Peri-op Care: Post-op Complications

Question 1

what is the most likely causative organism for surgical site infections generally? for laparotomy wounds?

Answer 1

Most common: S. aureus

Laparotomy wound: E. coli

Question 2

what are the signs/symptoms of surgical site infections? when do these typically appear?

Answer 2

3-7 days post-procedure (but can occur up to 3 wks later).

Features:

• localised pain
• unexplained persistent pyrexia
• spreading erythema
• pus/discharge from wound
• wound dehiscence

Question 3

how would you investigate possible surgical site infection?

Answer 3

1. wound swabs - for culture
2. bloods: FBC, CRP - for infection markers
3. blood cultures - if evidence of systemic involvement or sepsis

Question 4

how would you manage a pt with surgical site infection?

Answer 4

1. removal of sutures/clips - allows for drainage of pus and opportunity for wound to be packed if required
2. discharge or drainage of any pus
3. empirical antibiotic prescription - tailored to culture results
4. close monitoring - for signs of systemic infection/sepsis

Question 5

suggest possible patient factors and operation factors that increase risk of surgical site infection

Answer 5

Patient factors:

• extremes of age
• DM or renal failure
• immunosuppression
• smoking
• poor nutritional state
• co-existing infection at other site
• long post-op stay

Operation factors:

• pre-op shaving
• length off operation
• foreign material in surgical site
• insertion of surgical drain
• inadequate instrument sterilisation
• poor wound closure
• post-op hypothermia
• post-op haematoma or lymphatic lead
• site of procedure (e.g. at skin crease)

Question 6

what is wound dehiscence? what is the difference between simple dehiscence and burst abdomen?

Answer 6

Failure of a wound to close properly, most commonly affecting pts after abdo. surgery.

1. Simple dehiscence - skin wound alone fails
   Often secondary to infection, DM, poor nutrition or any co-morbidities that impede normal wound healing.
2. Burst abdomen - separation of abdominal wall closure with protrusion of abdominal content
   May occur secondary to increased intra-abdo. pressure (e.g. intra-abdo. compartment syndrome or ileus) or from surgical technical failure due to poor suture technique or poor suture choice.

Question 7

what are the signs/symptoms of wound dehiscence? when do these typically appear?

Answer 7

Typically 5-7 days post-op.

Features:

• visible opening of wound which heals poorly
• seepage of serous fluid
• bleeding
• increased pain

Question 8

which investigations would you perform on a pt with wound dehiscence?

Answer 8

Should focus on likely cause.

1. Wound swabs - for culture, if suspected SSI
2. Bloods: FBC, CRP - for infection markers
3. Blood cultures - if evidence of sepsis
4. Nutritional markers and blood glucose

Question 9

how would you manage a pt with wound dehiscence?

Answer 9

Depends on site and type of dehiscence.

1. Closure by secondary intention (occasionally).
2. Re-operation (usually): surgical debridement of contaminated or dead tissue and prophylactic antibiotics. May require re-suturing of wound using deep retention sutures.

Question 10

how would you manage a pt with wound dehiscence that cannot be closed immediately?

Answer 10

Saline-soaked gauze packing or negative pressure wound therapy.

Question 11

how would you manage a pt with sudden full dehiscence of wound (bust adbo)?

Answer 11

1. start analgesia and IV fluids
2. broad-spectrum IV antibiotics
3. cover wound in saline-soaked gauze
4. urgent return to theatre for re-closure of wound

Question 12

describe the pathophysiology of anastamotic leaks

Answer 12

Leak of luminal contents from a surgical joint, causing generalised sepsis and mediastinitis or peritonitis depending on site of leak.

Question 13

when and how does an anastamotic leak usually present?

Answer 13

5-7 days post-op.

Features:

• abdo. pain
• fever
• +/- tachycadia, delirium or prolonged ileus
• +/- signs of peritonism
• +/- faeculent/purulent material or bile in any drains

Question 14

suggest possible risk factors for anastamotic leaks

Answer 14

1. steroids and DMARDs
2. smoking or alcohol excess
3. DM, obesity or malnutrition
4. surgical factors: emergency surgery, longer intra-operative time, peritoneal contamination (e.g. pus, faeces or GI contents), oesophageal-gastric or rectal anastamosis

Question 15

which Ix would you perform on a pt with suspected anastamotic leak?

Answer 15

• urgent bloods: FBC, CRP, UandEs, LFTs, clotting screen, group and save, VBG
• contrast CT scan abdo/pelvis

Question 16

describe the management of a pt with anastamotic leak.

Answer 16

Initial Mx: keep NBM, broad-spectrum antibiotics, IV fluids, catheter

Definitive Mx:

• minor leak: may be managed conservatively with IV antibiotics
• larger leaks: percutaneous drainage if possible
• sepsis or multiple collections: exploratory laparotomy with extensive washouts and large drain insertion

Question 17

describe the pathophysiology of post-op ileus

Answer 17

Deceleration or arrest of intestinal motility - functional bowel obstruction… fluid sequestration and loss of electrolytes.

Question 18

how would a pt with post-op ileus present?

Answer 18

• failure to pass flatus or faeces
• bloating
• nausea and vomiting (or high NG output)
• abdo. distention and absent bowel sounds

Question 19

what are the risk factors for post-op ileus?

Answer 19

• increasing age
• electrolyte derangement (e.g. Na, K, Ca)
• neurological disorders (e.g. dementia or PD)
• use of anti-cholinergic medication
• surgical factors: use of opioid medication, pelvic surgery, extensive intra-operative intestinal handling, pertioneal contamination (pus or faeces), intestinal resection

Question 20

how would you Ix a pt with possible post-op ileus?

Answer 20

1. CT scan abdo/pelvis: confirm Dx and rule out collection/anastamotic leak
2. Bloods: FBC, CRP (check inflammatory markers), UandEs (fluid shifts can occur leading to AKI)

Question 21

describe the Mx of a pt with post-op ileus

Answer 21

Conservative:

• daily bloods, inc, electrolytes - correct any abnormalities and monitor for AKI
• encourage mobilisation
• reduce opiate analgesia and any other bowel mobility-reducing medication
• +/- NG tube insertion on free drainage, and catheterisation with fluid balance chart