Postoperative Complications

Question 1

common post op complications

Answer 1

post op fever
pain
vomitting
low urine output
bleeding
chest pain
ileum
wound problems
constipation
diarrhoea/large stoma output

Question 2

post op fever

Answer 2

practically every surgery patient will have a fever to some degree

Question 3

hypothermia

Answer 3

beware the hypothermic patient post trauma or major surgery
just as concerning as high temp

Question 4

fluctuations in temperature

Answer 4

body temp varies throughout the day due to normal metabolism
usually 36.5 at 06:00, and 37.5 at 20:00

Question 5

key to management of post op fever

Answer 5

the time since surgery at which the fever occurs determines management

Question 6

fever at day 0-2 is almost certainly due to

Answer 6

almost certainly due to Systemic inflammatory Response syndrome SIRS

Question 7

what is SIRS and why does it happen 0-2 days post op

Answer 7

cell damage during surgery attracts macrophages and neutrophils which release various interleukins, cytokines, TNF; causing activation of clotting cascade, complement system, kallikrien-bradykinin system etc leading to massive increase in metabolic activity
interleukins act on the hypothalamus to resent the thermal set point - hence fever

Question 8

usual post op temps due to SIRS

Answer 8

patients usually have post op temps of up to 38 for 1 to 2 days due to SIRS

Question 9

management of fever at day 0-2

Answer 9

observe
administer paracetamol (po or IV)
do not give antibiotics or do blood cultures - no need

Question 10

temp >40° at day 0

Answer 10

beware
could be malignant hyperpyrexia? rare
is an emergency - call anaesthetist
that with ice bath/slurry/IV fluids/Dantrolene

Question 11

possible causes of fever at day 1-3

Answer 11

aspiration
Acute MI
PE

Question 12

what to do if its aspiration

Answer 12

did they vomit during intubation?
do they have a post op ileus?

Question 13

what kind of people might get an acute MI post op

Answer 13

elderly
pre operative IHD
post operative AF

Question 14

why might they get a PE

Answer 14

innapprppriate prophylaxis
long operation
immobile

Question 15

what might cause a fever post op day 4-7

Answer 15

consider post operative infections
wound, line sites, urine, internal collection/abscess

Question 16

what to do if they have a fever day 4-7

Answer 16

check wounds - release sutures, swab, antibiotics, dressings
check line sites - remove, send for microscopy cultures and sensitivity (MCS), antibiotics
MCS urine
CT abdo, percutaneous drainage, antibiotics

Question 17

spiking fever at day 7+

Answer 17

consider anastomotic leak, abscess/collection
resuscitate with fluids, nil by mouth, CT, antibiotics, consider theatre

Question 18

temp above 36° at day 7+

Answer 18

beware
patient may be too unwell to mount a normal response

Question 19

post op pain is usually managed by

Answer 19

acute pain team
(anaesthetists who review post ops daily)

Question 20

types of pain management a patient may have after surgery

Answer 20

an epidural
patient controlled analgesia (PCA)
combined NSAID with Opiate for synergism

Question 21

using combined NSAID and opiate

Answer 21

use regularly with stronger opiate for breakthrough pain, prn
add antiemetic prior to opiate

Question 22

what causes post op nausea and vomiting

Answer 22

analgesia
post op ileus

Question 23

how to give antiemetics for post op nausea and vomiting

Answer 23

give parenterally (not orally)
eg. maxalon, ondansetron

Question 24

if post op nausea and vomiting is severe

Answer 24

change opiate

Question 25

minimum urine output should be

Answer 25

0.5mls/kg/hour

Question 26

pre renal causes of low urine output

Answer 26

dehydration (under volumed) haemorrhage pump failure (eg. AMI, CCF) vasodilation (epidural, sepsis) abdominal compartment syndrome (low venous return)

Question 27

renal causes of low UO

Answer 27

ATN - drugs, ischaemia (clamping renal vessels)

Question 28

post renal causes of low urine output

Answer 28

retention due to drugs, pain, prostatism, catheter problems (usually cause inability to void rather than low UO)

Question 29

most common cause of low UO

Answer 29

dehydration - but important to exclude haemorrhage

Question 30

assessment of a patient with low UO - history

Answer 30

feels thirsty, dizzy, unwell?

Question 31

assessment of a patient with low UO - examination

Answer 31

cool peripheries, tachycardic, tachypnoeic, hypotensive, check wound, abdo distension, other swellings, drains, check fluids given in theatre

Question 32

investigation for patient with low UO

Answer 32

bladder scan check FBC (? coags) if bleeding suspected

Question 33

a haemorrhage may be

Answer 33

primary (intraoperative) reactionary (post op when BP increases or clip/ti slips) secondary (several days later due to infection)

Question 34

if haemorrhage is obviously from a wound

Answer 34

apply pressure or insert suture reassess in 1-2 hours beware there could be massive intra-abdominal bleed that is welling up through the wound

Question 35

class 1 blood loss

Answer 35

<750ml obs normal

Question 36

class 2 blood loss

Answer 36

750-1500ml HR100-120 BP normal RR 20-30 UO 20-30

Question 37

class 3 blood loss

Answer 37

1500-2000ml HHR 120-140 BP reduced RR 30-35 UO 5-15 anxious

Question 38

class 4 blood loss

Answer 38

>2000ml HR > 140 BP reduced RR > 35 UO nil confused

Question 39

is low BP due to blood loss a big deal

Answer 39

yes

Question 40

paralytic ileus

Answer 40

disruption of normal small bowel motility from non mechanical causes occurs in post op patients

Question 41

aetiology of paralytic ileus

Answer 41

immobility low potassium or magnesium sepsis

Question 42

symptoms of paralytic ileus

Answer 42

bloating, abdo discomfort, nausea and vomiting

Question 43

signs of paralytic ileus

Answer 43

dehydration, abdo distension, absent bowel sounds

Question 44

investigation of paralytic ileus

Answer 44

blood test to exclude sepsis and dehydration consider imaging to exclude sepsis

Question 45

treatment of paralytic ileus

Answer 45

nasogastric tube, IV fluids, treat underlying cause

Question 46

symptoms of wound infection

Answer 46

erythema, swelling, pain, fever, discharge

Question 47

wound infection is usually due to

Answer 47

patients own skin flora and bowel contents

Question 48

management of wound infection

Answer 48

swab MCS remove clips/sutures open, decried slough, irrigate, pack involve wound specialist nurse start antibiotics

Question 49

wound dehiscence classification

Answer 49

superficial - skin deep - muscle and fascial layers only, skin intact full thickness - all layers open

Question 50

superficial wound dehiscence is managed by

Answer 50

dressings only you can resuture if clean and recognised early

Question 51

deep wound dehiscence manifests as

Answer 51

early hernia requires take back to theatre and resuture semi urgent

Question 52

full thickness dehiscence requires

Answer 52

urgent theatre