post-op care & complications Flashcards
Phases of Postoperative Care
- Post Anesthesthetic Observation - Immediate Post-Op; Recovery room (PACU)
- Intermediate Phase - Hospitalization period
- Convalescent Phase - Time from hospital discharge to full recovery; Time varies
Primary Goal of the first 2 phases of postop care
- Hemostasis
- Pain Control
- Prevention & early detection of complications
during the Immediate Postoperative Period, who is the main provider
anesthesiologist
components of coming from immediate to intermediate period
- Discharge from Recovery Room and transfer to hospital floor
- Admit Orders
- PostOp Note (Procedure Note)
- Operative Report
admit orders components
- Admit/OBS
- Diagnosis
- Condition
- Activity
- Vitals
- Diet
- IV Fluids
- Drains
- I&O
- Meds
- Antibiotics
- Pain Meds
- DVT Proph
- GI Proph
- Chronic meds - Allergies
- Labs/imaging
- Monitors
- Respiratory Care
- Wound/Dressing CAre
- Special Instructions
components of Post-Op Note / Procedure Note
- Patient Name
- Date/Time
- Pre-op Dx
- Post-op Dx
- Procedure
- Surgeon
- Assistant
- Anesthesia (type)
- Est. Blood Loss (EBL)
- Urine Output
- IVF
- Findings
- Specimens
- Drains
- Complications
- Disposition
who mostly dictate the operative report
surgeon
Who may provide a brief op note at physician request
PA
you can leave initial sterile dressings on for ?
48 hrs
- Change if dressings become saturated
- Must change under sterile technique within first 48 hrs
instruction components for wound care
- Include in orders instructions for wound checks
- Monitor for signs of infection
- Any sutures or staples removed within 5-10 d (depend on location)
- Face : 3-5 days
- Abdomen: 8-10 days
- Extremities: 10-14 days
- Once removed - steri-strips are applied - Typically keep incision dry for the first few days (there are always exceptions)
- Showering is ok
- No submerging for 2 wks
Epithelialization of the wound occurs in the first ? hours
48h
Management of Drains
- Orders include how often to check drains and record output
- Look for signs of infection, appearance of drain output
- Typically removed in 3-5 days, once output diminishes
how does Pulmonary function diminishes postoperatively? what is its timeline
- Remains markedly diminished for 12-14 hours postop
- Slowly increases over next 5-7 days
- Typically returns to baseline after 7 days
Pulmonary function depression worse in:
Elderly patients, smokers, obesity, pre-existing lung disease
MC pulmonary risk after surgery
atelectasis
Other pulmonary risks - Pulmonary edema, pneumonia, respiratory failure, PE
```
how to minimize risk of atelectasis complication from surgery
incentive spirometry and early mobilization
factors in fluid replacement selection
- Maintenance requirements - Extra needs due to systemic factors (fever, D/V, burns, etc.)
- Losses resulting from drains, operative blood/fluid loss
- Third space losses
what is the 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
MC fluid selection
LR (balanced crystaloid) or D5/0.5%NS
how to monitor blood loss during intermediate phase
- Monitor H&H
- In trauma/ICU patients serial labs
- Stable post op patients a.m. labs - Hemoglobin levels of 9 - 10g/dL are typically tolerated by most asymptomatic patients with normal medical history.
- Normal Values: Male: 14 - 17 g/dL; Female: 12 - 15 g/dL
A Hemoglobin < 7 (in any patient) or < 8 in patients with cardiac, pulmonary, or cerebrovascular disease require ?
blood transfusion.
MC blood transfusion
packed RBCs
General rule: 1 unit of RBC’s increase Hg by 1g/dL and Hct by 3%
Must obtain consent before giving blood!
pain control during intermediate phase
- Pain assessment/Pain scales
- No real standard regimen - must be tailored to patient
- Adequate pain control important
- Reduce hospital stay
- Improve mobility
- Increase patient satisfaction - Goal - adequate pain control; minimal side effects
- Start with IV/PCA for first 48 hours, then switch to oral
MC pain control
opioids
- IV or PCA (patient controlled analgesia)
- Morphine, Hydromorphone (Dilaudid), Fentanyl, Meperidine (Demerol)
non-opioid options for pain control during intermediate phase
- Ketorolac (Toradol) – NSAID
- Tylenol
Given in conjunction with opioids - reduce opioid requirements
non-opioids
Ketorolac (Toradol) - NSAID
Celecoxib (Celebrex) - Cox 2 inhibitor
Acetaminophen (IV, PO, rectal)
Gabapentin
Combination Approach and Alternatives/Adjuncts to Opioids
- local anesthesia
- spinal/epidural
- nerve blocks
- adjuvant therapy - Muscle relaxants, Anxiolytics
local anesthesia options for pain control
- Intraoperative injection
- Patches
- Pain-ball
Spinal/Epidural pain control is indicated for what
> 5 rib fractures
nerve blocks for pain control is indicated for what
ORIF, external fixation, hemiarthroplasty of extremities in trauma cases
what happens to peristalsis after abdominal surgery?
diminished peristalsis
(first 24 hrs, slowly improves over 72 hrs)
diminished peristalsis after abd surgery can lead to what?
how to manage?
