Post-Op Assessment

Question 1

What are the 2 methods of considering surgical risk factors?

Answer 1

Method 1:

Risk factors can be broken down into the following categories:
1) Pre-operative
2) Peri-operative
3) Post-operative

Method 2:
1) Patient factors (i.e. patient risk factors)
2) Operation factors (e.g. surgical technique, post-operative care/instructions)

Question 2

Example: “You are called to see an obese diabetic 50-year-old patient following their open mesh inguinal hernia repair. The patient is 3 days post-op and is complaining of pain around his surgical site in his groin. The nurse reports some swelling at the site and a foul odour.”

What are the pre-op risk factors?

Answer 2

• Diabetes
• Obesity

Diabetic and obese patients are more likely to develop surgical site infections and wound breakdown.

Question 3

Example: “You are called to see an obese diabetic 50-year-old patient following their open mesh inguinal hernia repair. The patient is 3 days post-op and is complaining of pain around his surgical site in his groin. The nurse reports some swelling at the site and a foul odour.”

What are the peri-op risk factors?

Answer 3

The operation was completed open and with a mesh. An open wound is more likely to breakdown in an obese patient and the mesh is a foreign material which increases the possibility of infection.

Question 4

Example: “You are called to see an obese diabetic 50-year-old patient following their open mesh inguinal hernia repair. The patient is 3 days post-op and is complaining of pain around his surgical site in his groin. The nurse reports some swelling at the site and a foul odour.”

What are the post-op risk factors?

Answer 4

What were the post-operative instructions on the operation note? Did the patient receive antibiotics?

Question 5

Give some examples of patient risk factors for a post-op infection?

Answer 5

1) Obesity
2) Diabetes
3) Steroids
4) Immunosuppression
5) Malnutrition

Question 6

Give some examples of operation risk factors for a post-op infection?

Answer 6

1) Contaminated/dirty operation
2) Foreign materials
3) Vascular grafts
4) Joint replacement

Question 7

Post-op complications can be classified by time.

What defines a:

a) immediate
b) early
c) late/long-term complications?

Answer 7

a) <24 hours

b) within 30 days (usually within 1 week)

c) after 30 days or after discharge

Question 8

Post-op complications can be classified by the underlying cause (i.e. aetiology).

Give some examples

Answer 8

General:

1) Reaction to anaesthesia
2) Haemorrhage
3) Pyrexia
4) Wound infection/surgical site infection
5) Thromboembolism
6) Urinary retention

Specific:

1) Damage to adjacent structures
2) GI: anastomotic leak, visceral injury, strictures
3) Vascular: ischaemic colitis, endoleaks, graft migration
4) Plastic surgery: scarring, flap failure

Question 9

What are 7 potential sources of post-op pyrexia (7 C’s)?

Answer 9

Chest
Catheter
Central line
Cannula
Cut (surgical wound)
Collections
Calves

Question 10

The timeline of post-op pyrexia determines the differentials.

What are possible causes of post-op pyrexia in days 1-3?

Answer 10

• Atelectasis
• Metabolic response to trauma
• Drug reaction – IV fluids/transfusion
• Systemic inflammatory response syndrome (SIRS)
• Line infection
• Instrumentation of viscus: transient bacteraemia

Question 11

What are possible causes of post-op pyrexia in days 4-6?

Answer 11

• Chest infection
• Superficial wound infection
• UTI
• Line infection
• Compartment syndrome

Question 12

What are possible causes of post-op pyrexia in >7 days post-op?

Answer 12

• Chest infection
• Suppurative wound infection
• Anastomotic leak
• Deep abscess (swinging pyrexia)
• DVT

Question 13

What should examination of a post-op febrile patient involve?

Answer 13

• Observation chart, fluid chart, notes and drug chart
• Wound check
• Abdominal examination + digital rectal examination (DRE)
• Legs
• Chest
• Lines
• Drains
• Urine
• Stool

Question 14

What should investigations include for a post-op febrile patient?

Answer 14

1) Urine: dip + send for culture (MCS)

2) Bloods: FBC, U&E, LFTs, G&S, clotting

3) Cultures: blood, wound, lines including central venous pressure (CVP) catheter tip/ percutaneous peripheral line (PICC)

4) Chest xray

5) Arterial Blood Gas (ABG)

Question 15

What is SIRS?

Answer 15

Systemic inflammatory response syndrome.

This is an exaggerated defence response of the body to a stressor e.g. infection, trauma, surgery.

Question 16

How is SIRS defined?

Answer 16

Defined as 2 or more of:

1) Fever >38?C or < 36?C

2) Heart rate >90 beats per minute

3) Respiratory rate >20 breaths per minute or PaCO2 <32 mm Hg

4) Abnormal white blood cell count (>12,000/mm3 or <4,000/ mm3 or >10% bands)

Question 17

What are some factors that increase the risk of a surgical site infection?

Answer 17

1) Shaving the wound using a razor (disposable clipper preferred)

2) Using a non-iodine impregnated incise drape if one is deemed to be necessary

3) Tissue hypoxia

4) Delayed administration of prophylactic antibiotics in tourniquet surgery

Question 18

What can be done pre-operatively to reduce risk of surgical site infection?

Answer 18

1) If hair needs removal, use electrical clippers with a single-use head (razors increase infection risk)

2) Antibiotic prophylaxis if:
- placement of prosthesis or valve
- clean-contaminated surgery
- contaminated surgery

3) Aim to give single-dose IV antibiotic on anaesthesia (if a tourniquet is to be used, give prophylactic antibiotics earlier)

Question 19

What should the skin be prepared with to reduce the risk of surgical site infections?

Answer 19

alcoholic chlorhexidine

Question 20

What electrolyte problem are patients with arrhythmias following cardiac surgery at risk of?

Answer 20

Susceptibility to hypokalaemia (K+ <4.0 in cardiac patients)

Question 21

What electrolyte problem are patients post cranial surgery at risk of?

Answer 21

SIADH cause hyponatraemia

Question 22

What complication are patients post pneumonectomy at risk of?

Answer 22

Pulmonary oedema: loss of lung volume makes these patients very sensitive to fluid overload.

Question 23

How can a post-op anastamotic leak present?

Answer 23

Generalised sepsis causing mediastinitis or peritonitis depending on site of leak.

Question 24

What surgery is the long thoracic at risk of being damaged in?

Answer 24

Axillary node clearance

Question 25

In post-op ileus, does hypovolaemia and electrolyte disturbances occur before or after N&V?

Answer 25

Before

Question 26

What is a potential, and serious, cause of new onset atrial fibrillation following gastrointestinal surgery?

Answer 26

An anastomotic leak

Question 27

How soon post-op does an anastomotic leak usually present?

Answer 27

5-7 days post-op

Question 28

How can an anastomotic leak cause post-op AF?

Answer 28

Can cause systemic inflammation, which sensitises the pacemaker cells.

Question 29

How can an anastomotic leak be diagnosed?

Answer 29

Abdominal CT