-180)
Return to preadmission regimen once diet has resumed.
48
Transfusion therapy: Whole blood
Contains 400-500 mL of donor blood with RBCs, Plasma, and clotting factors.
Platelets and granulocytes are not functions. Not routinely available.
49
Transfusion therapy: Fresh whole blood
Active clotting factors and functional platelets.
This is the ideal blood for massive trauma and availability is usually lacking.
50
Transfusion therapy: Packed red blood cells (RBCs)
One unit-300-350 mL of blood with plasma removed.
One unit should increase hemoglobin by 1 g/dL
51
Indications for blood transfusion
Hemoglobin < 7 g/dL
| Patients with cardiac, pulm, cerebrovascular disease may require transfusion at higher hemoglobin.
52
Transfusion therapy: Leukocyte-reduced RBCs
Filters remove more than 99.9% of contaminating leukocytes.
This is more expensive but may be indicated for those with previous transfusion reactions, chronically transfused, and immunosuppressed.
53
Transfusion therapy: Apheresis platelets
Platelets collected from a single donor by aphaeresis procedure.
Typically takes ~ 1-2 hours for collection.
54
Indications for platelet transfusion
Plateles count < 10,000/ uL
Active bleeding and count < 50,000
Prophylactic prior ot invasive procedure & platelet cound < 50,000
Prior to neurosurgical and ocular procedures and platelet count < 100,000
Active bleeding & patients has required 10 unites packed RBCs
55
Transfusion therapy: Renal failure
Platelet dysfunction in renal failure can cause bleeding issues.
Should: administer desmopressin (DDAVP)
for active bleeding and immediately prior to surgical incision.
56
Transfusion therapy: Fresh frozen plasma
Prepared from centrifugation of whole blood and apheresis.
Contains clotting factors, albumin, and fibrinogen
Can be used in patients with deficiency of coagulation factors (congenital, liver disease, DIC, warfarin overdose, massive transfusion, prior to invasive surgery with INR > 1.6)
Only give in circumstance of active bleeding or risk of bleeding from emergency procedure.
57
Fresh frozen plasma (FFP) usage
Monitor PT/ aPTT and INR
Contraindicated in INR < 1.5
For patients on warfarin consider holding medication and monitoring.
58
Transfusion therapy: Cryoprecipitate components
Fibrinogen
Factor VIII
Von Wildebrand factor
Factor XIII
Used to correct hypofirinogenemia & factor XIII deficiency
59
Postoperative Pain: pain control
Document pain control in daily chart
Control the patients pain while also trying to limit amount of opioid use.
Do not over sedate the patient.
60
Postoperative pain: pain management options
```
Parenteral opioids
Nonopioid parenteral analgesics
Oral analgesics
Patient-controlled analgesia
Continuous epidural analgesia
Intercostal block
```
61
Postoperative pain: Parenteral opioids
Bind to opioid receptors in CNS. Intravenous route preferred to intramuscular route.
```
Side effects:
Respiratory depression
Nausea & vomiting
Ileus
Clouded senorium
```
Especially see side effects in the geriatric patient!
62
Parenteral opioids examples
Morphine
+/- acetaminophen
Meperidine (Demerol)
Hydromorphone (Dilaudid)
63
Postoperative pain: nonopioid parental analgesics
NSAID drug (Toradol)
Available in injectable form
30 mg q6h
Want to limit use to 5 days.
Advantages: No respiratory depression
Side effects: GI, renal, impaired coagulation
**Avoid in orthopedic procedures
64
Postoperative pain: Oral analgesics
```
Indicated once pain level is decreased
options include:
Codeine + acetaminophen
Hydrocodone + acetaminophen
Oxycodone + acetaminophen
Oxycodone + ASA
```
65
Postoperative pain: Patient-controlled analgesia (PCA)
Consists of timing unit, pump, and analgesic. Patient can deliver predetermined dose of analgesic by pressing the button. Timing unit interposes an inactivation period between doses.
65
Postoperative pain: Patient-controlled analgesia (PCA)
Consists of timing unit, pump, and analgesic. Patient can deliver predetermined dose of analgesic by pressing the button. Timing unit interposes an inactivation period between doses.
66
Postoperative pain: Continuous epidural analgesia
Continuous infusion of morphine into the epidural space that can provide pain relief without respiratory depression or GI function disruption.
Side effects: Pruritis, nausea, urinary retention, infection
66
Postoperative pain: Continuous epidural analgesia
Continuous infusion of morphine into the epidural space that can provide pain relief without respiratory depression or GI function disruption.
