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Clin Med - II (Surgery) > Post-Op > Flashcards

Post-Op Flashcards

1
Q

Post-op complications depend on

A 
Sx performed
Baseline health of pt
- Body Habitus
- Tobacco, drug and alcohol use
- Comorbid conditions (heart / lung dz, DM)
- Medications (steroids, chemo, immunosuppressants)
Elective, urgent of emergent nature
Nutritional status
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2
Q

Pre-op Preparation

A 
Possible complications vs. probabl outcomes
Pre-op abx therapy
Fluid resuscitation
Electrolyte abnormalities
Nutritional optimization
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3
Q

Complications which could occur Days 1-5, post op

A 
Acute cerebreovascular event
Acute MI
Pyrexia due to  atelectiasis
Post-op Urinary retention (1-7 days)
Renal Impairment / failure (1-7 days)
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4
Q

Complications which could occur Days 1-7, post op

A

Post-op Urinary retention
Renal Impairment / failure
Delirium tremens (5-10 days)

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5
Q

Complications which could occur Days 5-10, post op

A

Delirium tremens

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6
Q

Complications which could occur Days 7-10, post op

A

Chest/wound/urinary infection
Secondary hemorrhage
Delirium tremens (5-10 days)

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7
Q

Complications which could occur Days 10-14, post op

A

DVT / PE

Wound dehiscence

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8
Q

Post-op fever - Infectious

A 
Abscess
Acalculous cholecystitis
Bacteremia
Decubitus ulcers
Device-related infections
Empyema
Endocarditis
Fungal sepsis
Hepatitis
Meningitis
Osteomyelitis
Pseudomembraneous Colitis
Parotitis
Perineal infections
Peritonits
PHarygitis
Pneumonia
Retained foreign body
Sinusitis
Soft tissue infection
Traceobraonchitis
UTI
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9
Q

Post-op fever - Noninfectious

A 
Acute hepatic necrosis
Adrenal insufficiency
Allergic reaction
Atelectasis
Dehydration
Drug reaction
Head injury
Hepatoma
Hyperthroidism
Lymphoma
MI
Pancreatitis
Pheochromocytoma
PE
Retroperitoneal hematoma
Solid organ hematoma
Subarachnoid hemorrhage
Systemic inflammatory response syndrome
Thrombophlebitis
Transfusion reaction
Withdrawal syndromes
Wound infection
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10
Q

The 5 W’s of a post-op fever

A 
Wind (Lungs)
Water (Urinary Tract)
Walking (DVT / PE)
Wound
Wonder about Drugs
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11
Q

Post-op fever - In general

A

2/3 of pts have fever after sx; only 1/3 have an infection
First 48-72h post-op - atelectasis is often the cause
Fever 5-8 days post-op is more worrisome
Pt’s s/s typically indicate the cause
Don’t jump to Tylenol for post-op fever - find the cause and tx appropriately

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12
Q

Wind - In general

A

Pre-op pulmonary eval - identify pre-existing conditions (COPD, asthma, smoking, CHF, obesity, etc)
Sx and incapacitation causes
- Loss of functional residual capacity
- Vital capacity may be reduced up to 50%
Narcotics inhibit repiratory drive
25% of post-op deaths are due to pulmonary complications
Aggressive pulmonary toilet, SMI and IS
Eval includes CBC, CXR and ABGs

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13
Q

Atelectasis

A

Collapse or incomplete expansion of part of the lung
Most common post-op fever in the first 48h
Responds to aggressive pulmonary toilet

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14
Q

Pneumonia

A

HCAP
Aspiration is the leading cause
Higher fever than atelectasis
Pts on ventilator are at a higher risk
Typically pts have fever, cough, leukocytosis and CXR infiltrates
Sputum and blood cultures
Abx should cover Gram negative - start broad then narrow down

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15
Q

Aspiration pneumonia

A

Inhalation of regurgitated gastric contents

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16
Q

Aspiration pneumonitis

A

Inhalation of oropharyngeal secretions colonized by bacteria

More common in the right lung

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17
Q

Aspiration pneumonia and aspiration pneumonitis

A

Elderly or pts with altered sensorium are more susceptible
Pts will have a cough, typically have wheezing and dyspnea
CXR, blood and sputum cultures
Secure the airway - frequently involves intubation
Empiric abx therapy that covers Gram negative bacteria

