8 - Post-op Flashcards
Asepcts of ensuring patient safety:
QA/QI
Communication (hand-off, time-out, consents)
Documentation of care
Reporting complications (M and M)
Patient feedback (surveys)
Surgical complications
Bleeding Anesthetic/medications reactions Infection Injury to surrounding structures Poor cosmetic outcome Retained foreign body (sponges, instruments) Recurrence
How to prevent retained foreign bodies
Increased communication with team members
X-ray and wand prior to leaving OR
Ensure accurate instrument / sponge count
Radiopaque line on sponges
Post-op complications at 0-48 hrs
Resp and card issues
Failure of ventilation
Aspiration
Sudden cardiac event
HOTN
Post-op complications 48hrs to 30 days
Localized - UTI, pneumonia
Systemic - SIRS, MODS
PROBABLE TEST QUESTION
What is atelectasis?
Collapsed alveoli -> decreased gas exchange -> one of the MC complications of general anesthesia
Causes of atelectasis
Pain inhibits cough, deep breath
hypoventilation
Retained secretions
Low tidal volume
Presentation of atelectasis
Low-grade fever
Decreased breath sounds
Basilar rales
Seen on CXR
How to prevent atelectasis
Stop smoking prior to surgery
Post-op - incentive spirometry, deep breathing, ambulate, pain management
Txt for atelectasis
Chest physiotherapy (percussion, postural drainage)
Naso-tracheal suctioning
Therapeutic bronchoscopy
Presentation of pneumonia
Fever
Cough (productive)
Leukocytosis
CXR - infiltrate, consolidation
Txt for pneumonia
ABX
Aggressive pulm toilet
Intubation (maintain PCO2 35-45, SpO2 > 95%)
Prevention of VAP
Elevate head of the bed
Ventilator liberation trials (daily) - see how they do off the vent
Don’t over-sedate
PUD prophylaxis
DVT prophylaxis
Aggressive oral hygiene
Causes of aspiration pneumonia
Vomiting 2/2 anesthesia, narcs, ileus/obstruction, meals before surgery, obese/pregnant, AMS
Prevention of aspiration pneumonia
NPO at least 6 hrs prior to surgery
NGT
Cricoid pressure / avoid insufflating the stomach
Management of aspiration pneumonia
Suction immediately
Bronchial hygiene
ABX
Mechanical ventilation
Causes of pulmonary edema
Volume overload
CHF
Renal failure
Management of pulmonary edema
Close monitoring of fluid status
Sit up
Diuretics PRN
Consider / rule out PE and MI
Low threshold for intubation and mechanical ventilation
ARDS
Non-cardiogenic pulmonary edema
Interstitial - doesn’t respond to diuretics
Not 2/2 HF or fluid overload
Inflammatory process - 3rd-spaced fluid
Txt of ARDS?
Mechanical ventilation
Moderate PEEP settings 10-15cm (>15cm considered high)
Lower tidal volumes 5-7ml/kg IBW vs traditional 10-15ml/kg IBW
Maintain FiO2 <60% to avoid O2 toxicity
Increase the expiration time (more alveoli open)
Airway pressure release ventilation - full inspirations, little pulsing expirations (possibly works better than prone)
Central lines good for:
More caustic meds, ABX, blood
Monitoring hemodynamics (Swan Ganz, Vigeleo)
Easy to draw blood
Easy access
Complications of central line
Infection
PTX
Hematoma
Sterile technique critical
Fat emboli associated with:
Long bone / pelvic fx
Fat globules move into pulmonary capillary bed
Petechial rash
Normal d-dimer
Supportive care
Don’t forget to r/o PE / MI
Risk factors for PE
Malignancy Pregnancy Immobilization Nephrotic syndrome Blood dyscrasia (hypercoagulable)
Presentation of PE
Hypoxia
Tachypnea
Signs of DVT
PE workup
Low pulse ox Hypoxemia Hypocarbia D-dimer Cardiac isoenzymes and BNP to r/o MI and CHF
Imaging for PE workup
CXR limited
Spiral CT with PE protocol
VQ if pregnant or renal problems
Pulmonary angiogram - good but requires a central line
Txt for PE:
O2, IV access
Anticoag - heparin or SQ LMWH
Oral warfarin x 3-6 mos (INR 2-3)
Oral Xa inhibitors to replace warfarin
Inferior Vena Cava Filter - Christmas ornament
Virchow’s triad
Venous stasis
Endothelial injury
Hypercoagulability
Risk factors for DVT
Malignancy Elderly Pregnancy OCP use Post-partum Prolonged immobility Surgery stuff
DVT presentation
Swollen
Warm
Pitting edema
Homan’s sign
Txt for DVT
Elastic stockings
Early ambulation
Compression devices
Anticoag - heparin, LMWH, Anti-Xa, warfarin
Compartment syndrome
Normally from long bone fx
Fascia surrounds muscle