Side effects: Pruritis, nausea, urinary retention, infection
67
Postoperative pain: Intercostal block
Used to reduce postop pain following thoracotomy. Eliminates muscle spasm induced by cutaneous pain,., improves respiratory function.
Disadvantages:
Risk of pneumothorax
Need to repeated injections
67
Postoperative pain: Intercostal block
Used to reduce postop pain following thoracotomy. Eliminates muscle spasm induced by cutaneous pain,., improves respiratory function.
Disadvantages:
Risk of pneumothorax
Need to repeated injections
68
Postoperative complications: mechanical
Occur as a direct result of a technical failure from a procedure or operation.
```
ex: Hematoma
Hemoperitoneum
Seroma (collection of clear serous fluid)
Wound dehiscence
Anastomotic leak
```
68
Postoperative complications: mechanical
Occur as a direct result of a technical failure from a procedure or operation.
```
ex: Hematoma
Hemoperitoneum
Seroma (collection of clear serous fluid)
Wound dehiscence
Anastomotic leak
```
69
Seroma management
Can solve by aspiration and compression dressing.
For some areas (groin) allow to resorb without aspiration.
69
wound hematoma
Collection of blood & clot in wound. Usually secondary to inadequate hemostasis.
Large hematomas should be evacuated.
70
Peritoneal complications: Hemoperitoneum
Bleeding into peritoneal cavity. Can be due to technical error, transfusion reaction, coagulopathy.
70
Peritoneal complications: Hemoperitoneum
Bleeding into peritoneal cavity. Can be due to technical error, transfusion reaction, coagulopathy.
71
Diagnosis of wound dehiscence
Usually occurs between post op day 5 and 8 and has discharge to serosanguineous fluid from the wound.
72
Wound complications: Seroma
Serous fluid collection often related to elevation of skin flap and disruption of lymphatics that can cause in increased risk of infection.
73
Seroma management
Can solve by aspiration and compression dressing.
For some areas (groin) allow to resorb without aspiration.
74
Wound dehiscence
Disruption of any or all layers of operative wound
Disruption of all layers allows for evisceration (or protrusion of abdominal viscera)
75
What are some systemic factors that can lead to wound dehiscence.
```
Diabetes mellitus
Pulmonary disease
COPD, chronic cough
Immunosuppression
Glucocorticoids, chemotherapy
Jaundice
Sepsis
Hypoalbuminemia
Cancer
Obesity
Anemia
Ascites
Emergency surgery
```
76
What are some systemic risk factors for wound dehiscence
Adequacy of closure
Intra-abdominal pressure (bowel obstruction, obesity, cirrhosis)
Poor wound healing (infection, seroma, hematoma)
77
Diagnosis of wound dehiscence
Usually occurs between post op day 5 and 8 and has discharge to serosanguineous fluid from the wound.
78
Treatment of laparotomy wound
Without evisceration --> promp reclosure of incision
W/ evisceration --> Cover eviscerated organs with moist towels to OR as soon as possible!
79
Complications of IV therapy: Suppurative phlebitis
Infected thrombus around IV catheter. Evident by inflammation, pus, and fever.
Treatment: Excise vein and antibiotics
80
Anastomotic leak
Disruption of surgical connection between two parts of intestine. May result in leakage of gastrointestinal contents into peritoneal cavity
81
Anastomotic leak systemic risk factors
```
Age
Malnutrition
Diabetes mellitus
Smoking
Inflammatory bowel disease
Recent radiation / chemotherapy
Anemia
Hypotension
```
82
Anastomotic leak local risk factors
Tension
Inadequate blood supply
Radiation
Contamination
83
Anastomotic leak diagnosis
Clinical: pain, fever, ileus, peritonitis, drainage of purulent material
Imaging: Fluid & gas containing collections
84
Complications of IV therapy: Phlebitis
Inflammation at entry site of IV catheter.
Management:Remove catheter at the first sign of induration, erythema, and tenderness!
85
Complications of IV therapy: Suppurative phlebitis
Infected thrombus around IV catheter. Evident by inflammation, pus, and fever.
Treatment: Excise vein and antibiotics
86
Complications of IV therapy: Venous air embolism
Air introduced into venous circulation that travels to R ventricle and pulmonary circulation.
Signs: Hypotension, jugular venous distention, tachycardia
Treatment:
Prevent by placing in Trendelenburn with placing catheter. Aspiration of air from IV line, turn onto left lateral decubitus position.