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18
Q

Pulmonary Edema

A

Fluid overload and chronic renal failure
Kerley B lines - more localized to bases
Diuretics and supplemental oxygen

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19
Q

ARDS - causes

A 
Septic shock
Drug OD
Acute pancreatitis
Aspiration
Smoke inhalation
Near-drowning
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20
Q

ARDS - in general

A

Bilateral
Widespread
Confluent alveolar consolidation often with air bronchograms
Typically lacks cardiomegaly

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21
Q

Which dz state typically produces a pleural effusion that is transudative?

A - CHF
B - RA
C - Lung cancer
D - Pancreatitis

A

A

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22
Q

UTI - in general

A

UTIs associated with catheters are the leading cause of secondary healthcare-associated bacteremia
Approximately 20% of hospital-acquired bacteremia cases arise from the urinary tract
UTI is more common in pts who have undergone a GU procedure and in those who have chronic, indwelling catheters

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23
Q

C.A.U.T.I. to prevent CAUTI

A 
Catheter removal
Aseptic insertion
Use regular assessments
Training for catheter care
Incontinence care planning
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24
Q

C.A.U.T.I. to prevent CAUTI

A 
Catheter removal
Aseptic inserUTI - tion
Use regular assessments
Training for catheter care
Incontinence care planning
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25
Q

UTI - RF

A

Females
Elderly
DM
Duration of catherization

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26
Q

UTI - s/s

A

Fever is the most common symptom
Flank or suprapubic pain
CVA tenderness
Cloudy or foul smelling urine

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27
Q

UTI - dx

A

Cath urine specimen is most reliable - straight cath

Can culture bag/foley tip

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28
Q

UTI - tx

A

Empiric broad-spectrum abx until culture results

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29
Q

Urinary retention

A

Most commonly it is a reversible abnormality of the trigone and detrusor muscles
- BPH and low pelvic operations will increase risk of urinary retention
Bladder scan, straight cath, or leave foley catheter out
Rapaflo, flomax

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30
Q

Acute Renal Failure - “areas of failure”

A

Prerenal - secondary to hypotension, NSAIDs and Gram negative sepsis
Renal - damage to kidneys
Postrenal - outflow obstruction

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31
Q

Acute Renal Failure - Contrast

A

Induced nephropathy is on the rise with incrased use of contrast studies

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32
Q

Acute Renal Failure - prevention

A

Avoid hypovolemia, hypotension, and nephrotoxic meds

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33
Q

Acute Renal Failure - rise in Cr

A

Decrease in Cr clearance

Decrease in urinary output

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34
Q

Acute Renal Failure - tx

A 
management of fluids
Correct electrolyte abnormalities
Avoiding nephrotoxicity 
Optimizing nutrition
Some pts require dialysis
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35
Q

A 41yo M presents with acute onset right flank pain. The pain is intermittent and now radiates into his right tesicale. He is afrebrile. Which of the following is the most likely dx?

A - Incarcerated inguinal hernia
B - Appendicitis
C - Ureteral stone
D - Varicocele

A

C

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36
Q

Which of the following is indicated by the presence of broad waxy casts on UA?

A

D

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37
Q

Walking - In general

A

To ward off DVT / PE
More common after oncologic, pelvic, orthopedic, and neurosx - procedures that directly or indirectly cause venous stasis

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38
Q

Walking - RF

A 
Type and extent of sx
Trauma
Duration of hospital stay
Hx of previous VTE or cancer
Immobility
Recent sepsis
Presence of a central venous access device
PG or the postpartum period
Inherited or acquired hypercoaguable states
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39
Q

Virchow’s Triad

A

Stasis
Endothelial injury
Hypercoagulable state

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40
Q

DVT - Prevention

A

Prevention is key

Post-op anticoagulation (lovenox), early ambulation and sequential compression devices (SCDs)