- NG tube may be necessary - ileus
- Patient N/V
- Listen for bowel sounds (hypoactive, high pitched “tinkering”)
- Inspect/palpate for abdominal distention - Constipation
- Bowel regimen - ex) Miralax or Colace
GI prophylaxis (stress ulcer) for intermediate care?
PPI/H2 blocker
what antiemetics can be given during intermediate care from abd surgery
Zofran, Phenergan
Intermediate Care - DVT Prophylaxis
- Medications - most commonly Lovenox (LMWH) or SQ Heparin
- Compression stockings/SCDs
- Early ambulation
what ist he pauda prediction score?
> = 4 high risk for DVT
- active cancer
- previous clot
- reduced mobility
- known clotting disorder
- recent trauma/surgery
- > 70 y/o
- heart/rsp failure
- acute MI/ischemic stoke
- acute infection or rheumatologic disorder
- BMI >30
- hormonal tx
what are the 5 W’s
Wind - Atelectasis/Pneumonia; Fever in first 24-48h post op = CXR
Water - UTI; Fever 3-5 days post op = UA with cx
Wound - Superficial or deep infection; Fever 5-7 days post op = Visual inspection; CT scan
Walking - DVT -> PE; Fever 7-10 days post op = Venous Doppler/ CT scan PE protocol
Wonder Drugs - meds or blood products ; Fever at anytime post op = dx of exclusion
other considerations for 5 W’s
- (W)Abscess (5-7d)
- organ or space, not necessarily incisional
-CT scan - Waterway “bloodstream’”
- bacteremia (within 24h)
- blood culture x2 two sites
Most common cause of fever in the first 24-48h after surgery
atelectasis
after surgery pt exhibits
Collapse of the bronchioles - Caused by shallow breathing and failure to hyperinflate the lungs
Fever, Tachypnea, Tachycardia
Hypoxemia - after 48h postop
diminished breath sounds at bases
whats going on
atelectasis
RF for atelectasis
- Smokers, COPD - already have loss of elastic recoil
- Increased secretions which can lead to obstructions
- Elderly - loss of elastic recoil
complications of atelectasis
- Decreased oxygenation of blood
- Infection of atelectasis segment
- In general - If atelectasis persist for >72h - pneumonia will develop
tx atelectasis
- Deep breathing exercises/incentive spirometry/coughing
- Chest percussion, bronchodilators
- Bronchoscopy if severe
causes of pneumonia
❧ Aspiration
❧ Atelectasis
❧ Underlying pulmonary disease/smoking
❧ Increased pulmonary secretions
❧ Diminished defense mechanisms postoperatively
❧ Impaired cough reflex, loss of ciliary coordination
manifestations of penumonia
- Tends to occur within 3 - 5 d postop
- Fever, tachypnea, SOB, 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
management/tx for postop hospital acquired pneumonia with no other risk factors or known resistance
Ceftriaxone (Rocephin), Ampicillin/Sulbactam (Unasyn), Levofloxacin (Levaquin), Ertapenem (Invanz)
tx for penumonia if concerns about resistant organisms or coverage for pseudomonas:
Piperacillin/Tazobactam (Zosyn), Cefepime (Maxipime), Imipenem
tx for MRSA pneumonia
Vancomycin, Linezolid
More significant effusions can present with ___ and ___
atelectasis and pneumonia
s/s of pleural effusion
- Cough
- SOB
- Chest pain
- Fever
- Dullness to percussion
- Decreased tactile fremitus
- Asymmetrical chest expansion (delayed expansion on side of effusion)
tx for pleural effusion
- Small & causing no compromise - do nothing
- Causing respiratory compromise or associated with pneumonia - drain
Greatest risk of pneumothorax associated with what line or procedure
- subclavian central line placement
- after surgery where diaphragm may be punctured (adrenalectomy, nephrectomy)
presenation of pneumothorax
- Sudden SOB
- Chest pain/tightness
- Hypoxia
- Tachycardia
- Tachypnea
- Exam - Unequal breath sounds; Hyperresonance with percussion; Decreased wall expansion
tx for pneumothorax
thoracostomy (chest) tube
UTI Risk increases with
prolonged catheterization (>2 days)
MC pahtogen to cause UTI
E coli
s/s of UTI
Dysuria
Hematuria
Frequency
Fever/N/V
Malodorous urine
dx UTI
UA with cx
tx for UTI
Ciprofloxacin, Rocephin
MCC of postop fever after 48 hrs?