93
Complications of IV therapy: continuous monitoring of arterial blood pressure
Continuous monitoring in radial artery you must do the allen test prior to inserting line to avoid ischemia necrosis of a finger.
94
Peritoneal complications: Drains
Only use when indicated!
Watch for erosion into vessels and viscera.
Avoid placing over anastomosis.
Try to avoid open drains due to risk of infection.
95
Neuro complications: Post op CVA
Severe hypotensive episode (esp. in elderly)
S/p endarterectomy
s/p cardiac surgery requiring extracorporeal circulation.
96
Neuro complications: Post op seizures
Metabolic derangement
Previous history of epilepsy
Alcohol withdrawal
97
Postoperative seizure management
Restrain the patient
Administer IV benzodiazepine
Order --> metabolic panel and serum magnesium
Consult with neurology
98
Psychiatric complications: postoperative psychosis
```
Usually occurs after postoperative day 3
Symptoms include:
Confusion
Fear
Disorientation
Delirium may present as altered consciousness with cognitive impairment
```
```
R/o:
Sepsis
Metabolic disturbances
Endocrine dysfunction
Respiratory dysfunction
```
99
Psychiatric complications: ICU psychosis
Causes:
Sleep deprivation due to bright lights, monitoring equipment, and continuous noise
Symptoms:
distorted visual, auditory, and tactile perception, confusion, restlessness, and inability to differentiate reality from fantasy.
100
ICU psychosis prevention
Adequate sleep and decreased noise levels.
Transfer from ICU as soon as patient is hemodynamically stable and can be managed on med/surg ward
101
Psychiatric complications: Delirium tremens
May occur 48h to 14 days after acute withdrawal of alcohol
102
DT: Early signs
Anxiety, fever, tremor, tachycardia
103
DT: late signs
Confusion, restlessness, agitation, hallucinations, seizures.
104
Delirium tremens prevention and treatment
Prevent: benzodiazepines
Treatment: Close observation and monitoring
Restore nutrition
Correct electrolyte abnormalities
hydration
Restrain as needed and prevent aspiration.
May require transfer to critical care unit.
105
Postoperative cardiac complications
May be life threatening!
Need to prepare for them with appropriate evaluation of the patient.
Specifically address:
dysrhythmia, unstable angina, heart failure, severe HTN, severe valvular disease.
In patients at higher risk for cardiac complications continuous EKG monitoring is required during first 3-4 days.
106
Anticoagulation: Warfarin
Stop oral anticoagulant prior to surgery.
Warfarin: Stop 5 days prior to surgery and bridge with low molecular weight heparin 3 days prior to procedure, stop 1 day prior
For major operation resume LMW heparin 2-3 days postop then resume warfarin once patient is anti coagulated --> continue LMW heparin until anticoagulated on warfarin.
107
Anticoagulation: Direct thrombin inhibitor
Stop 2-3 days prior to surgery depending on bleeding risk and planned surgical procedure.
Restart POD 1 for low risk bleeding procedure and POD 2-3 for high risk.
Bridge with heparin in patients at high risk of post op thromboembolism and unable to take po meds initially post op
108
Anticoagulation: Direct factor Xa inhibitor
Same as Direct thrombin inhibitor**
Stop 2-3 days prior to surgery depending on bleeding risk and planned surgical procedure.
Restart POD 1 for low risk bleeding procedure and POD 2-3 for high risk.
Bridge with heparin in patients at high risk of post op thromboembolism and unable to take po meds initially post op
109
Anticoagulation: Cardiologist consult
Take home message:
Consult patient’s cardiologist preoperatively & postoperatively regarding management of anticoagulants & document in the medical record
110
Possible cardiac complications of general anesthesia
Depresses the myocardium
| Some agents can predispose to arrhythmias
111
Possible cardiac complications of neuraxial regional block (spinal, epidural)
Vasodilation and hypotension
Risk of spinal HA
Risk of epidural hematoma
112
Pacemakers and electrocautery
When using electrocautery it may interfere with pacemaker function --> inactivate pacemaker by placing a magnet over to disable all sensing.
113
Cardiac complications: intraoperative dysrhythmias
Incidence is higher with preexisting dysrhythmia or known cardiac disease
~ 35% of patients
One-third of intraoperative dysrhythmias occur during induction of anesthesia
114
Cardiac complications: Postoperative dysrhythmias
```
Etiology-
Hypokalemia
Hypomagnesemia
Hypoxemia
Alkalosis
Stress emerging from anesthesia
```
115
What are the risk factors for postoperative MI?
