Post operative complications Flashcards
What are the risk factors for post-operative complciations
• Poor nutritional state • Inflammatory state • Organ failure • Compromised immunity • Vascular disease • Elderly, smoking, DM, obesity • Dementia - patients who are not fully optimised pre-operatively
How do you manage the risk in post operative care
Monitoring
- vital signs
- fluid balance
- wounds, stomas, drains
- monitoring blood results
Medication
- VTE prophylaxis
- Antibiotics
- analgesia
- Nutrition
- Enhanced recovery
- Physiotherapy
What are the three classification for post operative complications
- General complications of surgery
- complications to specific surgery
- complications related to pre-exisiting comordbities
Name the general complications of surgery
- Haemorrhage
- SIRS
- VTE
- Wound complications and surgical site infections
Name complications that are specific to surgery
- Anastomotic leak, visceral injury
- Infected prosthetic materials
- Dysfunction of operated organ e.g transplanted organs
Name complications that are related to pre-existing comordbities
• Cardiovascular/ Respiratory pathologies
name another way of categoriesing post operative complications
By time
- immediate - first 24 hours
- early - first 4 days
- late - 5 days onwards
Name examples of immediate post-operative complications
- airway obstruction
- reactive haemorrhage
- acute pneumothorax
Name examples of early post operative complications
- acute cerebrovascular event
- acute myocardial infarction
- pyrexia
- post operative urinary retention
- renal impairment and failure
Name some examples of late post operative complications
- chest/wound/urinary infection
- secondary haemorrhage
- DVT/pulmonary embolism
- wound dehiscence
- delirium tremens
What is the systematic approach to assesing every patient
- ABCDE
- Stop if you find a problem; do something, reassess and start from the top again
- Correct abnormal physiology
- Re-assess
What is the score to check post operative complications
NEWS2
What is NEWS2 based of of
- respiration rate
- oxygen saturation
- systolic blood pressure
- pulse rate
- level of consciousness or new confusion
- temperature
What are the actions of NEWS2 based on the scores
less than 2
- qualified nurse to review patient at next hand over
score 2-3
- qualified nurse to review immediatley
- repeat observations and instigate therapy as prescribed
score 4-5
- qualified nurse to review immediately
- repeat observations and instigate therapy as prescribed
- junior doctor to review within 30 minutes
score 6-7
- qualified nurse to review immediately
- repeat observations and instigate therapy as prescribed
- urgent review by SHO or StR immediately plus inform critical care outreach team of patient
score 8
- qualified nurse to review immediately
- repeat observations and instigate therapy as prescribed
- urgent review by SHO or StR immediately plus
- urgent review by medical emergency team (MET immediately
What is the point of early warning
- Quantifies the change in observations
- Allows for early recognition of deteriorating patient which reduces mortality
- Empowers ward staff to call for help
What is shock
Shock is hypoperfusion leading to end organ damage
What are the types of shock
- Hypovolaemic
- cardiogenic
- obstructive
- distributive
What can cause hypovolaemic shock
- Bleeding
- burns
What can cause cardiogenic shock
- MI
- CCF
- arrhythmia - metabolic disturbances
- infection - infective endocarditis
- cardiac depression in sepsis
What can cause obstructive shock
- tamponade
- PE
- tension pneumothorax
What can caue distributive shock
- Sepsis
- anaphylaxis
What are the classes of hypovalemic shock
- Class I
- Class II
- Class III
- Class IV
What is sepsis
- charactersied by a life-threatening organ dysfunction due to a dysregulated host response to an infection
What is septic shock
- a subset of sepsis where particulary profound circualtory cellular and metabolic abnormaliteis substantially increase mortality
What is the new definition for sepsis
- Change in two point on the sequential organ failure assessment (SOFA) score
What is the new tool used for defining sepsis
