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 would determine whether a patient goes to immediate post op or to a recovery room?
Whether they are in patient or out patient
immediate postop: out patient
recovery room: in patient
i wrote this in so literally wont be a question lol i just wanna know
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 is the main provider during the immediate post operative period?
anesthesiologist
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
remains markedly diminished for 12-14 hours post op
Who is pulmonary function depression worse in?
elderly
smokers
obesity
pre existing lung diease
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
LR or D5/0.5%NS are most commonly used
When is blood transfusion indicated postop?
- Hgb < 7 in any pt
- Hgb < 8 + cardiac/pulm/CVD
Must obtain consent before giving blood!!
What is the MC blood transfusion?
packed RBCs
general rule: 1 unit of RBCs increases Hg by 1 g/dL and Hct by 3%
MC postop pain control
Opiates via IV or PCA
Usually transition to oral after 48h
goal: adequate pain control; minimal side effects
What is the main purpose of non-opioids in pain control postop?
Ketorolac (Toradol)-NSAID
Tylenol
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 can be used for DVT prophylaxis
chemical vs mechanical
- Medications: MC Lovenox (LMWH) or SQ Heparin
- Compression Stockings
- Early ambulation
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
Also the most common post operative pulmonary complication
What is atelectasis? How would a patient with Atelectasis present?
Collapse of the bronchioles
Caused by shallow breathing and failure to hyperinflate the lungs
fever, tachypnea, tachycardia
hypoxemia after 48 h postop
Diminished breath sounds at bases
What are the risk factors for atelectasis?
Smokers/COPD/Elderly
increase secretions can lead to obstructions
What are the main complications associated with atelectasis?
smokers/elderly/COPD patients are so HIP
- Hypoxia
- Infection of atelectasis segment
- PNA if persisting > 72h
Tx of atelectasis
- Deep breathing/incentive spirometry/coughing
- Chest percussion, BDs
- Bronchoscopy for severe
prevention: early mobilization, incentive spirometry
Clinical features of PNA
+ what would you see on exam
- 3-5days post op fever
- fever, tachypnea, SOB, increased respiratory secretions are common.
exam: auscultatory crackles or dimished breath sounds, dullness to percussion if consolidation is present
labs: leukocytosis
CXR: infiltrates or consolidation on CXR
What is the MCC of pulmonary related postop death?
PNA
Tx of postop PNA
what if its resistant?
what about vanc?
PNA post op RULE #1 killa
- Obtain culture, then empiric abx
- Rocephin, Unasyn, levofloxacin, ertapenem
resistant organisms: pip/taz, cefepime, imipenem
MRSA: vanc, linezolid
after what surgery are small pleural effusions common + s/sx
small effusion common after abdominal/thoracic surgery
s/s: cough, sob, chest pain, ….surprise surprise…fever
PE findings for pleural effusion
- Dullness to percussion
- Decreased tactile fremitus
- Asymmetrical chest expansion (delayed expansion on side of effusion)
Tx of pleural effusions
- Small/no resp compromise: do 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
Clinical presentation of Pneumothorax:
What would you see (hear) on an exam?
Sudden SOB, CP/tightness, hypoxia, tachycardia, tachypnea
Exam:
* Unequal breath sounds
* Hyperresonance with percussion
* decreased wall expansion
Tx of pneumothorax
Thoracostomy
What increases the risk of a UTI post op?
prolonged cath (>2days)
MCC of UTI (organism)
E. coli
S/Sx of UTI
+ how is it diagnosed
dysuria
hematuria
frequency
fever
N/V
Malodorous urine
Dx: Urinalysis w/ culture
Tx of UTI postop
- Rocephin
- Cipro
common cause of postop fever 48h
Risk factors of Urinary retention
- pelvic/perineal surgery
- Spinal anesthesia
- Over distention of urinary bladder
- h/o BPH/prostate tumor
S/Sx of Urinary retention
+what may you see on an exam?
oliguria/anuria
abdominal/pelvic discomfort
Exam: palpation of lower abdomen may demonstrate distended bladder
Dx of urinary retention
Bladder scan of >400 mL PVR (post void residual)
Treatment of urine retention
Bladder catheterization (foley)
What is a hematoma? +how does it present
collection of blood d/t inadequate hemostasis
clinical appearance: swelling, discoloration, bruising pain/discomfort, blood leaking through incision
Risk factors for hematoma postop
- AC
- Coagulopathies
- Marked postop HTN
- Vigorous cough/straining
Where are some common sites where hematomas occur?
Thyroid
Joints
Breast
Tx of hematoma
- Small: let it resorb on its own
- Compression dressings
- Evacuation or ligation
What two hematoma locations are extremely dangerous?