Operation for other manifestations of atherosclerosis
Preoperative CHF
Ischemia detected on stress test
Age > 70 years
116
Postoperative MI precipitating factors
Hypotension
Hypoxemia
Typically occurs within 48 hours of surgery
117
Postoperative MI symptoms
```
Chest pain
Hypotension
Tachycardia
Dysrhythmias
Dyspnea
Respiratory failure
Asymptomatic (~50%)
```
118
Postoperative MI evaluation
EKG (compare with preop)
Serum creatine kinase levels (x3)
Serum troponin levels (x3)
Trend!
119
Postoperative cardiac failure
Possible etiology:
Fluid overload in patient with limited cardiac reserve
MI
Dysrhythmia producing a high ventricular rate
Clinical manifestations:
Dyspnea
Hypoxemia
Diffuse congestion on chest xray
120
What is the most common cause of morbidity after major surgical procedures?
Respiratory complications
121
Risk factors for respiratory complications postoperatively
Chest & upper abdominal procedures
Emergency operations
Preexisting COPD
Elderly patients
122
Respiratory complications: Atelectasis
Affects 25% of patients with abdominal surgery and typically appears in first 48 hours.
123
Obstructive atelectasis
Atelectasis due to increased secretions that causes obstruction of the bronchus
124
Nonobstructive secretions
Decreased functional residual capacity and higher closing volume
Poor pain control --> poor inspiratory effort --> collapse of lower lobes --> decreased oxygenation of the lungs
If atelectasis persist for > 72 hours you can develop pneumonia.
125
Manifestations of atelectasis
Tachypnea
Tachycardia
Scattered rales
Elevation of diaphragm
126
Prevention of atelectasis
Early mobilization
Cough and deep breath
Incentive spirometer qh while awake
127
Respiratory complications: Pulmonary aspiration contributing factors
```
Depressed level of consciousness
NGT
GERD
Recumbent position
Intestinal obstruction
Pregnancy
```
128
Pulmonary aspiration dx
```
Clinical diagnosis
Dyspnea
Fever
Diffuse crackles of auscultation
Hypoxia
```
CXR abnormalities within 2 hours.
Bronchoscopy- erythema of bronchi
129
Pulmonary aspiration treatment
Suction airway
Mechanical ventilation for respiratory failure
Antibiotics indicated if heavily contaminated aspirate or if it does not improve in 48 hrs
130
Predisposing factors of postoperative pneumonia
```
Atelectasis
Aspiration
Prolonged mechanical ventilation
Immune suppression
Poor nutritional state
Smoking
NGT
Gastric acid reducing agent
```
131
Postoperative pneumonia prevention
Pain control
Encourage cough and deep breath
Incentive spirometer
If intubated:
Semi recumbent position
Oral hygiene with chlorhexidine rinse
Extubate as soon as it is safe to do so.
132
Postoperative pneumonia treatment
Aggressive pulmonary toilet (to clear secretions)
Mobilize patient
Sputum for culture and sensitivity
Antibiotics
133
Pleural effusion management
Asymptomatic --> observation
Suspicion of infection- thoracentesis for C&S
Respiratory compromise--. Drain
134
Postop complications: Fat embolism
Most commonly associated with long bone fractures (fat from disrupted bone marrow) or pelvic fractures
Fat enters the venules and travels to the lung (potentially after it is degraded into toxic intermediaries--> CRP and free fatty acid)
Manifests 12-72 hrs after initial injury
135
Fat embolism clinical manifestations
Respiratory distress: Hypoxia, dyspnea, tachypnea
Neurologic abnormalities: Confusion and altered level of consciousness
Petechial rash in axillae, chest, and neck
136
Fat embolism diagnosis
Clinical presentation
| Bronchoalveolar lavage may be useful --> fat droplets within alveolar macrophages
137
GI postop complications: Postoperative ileus etiology
```
Anesthesia
Manipulation of GI tract
Opioids
Electrolyte abnormalities
Inflammatory conditions
Peritonitis
Pancreatitis
```
All things that can slow down or stop peristaltic movement of the gut
138
GI postop complications: Gastric dilation
Massive distention of stomach by gas and fluid
treat with gastric decompression by NGT
139
GI postop complications: Bowel obstruction
Causes can be postoperative adhesions or internal hernia
Dx with abdominal radiographs (obstruction vs ileus) or CT of A&P (localize point of obstruction)
140
Bowel obstruction treatment
Fluid resuscitation
NGT
Check serum electrolytes
Partial obstruction can be treated initially with NGT suction.