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41
Q

DVT - s/s

A

Unilateral edema, erythema and tenderness
Positive Homan’s sign
May include SOB
Legs may look a little different

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42
Q

DVT - Dx

A

Venous US

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43
Q

DVT - Tx

A 
Therapeutic anticoagulation (Eliquis, Xarelto, etc.)
Compression stockings
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44
Q

PE - in general

A

Remains the most common preventable cause of hospital death

Responsible for approximately 150-200,000 deaths per year in the US

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45
Q

PE - s/s

A 
Sudden dyspnea
Tachypnea
Hemoptysis
Tachycardia
Acute RV Dysfunction
Pleuritic CP
Leg swelling 
4th heart sound
Inspiratory crackles
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46
Q

PE - Eval

A 
VQ Scan
CT PE Protocol (CT angiogram
EKG
ECHO
Venous Doppler
CXR
ABG
D-Dimer (cannot be excluded with D-Dimer)
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47
Q

PE - Therapeutic anticoagulation

A

Heparin - Full strength for 6 months

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48
Q

Wound - in general

A

Bacterial contamination of the sx site

Typically develop 5-6 days post-op

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49
Q

Wound - most common pathogens

A

Staph aureus

Coagulase - negative staph

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50
Q

Wound - Most common GI operation pathogens

A

Enterobacter species
E. coli
Group D enterococcus

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51
Q

Wound - Prevention

A

Bowel Prep
Pre-op abx +/- redosing
Drain placement in deep wounds or wounds with large flaps

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52
Q

Wounds - Pt Factors

A 
Ascites
Chronic inflammation
Undernutrition obesity
DM
Extremes of age
Hypercholesterolemia
Hypoxemia
Peripheral vascular dz
Post-op anemia
Previous site of irradiation
Recent operation
Remote infection
Skin carriage of staph
Skin dz in the area of infection
Immunosuppression
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53
Q

Wounds - Environmental factors

A 
Contaminated meds
Inadequate disinfection / sterilization
Inadequate skin antisepsis
Inadequate ventilation
Presence of a foreign body
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54
Q

Wounds - Tx factors

A 
Drains
Emergency procedure
Inadequate abx coverage
Pre-op hospitalization
Prolonged operation
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55
Q

Wound infection - S/s

A 
Tenderness
Erythmatous
Edematous +/- drainage
Leukocytosis
Fever
Occasional fluctuance
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56
Q

Wound infection - tx

A

Open the wound and pack / dress
If cellulitis - abx - heavy use can increase risk of C.diff
If purulence from below fascia - drainage vs. operative exploration at site of infection

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57
Q

Seroma - in general

A

Collection of liquefied fat, serum and lymphatic fluid under the incision
Typically thin, yellow or serosanguinous drainage

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58
Q

Seroma - exam

A

Localized swelling, pressure / pain

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59
Q

Seroma - tx

A

Open the areas to wound and allow it to drain

Pack wound or leave open

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60
Q

Seroma - Prevention

A

Surgical drains help to prevent these (JP drains)

Can become infected - wet to dry dressing changes

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61
Q

Hematoma - in general

A

Abnormal collection of blood

Typically caused by inadequate hemostasis, lack of clotting factors or coagulopathy (asa, plavix, etc.)

62
Q

Hematoma - Exam

A

Localized soft-tissue swelling to skin breakdown

63
Q

Hematoma - Complications

A

Depednind on location of hematoma

  • Ileus
  • Compartment syndrome
  • Airway compromise
64
Q

Hematoma - Prevention

A

Hold anticoagulation pre-op

Identify clotting d/o

65
Q

Hematoma - Intraoperative hemostasis

A

Cautery
Suture control of hemorrhage
Pro-clotting materials

66
Q

Hematoma - tx

A

Typically resorbed but can be drained or sx evacuated

67
Q

Dehiscence - In general

A

Wound failure and separation of abdominal layers
1-3% of pts with an abdominal operation - obesity increases the risk
Acute, large volume of clear or light pink colored drainage precedes dehiscence -in 25% of cases

68
Q

Dehiscence - Common causes

A 
Deep wound infection (most common)
Technical error in closure 
Age
Steroid use
Malnutrition
Radiation or chemo
DM
69
Q

