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Surgery > post-op care & complications > Flashcards

post-op care & complications Flashcards

1
Q

Phases of Postoperative Care

A
  • Post Anesthesthetic Observation - Immediate Post-Op; Recovery room (PACU)
  • Intermediate Phase - Hospitalization period
  • Convalescent Phase - Time from hospital discharge to full recovery; Time varies
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2
Q

Primary Goal of the first 2 phases of postop care

A
  1. Hemostasis
  2. Pain Control
  3. Prevention & early detection of complications
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3
Q

during the Immediate Postoperative Period, who is the main provider

A

anesthesiologist

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4
Q

components of coming 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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5
Q

admit orders components

A
  1. Admit/OBS
  2. Diagnosis
  3. Condition
  4. Activity
  5. Vitals
  6. Diet
  7. IV Fluids
  8. Drains
  9. I&O
  10. Meds
    - Antibiotics
    - Pain Meds
    - DVT Proph
    - GI Proph
    - Chronic meds
  11. Allergies
  12. Labs/imaging
  13. Monitors
  14. Respiratory Care
  15. Wound/Dressing CAre
  16. Special Instructions
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6
Q

components of Post-Op Note / Procedure Note

A
  1. Patient Name
  2. Date/Time
  3. Pre-op Dx
  4. Post-op Dx
  5. Procedure
  6. Surgeon
  7. Assistant
  8. Anesthesia (type)
  9. Est. Blood Loss (EBL)
  10. Urine Output
  11. IVF
  12. Findings
  13. Specimens
  14. Drains
  15. Complications
  16. Disposition
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7
Q

who mostly dictate the operative report

A

surgeon

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8
Q

Who may provide a brief op note at physician request

A

PA

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9
Q

you can leave initial sterile dressings on for ?

A

48 hrs

  • Change if dressings become saturated
  • Must change under sterile technique within first 48 hrs
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10
Q

instruction components for wound care

A
  1. Include in orders instructions for wound checks
  2. Monitor for signs of infection
  3. 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
  4. Typically keep incision dry for the first few days (there are always exceptions)
    - Showering is ok
    - No submerging for 2 wks
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11
Q

Epithelialization of the wound occurs in the first ? hours

A

48h

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12
Q

Management of Drains

A
  • 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
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13
Q

how does Pulmonary function diminishes postoperatively? what is its timeline

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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14
Q

Pulmonary function depression worse in:

