PERI - Management of Post-Op Complications Flashcards
Post-Op Shortness of Breath
Atelectasis
Pneumonia
PE
1.) Atelectasis - due to airway compression, alveolar gas resorption, ↓surfactant production during the operation
- predisposes patients to pulmonary complications
- bad pain control –> shallow breathing –> ↑likelihood
- ↑RR, ↓SpO2, fine crackles, low fever, CXR
- clinical diagnosis within 24hrs post-operatively
- managed w/ chest physio, if not, bronchoscopy
2.) Pneumonia - can be quite common, can lead to:
- pleural effusion, empyema, sepsis, respiratory failure
- occurs >5 days post op
3.) Pulmonary Embolism - due to a DVT
- sudden SOB, chest pain, cough, haemoptysis.
- ↑HR, ↑RR, pyrexic, ↑JVP, pleural rub or effusion
- initiate wells score and follow PE protocol
- occurs 5-10 days post-op
Post-Op Urinary Symptoms
Urinary Retention
AKI
UTI
1.) Urinary Retention - common post-op complication
- anuric, voiding sensation, suprapubic mass
- post-op causes: uncontrolled pain, constipation, infection, anaesthetic agents (not worn off)
- US bladder scan and U+Es essential
- most resolve spontaneously, others need catheter
2.) AKI - often due to pre-renal causes:
- sepsis, dehydration (NBM), haemorrhage
- damage to renal arteries during the operation
- post-renal: urinary retention, blocked catheter
- bloods, urine dip, US-KUB
3.) UTI - frequency, urgency, dysuria, and pyrexia
- urine dip +leucocytes and +nitrites
Post-Op Confusion/Delirium
Types of Delirium
Common Causes
Assessement
Investigations
Management
1.) Types of Delirium
- hypoactive: lethargy and ↓motor activity
- hyperactive: agitation and ↑motor activity
- mixed agitation: fluctuations throughout the day
2.) Common Causes
- hypoxia, infection (UTI, LRTIs), dehydration, pain, constipation, urinary retention, electrolyte imbalances
- drug induced (benzos, diuretics, opioids, steroids)
- drug withdrawal (alcohol, benzos)
3.) Assessment - collateral history
- abbreviated mental test or mini-mental state exam
- investigate possible causes, neuro exam
4.) Investigations - bloods (confusion screen),
- bloods (confusion screen): routine bloods + TFTs, glucose, B12/folate
- blood cultures, urinalysis, CXR, CT Head
5.) Management - correct identified cause
- appropriate environment: quiet area, regular routines/sleeping patterns, clocks
- ↑fluid intake, provide analgesia, monitor bowels
- oral haloperidol (sedative) if necessary
Post-Op Wound Issues
Surgical Site Infection
Tertiary Wound Healing
Superficial Wound Dehiscence
Full Thickness Wound Dehiscence
1.) Surgical Site Infection
- sx appear 5-7 days up to 3 wks post-procedure
- wound swabs, bloods, and blood culture required
- remove sutures/clips, start empirical antibiotics
2.) Tertiary Wound Healing - delayed closure of a wound to prevent infection (pack w/ gauzes)
- e.g. dirty abscess cavity wound cannot be closed until granulation tissue is formed (6wks)
- wound is then surgically closed after period of time
2.) Superficial Wound Dehiscence - skin wound fails to heal with rectus sheath remaining intact
- risk factors: infection (main), diabetes, bad nutrition
- wash out wound then wound packing
- wound re-heals as secondary intention
3.) Full Thickness Wound Dehiscence - rectus sheath bursts with protruding abdominal contents
- due to ↑abdominal pressure, poor suturing
- cover the wound w/ saline impregnated gauze
- need analgesia, IV fluids and IV broad-spectrum antibiotics
- urgent return to theatre to close the wound
Post-Op Nausea and Vomiting (PONV)
Patient and Surgical Risk Factors
Anaesthetic Risk Factors
Management
Pharmaceutical Management
Alternative Causes
1.) Patient and Surgical Risk Factors
- patient: female, young age, previous PONV or motion sickness, use of opioids, analgesics, non-smoker
- surgical: specific surgeries, ↑operation times, poor pain control post-operatively
2.) Anaesthetic Risk Factors
- opiate or spinal anaesthesia, inhalational agents,
- ↑anaesthetic time, dehydration/bleed (during surgery)
- overuse of bag and mask ventilation
3.) Management
- prophylactic: anaesthetic measures, prophylactic antiemetics, dexamethasone at induction
- conservative: adequate hydration and analgesia
- pharmaceutical: anti-emetics
4.) Pharmaceutical Management
- ondansetron or cyclizine for opioid induced N/V
- metoclopramide: impaired gastric emptying, metabolic or biochemical imbalance
- hyoscine: bowel obstruction (reduces secretions)
5.) Alternative Causes - some examples
- infection, ileus, bowel obstruction, antibiotics, opioids