- Neck (cut off air supply)
- Spine (compress spinal cord)
What is a seroma? +appearance
- collection of serous fluid (typically from lymphatics)
- Not pus or blood
- Swelling, discomfort, leakage of serous fluid from incision
Where are seromas MC postop?
- Breasts
- Axilla
- Inguinal
Tx of seromas
- Needle aspiration
- Compression dressings
- surgical exploration if recurrent
what is a wound dehiscence?
complete or partial disruption of any or all layers of incision
if all layers repture and expose internal organs its called evisceration
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
mmmm no thx
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
Small areas that aren’t full thickness may be managed with meticulous wound care and avoid operative intervention
MCC of wound infection (organism)
S. aureus
Types of SSI
Superficial, deep, organ
superficial-skin and subcutaneous tissue
Deep: fascia, muscle, tissues
Organ/open space
4 types of surgical wounds
- Clean: no hollow viscus entered, no break in aseptic technique
- Clean-contaminated: hollow viscus entered but controlled, primary wound closure
- Contaminated: uncontrolled spillage from viscus, major break in aseptic tech
- Dirty: untreated, uncontrolled spillage, pus in operative wound, open dirty traumatic wound
When do SSI tend to present?
Surgical site infection
POD 5-6
SSI host risk factors
probably not learning but i’m gonna try
DM
Hypoxemia
Immunosuppresive drugs
Cigarette smoking
Malnutrition
Poor skin hygiene/contaminated or infected wounds
they literally make sense, i now see why enoch didnt put them in his cards lol
How do you treat SSI?
Culture, Abx, surgical debridement
SSI prevention? this slide had a lot but im just asking for the abx prophylaxis
MC: cefazolin, ceftriaxone, cefoxitin
with colorectal or appendix-add flagyl or clinda
When is ileus normal postop?
First 24-72h
What usually causes GI obstruction postop?
Adhesions/blockage
how would someone with ileus/obstruction present? +what would you see on exam?
abd distenstion
abd pain
absence of flatus
N/V (bilious emesis)
Exam:
* protuberant tense abdomen
* tympanic abd to percussion
* lack of bowel sounds after 2 min (high pitched tinkering intermittent sounds)
What is the treatment for Ileus/obstruction post op?
NG tube decompression
Bowel rest/NPO
need for adhesiolysis
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
Alright what do we know about fecal impaction
MC in:
results from:
S/Sx:
Dx
Tx:
literally one slide so it wont be a question but im crazy
MC: elderly
results from: post op ileus, opiods, reduced mobility
Dx: Rectal exam/KUB Xray
Tx: manual removal, bowel regimen
When is acute pancreatitis and cholecystitis MC postop?
- Biliary tract surgeries
- Acute pan: after ERCP or cholecystectomy
- Acute chole: After ERCP or upper GI procedures
more likely to develop into infected necrotizing pancreatitis
What 3 areas increase risk of a postop hepatic injury?
- Surgery of upper ab
- Biliary tract
- Pancreas
What can cause jaundice post op + how do you treat it?
Drugs, blood transfusion ractions, damage to liver, obstruction d/t injury of bile ducts
Tx: Discontinue drugs, blood transfusion, fluid replacemnt
GI consult-ERCP, stenting
What is postop C Diff colitis mainly caused by?
Postop abx use
Pseudomembranous colitis, abx associated colitis
Dx w stool culture
What surgery is highest risk for a CVA postop?
CEA (Carotid endarterectomy)
Most commonly result from prolonged ischemia/poor perfusion
What are postop dysrhythmias MC due to?
- Electrolyte disturbances/drug toxicity
- Potential sign of an MI
There is one slide on MI but i dont think it matters
literally
When is phlebitis fever MC postop?
What can it lead to?
How can you prevent it?
72h
can lead to infection and thrombosis
prevent with good aseptic technique!!! (Idk she bolded this)
Tx: removal of catheter/warm compress/NSAIDS
S/Sx of Phlebitis
induration, edema, and tenderness, erythema, drainage, pronounced pain with infection
What is Virchow’s triad?
- Endothelial injury
- Hypercoagulability
- Venous stasis
DVT
Risk factors
S/Sx
Diagnosis
Complications
Tx
Prevention
wont be a question
When is fat embolism most common?
Postop for orthopedic sx or long bone fx
tiny fat globules entering blood stream through bone marrow
PE S/Sx, Dx, Tx
its literally one slide
S/Sx: tachycardic, tachypneic, hypotensive, hypoxic, chest pain
Dx: STAT CTA
Tx: antiCoagulation therapy, embolectomy
When to discharge a patient (8 things)
the fact that this class only has one exam has me wanting to memorize everything lol
Convalescent phase begins once patient is home