A

Elderly patients, smokers, obesity, pre-existing lung disease

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15
Q

MC pulmonary risk after surgery

A

atelectasis

Other pulmonary risks - Pulmonary edema, pneumonia, respiratory failure, PE

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16
Q

```

how to minimize risk of atelectasis complication from surgery

A

incentive spirometry and early mobilization

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17
Q

factors in fluid replacement selection

A
  1. Maintenance requirements - Extra needs due to systemic factors (fever, D/V, burns, etc.)
  2. Losses resulting from drains, operative blood/fluid loss
  3. Third space losses
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18
Q

what is the 4:2:1 rule for maintenance fluids

A
  • 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

MC fluid selection

A

LR (balanced crystaloid) or D5/0.5%NS

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20
Q

how to monitor blood loss during intermediate phase

A
  1. Monitor H&H
    - In trauma/ICU patients serial labs
    - Stable post op patients a.m. labs
  2. 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
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21
Q

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

A

blood transfusion.

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22
Q

MC blood transfusion

A

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

Must obtain consent before giving blood!

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23
Q

pain control during intermediate phase

A
  1. Pain assessment/Pain scales
  2. No real standard regimen - must be tailored to patient
  3. Adequate pain control important
    - Reduce hospital stay
    - Improve mobility
    - Increase patient satisfaction
  4. Goal - adequate pain control; minimal side effects
  5. Start with IV/PCA for first 48 hours, then switch to oral
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24
Q

MC pain control

A

opioids

  • IV or PCA (patient controlled analgesia)
  • Morphine, Hydromorphone (Dilaudid), Fentanyl, Meperidine (Demerol)
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25
Q

non-opioid options for pain control during intermediate phase

A
  • Ketorolac (Toradol) – NSAID
  • Tylenol
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26
Q

Given in conjunction with opioids - reduce opioid requirements

A

non-opioids
Ketorolac (Toradol) - NSAID
Celecoxib (Celebrex) - Cox 2 inhibitor
Acetaminophen (IV, PO, rectal)
Gabapentin

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27
Q

Combination Approach and Alternatives/Adjuncts to Opioids

A
  1. local anesthesia
  2. spinal/epidural
  3. nerve blocks
  4. adjuvant therapy - Muscle relaxants, Anxiolytics
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28
Q

local anesthesia options for pain control

A
  • Intraoperative injection
  • Patches
  • Pain-ball
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29
Q

Spinal/Epidural pain control is indicated for what

A

> 5 rib fractures

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30
Q

nerve blocks for pain control is indicated for what

A

ORIF, external fixation, hemiarthroplasty of extremities in trauma cases

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31
Q

what happens to peristalsis after abdominal surgery?

A

diminished peristalsis
(first 24 hrs, slowly improves over 72 hrs)

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32
Q

diminished peristalsis after abd surgery can lead to what?
how to manage?

A
  1. NG tube may be necessary - ileus
    - Patient N/V
    - Listen for bowel sounds (hypoactive, high pitched “tinkering”)
    - Inspect/palpate for abdominal distention
  2. Constipation
    - Bowel regimen - ex) Miralax or Colace
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33
Q

GI prophylaxis (stress ulcer) for intermediate care?

A

PPI/H2 blocker

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34
Q

what antiemetics can be given during intermediate care from abd surgery

A

Zofran, Phenergan

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35
Q

Intermediate Care - DVT Prophylaxis

A
  • Medications - most commonly Lovenox (LMWH) or SQ Heparin
  • Compression stockings/SCDs
  • Early ambulation
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36
Q

what ist he pauda prediction score?