- hypercalcaemia, uraemia, DKA, raised ICP, anxiety
Post-Op Pneumonia
Risk Factors for Hospital Acquired Pneumonia
Diagnosis
Aspiration Pneumonia
1.) Risk Factors for Hospital Acquired Pneumonia
- ↓mobility leads to ↓ chest ventilation
- new commensals (E.coli, S.aureus, S.pneumoniae)
- debilitation (several co-morbidities)
- intubation and ventilation ↑ risk of HAP
2.) Diagnosis - SOB, cough, pleuritic chest pain
- ↑RR, ↑HR, pyrexic, bronchial breath sounds, inspiratory crackles, dull percussion
- routine bloods, ABG, sputum sample, CXR, CURB-65
3.) Aspiration Pneumonia - gastric contents into pulmonary tissue causes chemical pneumonitis
- usually affects right middle and lower lobes
- risk factors: ↓GCS, prolonged vomiting, misplaced NG, neuro disease, post-abdo surgery
Stomas
Colostomies
Types of Colostomies
Ileostomies
Types of Ileostomies
1.) Colostomies - uses large bowel and found in LIF
- solid contents due to water absorption in large bowel
- positioned flush to the skin (no spout) as enzymes in large bowel are less alkali so less irritating to the skin
2.) Types of Colostomies
- permanent-end: often done for resection of large rectal cancer causing removal of the entire rectum
- temporary-end: rest the bowel (e.g after a Hartmann’s) it will be re-anastomosed at a later date
- loop: allows faecal matter to drain into the stoma bag without reaching the distal anastomoses
3.) Ileostomies - uses small bowel and found in RIF
- liquidy contents due to less water absorption
- enzymes in SI can irritate the skin so bowel has a spout, allowing faeces to drain without touching skin
4.) Types of Ileostomies
- permanent-end: usually after a panproctocolectomy for ulcerative colitis or familial adenomatous polyposis
- temporary-end: emergency bowel resection when unsafe to form anastamosis (e.g. sepsis, bleeding)
- loop: to protect distal anastamoses
Sub-Phrenic Abscess
What is it?
Clinical Features
Investigations
Management
1.) What is it? - abscess formation in subphrenic space
- causes: bowel perforation, inflammation, trauma
- post-surgical complication (1-3wks): appendicectomy, cholecystectomy, splenectomy etc.
- usually caused by anaerobes or G-ve pathogens
2.) Clinical Features
- fever, chills, (R/L)UQ pain (can refer to shoulder)
- features of infection/sepsis, systemic symptoms
- reduced appetite, N/V
3.) Investigations
- bloods(+culture): infection (WCC, CRP)
- CXR: elevation and air-fluid level beneath the hemidiaphragm, signs of reactive pleural effusion
- USS-abdo: percutaneous drainage, CT can be useful
4.) Management
- analgesia, IV fluids, antibiotics/sepsis6
- USS guided percutaneous drainage
- pleural effusion resolves with abscess drainage
Post-Op (Paralytic) Ileus
What is it?
Clinical Features
Investigation/Management
1.) What is it? - reduced bowel peristalsis after bowel surgery resulting in pseudo-obstruction, causes include:
- extensive handling of the bowel
- inflammation of the intra-abdominal organs
- medications used intra- and post-operatively
- intra-abdominal sepsis
2.) Clinical Features
- abdominal pain, abdominal distention/bloating
- nausea/vomiting, inability to tolerate an oral diet
- inability to pass flatus or open bowels
- absent bowels sounds on auscultation
3.) Investigation/Management
- daily U+Es (esp K+, Mg, PO4-) as deranged electrolytes can contribute to postoperative ileus
- NBM + NG (if vomiting): may progress to small sips
- IV fluids (+additives): to maintain normovolaemia and correct any electrolyte disturbances
- TPN: occasionally required for prolonged/severe cases
Anastomotic Leak
Risk Factors
Clinical Features
Investigations
General Management
Definitive Management
1.) Risk Factors
- patient: smoking, alcohol, DM, obesity, malnutrition,
use of corticosteroids or immunosuppressants
- surgical: emergency/long surgery, peritoneal contamination, oesophageal-gastric/rectal anastomosis
2.) Clinical Features - presents 5-7 days post-op
- abdo pain, fever, delirium, prolonged ileus
- signs of peritonitis/sepsis, tachycardia
- faeculent/purulent material or bile in drains
- can cause new-onset atrial fibrillation
3.) Investigations
- urgent bloods (inc G+S), VBG (lactate)
- CT-CAP/CT-AP w/ oral contrast: extraluminal contents
- ECG
4.) General Management - SURGICAL EMERGENCY
- sepsis 6, IV fluids+NBM (consider TPN)
- broad spec abx, urinary catheter
- URGENT senior review: should return to theatre ASAP
5.) Definitive Management
- minor leak (<5cm): conservative, IV Abx
- larger leak: percutaneous drainage
- septic: exploratory laparotomy
