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Perioperative managment > Post-OP > Flashcards

Post-OP Flashcards

1
Q

What is Enhanced recovery after surgery?

A

ERAS is an evidence based approach to help people recover quicker after surgery.

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2
Q

What are the principles underyling the Enhanced recovery after surgery programme?

A

Whilst the exact programmes differ for different surgeries, general principles include:

  • Being as healthy as possible before the operation
    • Hydration
    • Co-morbidities (e.g. diabetes, HTN, anaemia)
    • Smoking cessation 4 weeks before
  • Optimal surgical care
    • Short-acting anaesthetic agents (TCI, spinal)
    • Minimally invasive surgery
  • Optimised post-OP programme:
    • Aggressively treat pain and nausea
    • Physiotherapy + early mobilisation
    • Early oral intake and discontinuation of IV fluids
    • Remove drains/catheters asap
  • MDT input
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3
Q

What are the immediate general surgical Complications?

A

Immediate:

  • Intubation -> oropharyngeal trauma
  • Surgical trauma to local structires
  • Primary or reactive haemorrhage
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4
Q

What are the early general surgical Complications?

A

Early:

  • Secondary haemorrhage
  • VTE
  • Urinary retention
  • Atelectasis and pneumonia
  • Wound infection
  • Wound dehiscence
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5
Q

What are the late general surgical Complications?

A

Late:

  • Scarring
  • Neruopathy
  • Failure of surgery or recurrence of the problem
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6
Q

What is meant by reactive bleeding?

A

Reactive bleeding refers to bleeding wihtin 24 hours of the operation.

During surgery patients are often hypotensive and relatively vasoconstricted. In the post-operative period when the blood pressure rises and vasodilatation occurs, a damaged blood vessel may start to bleed more.

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7
Q

What are the timeframes used to classify surgical complications into immediate, early and late?

A
  • Immediate: <24 hours.
  • Early: 1d - 1 month
  • Late: >1 month
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8
Q

What are causes of post-surgical urinary retention?

A

Post-OP urinary rentention can be due to:

Drugs:

  • Opioids
  • Epidural/spinal anaesthesia
  • Anti-cholinergics

Pain

  • leads to sympathetic activtion and spincter contraction
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9
Q

What are risk factors for post-surgical urinary retention?

A
  • Male
  • Increasing age
  • Neuropathy (e.g. DM, EtOH related)
  • Prostatic hyperplasia
  • Specific to type of surgery: anorectal, hernia, orthopaedic.
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10
Q

Summarise the managemetn of post-surgical urinary retention.

A

Conservative:

  • Aid the patient to void by giving privacy, let taps run whilst trying or trying in a hot bath

Medical:

  • Remove or replace drugs associated with retention
  • Optimise analgesia

Surgical:

  • Catheterise
    • TWOC after 2-3 days. If fails, give silicone catheter and follow-up with Urology
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11
Q

What is atelectasis?

A

Atelectasis is the collapse/closure of a lung resulting in reduced or absent gas exchange.

The alveoli are deflated down to little/no volume.

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12
Q

What are reasons why atelectasis commonly occurs during after surgery?

A
  • General anaesthetic agents
  • Mucous plugging (increased mucus production and decrased mucociliary clearance)
  • Improper respiration due to pain and immobility
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13
Q

How does post-OP atelectesis present?

A
  • within first 48 hours
  • Mild pyrexia
  • Dyspnoea
  • Dull bases with decreased air entry
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14
Q

How is post-surgical atelectasis managed?

A

It is essential to resotre normal repisration.

  • Encourage coughing - incentive spirometer
  • Chest physiotherapy
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15
Q

What are risk factors for post-OP wound infections?

A

Pre-operative:

  • Increasing age
  • Comorbidities (e.g. DM)
  • Smoking (decreased blood supply)
  • Pre-existing infection (e.g. appendix perf)
  • Patient colonisation with e.g. MRSA

Operative:

  • Type of surgery (aka. “Operative Classification”
  • Duration - longer = higher risk
  • Technical (was everything sterile? where prophylactic ABx given?)

Post-operative:

  • Contamination of wound from environment
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16
Q

What is wound dehiscence?

When does this usually occur?

A

Wound dehiscence is is when a surgical incision reopens either internally or externally.

Usually occurs within 10 days of surgery.

17
Q

What are risk factors for wound dehiscnece?

A

Pre-operative:

  • Age
  • Smoking (poorer healing)
  • Comorbidities (DM, uraemia, chronic cough)
  • Drugs (steroids, chemo/radio)

Operative

  • Length & orientation
  • Closing technique (scars extend, so use thread 4x longer than scar)
  • Suture material

Post-operative:

  • Increased abdominal pressure (e.g. obstruction/distension)
  • Infection (makes wound healing weak and tissue friable)
  • Haematoma/seroma formation
18
Q

How is wound dehiscence managed if you spot it on the ward?

A
  • Replace abdominal contentes and cover with sterile soaked gauze
  • Prescribe anitbiotics (e.g. cef + met)
  • Opioid analgesia
  • Call senior to arrange for theatre:
    • Wash bowel
    • Debride wound edges
    • Close with deep non-absorbable sutures
  • Think about VAC dressing or grafting
19
Q

What are potential specific complications of laparoscopic cholcystectomy?