Dehiscence - Tx

A

Pack the wound, open with wet to dry dressing changes

Wound VAC

70
Q

Dehiscence - with evisceration

A

Requires operative intervention

Abthera or temporary closure device

71
Q

Dehiscence - wound cultures

A

Use with caution

Blood cultures only if s/s of sepsis are present

72
Q

Wonder about Drugs - in general

A

Chart review on what meds pt is taking

Interactions with other meds and possible missing home meds

73
Q

Medications that can cause fever

A 
Anesthesia
Heparin
Abx
Anticonvulsants
Anti-inflammatories
Blood products / transfusions
Stopping home meds
74
Q

Stevens-Johnson syndrome is most commonly linked to exposure of which of the following medications?

A - Levquin
B - Metformin
C - Dilantin
D - Cordarone

A

C

75
Q

A pt currently taking coumadin presents with spontaneous nosebleeds. Labs demonstrate a PT = 45s and an INR = 6.9. Which of the following is the tx of choice?

A - Heparin
B - Salicylate
C - Vitamin K
D - Protamine sulfate

A

C

76
Q

Post-op HTN - Common causes

A 
Pain
Hypothermia
Hypoxia
Fluid overload
Discontinued home meds
77
Q

Post-op HTN - More “serious” causes

A

Bleeding
Head trauma
Withdrawal
Pheochromocytoma

78
Q

Post-op HTN - tx

A

slow steady reduction of pressure to avoid ischemia and hypoprofusion

79
Q

Post-op MI - in general

A

STEMI vs. NSTEMI
Greatest risk in the first 48 h
Pre-op cardiac risk stratificaiton

80
Q

Post-op MI - s/s

A

CP / tightness
Cyspnea
Tachycardia
Hypotension

81
Q

Post-op MI - work-up

A 
EKG
Troponins
CXR
ABG
Echo
82
Q

Post-op MI - tx

A

Medical management
Cardiac catheterization
CABG

83
Q

Post-op arrhythmias - in general

A

Brady / Tachy / Heart Block
Sinus tachycardia, A. Fib and Atrial flutter are most common tachyarrhythmias
Most are transient and benign, but can be precursor to hemodynamic compromise (sinus tach vs. Afib vs Afib with RVE)

84
Q

Post-op arrhythmias - s/s

A 
Palpitations
CP
Dyspnea
Dizziness /syncope
Hypotension
85
Q

Post-op arrhythmias - work-up

A

EKG +/- echo

86
Q

Post-op arrhythmias - tx

A

Rate control
Rhythm control
Possibly anticoagulation or cardioversion

87
Q

Post-op heart failure -

A

Risk is the greatest in the first 24-48h after sx

88
Q

Post-op heart failure - increased risk

A

CAD
HTN
Elderly

89
Q

Post-op heart failure - S/s

A

Dypnea
Wheezing and rales
Tachycardia
Peripheral edema

90
Q

Post-op heart failure - work-up

A

EKG
Echo
CXR
BNP

91
Q

Post-op heart failure - tx

A

ACEI

Diuretics

92
Q

Which of the following coronary arteries is typically involved in a lateral wall MI?

A - Right coronary A.
B - Circumflex A.
C - Left anterior descending A.
D - Left coronary A.

A

B

93
Q

Which of the following conduction d/o increases the risk of intra-arterial clot formation?

A - Ventricular tachycardia
B - A. fib
C - Premature atrial contractions
D - Wolff-Parkinson-White syndrome

A

B

94
Q

A 55yo presents with orthopnea and PND. On physical exam, jugular venous distention and pulmonary rales are noted. Which of the following laboratory tests would most likely be elevated in this pt?