UTI
RF for urinary retention
Pelvic/Perineal Surgery, Spinal Anesthesia, Over distention of Urinary Bladder (not catheterized), h/o BPH/prostate tumor
s/s of urinary retention
- Oliguria/anuria
- Abdominal/pelvic pain discomfort
- Palpation of lower abdomen may demonstrate distended bladder
dx for urinary retention
Bladder scan with PVR of >400mL
tx for urinary retention
Bladder catheterization (Foley)
4 wound complications
- Hematoma
- Seroma
- Wound Dehiscence
- Surgical Site Infection (SSI)
Collection of blood caused by inadequate hemostasis
hematoma
RF hematoma
Anticoagulants, Coagulopathies, Marked post-op HTN, Vigorous coughing/straining after surgery
appearance of hematoma
Swelling, discoloration, bruising, pain/discomfort, blood leaking through incision
tx hematoma
- Small hematomas may resorb on own
- Compression Dressing
- Evacuation of hematoma, ligation of bleeding vessels
common sites for hematoma
Breast, Joints, Thyroid
complications with hematoma
Compress nearby structures, reduced perfusion to site (poor healing - tissue necrosis), infections
most serious complications of hematoma
Neck: cut off air supply, Spine: compress spinal cord
hematoma prevention
- Stop anticoagulants
- Drain placement intraoperatively
Collection of serous fluid
Typically from lymphatics
Not pus or blood
Caused by transection of lymphatics
seroma
appearance of seroma
- Swelling, discomfort
- Leakage of serous fluid from incision
common sites for seroma
Axilla & Breast (post-mastectomy)
Inguinal region
tx for seroma
- Needle aspiration, compression dressings
- If recurrent or severe = surgical wound exploration
complications of seroma
- Compression of nearby structures
- Delay wound healing
- Increase risk of infection
Complete or partial disruption of any or all layers of incision
Wound Dehiscence
Rupture of all layers exposing internal organs
Evisceration
common site for wound dehiscence
abdominal
RF for wound dehiscence
- Age > 60
- DM, immunosuppression, liver ds, sepsis, cancer, obesity, inadequacy of closure, increased intra-abdominal pressure, infection
presentation of dehiscence
- MC occurs between POD 5-8
- May start with increased drainage from incision, or sudden opening
- Absence of “healing ridge” by day 5
tx for dehiscence
- 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 that are not full thickness can be managed with meticulous wound care and not require operative intervention.
MC pathogen for wound infection
s. aureus
Types of SSI’s
- Superficial - skin and subcutaneous tissues
- Deep - fascia, muscles, tissues
- Organ/Open Space
classifications of surgical wounds
- 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
host RF for SSI
- DM
- Hypoxemia
- Immunosuppressive drugs
- Cigarette smoking
- Malnutrition
- Poor skin hygiene/contaminated or infected wounds
infection RF for SSI
- Operative Site Shaving
- Poor sterile technique/contaminated instruments
- Inadequate skin prep
- Inadequate antimicrobial prophylaxis
- Prolonged hypotension
- Poor OR air quality
- Poor postop wound care
s/s of SSI
- 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 for tx for SSI
- Culture
- Abx
- Surgical debridement
prevention of SSI
- good aseptic technique
- incisions made w/o undue injury - good skin and subcutaneous tissue perfusion
- good hemostasis
- control of intraluminal contents/thorough irrigation if spillage
- skin closure does not strangulate
- leave no “dead space”
- abx prophylaxis - one dose 30 mins before incision and no longer than 24 hrs post op.
MC abx prophylaxis for SSI
Cefazolin (Ancef)
Ceftriaxone (Rocephin)
Cefoxitin (Mefoxin)
SSI abx prophylaxis with colorectal or appendix
add Metronidazole (Flagyl) or Clindamycin
GI postop complications
- Stress Gastritis
- N/V
- Gastric Dilation
- Bowel Obstruction
- Fecal Impaction
- Postoperative Pancreatitis
- Postoperative Hepatic Dysfunction
- Postoperative Cholecystitis
- C. difficile colitis
Functional postop ileus are normal when?
for first 24-72 hrs
Obstruction usually due to ?
adhesions/blockage
- MC occurs later in post op phase
- Early post op obstruction MC with colorectal surgery
- Intussusception - CC in peds
what is KUB XR
pronounced air fluid levels with distinct dilation above area of obstruction for bowel obstructions
s/s of ileus and obstruction
- Abd distention
- Abd Pain
- Absence of flatus
- N/V
- Bilious emesis
- Exam: Protuberant tense abdomen; Tympanic abdomen to percussion; Lack of BS after 2min, High pitch tinkering intermittent sounds
tx ileus and obstruction
- Nasogastric tube decompression
- Bowel rest / NPO
- ?need for adhesiolysis
fecal impaction is MC in who?