A
  • Conversion to open in 5%
  • Injury to surrounding structures:
    • Common bile duct injury in 0.3%
    • Associated bile leak (often see bile in drain)
  • Retained stones (which will then require ERCP)
  • Fat intolerance/statorrhoea (as bile is responsible for making fats absorbable)
20
Q

What are specific complications of an Inguinal hernia repair?

A

Early:

  • Haematoma or seroma formation (10%)
  • Damage to intra-abdominal structures during surgery
  • Infection
  • Urinary retention

Late:

  • Recurrence (0.5%)
  • Ischaemic orchitis (0.05%)
  • Chronic pain/paraesthesia related to mesh (20-30%)
21
Q

What are the specific post-OP complications after an appendicectomy?

A
  • Residual inflammation of the sump (“stumpitis”)
  • Leakage from stump
  • Abscess formation
  • Trauma to surrounding structures:
    • Anything intra-abdomina
    • Esp. fallopian tube
  • Ileus
22
Q

What are the complications with colonic surgery?

A

Early:

  • Ileus
  • Anastomotic leak
  • Enterocutaneous fistula
  • Abdominal or pelvic abscess

Late:

  • Adhesions (-> obstruction)
  • Incisional hernias
23
Q

What are the cuases of post-OP ileus?

A
  • Electrolyte imbalances (e.g. hypokalaemia)
  • Bowel handling during abdominal surgery
  • Anaesthetic drugs during any surgery
  • Some infections
  • Bowel ischaemia
24
Q

How does post-OP ileus present?

A

Ileus presents like obstruction:

  • Distension
  • Constipation
  • Absent bowel sounds
  • Pain, nausea and vomiting
25
Q

Summarise the management of post-OP ileus.

A

Conservative:

  • Insert a Ryles tube (suck) and insert cannula to give IV fluids (drip). Keep patients NBM.
  • Monitor urine output (catheter).
  • Do imaging (AXR ± CT) to rule out other cause of obstruction.

Medical:

  • Reduce opioid analgesia; replace with non-opioid

Surgical not relevant.

26
Q

What are specific complications of anorectal surgery?

A
  • Anal incontinence
  • Stenosis
  • Anal fissures
27
Q

What is a complication that can occur if a lot of small bowel has to be removed?

A

Shoer bowel syndrome. It usually only occurs after 4m of the 6m have been removed.

This is a malabsorption disorder caused by too little functional small bowel.

Complications inlcude:

  • Anaemia (iron absorption happens in duodenum)
  • Neuropathies: B12 (absorbed in ileum)
  • Other symptoms related to nutrient deficiencies: ADEK vitamins, calcium, zinc (e.g. easy bruising, muscle spasm, bone pain)
28
Q

What are post-OP complications after a splenectomy?

A
  • Infection with encapsulated organisms (Neisseria, Haemophilus, Streptococcus pneumoniae)
    • Give prophylactic vaccinations and consider antibiotics
  • Thrombocytosis -> increased risk of VTE
29
Q

What are some specific complications from arterial surgery?

A

This varies based on the specific type of vascular surgery that was done. In general:

  • Thrombosis and embolisation
  • Anastomotic leak
  • Graft infection
30
Q

What are some specific complications from aortic surgery?

A
  • Gut ischaemia
  • Renal failure (if renal arteries damaged or pre-renal AKI)
  • Emboli -> distal ischaemia (aka. trash foot)
  • Anterior spinal cord syndrome (ischemia of the anterior spinal artery -> loss of function of the anterior 2/3rds of spinal cord)
  • Aorto-enteric fistula
31
Q

What are specific complications of breast surgery?

A
  • Arm lymphoedema (if axillary LNs removed)
  • Seroma formation (within wound)
  • Altered sensation
  • Winging of the scapula due to damage of the long thoracic nerve
32
Q

What are some specific complications of prostatectomy?

A
  • Urinary incontinence (5%)
  • Erectile dysfunction (70%)
  • Retrograde ejaculation
33
Q

What are some speific complications of thyroid surgery?

A
  • Wound haematoma which can compress the trachea!
    • Therefore always have wire cutters next to patient’s bed so you can act quicly
  • Recurrent laryngeal nerve trauma
    • Transient in 1-2%
    • Permanent in <1%
    • Leads to hoarse voice, but can also lead to quite breathing problems especially when both nerves are damaged.
  • Parathyroid injury: hypocalcaemia
  • Thyroid hormone: thyroid storm or hypothyroidism.
  • Rarely: damage to vessels in neck.
34
Q

What are some common complications of fracture repairs?

A
  • Incorrect healing: malunion, non-union
  • Osteomylelitis
  • Avascular necrosis of the bone
  • Compartment syndrome
35
Q

What are some specific complitions to hip replacement surgery?

A
  • VTEs are very common post hip replacement.
  • Injury to the superior gluteal nerve (-> Trendelenbur gait)
  • Injury to sciatic nerve
  • Leg length discrepancy
36
Q

What are some specific complitions to cardiothoracic surgery?

A
  • Pneumothorax
  • Haemothorax
  • Mediastinitis
37
Q

What are causes of post-OP pyrexia?

A

Early (0-5 days):

  • Physiological - systemic inflammation 2° to trauma. (first 24h)
  • Blood transfusion
  • Pulmonary atelectasis
  • Infection
  • Drug reaction

Late (>5 days):

  • Pneumonia
  • TE
  • Wound infecion, anastomotic leak

Perioperative managment (2 decks)

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