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Post OP care and complications Flashcards

1
Q

What are the phases of postoperative care

A

Post Anesthesthetic Observation
Intermediate Phase
Convalescent Phase

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2
Q

Post Anesthesthetic Observation

A

taken to recovery room to make sure that everything is ok

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3
Q

What is the intermediate phase?

A

Hospitalization period

amount of time at the hospital

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4
Q

Primary Goal of the first 2 phases (post anestehsia and observatino)

A

Hemostasis
Pain Control
Prevention & early detection of complications

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5
Q

Convalescent Phase

A

Time from hospital discharge to full recovery
Time varies

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6
Q

Who is in charge of the patient from when they are asleep to awake?

A

anesthesiologists

monitor:
Vital Signs (HR, BP, RR, Temp)
Monitoring of EKG
O2 sat - maintain on supplemental oxygen as needed
Fluid monitoring (I&O ins and outs)
Mental status and neuro checks
Pain assessment (how would you rate your pain? You give meds based on pain level)

Usually ready for d/c from recovery room within an hour or 2

Unstable/intubated pts are transferred to the ICU for management

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7
Q

what happens from immediate to intermediate period?

A

Discharge from Recovery Room and transfer to hospital floor
Admit Orders
PostOp Note (Procedure Note)
Operative Report

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8
Q

What goes into admit orders?

A

Explains if you are admitted or under observation
Dx
Condition (stable/critical/guarded)
activity
vitals (how often you want them to be checked)
Diet (patient-dependent, any restrictions, liquids only)
IV Fluids (what type, typically NS)
Drains (surgical drain stuck in skin and pulled through how often you check it and what is in it)
I&O
Meds (patient dependent - often pain meds, DVT prophylaxis, GI prohpylaxis, chronic meds)
Allergies
Labs/imaging (typically trending - WBC and H&H)
monitors (based on patient presentation)
respiratory care (COPD, sleep apnea, respiratory therapist help)
Wound/dressing care and how often
Special instructions (if temp above X call me. If pain above X call me)

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9
Q

explain a drain

A

cut off scary sharp end
push air out
let go and it will pull out the blood/fluid in that area

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10
Q

Who dictates the POST-OP note

A

physician

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11
Q

What is in a post-op note?

A

Patient Name
Date/Time
Pre-op Dx (pelvic pain)
Post-op Dx (stage 2 endometriosis
Procedure
Surgeon
Assistant (PA)
Anesthesia (type)
Est. Blood Loss (EBL)
Urine Output
IVF
Findings (what we found)
Specimens
Drains (what kind of drain and how it was secured)
Complications
Disposition (to be admitted to the floor in satisfactory condition - all surgical counts were correct)

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12
Q

What is included in intermediate stage

A

wound care
drains
pulm care
fluid replacement
blood loss
pain control
GI tract
DVT prophylaxis

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13
Q

what do you do if a wound cannot be closed?

A

Use a wound back

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14
Q

During intermediate phase, what do you look at for drains?

A

Orders include how often to check drains and record output (typically every shift change)
Look for signs of infection, appearance of drain output
Typically removed in 3-5 days, once output diminishes (shows that there is not much more fluid to get rid of)

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15
Q

When does pulm function come back after surgery?

A

Remains markedly diminished for 12-14 hours postop
Slowly increases over next 5-7 days
Typically returns to baseline after 7 days

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16
Q

MC pulmonary risk of surgery and how to prevent

A

Atelectasis

Minimize risk with - incentive spirometry and early mobilization

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17
Q

When do yo uneed fluids?

A

Maintenance requirements
Extra needs due to systemic factors (fever, D/V, burns, etc.)
Losses resulting from drains, operative blood/fluid loss
Third space losses

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18
Q

How much maintanence fluids do you need during intermediate phase for a 75 kg?

A

4:2:1 rule for maintenance fluids
4x10 for the first 10kg
2x10 for the second 10kg
1x remain kg

example: 75kg
4x10 + 2x10 + 1x55 = 115mL/h x 24h =2,760mL
Fluid needs over the first 24 hours postoperatively are greater

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19
Q

What hemoglobins do you give packed RBCs for?

A

A Hemoglobin < 7 (in any patient) or < 8 in patients with cardiac, pulmonary, or cerebrovascular disease require blood transfusion

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20
Q

What is the conversion of 1 unit of RBCs for Hct and Hg?

A

General rule: 1 unit of RBC’s increase Hg by 1g/dL and Hct by 3%

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21
Q

how is pain managed for surgery?

A

subjective based on patient

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22
Q

MC post op pain control

A

Opioids, but others worse

IV and then switch to oral
NSAIDs also work (toradol MC)

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23
Q

What can be used for breakthrough pain (high pain)

A

IV morphine

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24
Q

What non-opioids can be used for surgery pain?