A - Thyroid-stimulating hormone
B - Brain natriuretic peptide
C - Myoglobin
D - Renin

A

B

95
Q

Thermal regulation complications - in general

A

Malignant hyperthermia occurs in 1:30,000-50,000 individuals

96
Q

Thermal regulation complications - cause

A

An abnormal reaction to anesthetic which causes rapid release of CA2+

97
Q

Thermal regulation complications - s/s

A 
Cellular hypoxia
Lactic acidosis
Hypercapnia
Hypotension
Tachypnea
Arrhythmias
98
Q

Thermal regulation complications - tx

A

Identify at risk individuals pre-op
Identify the problem in the OR and abort the procedure
Give dantrolene - muscle relaxant
Administer alternative anesthesia and stabilize pt

99
Q

Endocrine complications - in general

A

Adrenal insufficiency
Hyperthyroid crisis
Hypothyroidism
SIADH

100
Q

Endocrine complications - Adrenal insufficiency

A 
Fatigue
Weakness
Abdominal pain
Diarrhea
Hyponatremia
Hypoglycemia
Ha
Visual disturbances
101
Q

Endocrine complications - Hyperthyroid crisis

A 
Nervousness
Fatigue
Palpitations
A.fib
Periorbitial edema
Proptosis
102
Q

Endocrine complications - Hypothyroidism

A

Rarely to pts develop myxeda coma

103
Q

Endocrine complications - SIADH

A 
Anorexia
N / V
Obtundaiton
Seizures
Hyponatremia
104
Q

GI Complications - Ileus and obstruction in general

A

Ileus and obstruction
Functional
Mechanical

105
Q

GI Complications - Function obstruction

A

“Sleepy bowels”

Caused by manipulation during sx, restricted oral intake and analgesics

106
Q

GI Complications - mechanical

A 
Early post-op SBO
Adhesions (>90%)
Abscess
Internal hernia
Intestinal ischemia or intussusception
107
Q

GI Complications - S/s of Ileus and obstruction

A 
Abdominal pain
Distention
N/V
Belching and hiccupping
Obstipation
108
Q

GI Complications - Work-up of Ileus and obstruction

A

Abdominal XR - “Transition point”

109
Q

GI Complications - tx of Ileus and obstruction

A 
Correct electrolyte abnormalities 
NGT decompression
Promotility meds
Reduction or elimination or narcotics
NPO / ice chips
Consider TPN or TF
110
Q

Post -op GI bleeding - Differential

A

PUD
Mallory-Weiss Tear
Stress Ulcers

111
Q

Post -op GI bleeding - s/s

A

Hematemesis
Hematochezia / Melana
Anemia

112
Q

Post -op GI bleeding - Work-up

A

H and H
Bleeding scan
Colonscopy / EGD

113
Q

Post -op GI bleeding - tx

A

PPI therapy and prophylaxis

Transfusion as needed

114
Q

Post-op C.diff Colitis - in general

A 
Gram positive
Anaerobic
Spore forming bacillus 
Can produce toxins A and B
Abx use precedes most cases
45-55% are sx pts
115
Q

Post-op C.diff Colitis - s/s

A

Ranging from asymptomatic carriers to toxic megacolon

Typically pts have profuse, watery diarrhea

116
Q

Post-op C.diff Colitis - dx

A

Stool sample

117
Q

Post-op C.diff Colitis - tx

A 
Oral vancomycin (Gold standard)
Alternatives
- Vancomycin ememas or per stoma
- Fecal transplant
- TAC with ileostomy
118
Q

Post-op C.diff Colitis - Pt related RF

A 
Increasing age
Pre-existing renal dz
Pre-exisiting COPD
Impaired immune defense
Underlying malignancy
Underlying GI dz
119
Q

Post-op C.diff Colitis - Tx-related RF

A 
Pre-op bowel cleansing
Abx use
Immunosuppressive therapy
Sx
Prolonged hospital stay
120
Q

Post-op C.diff Colitis - facility-related RF

A

ICU
Caregivers
Long-term facilities

121
Q

GI Complications - in general

A 
Ileus
Obstruction
GI Bleed
C. diff Colitis
Anastomotic leaks
Intestinal fistula
Stomal complications
Abdominal compartment syndorme
Ischemia / infarct
122
Q

45 yo M presents wit abdominal pain, N/V. Exam demonstrates high-pitched bowel sounds and X-ray of the abdomen shows multiple air-fluid levels. What is the most likely dx?