Closed loop on xray --> exploratory laparotomy
141
Postoperative hepatic dysfunction
1% of surgical procedures performed under general anesthesia but more common related to pancreas or hepatobiliary system
142
Prehepatic jaundice
Hemolysis -->
transfusions, sickle cell crisis
or reabsorption of hematomsa
143
Hepatocellular insufficiency
Viral hepatitis, drug induces (anesthesia), hypotension, sepsis, liver resection
144
Posthepatic obstruction
```
Retained bile duct stone(s)
Injury to bile ducts
Tumor of bile duct
Sepsis (early)
Pancreatitis
Viral hepatitis (early)
```
145
Hepatic dysfunction evaluation
```
Liver function tests
Ultrasound
CT scan of abdomen & pelvis
Liver biopsy
Transhepatic cholangiogram
Endoscopic retrograde cholangiogram
Monitor renal function
```
146
Postoperative urinary retention
Common after pelvic and perineal operations & spinal anesthetic (leave catheter in place 4-5 days)
Treat with catheterization of bladder and sometimes leave in place
147
Post op: UTI etiology
Preexisting contamination of urinary tract
Urinary retention
Instrumentation
148
Post op: UTI manifestations and diagnosis
Dysuria, fever, flank tenderness, ileus
UA, Urine culture and sensitivity
149
Post op: UTI prevention and treatment
Prevent:
Treat urinary contamination preoperatively
Prompt treatment of urinary retention
Careful instrumentation
```
Treatment:
Hydration
Adequate drainage of bladder
Specific antibiotics
Removal of catheter as soon as possible
```
150
What are the 3 locations of surgical site infection (SSI)
Superficial incisional
Deep incisional
Orgam space
151
Systemic risk factors for SSI
```
Diabetes
Smoking
Obesity
Immunosuppression
Previous radiation
Malnutrition
```
152
Local risk factors for SSI
Surgical wound classification
(Clean, clean contaminated, contaminated, dirty)
Surgical technique
153
Diagnosis of superficial incisional (SSI)
Pain
Warmth
Erythema
Drainage through incision
154
Diagnosis of deep incisional & organ space SSI
Radiographic imaging may be helpful
155
Post op C. diff risk factor
Perioperative antibiotic use
156
Post op C. diff diagnosis and treatment
C. diff toxin in stool
Colonscopy with pseudomembrane present
Treat with IV metronidazole or PO Vancomycin
157
Operation specific risk for VTE
```
Cancer surgeries
Trauma
Pelvis procedure
Hip & lower limp procedures
Major general surgery operations
```
158
Patient specific risk factors for VTE
```
Thrombophilia- inherited hypercoagulable state
Prior VTE
CHF
Chronic lung disease
Paralytic stroke
Spinal cord injury
Malignancy
Obesity
Age > 40 years
Hormone replacement
Pregnancy
Immobility
```
159
Postoperative fever - What to consider in the first 48 hours?
Atelectasis
SSI
Systemic inflammatory response (blood products, trauma, laparotomy, major burn wound excision)
160
Postoperative fever > 48 hours postop
```
Central venous catheter
Catheter related phlebitis
Septic thrombophlebitis, endocarditis
Sinusitis
Pneumonia
Urinary tract infection
VTE
Drugs
Transfusions
Resolving hematoma
```
161
Postoperative fever > 4 days
```
Wound infection
Anastomotic breakdown
Intra-abdominal abscess
Enteric infection
Clostridium difficle
Empyema
Osteomyelitis (Sternum, fracture site -especially if open fracture)
```
162
Postop fever work up
```
Physical assessment
CBC, UA
Blood cultures
CXR
Sputum gram stain, C&S
Wound C&S
Culture fluid from any drain
Change CVP catheter & send tip for C&S
Venous doppler of BLE to R/O DVT
If blood cultures are positive & no obvious source --> echo
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163
What are the 6 Ws of postoperative fever?
Wind, water, wound, walking, wonder drugs, and what did we do?
A reminder to consider treatments as a cause of fever
Includes blood product transfusions; & intravascular, urethral, nasal, chest, & abdominal catheters/tubes
164
Post op fever imaging
NGT --> CT of sinus
Chest source --> CT of chest
Abdomen or plevis --> CT A&P
Diarrhea --> stool for C diff
