Post-OP Flashcards
What is Enhanced recovery after surgery?
ERAS is an evidence based approach to help people recover quicker after surgery.
What are the principles underyling the Enhanced recovery after surgery programme?
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
What are the immediate general surgical Complications?
Immediate:
- Intubation -> oropharyngeal trauma
- Surgical trauma to local structires
- Primary or reactive haemorrhage
What are the early general surgical Complications?
Early:
- Secondary haemorrhage
- VTE
- Urinary retention
- Atelectasis and pneumonia
- Wound infection
- Wound dehiscence
What are the late general surgical Complications?
Late:
- Scarring
- Neruopathy
- Failure of surgery or recurrence of the problem
What is meant by reactive bleeding?
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.
What are the timeframes used to classify surgical complications into immediate, early and late?
- Immediate: <24 hours.
- Early: 1d - 1 month
- Late: >1 month
What are causes of post-surgical urinary retention?
Post-OP urinary rentention can be due to:
Drugs:
- Opioids
- Epidural/spinal anaesthesia
- Anti-cholinergics
Pain
- leads to sympathetic activtion and spincter contraction
What are risk factors for post-surgical urinary retention?
- Male
- Increasing age
- Neuropathy (e.g. DM, EtOH related)
- Prostatic hyperplasia
- Specific to type of surgery: anorectal, hernia, orthopaedic.
Summarise the managemetn of post-surgical urinary retention.
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
What is atelectasis?
Atelectasis is the collapse/closure of a lung resulting in reduced or absent gas exchange.
The alveoli are deflated down to little/no volume.
What are reasons why atelectasis commonly occurs during after surgery?
- General anaesthetic agents
- Mucous plugging (increased mucus production and decrased mucociliary clearance)
- Improper respiration due to pain and immobility
How does post-OP atelectesis present?
- within first 48 hours
- Mild pyrexia
- Dyspnoea
- Dull bases with decreased air entry
How is post-surgical atelectasis managed?
It is essential to resotre normal repisration.
- Encourage coughing - incentive spirometer
- Chest physiotherapy
What are risk factors for post-OP wound infections?
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
What is wound dehiscence?
When does this usually occur?
Wound dehiscence is is when a surgical incision reopens either internally or externally.
Usually occurs within 10 days of surgery.
What are risk factors for wound dehiscnece?
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
How is wound dehiscence managed if you spot it on the ward?
- 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
What are potential specific complications of laparoscopic cholcystectomy?
- 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)
What are specific complications of an Inguinal hernia repair?
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%)
What are the specific post-OP complications after an appendicectomy?
- Residual inflammation of the sump (“stumpitis”)
- Leakage from stump
- Abscess formation
- Trauma to surrounding structures:
- Anything intra-abdomina
- Esp. fallopian tube
- Ileus
What are the complications with colonic surgery?
Early:
- Ileus
- Anastomotic leak
- Enterocutaneous fistula
- Abdominal or pelvic abscess
Late:
- Adhesions (-> obstruction)
- Incisional hernias
What are the cuases of post-OP ileus?
- Electrolyte imbalances (e.g. hypokalaemia)
- Bowel handling during abdominal surgery
- Anaesthetic drugs during any surgery
- Some infections
- Bowel ischaemia
How does post-OP ileus present?
Ileus presents like obstruction:
- Distension
- Constipation
- Absent bowel sounds
- Pain, nausea and vomiting