elderly
fecal impaction is a result from a combination of:
Postoperative ileus, opioids, and reduced mobility
s/s of fecal impaction
anorexia, obstipation
dx fecal impaction
Rectal Exam
KUB XR
tx for fecal impaction
- Manual Removal
- Bowel regimen
Pancreatitis & Cholecystitis is MCC by what type of surgeries?
biliary tract surgeries
- Acute pancreatitis - after ERCP, cholecystectomy
- Acute cholecystitis - after ERCP or upper GI procedures
Pancreatitis & Cholecystitis is more likely to develop which type of condition
infected necrotizing pancreatitis
s/s Pancreatitis & Cholecystitis
acute severe abdominal pain, N/V/D, fever
dx Pancreatitis and Cholecystitis
US/CT scan/MRI, elevated enzymes, leukocytosis
Post Op Hepatic Injury has increased risk with surgeries of?
upper abdomen, biliary tract, and/or pancreas
jaundice from postop hepatic injury can be d/t:
- Drugs
- Blood transfusion reactions
- Damage to liver or liver resections
- Obstruction due to injury of bile ducts
tx for postop hepatic injury
- DC drug
- DC blood transfusion, fluid replacement
- GI consult-ERCP, stenting
Main risk associated with postoperative antibiotic use
Can be transmitted person to person (healthcare providers)
C. diff
s/s of C. diff
malodorous diarrhea, abdominal distention, pain
Dx C. diff colitis
stool cx
complications with c. diff colitis
toxic megacolon
cardiac complications from surgery
- CVA
- Dysrhythmias
- MI
- DVT/Thromboembolism
- Phlebitis/Bacteremia
MCC of CVA
prolonged ischemia/poor perfusion
highest risk surgery to cause CVA
CEA (can also result from plaque being displaced), open heart surgery
RF for CVA
Elderly, Patients with severe known atherosclerosis, and severe hypotension during surgery (bleeding, sepsis, etc)
Cardiac complication that is common during induction of anesthesia and during surgery - typically self limiting
Dysrhythmias
postop Dysrhythmias d/t
- Electrolyte disturbances, drug toxicity
- May be first sign of MI
s/s of dysrhythmias
often asx, may have CP, palpitations, or dyspnea
tx depends on specific arrhythmia
RF for MI
- Duration & type of surgery, prolonged hypotension, prolonged hypoxemia
- Patients with known CAD, HTN, CHF, angina
s/s, dx and prevention for MI
- S/SX – CP, SOB
- dx – EKG, labs
- Prevention - Stabilize CV disorders prior to elective surgery
Caused by needle or catheter introduced into the vein causing inflammation of the vein
Phlebitis
Phlebitis can lead to ___ and ___
infection
thrombosis
MCC of fever after 72 h
phlebitis
s/s, tx, and prevention of phlebitis
- S/Sx - induration, edema, and tenderness, erythema, drainage, pronounced pain with infection (suppurative phlebitis)
- Tx - removal of catheter/warm compresses/NSAIDS
- Abx and excision of affected area of vein with suppurative phlebitis - Prevention - GOOD ASEPTIC TECHNIQUE, rotation of insertion site
RF for DVT
- FHx
- obesity
- immobility
- trauma
- surgery
- smoking
- oral
- contraceptives
- age
s/s and dx for DVT
- S/SX: posterior calf pain, erythema, induration, tenderness
- dx: Venous Doppler
complication of DVT
embolism
tx and prevention for DVT
- Treatment: Anticoagulation therapy, ?Filter
- Prevention: Chemical/mechanical DVT prophylaxis, early mobilization
what is virchow’s triad
endothelial injury, hypercoag, venous stasis
fat embolism is MC with what surgery?
orthopedic surgeries/long bone fractures
s/s of fat embolism
- mostly asx
- Onset - 12-72h after surgery
- rsp distress/hypoxemia, petechiae of axilla and chest, neurologic abnormalities
dx and tx for fat embolism
- Dx - clinical, MRI can show emboli in the brain
- Tx - Symptomatic respiratory support
s/s of pulm embolism
- Tachycardic
- Hypotensive
- Tachypneic
- Hypoxic
- Chest pain
dx and tx for pulmonary embolism
- Dx - Stat CTA PE protocol
- Tx - Anticoagulation therapy, ?embolectomy
when to DC pt
- afebrile >24 h
- tolerating oral intake
- returned bowel function
- ambulatory
- colled with PO meds
- voiding spontaneously
- remains hemodynamically stable
- safe disposition
may require LTAC or SNF placement
what is the Convalescent Phase
phase of postop care
- 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
f/u instructions during convalescent phase
f/u with surgeon
* Typically at 2 wks, sooner with issues
* Additional labs/imaging only if indicated
F/u with Primary Provider
* Recommend 2-4 weeks post discharge for continuity of care