A

> = 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
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37
Q

what are the 5 W’s

A

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

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38
Q

other considerations for 5 W’s

A
  1. (W)Abscess (5-7d)
    - organ or space, not necessarily incisional
    -CT scan
  2. Waterway “bloodstream’”
    - bacteremia (within 24h)
    - blood culture x2 two sites
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39
Q

Most common cause of fever in the first 24-48h after surgery

A

atelectasis

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40
Q

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

A

atelectasis

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41
Q

RF for atelectasis

A
  1. Smokers, COPD - already have loss of elastic recoil
  2. Increased secretions which can lead to obstructions
  3. Elderly - loss of elastic recoil
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42
Q

complications of atelectasis

A
  1. Decreased oxygenation of blood
  2. Infection of atelectasis segment
    - In general - If atelectasis persist for >72h - pneumonia will develop
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43
Q

tx atelectasis

A
  • Deep breathing exercises/incentive spirometry/coughing
  • Chest percussion, bronchodilators
  • Bronchoscopy if severe
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44
Q

causes of pneumonia

A

❧ Aspiration
❧ Atelectasis
❧ Underlying pulmonary disease/smoking
❧ Increased pulmonary secretions
❧ Diminished defense mechanisms postoperatively
❧ Impaired cough reflex, loss of ciliary coordination

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45
Q

manifestations of penumonia

A
  1. Tends to occur within 3 - 5 d postop
  2. Fever, tachypnea, SOB, increased respiratory secretions
  3. Exam - auscultatory crackles or diminished breath sounds, dullness to percussion if consolidation is present
  4. Labs - leukocytosis
  5. Imaging - infiltrates or consolidation on CXR
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46
Q

management/tx for postop hospital acquired pneumonia with no other risk factors or known resistance

A

Ceftriaxone (Rocephin), Ampicillin/Sulbactam (Unasyn), Levofloxacin (Levaquin), Ertapenem (Invanz)

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47
Q

tx for penumonia if concerns about resistant organisms or coverage for pseudomonas:

A

Piperacillin/Tazobactam (Zosyn), Cefepime (Maxipime), Imipenem

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48
Q

tx for MRSA pneumonia

A

Vancomycin, Linezolid

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49
Q

More significant effusions can present with ___ and ___

A

atelectasis and pneumonia

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50
Q

s/s of pleural effusion

A
  • Cough
  • SOB
  • Chest pain
  • Fever
  • Dullness to percussion
  • Decreased tactile fremitus
  • Asymmetrical chest expansion (delayed expansion on side of effusion)
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51
Q

tx for pleural effusion

A
  • Small & causing no compromise - do nothing
  • Causing respiratory compromise or associated with pneumonia - drain
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52
Q

Greatest risk of pneumothorax associated with what line or procedure

A
  • subclavian central line placement
  • after surgery where diaphragm may be punctured (adrenalectomy, nephrectomy)
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53
Q

presenation of pneumothorax

A
  • Sudden SOB
  • Chest pain/tightness
  • Hypoxia
  • Tachycardia
  • Tachypnea
  • Exam - Unequal breath sounds; Hyperresonance with percussion; Decreased wall expansion
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54
Q

tx for pneumothorax

A

thoracostomy (chest) tube

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55
Q

UTI Risk increases with

A

prolonged catheterization (>2 days)

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56
Q

MC pahtogen to cause UTI

A

E coli

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57
Q

s/s of UTI

A

Dysuria
Hematuria
Frequency
Fever/N/V
Malodorous urine

58
Q

dx UTI

A

UA with cx

59
Q

tx for UTI

A

Ciprofloxacin, Rocephin

60
Q

MCC of postop fever after 48 hrs?

A

UTI

61
Q

RF for urinary retention

A