A

Avoid opiods if possible with:

Toradol
CElebrex
Tylenol
Gabapentin

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25
Do we just use one pain med after surgery?
NO can give based on location as well wanna decrease the use of nacrotics
26
What can be used for local anesthesia?
Local Anesthesia Intraoperative injection Patches Pain-ball (2 days of a numbing agent like lidocaine)
27
When are spinal/epidurals typically used?
If surgery led to >5 rib fractures for big surgeries
28
When are nerve blocks typically used?
typically in extremeties
29
What is often given for GI tract?
Stool softener (Miralax or Colace) to minimize constipation Zofran for antiemeics
30
What mechanical methods do you use for DVT prophylaxis?
compression stockings/ SCDs early ambulation
31
What chemical prophylaxis do you use for DVT?
Lovenox (LMWH) or SQ Heparin
32
If a patient has an immediate fever (<24 hours), what do you do?
Evaluate and look at wound (can be normal) transfusion reaction? infection?
33
If a patient has an fever in a week what is it?
Acute
34
Subacute fever
1-4 weeks
35
Delayed fever
> 1 month, likely a viral infection
36
5 W's of acute fever
Wind (PNA, CXR) Water (UTI) Wound (look at the wound with CT scan) Walking (is there a clot? DVT/PE?, depends on how they present) Wonder drugs (medications, blood products, dx of exclusion)
37
MCC of pulm death post op
PNA
38
What is the MC pulmonary posteoperative complication and when does it typical occur?
The most common postoperative pulmonary complication Occurs in up to 25% of patients after abdominal surgery Most common cause of fever in the first 24-48h after surgery
39
What leads to atelectasis?
Shallow breathing and failure to hyperventilate the lungs typically at the base of the lungs
40
MC complication of atletcatiis and presentation?
PNA atelectasis presents with: fever, tachypnea, tachcardia, hypoxemia diminhsed breath sounds at base
41
treatment and prevention of atelectasis?
Treatment Deep breathing exercises/incentive spirometry/coughing Chest percussion, bronchodilators Bronchoscopy if severe Prevention Early mobilization Incentive Spirometry
42
What are the causes of PNA in post op surgery?
Aspiration (DON'T DRINK ANYTHING, this is why you are NPO) Atelectasis Underlying pulmonary disease/smoking ❧Increased pulmonary secretions ❧Diminished defense mechanisms postoperatively ❧Impaired cough reflex, loss of ciliary coordination
43
clinical manifestations of PNA
❧Clinical Manifestations ❧Tends to occur within 3 - 5 days postop ❧Fever, tachypnea, shortness of breath, increased respiratory secretions ❧Exam - auscultatory crackles or diminished breath sounds, dullness to percussion if consolidation is present ❧Labs - leukocytosis ❧Imaging - infiltrates or consolidation on CXR
44
treatment of PNA
AB For coverage of postoperative hospital acquired pneumonia with no other risk factors or known resistance: Ceftriaxone (Rocephin), Ampicillin/Sulbactam (Unasyn), Levofloxacin (Levaquin), Ertapenem (Invanz) If concerns about resistant organisms or coverage for pseudomonas: Piperacillin/Tazobactam (Zosyn), Cefepime (Maxipime), Imipenem For MRSA Vancomycin, Linezolid
45
s/s of pleural effusion
Cough SOB Chest pain Fever
46
pneumothorax treatment
Thoracostomy (chest) tube
47
clinical presnetation of pneumothorax
Sudden shortness of breath Chest pain/tightness Hypoxia Tachycardia Tachypnea
48
UTI is typically caused by
bladder catheterization/instrumentation prolonged catheterization >2 days
49
dx and treatment of UTI
dx with UA and culture tx with cipro or rocephin
50
What are the RFs of urinary retention
Pelvic/Perineal Surgery, Spinal Anesthesia, Over distention of Urinary Bladder (not catheterized), h/o BPH/prostate tumor
51
diagnosis of urinary retention
Bladder scan with PVR (post void residual) of >400mL
52
treatment of urinary retention
bladder cath
53
What are the 3 wound complications of post op?
Hematoma Seroma Wound Dehiscence Surgical Site Infection (SSI)
54
What can cause a hematoma
inadequate hemostasis post-op HTN vigorous coughing/straining (loosens eschar on vessel)
55
clinical appearance of hematoma
Swelling, discoloration, bruising, pain/discomfort, blood leaking through incision bleeding under the skin
56
treatment of small hematoma
resolves on own use compression dressing
57
treatment of large hematoma
surgery
58
MC sites of hematoma
Breast, Joints, Thyroid
59
complications of a hematoma
compressing nearby structures
60
Most serious complications of hematoma
Neck cutting off air supply Compression of spinal cord
61
prevention of hematoma
stop anticoagulation (remember, internal bleed) drain placement intraopteratively
62
seroma and common sites
Collection of serous fluid Typically from lymphatics Not pus or blood Caused by transection of lymphatics Clinical Appearance Swelling, discomfort Leakage of serous fluid from incision Common Sites Axilla & Breast (post-mastectomy), Inguinal region (areas of lymphatics)
63
treatment and complications of seroma
Treatment Needle aspiration, compression dressings If recurrent or severe = surgical wound exploration Complications Compression of nearby structures Delay wound healing Increase risk of infection
64
What is wound dehiiscence?
