Lecture 5: Postoperative Care Flashcards
What are the primary goals during the PACU and intermediate phase of postop care?
- Hemostasis
- Pain control
- Prevention and early detection of complications
What occurs in between the immediate to intermediate period of postop care?
- Discharge from recovery to floor
- Admit orders
- PostOp note + Procedure Note
- Operative report
Who must dictate the operative note?
Surgeon
When does epithelialization of a wound occur and what does this mean for sterile dressings?
First 48h, which means sterile dressings must also be changed under sterile technique
What patient education should be provided for wound care?
- Generally want to keep incision dry for a few days
- Showering is ok
- Avoid submerging wounds for 2 weeks
How long does it take baseline pulmonary function to return generally postop?
a week
What is the MC pulmonary risk post op and management for it?
Atelectasis, managed by incentive spirometry and early mobilization
What is the 4:2:1 rule for maintenance fluids?
- 4x10 for first 10kg
- 2x10 for second 10kg
- 1x remaining kg
- I.e 75kg = 40 + 20 + 55 = 115mL/hr x24 = 2760 mL/day
When is blood transfusion indicated postop?
- Hgb < 7 in any pt
- Hgb < 8 + cardiac/pulm/CVD
MC postop pain control
Opiates via IV or PCA
Usually transition to oral after 48h
What is the main purpose of non-opioids in pain control postop?
Reducing the amt of opioid required
Multimodal pain therapy is key
Why might a NG tube be used postop?
- N/V
- Ileus due to anesthesia
- Abdominal distension
Diminished peristalsis 24h postop is common
What Pauda prediction score is high risk for DVT?
> = 4
What is the key factor in differentiating postop fever?
Its onset
What are the 5 W’s of an acute postop fever?
- Wind: Atelectasis/PNA, 24-48h postop, CXR
- Water: UTI, 3-5d postop, UA with culture
- Wound: Superficial vs deep, 5-7d postop, Visual/CT
- Walking: DVT => PE, 7-10d postop, Venous doppler/CT scan PE
- Wonder Drugs: Anytime, dx of exclusion
Increasing in onset timing
What is the MCC of fever 24-48h postop?
Atelectasis
What are the risk factors for atelectasis?
Smokers/COPD/Elderly
What are the main complications associated with atelectasis?
- Hypoxia
- Infection of atelectasis segment
- PNA if persisting > 72h
Tx of atelectasis
- Deep breathing/incentive spirometry/coughing
- Chest percussion, BDs
- Bronchoscopy for severe
Clinical features of PNA
- 3-5days pstop fever
- Tachypnea, SOB, increased respiatory secretions are common.
What is the MCC of pulmonary related postop death?
PNA
Tx of postop PNA
- Obtain culture, then empiric abx
- Rocephin, Unasyn, levofloxacin, ertapenem
PE findings for pleural effusion
- Dullness to percussion
- Decreased tactile fremitus
- Asymmetrical chest expansion
Tx of pleural effusions
- Small: no nothing
- Symptoms/PNA: drain
When is risk of pneumothorax highest postop?
Placement of subclavian central line or in a surgery where diaphragm puncture could occur
Tx of pneumothorax
Thoracostomy
MCC of UTI (organism)
E. coli
Tx of UTI postop
- Rocephin
- Cipro
common cause of postop fever 48h
Dx of urinary retention
Bladder scan of >400 mL PVR (post void residual)
Risk factors for hematoma postop
- AC
- Coagulopathies
- Marked postop HTN
- Vigorous cough/straining
Tx of hematoma
- Small: let it resorb on its own
- Compression dressings
- Evacuation or ligation
What two hematoma locations are extremely dangerous?
- Neck
- Spine
Where are seromas MC postop?
- Breasts
- Axilla
- Inguinal
Tx of seromas
- Needle aspiration
- Compression dressings
- Exploration if recurrent
Where is wound dehiscence MC?
Abdomen
Primary risk factors for wound dehiscence
- > 60 yo
- DM
- Immunosuppressed
- Liver Ds
- Sepsis
- Cancer
- Obesity
- Inadequate closure
- Increased intra-ab pressure
- Infection
When does wound dehiscence tend to occur?
POD 5-8
Tx of wound dehiscence
- Moist towels + binder until surgical consult
- Debridement and reclosure of fascia with secondary intention
MCC of wound infection (organism)
S. aureus
4 types of surgical wounds
- Clean: no hollow viscus entered
- Clean-contaminated: hollow viscus entered but controlled
- Contaminated: uncontrolled, major break in aseptic tech
- Dirty: untreated, uncontrolled
When do SSI tend to present?
Surgical site infection
POD 5-6
When is ileus normal postop?
First 24-72h
What usually causes GI obstruction postop?
Adhesions/blockage
What would KUB XR show for GI obstruction?
Air fluid levels with distinct dilation above area of obstruction
In postop peds pts specifically, what is the MCC of obstruction?
Intussusception
When is acute pancreatitis and cholecystitisMC postop?
- Biliary tract surgeries
- Acute pan: after ERCP or cholecystectomy
- Acute chole: After ERCP or upper GI procedures
What 3 areas increase risk of a postop hepatic injury?
- Surgery of upper ab
- Biliary tract
- Pancreas
What is postop C Diff colitis mainly caused by?
Postop abx use
What surgery is highest risk for a CVA postop?
CEA (Carotid endarterectomy)
What are postop dysrhythmias MC due to?
- Electrolyte disturbances/drug toxicity
- Potential sign of an MI
When is phlebitis fever MC postop?
72h
What is Virchow’s triad?
- Endothelial injury
- Hypercoagulability
- Venous stasis
When is fat embolism most common?
Postop for ortho sx involving long bone fx