Pelvic/Perineal Surgery, Spinal Anesthesia, Over distention of Urinary Bladder (not catheterized), h/o BPH/prostate tumor

62
Q

s/s of urinary retention

A
  • Oliguria/anuria
  • Abdominal/pelvic pain discomfort
  • Palpation of lower abdomen may demonstrate distended bladder
63
Q

dx for urinary retention

A

Bladder scan with PVR of >400mL

64
Q

tx for urinary retention

A

Bladder catheterization (Foley)

65
Q

4 wound complications

A
  1. Hematoma
  2. Seroma
  3. Wound Dehiscence
  4. Surgical Site Infection (SSI)
66
Q

Collection of blood caused by inadequate hemostasis

A

hematoma

67
Q

RF hematoma

A

Anticoagulants, Coagulopathies, Marked post-op HTN, Vigorous coughing/straining after surgery

68
Q

appearance of hematoma

A

Swelling, discoloration, bruising, pain/discomfort, blood leaking through incision

69
Q

tx hematoma

A
  • Small hematomas may resorb on own
  • Compression Dressing
  • Evacuation of hematoma, ligation of bleeding vessels
70
Q

common sites for hematoma

A

Breast, Joints, Thyroid

71
Q

complications with hematoma

A

Compress nearby structures, reduced perfusion to site (poor healing - tissue necrosis), infections

72
Q

most serious complications of hematoma

A

Neck: cut off air supply, Spine: compress spinal cord

73
Q

hematoma prevention

A
  • Stop anticoagulants
  • Drain placement intraoperatively
74
Q

Collection of serous fluid
Typically from lymphatics
Not pus or blood
Caused by transection of lymphatics

A

seroma

75
Q

appearance of seroma

A
  • Swelling, discomfort
  • Leakage of serous fluid from incision
76
Q

common sites for seroma

A

Axilla & Breast (post-mastectomy)
Inguinal region

77
Q

tx for seroma

A
  • Needle aspiration, compression dressings
  • If recurrent or severe = surgical wound exploration
78
Q

complications of seroma

A
  • Compression of nearby structures
  • Delay wound healing
  • Increase risk of infection
79
Q

Complete or partial disruption of any or all layers of incision

A

Wound Dehiscence

80
Q

Rupture of all layers exposing internal organs

A

Evisceration

81
Q

common site for wound dehiscence

A

abdominal

82
Q

RF for wound dehiscence

A
  • Age > 60
  • DM, immunosuppression, liver ds, sepsis, cancer, obesity, inadequacy of closure, increased intra-abdominal pressure, infection
83
Q

presentation of dehiscence

A
  • MC occurs between POD 5-8
  • May start with increased drainage from incision, or sudden opening
  • Absence of “healing ridge” by day 5
84
Q

tx for dehiscence

A
  1. Moist towels and binder until surgical consult –return to OR
  2. 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.

85
Q

MC pathogen for wound infection

A

s. aureus

86
Q

Types of SSI’s

A
  • Superficial - skin and subcutaneous tissues
  • Deep - fascia, muscles, tissues
  • Organ/Open Space
87
Q

classifications of surgical wounds

A
  • 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
88
Q

host RF for SSI

A
  • DM
  • Hypoxemia
  • Immunosuppressive drugs
  • Cigarette smoking
  • Malnutrition
  • Poor skin hygiene/contaminated or infected wounds
89
Q

infection RF for SSI

A
  • Operative Site Shaving
  • Poor sterile technique/contaminated instruments
  • Inadequate skin prep
  • Inadequate antimicrobial prophylaxis
  • Prolonged hypotension
  • Poor OR air quality
  • Poor postop wound care
90
Q

s/s of SSI

A
  • 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
91
Q

management for tx for SSI

A
  • Culture
  • Abx
  • Surgical debridement
92
Q

prevention of SSI

A
  • 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.
93
Q

MC abx prophylaxis for SSI

A

Cefazolin (Ancef)
Ceftriaxone (Rocephin)
Cefoxitin (Mefoxin)

94
Q

SSI abx prophylaxis with colorectal or appendix

A

add Metronidazole (Flagyl) or Clindamycin

95
Q

GI postop complications

A
  1. Stress Gastritis
  2. N/V
  3. Gastric Dilation
  4. Bowel Obstruction
  5. Fecal Impaction
  6. Postoperative Pancreatitis
  7. Postoperative Hepatic Dysfunction
  8. Postoperative Cholecystitis
  9. C. difficile colitis
96
Q

Functional postop ileus are normal when?

A

for first 24-72 hrs

97
Q

Obstruction usually due to ?

A

adhesions/blockage

  • MC occurs later in post op phase
  • Early post op obstruction MC with colorectal surgery
  • Intussusception - CC in peds
98
Q

what is KUB XR

A

pronounced air fluid levels with distinct dilation above area of obstruction for bowel obstructions

98
Q

s/s of ileus and obstruction