A - Paralytic ileus
B - Small Bowel obstruction
C - Crohn’s dz
D - Ulcerative Colitis

A

B

123
Q

Which of the following findings is indicative of acute cholecystitis?

A - Cullen’s
B - Chadwick’s
C - Hegar’s
D - Murphy’s

A

D

124
Q

Which of the following leads to Barrett’s esophagus?

A - Pyloric stenosis
B - Mallory-Weiss Tear
C - Esophageal Stricture
D - Gastroesophageal Reflux dz

A

D

125
Q

Bile Duct Injuries - in general

A

Most dreaded cholecystectomy complication

126
Q

Biloma or Bile ascites - s/s

A 
RUQ pain
Fever
Nausea
Distention
Drain with bilious output
Leukocytosis
127
Q

Bile Duct Injuries - cause

A

Bile duct that has been clipped

Can cause elevated LFTs

128
Q

Bile Duct Injuries - strictures s/s

A

Cholangitis
Pain
Fever
Jaundice

129
Q

Bile Duct Injuries - dx

A

CT

ERCP

130
Q

Bile Duct Injuries - Tx

A

Percutaneous drain
Sphincterotomy
Stenting

131
Q

Neurologic complications - in general

A 
Delirium
Psychosis
Delirium Tremens
Stroke
TIA
132
Q

Delirium and Psychosis - in general

A

Acute confusion or mental status change

133
Q

Delirium and Psychosis - s/s

A 
Agitation
Uncooperative 
Confused
Emotionally labile
Hallucinations
Disturbances of sleep-wake cycle
ICU Delirium
134
Q

Delirium and Psychosis - causes

A 
Loss of routine
Stress of dz
Fear of operation
Loss of control
Unfamiliar environment
Meds
Pain
Post-op anemia
Electrolyte imbalance
Sepsis
Catheterization
Extended anethesia
Infection
135
Q

Delirium and Psychosis - RF

A

Elderly
Those with a substance abuse hx
Psychiatric d/o
Children

136
Q

Delirium and Psychosis - tx

A

Minimizing meds
Optimizing fluids and nutrition
Early ambulation

137
Q

Delirium Tremens

A

Acute alcohol w/d causing fever, tachycardia, agitation, seizures and psychosis
Prevention is key
Tx - Haldol and benzodiazepines

138
Q

Stroke and TIA - RF

A

Elderly with CV dz

Young with inherited thrombophilia

139
Q

Stroke and TIA - s/s

A

Acute alteration in motor function
Alteration in mental status
Aphasia

140
Q

Ischemic Stroke

A

Perioperative hypotension or cardioembolic

141
Q

Hemorrhagic stroke

A

Typically related to anticoagulation therapy

142
Q

Stroke and TIA - prevention

A

Managing BP and anticoagulation

143
Q

Stroke and TIA - dx

A

Heat CT

144
Q

Stroke and TIA - tx

A

Based on type of stroke

  • TPA or anticoag
  • HTN control
145
Q

ENT complications - in general

A

Epistaxis
Acute hearing loss
Nosocomial Sinusitis
Parotitis

146
Q

Epitaxis

A

Caused by

  • Blood dyscrasias
  • Excessive anticoagulation
  • HTN

Tx - firm pressure or packing resolves the bleeding

147
Q

Acute hearing loss

A

Unilateral loss - Obstruction or edema

Bilateral loss - typicall caused by ototoxic meds (aminoglycosides and diuretics)

148
Q

Noscomial Sinusitis

A

Typically in the second week of hospitalization
Most often maxillary sinuses
More common with pts on ventilator
Commonly an incidental CT finding when eval for fever

149
Q

Parotitis

A

More often elderly gentleman with poor oral hygiene, poor oral intake and decreased salivary production

Demonstrate edema and focal tenderness

Broad spectrum IV abx to cover staph infections

150
Q

Lines and Drains

A

All “foreign” objects can get infected - PICC infections, CAUTI, etc.
Phlebitis from IV placement
Most of the time the removal of offending line/drain will resolve the issue
- If infection is present, then abx are required

Clin Med - II (Surgery) (10 decks)

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