Muscle belly inflames or bleeds with intact fascia
Pressure causes impaired perfusion -> ischemia -> necrosis
S/s of compartment syndrome
Pain out of proportion (early)
Loss of function / distal pulses (late)
Prevention / treatment of compartment syndrome
Incise from skin through fascia
Fasciotomy - allows muscle to swell without compressing vessels
Rusk factors for decubitus ulcer
Immobility (sedated, on vent, SCI)
Prevention of decubitus ulcer
Adequate nutrition Frequent turning Pad pressure points Special beds Daily skin inspections Good skin hygiene
Parotiditis
Inadequate oral hygiene
Dehydration
Epistaxis
Unhumidified O2
Ototoxicity
Aminoglycosides
Vancomycin
A-fib
Rule out MI and PE first
Check electrolytes and volume status
Cardiogenic shock
Decreased forward flow from the heart
Neurogenic shock
Loss of neurogenic tone
Distributive shock
Loss of vascular tone
Ileus complications
Hypovolemia
Abd surgery
Mitigate with preop Entereg (alvimopan) and minimizing bowel manipulation
Mitigate GI bleed risk with:
PPI
H2 blockers
Pancreatitis can occur after
ERCP
Biliary surgery
C dif is the MCC of:
ABX-associated diarrhea
Suspect c diff in pts with:
> 3 loose stools in 24 hrs
Most c diff pts respond to:
Oral vanc or metronidazole
Drastic c diff measures
Fecal transplant
Subtotal colectomy
Prevention of c diff
Hand washing
Judicious use of ABX
Contact precautions
Avoid gastric acid suppression
Pre-renal dehydration / hypovolemia
Can lead to oliguria
Consider first in post-operative patient
Higher insensible losses
Intra-renal oliguria
Consider in pts who received IV contrast, ABX, and diuretics
Crush, electrical injuries - myoglobin obstructs glomerulus - push IVF to flush it out - can alkalinize IVF to enhance myoglobin solubility
Post-renal oliguria
Prostate hypertrophy
- restart alpha blockers in pts with BPH
Obstructed bladder catheter
DOPE the catheter - Displaced-Obstructed-Positional-Equipment failure
Neurogenic bladder - DM, narcs, antihistamines / cold medicine
MC complication of bladder catheterization
UTI
Minimize catheter UTI by:
Using sterile technique
Removing ASAP when no longer needed
Hernia repair can impact which nerve
Ilio-inguinal
Leads to skin numbness
Mastectomy can impact which nerve
Long thoracic nerve
Leads to winged scapula
Thyroid / parathyroid surg can impact which nerve
Recurrent laryngeal
Leads to hoarseness
Carotid endarterectomy can impact which nerve
Hypoglossal nerve
Leads to deviated tongue
DIC
Initially prothrombotic condition which results in multi-vascular thrombi and MODS
• Progresses to consumption of all coagulation proteins and results in severe bleeding
Transfusion related complications
Hypocalcemia- serum Ca binds to the citrate in banked blood
• Transfusion reaction
• TRALI- Transfusion Ralated Acute Lung Injury
• Metabolic acidosis- hyperkalemia of banked blood 2/2 hemolysis
• Hypothermia during transfusion
Hypothermia leads to decrease in
SpO2
Oxy-hemoglobin dissociation curve
Lethal triad - metabolic acidosis, coagulopathy, hypothermia
Abdominal compartment syndrome
Usually after long abdominal case with
manipulation or trauma which required massive
fluid resuscitation
Ways to mitigate abdominal compartment syndrome
Abdomen not closed and converted to wound vac
Allows for tissue expansion to minimize tissue ischemia and dehiscence
Wound complications
Hematoma / seroma: small - resolve on their own….larger - aspirate or open to decompress
Salmon colored fluid?
Early fascial dehiscence
It’s peritoneal fluid
Late fascial dehiscence leads to
Incisional hernia
If surgical site infection
Open, irrigate, pack
Avoid temptation to reclose
MC nosocomial infection is:
A surgical site infection
Test question!
Other causes: c. diff, catheter UTI, central line infx, VAP
Fever workup
H and P
Atelectasis, pneumonia
UTI
SSI
Cultures
CXR
Inspect IV sites
DC invasive stuff you don’t need
Keeping your patient alive
Round on the sickest patients first
If the nurse calls: see the patient, note GCS, assess ABC’s, always consider MI and PE
Anaphylaxis? Epi, diphenhydramine, solumedrol
Keep in touch with senior resident
SIRS criteria
Temp
Tachycardia
Tachypnea
Leukocytosis
There are 2 kinds of Subaru owners
Pre-op and post-op