Complete or partial disruption of any or all layers of incision
65
What is it called if wound dehiscence exposes all layers of internal organs?
Evisceration
66
MC site of wound dehiscence
abdominal > 60 or underlying RFs is MC
67
When does wound dehiscence typically occur? treatment?
Clinical Presentation Most commonly occurs between POD 5-8 May start with increased drainage from incision, or sudden opening Absence of “healing ridge” by day 5 Treatment Moist towels and binder until surgical consult –return to OR Debridement and Reclosure of fascia - skin typically loosely approximated - heal by secondary intention (Retention Sutures/wound vac) Small areas of wound dehiscence that are not full thickness can be managed with meticulous wound care and not require operative intervention
68
MC wound infection post op
staph
69
4 classifications of surgical wounds (clean, clean contaminated, contaminated, dirty)
Clean - no hollow viscus entered, no inflammation/infection, no breaks in aseptic technique, primary wound closure, non-traumatic surgery Clean-Contaminated - hollow viscus entered but controlled, no inflammation/infection, minor break in aseptic technique, primary wound closure Contaminated - Uncontrolled spillage from viscus, inflammation/infection apparent, traumatic wounds, major break in aseptic technique Dirty - Untreated, uncontrolled spillage from viscus, pus in operative wound, open dirty traumatic wound know these
70
What is SSI
surgical site infection
71
when does SSI typically occur and presentation? Diagnosis? Treatment?
Usually start 5-6 days post op (deep infections may be as late as months) Fever, surgical site pain, edema, erythema, drainage Palpation may elicit discharge Can lead to wound dehiscence Management & Treatment Culture Abx Surgical debridement
72
why do we wanna maintain good hemostasis to prevent SSI?
Hematomas can lead to dehiscence, which can lead to infection
73
Preop SSI prophyalxis
typically a high gen cephalosporin add metro or clinda if colorectal or appendix
74
What are the GI complications?
Stress Gastritis N/V Gastric Dilation Bowel Obstruction Fecal Impaction Postoperative Pancreatitis Postoperative Hepatic Dysfunction Postoperative Cholecystitis C. difficile colitis
75
s/s of ileus and obstruction
Abdominal Pain Absence of flatus N/V Bilious emesis Exam Protuberant tense abdomen Tympanic abdomen to percussion Lack of bowel sounds after 2min, High pitch tinkering intermittent sounds (at the beginning)
76
treatment of ileus and obstruction
Nasogastric tube decompression Bowel rest / NPO ?need for adhesiolysis
77
Fecal impaction is MC in? What is the treatment?
elderly opiods reduced motility trifecta manual removal
78
What can lead to pancreatitis or cholecystits?
ERCP high mortalitiy
79
s/s of pancreatits / cholecystitsi. dx treatment
S/SX – acute severe abdominal pain, N/V/D, fever Diagnosis – US/CT scan/MRI, elevated enzymes, leukocytosis Treatment - ?Pancreatitis vs cholecystitis
80
What can lead to post op liver problems?
blood transfusion drugs direct dmg obstruction Treatment Discontinuation of drug Discontinuation of blood transfusion, fluid replacement GI consult-ERCP, stenting
81
Common complications of C dif
toxic megacolon
82
What is a CVA?
Most commonly result from prolonged ischemia/poor perfusion Highest risk surgery - CEA (can also result from plaque being displaced), open heart surgery Risk Factors - Elderly, Patients with severe known atherosclerosis, and severe hypotension during surgery (bleeding, sepsis, etc)
83
dysrhytmias in post op?
usually self limiting can be an electrolyte abnormalities, but can be the first sign of an MI treated based on the type of rhythm
84
MI RF and prevention
Duration & type of surgery, prolonged hypotension, prolonged hypoxemia Patients with known CAD, HTN, CHF, angina S/SX – CP, SOB Diagnosis – EKG, labs Prevention - Stabilizing any underlying cardiovascular disorders prior to elective surgery
85
Phlebitis?
something we cause can lead to infection, fever induration and tenderness at IV site remove catheter NSAIDs Good aseptic technique and rotating sites to prevent it
86
Virchows triad
Injury Hypercoaguability venous stasis
87
fat embolism is MC in
orthopedic surgeries involved with long bones
88
s/s of fat embolism and treatment
MRI shows embolism in the brain supportive treatent
89
S/s of PE
Tachycardic Hypotensive Tachypneic Hypoxic Chest pain Dx Stat CTA PE protocol Tx Anticoagulation therapy, ?embolectomy
90
When to discharge a patient?
No fever w/in 24 hours can eat return of bowel function is ambulatory off IV pain meds All labs are trending Safe place to go hoe Patient may require LTAC or SNF placement if the answer to these is no
91
What is the convalescent phase?
Getting better as you get back home Begins once patient is home Ongoing over the weeks and months post operatively Length is dependent upon the type of surgery Longer course of recovery with post operative complications Longer in patient with significant comorbidities Close follow up with surgeon Typically at 2 weeks, sooner with issues Additional labs/imaging only if indicated Follow up with Primary Provider Recommend 2-4 weeks post discharge for continuity of care

Surgery (4 decks)

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