1.8 Postoperative care and complications Flashcards
What are the general steps in postoperative treatment?
- precise observation (monitoring)
- temperature, BP, pulse, breathing
- checking urinations and stool
- checking drains (quality and amount of discharge)
- checking wound, catheters and canules - early mobilization/physiotherapy
- thrombosis prophylaxis
- early enteral nutrition
Recommended thrombosis prophylaxis for surgery
- mechanical methods
- early mobilization, active or passive movement of the extremity
- elastic shocking
- intermittent pneumatic compression pump
- medication
- non-fractionated heparin (antidote: protamine-sulfate)
- LMW heparin
- Xa inhibitors, indirect thrombin inhibitors
What to do if the patient is on aspirin?
low operative risk: continue aspirin
high operative risk: stop 7 days before surgery, and continue 48hrs after it
What to do if the patient is on clopidogrel or double TAG?
low operative risk: continue
high operative risk: stop 5 days before the surgery and continue aspirin according to cardiologist’s opinion
What to do if the patient is on cumarine?
for both low and high operative risk:
- if target INR<1.5, use LMWH instead at least 5 days prior to surgery
- after surgery, continue LMWH with cumarine for a few days until target INR=2-3
What is a postoperative complication?
any difference from normal expected healing has to be considered as a complication
Classification of post operative complications by severity
this is called the Clavien-Dindo Classification
grade I: any deviation from the normal postoperative course; only medication for management of symptoms
grade II: normal course is altered so blood transfusions or parenteral nutrition might be necessary
grade III: complications require intervention of various degrees (IIIa requires intervention under local anesthesia; IIIb is any intervention under general/epidural anesthesia)
grade IV: complications threatening life of patient (IVa is a single organ dysfunction; IVb is a multi-organ dysfunction
grade V: death
What are the most common surgical complications?
- bleeding
- fever <24h (>38.5º)
- mostly abnormal, could be community acquired or nosocomial infection
- check operation site, airways, cannulas and catheters - anastomosis leakage
- hypotension, hypovolemia, hypoxia, microcirulation failure - confusion (old age, acute case, oversedation, opioids)
- ileus (paralytic, mechanical, vascular)
- sepsis (intraabdominal abscesses)
- fistula (late consequence of anastomotic leakage)
- impaired wound healing
- factors reducing defenses
- hernia formation
- suppuration (overgrowth of bacteria)
- wound disruption
What are the non-surgical respiratory complications?
ventilation, perfusion and diffusion can be affected by surgery – especially, ventilation and diffusion because respiratory motors are affected by thoraoabdominal surgeries.
- atelectasis: treated with physiotherapy, correct body position, removal of NG tube, bronchoscopic suction and inhalation drugs
- aspiration
- postoperative pneumonia
- pleural effusion
- pulmonary embolism
- pulmonary edema
- ARDS (acute resp. distress syndrome)
What are the non-surgical cardiovascular complications?
- arrythmias, heart failure
- postoperative acute MI, hypertensive crisis
- thrombosis and embolism
What are the non-surgical renal complications:
- acute renal failure
- indication for hemodialysis
- extracellular [K+] > 6.5mmol/L
- volume overload
- exctracellular [Cre] > 900μmol/L
- metabolic acidosis
What is malignant hyperthermia?
- if the patient has an underlying muscle disorder caused by RyR mutation, they may develop muscle rigidity, heat production and acidosis. This is caused by excess Ca2+ in the muscles that is triggered by inhalation of anesthetics and succinyl choline
- symptoms: continuous muscle shivering leading to heat production, then hyperthermia
- treatment: dantrolene to reduce Ca2+ release from SR
