Post-Op Assessment Flashcards
What are the 2 methods of considering surgical risk factors?
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)
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?
- Diabetes
- Obesity
Diabetic and obese patients are more likely to develop surgical site infections and wound breakdown.
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?
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.
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?
What were the post-operative instructions on the operation note? Did the patient receive antibiotics?
Give some examples of patient risk factors for a post-op infection?
1) Obesity
2) Diabetes
3) Steroids
4) Immunosuppression
5) Malnutrition
Give some examples of operation risk factors for a post-op infection?
1) Contaminated/dirty operation
2) Foreign materials
3) Vascular grafts
4) Joint replacement
Post-op complications can be classified by time.
What defines a:
a) immediate
b) early
c) late/long-term complications?
a) <24 hours
b) within 30 days (usually within 1 week)
c) after 30 days or after discharge
Post-op complications can be classified by the underlying cause (i.e. aetiology).
Give some examples
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
What are 7 potential sources of post-op pyrexia (7 C’s)?
Chest
Catheter
Central line
Cannula
Cut (surgical wound)
Collections
Calves
The timeline of post-op pyrexia determines the differentials.
What are possible causes of post-op pyrexia in days 1-3?
- Atelectasis
- Metabolic response to trauma
- Drug reaction – IV fluids/transfusion
- Systemic inflammatory response syndrome (SIRS)
- Line infection
- Instrumentation of viscus: transient bacteraemia
What are possible causes of post-op pyrexia in days 4-6?
- Chest infection
- Superficial wound infection
- UTI
- Line infection
- Compartment syndrome
What are possible causes of post-op pyrexia in >7 days post-op?
- Chest infection
- Suppurative wound infection
- Anastomotic leak
- Deep abscess (swinging pyrexia)
- DVT
What should examination of a post-op febrile patient involve?
- Observation chart, fluid chart, notes and drug chart
- Wound check
- Abdominal examination + digital rectal examination (DRE)
- Legs
- Chest
- Lines
- Drains
- Urine
- Stool
What should investigations include for a post-op febrile patient?
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)
What is SIRS?
Systemic inflammatory response syndrome.
This is an exaggerated defence response of the body to a stressor e.g. infection, trauma, surgery.
How is SIRS defined?
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)
What are some factors that increase the risk of a surgical site infection?
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
What can be done pre-operatively to reduce risk of surgical site infection?
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)
What should the skin be prepared with to reduce the risk of surgical site infections?
alcoholic chlorhexidine
What electrolyte problem are patients with arrhythmias following cardiac surgery at risk of?
Susceptibility to hypokalaemia (K+ <4.0 in cardiac patients)
What electrolyte problem are patients post cranial surgery at risk of?
SIADH cause hyponatraemia
What complication are patients post pneumonectomy at risk of?
Pulmonary oedema: loss of lung volume makes these patients very sensitive to fluid overload.
How can a post-op anastamotic leak present?
Generalised sepsis causing mediastinitis or peritonitis depending on site of leak.
What surgery is the long thoracic at risk of being damaged in?
Axillary node clearance