qSOFA score (quick SOFA score)
describe how the qSOFA score works
- Respiratory rate of 22/min or greater
- altered mentation (glasgow coma score of less than 15)
- systolic blood pressure of 100mmhg or less
- two of the above is recommended as a screening tool but triggering on an early warning score may be superior
what is red flag sepsis
- Red Flag sepsis is not a definitive diagnosis but a tool to empower you to treat the patient
- It is based on early warning scores
describe what makes up red flag sepsis
Any one of the following
- AVPU= V, P or U (if changed from normal)
- Acute confusion
- Respiratory rate ≥25 per minute
- Needs oxygen to keep SpO2 ≥92% (88% in COPD)
- Heart rate >130 per minute
- Systolic B.P ≤90 mmHg (or drop >40 from normal)
- Not passed urine in last 18h/UO <0.5 ml/kg/hr
- Non-blanching rash, mottled/ashen/cyanotic
- Recent chemotherapy (last 6 weeks)
How do you manage sepsis
- give high flow oxygen
- take blood culutres
- give IV antibitoics
- give a fluid challenge
- measure lactate
- measure urine output
- give 3 and take 3
what does MOVE stand for (useful for emergency)
- monritoring
- oxygen
- venous access and bloods
- ECG adn escalate
What is a common finding in an ECG of a patient with an PE
- sinus tachycardia - most common sign
- S1, Q waves in lead 3, interveted T waves in lead 3 pattern (only 20% will actually have this)
what is mild pyrexia in the first 48 hours following an operation often from:
- atelectasis (need prompt physio, not antibiotics)
- tissue damage/necrosis
- blood transfusions
- infection (although less likely)
What investigations do you do for a mild pyrexia after surgery
- Blood - FBC, U&ES, CRP, Cultures +/- LFT
- urine dipstick
- consider MSU, CXR, and abode US/CT
What are the common causes of confusion after an operation
- hypoxia
- drugs (opiates, sedatives)
- urinary retention
- MI
- stroke
- infection
- alcohol withdrawal
- liver/renal failure
what are the causes of dyspnoea or hypoxia after an operation
- pneumonia
- pulmonary collapse
- aspiration
- LVF
- PE
- pnuemothroax
How do you investigate dyspnoea or hypoxia after an operation
- FBC
- ABG
- CXR
- ECG
What is a drop in blood pressure usually due to in post operative care
- often due to hypovoalemia - check fluid chart and replace losses
- monitor urine output
- hypovolaemia may also be caused by haemorrhage so check
What can cause an increase in blood pressure in post operative care
- pain
- urinary retention
- idiopathic
- inotropic drugs
What is anuria a sign of in post operative care
- may reflect blocked or mispositioned catheter
- AKI
What should the aim for urine output be in post operative care
- aim for urine output >30 ml/h in adults
How do you manage AKI in post operative care
- Review fluid chart and examine for signs of fluid depletion
- Examine for urinary retention (palpable bladder)
- Establish normovolaemia (CVP line may help) IVI or fluid challenge
- Catheterise bladder for accurate monitoring
- If intrinsic renal failure is suspected – stop nephrotoxic drugs and refer to nephrologist
what should you suspect if you have nausea and vomiting in post operative care
- Any mechanical obstruction, ileus or emetic drugs
What is a primary haemorrhage
- continuous bleeding
- starting during surgery
How do you treat a primary haemorrhage
- replace blood loss
- if severe return to theatre for Haemostasis
- treat shock vigorously
What is a reactive haemorrhage and how do you treat it
- Haemostasis appears secure until BP rises and bleeding starts
- replace blood
- re-explore wound
What is a secondary haemorrhage
- caused by infection
- occurs 1-2 weeks post op
what is the stress response to surgery
- This is the name given to the hormonal and metabolic changes which follow injury or trauma
Name the components of the stress response to surgery
- Sympathetic autonomic nervous system which results in an increased secretion of adrenaline
- Anterior pituitary - increased risk of ACTH - leading to increased cortisol risk
- increased ADH
- growth hormone is increase
- increased breakdown of carbohydrates
- protein metabolism is increased
- fat metabolism is increased
