post op Flashcards
cellulitis presentation
can occur form any breach of the skin
will appear read slightly swollen warm to touch
might blanch
staph and strep (gram negative) most common
tx of cellulitis
MSSA –>keflex (cephalexin) 7-10 days (no purulent)
if it is purulent, MRSA is suspected
subcutaneous abscess workup
want packing to help heal from inside out
lymphatic fluid with liquified fat under incision presenting post surgery complication
seroma
no erythema or acute pain and seen after breast surgery or sentinal node biopsy
can get this from overactivity
complications of seroma
can become so large that it is painful
preventions of seroma
can send to patients home with JP drains especially after a surgery in the axilla
20cc for 2 days in a row can take out the JP
sutures or staples are removed POD
5
sutures over creases and extremities are left on for
2 weeks
hwo does the timing of the fever influence the etiology of cause
fever that starts POD#5 is surgical infection
fever that lasts 5 days post op is surgical in
immediate fever causes
bactermia
catheter with bladder infection
or reaction to the antibiotics
or gangrene
tx of gangrene
surgical debridement and antibitocs
acute fever
post op day 1 -POD7
unresolved atelectasis can progress
to pneumonia
POD 6 the source of elevated temperature is a
PE
SOB
Pleuritic CP
CTA dx
wound infection fever usually occurs
POD 7-10
sxs of pulmonary aspirations
basilar rales
hypoxia
tachypnea
prevention of pulmonary aspiration
pre-op fasting
patient positioning
careful intubation and extubation
H2 blocker or PPI before intubation-
causes of postop pneumonia
what type of organism is most commonly the culprit
aspiration
stelectasis
copious secretions
usually gram negative
sxs of pneumonia post op
fever
tachypnea
increased screations
CXR confirms consolidations
tx of post op PNA
culture sputume and treatment if anbx
respiratory management to prevent atelectasis, aspiration, and PNA
everyone get’s this that is admitted
Encourage coughing
Frequent change in position
Get out of bed!
I/S incentive spirometer (5x a day)
Deep breathing
RF for post op PE
Obesity
Age
Lengthy operative procedure (>5 hrs)
Birth control pills
Malignancy
Trauma
Immobilization
Paralysis
IBS, Crohn’s
Chronic heart dz
Coagulation disorders
longer surgery is usually
mroe than 5 or 6 hours on the table
infectous causes of post op fever
— SSI, pneumonia (especially VAP), UTI, and intravascular catheter-associated infection are the most common infectious causes of postoperative fever.
sxs of PE postop
Cough
Dyspnea
Pleuritic chest pain
Apprehension!
Tachypnea
Tachycardia
P02 less than 70
MC non infectious cause of postop fever
Medications are the most common noninfectious cause of fever. Antimicrobials and heparin are the medications most commonly associated with postoperative fever, at least in part because they are used so frequently in the postoperative period
we would be concerned for urinary retention if
pain and fullness over bladder with distension
unable to void after 6 hours
treatment for urinary retention
Bladder scan
if residual is greater than 500 cc, patient is catheterized
ileus post op usually occurs as a result of
After abdominal surgery, the colon ceases to function for a period of time 3-5 days due to:
bowel manipulation intra-abd infection pancreatitis pneumonia peritonitis narcotics
ileus sxs
Abd distension
N/V
Obstipation (failure to pass gas and stool)
Abd pain
tx of a ileus
Full liquid diet until 1st BM
Patience
how do you know if ileus has resolved
Flatulence
Sharp, colicky pain
Cellulitis
Tissue center with blood supply
Will resolve with antibiotics
Subcutaneous abscess
Necrotic center without blood supply
Pus
Will not heal unless pus is drained
Lymphatic fluid with liquefied fat under incision
Seroma
seromas are of concern in these types of sugeries
Concern in breast surgery
ventral hernia repairs
Axillary and groin dissection
Edema
fluid from seromas is usually
erythema? pain?
Clear or yellow liquid from incision
No erythema or acute pain
prevention of a seroma should look like
Close subcutaneous layers to avoid dead space
lymphatic fluid collecting is the problem here
Use drains and don’t remove prematurely
25cc for two days in a row to remove
Most common surgical complication due to lack of coagulation of vessels during surgery
Risk when patient is anti-coagulated with heparin or patient is an aspirin user
hematomas are of particular concern when pt is taking
Risk when patient is anti-coagulated with heparin or patient is an aspirin user
Hematoma increases risk of
Hematoma increases risk of infection
Neck hematomas can compromise airways
5 signs and sxs of infection
i. Fever
ii. N/V/D possibly
iii. Erythema
iv. Edema
v. Exudate (fluid/pus at incision site)
how to tx a seroma
can leave it alone or aspirate
20 gauge syringe and suck out a lot
might need to culture if it doesn’t look clear
wear a binder or sports bra
DO NOT RADIATE A SEROMA
Dressing over closed wounds should be removed on ______ postop day if dry
Dressing over closed wounds should be removed on 3rd postop day if dry
treatment for itching associated with wound adhesives
Treatment is remove offending agent and use of hydrocortisone 1% cream and benadryl cream if itchy
5 “w”s
5 causes of post op fever
wind -atelectasis water- UTI or PNA from atelectasis wound - look at dressings post op (7) walking-PE/dvt wonder -check all the drugs your pt is on
refers to acute fever complications
definition of a post op fever
greater than 30 degress
or 100.4 on two consecutive post op days
OR
102.2 on any post op day
how to we classify post op fevers
immediate
acute
subacute
delayed
immediate fever occurs when
immediately after surgery or within hours
post op day 0 (day of surgery)
or POD 1
what are the three causes of immediate fever
malignant hypothermia
bacteremia (w/ 30 of beginning)
gas gangrene (greater than 40) due to C. Diff
transfusion reaction
malignant as the source of an immediate fever is usually caused by….
reaction to anesthesia or muscle relaxants
managed by anesthesiaologists
immediate fever bacteremia is usually b/c of
urinary tract infection with a catheter
three blood cultures and antibiotics
managed by anesthesiolgist
gas gangrene as the source of an immediate fever is usually caused by….
what is the treatment
fever greater than 40
(104)
severe wound pain
usually because of C diff
debridement and antibiotic
transfusion reaction is usually seen
6 hours post op
stop transfusi
RF for atelectasis
i. Elderly
ii. Overweight
iii. Smokers
iv. Hx of respiratory dz
tx atelectasis with fever
incentive spirometery
pain control
early ambulation
chest physiotherapy
semi -recumbent position
POD 3 fever
unresolved atelectasis
PNA
or UTI
POD 5 fever
thrombophlebitis
can be asymptomatic or sxs
dx with Doppler
subacute
week 1-7
seep infection
pelvic or abdominal
CT or reexplanation
sxs of atelectasis (acute)
i. None or
ii. Elevation of diaphragm
iii. Scattered rales
iv. Decreased breath sounds
injury to bowel with bowel leak is seen with what sxs
fever
tachycardia
hypotensive
low u/o (urinary output)
abd tenderness out-of-proportion to p
rocedure vs abd ttp app to proc
RF for Pulmonary aspirations
GERD
Eating before surgery
Pregnant women
Small bowel or colon obstruction
why are pregnant women at greater risk for pulmonary aspirations
– high intra-abdominal pressure and decreased gastric motility
how do H2 blockers prevent pulmonary aspiration
reducing acidity of stomach contents thus preventing chemical pneumonitis