A
  • 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
99
Q

tx ileus and obstruction

A
  • Nasogastric tube decompression
  • Bowel rest / NPO
  • ?need for adhesiolysis
100
Q

fecal impaction is MC in who?

A

elderly

101
Q

fecal impaction is a result from a combination of:

A

Postoperative ileus, opioids, and reduced mobility

102
Q

s/s of fecal impaction

A

anorexia, obstipation

103
Q

dx fecal impaction

A

Rectal Exam
KUB XR

104
Q

tx for fecal impaction

A
  • Manual Removal
  • Bowel regimen
105
Q

Pancreatitis & Cholecystitis is MCC by what type of surgeries?

A

biliary tract surgeries

  • Acute pancreatitis - after ERCP, cholecystectomy
  • Acute cholecystitis - after ERCP or upper GI procedures
106
Q

Pancreatitis & Cholecystitis is more likely to develop which type of condition

A

infected necrotizing pancreatitis

107
Q

s/s Pancreatitis & Cholecystitis

A

acute severe abdominal pain, N/V/D, fever

108
Q

dx Pancreatitis and Cholecystitis

A

US/CT scan/MRI, elevated enzymes, leukocytosis

109
Q

Post Op Hepatic Injury has increased risk with surgeries of?

A

upper abdomen, biliary tract, and/or pancreas

110
Q

jaundice from postop hepatic injury can be d/t:

A
  1. Drugs
  2. Blood transfusion reactions
  3. Damage to liver or liver resections
  4. Obstruction due to injury of bile ducts
111
Q

tx for postop hepatic injury

A
  • DC drug
  • DC blood transfusion, fluid replacement
  • GI consult-ERCP, stenting
112
Q

Main risk associated with postoperative antibiotic use
Can be transmitted person to person (healthcare providers)

A

C. diff

113
Q

s/s of C. diff

A

malodorous diarrhea, abdominal distention, pain

114
Q

Dx C. diff colitis

A

stool cx

115
Q

complications with c. diff colitis

A

toxic megacolon

116
Q

cardiac complications from surgery

A
  • CVA
  • Dysrhythmias
  • MI
  • DVT/Thromboembolism
  • Phlebitis/Bacteremia
117
Q

MCC of CVA

A

prolonged ischemia/poor perfusion

118
Q

highest risk surgery to cause CVA

A

CEA (can also result from plaque being displaced), open heart surgery

119
Q

RF for CVA

A

Elderly, Patients with severe known atherosclerosis, and severe hypotension during surgery (bleeding, sepsis, etc)

120
Q

Cardiac complication that is common during induction of anesthesia and during surgery - typically self limiting

A

Dysrhythmias

121
Q

postop Dysrhythmias d/t

A
  • Electrolyte disturbances, drug toxicity
  • May be first sign of MI
122
Q

s/s of dysrhythmias

A

often asx, may have CP, palpitations, or dyspnea
tx depends on specific arrhythmia

123
Q

RF for MI

A
  • Duration & type of surgery, prolonged hypotension, prolonged hypoxemia
  • Patients with known CAD, HTN, CHF, angina
123
Q

s/s, dx and prevention for MI

A
  • S/SX – CP, SOB
  • dx – EKG, labs
  • Prevention - Stabilize CV disorders prior to elective surgery
124
Q

Caused by needle or catheter introduced into the vein causing inflammation of the vein

A

Phlebitis

125
Q

Phlebitis can lead to ___ and ___

A

infection
thrombosis

126
Q

MCC of fever after 72 h

A

phlebitis

127
Q

s/s, tx, and prevention of phlebitis

A
  1. S/Sx - induration, edema, and tenderness, erythema, drainage, pronounced pain with infection (suppurative phlebitis)
  2. Tx - removal of catheter/warm compresses/NSAIDS
    - Abx and excision of affected area of vein with suppurative phlebitis
  3. Prevention - GOOD ASEPTIC TECHNIQUE, rotation of insertion site
128
Q

RF for DVT

A
  1. FHx
  2. obesity
  3. immobility
  4. trauma
  5. surgery
  6. smoking
  7. oral
  8. contraceptives
  9. age
129
Q

s/s and dx for DVT

A
  • S/SX: posterior calf pain, erythema, induration, tenderness
  • dx: Venous Doppler
130
Q

complication of DVT

A

embolism

131
Q

tx and prevention for DVT

A
  • Treatment: Anticoagulation therapy, ?Filter
  • Prevention: Chemical/mechanical DVT prophylaxis, early mobilization
132
Q

what is virchow’s triad

A

endothelial injury, hypercoag, venous stasis

133
Q

fat embolism is MC with what surgery?

A

orthopedic surgeries/long bone fractures

134
Q

s/s of fat embolism

A
  • mostly asx
  • Onset - 12-72h after surgery
  • rsp distress/hypoxemia, petechiae of axilla and chest, neurologic abnormalities
135
Q

dx and tx for fat embolism

A
  • Dx - clinical, MRI can show emboli in the brain
  • Tx - Symptomatic respiratory support
136
Q

s/s of pulm embolism

A
  • Tachycardic
  • Hypotensive
  • Tachypneic
  • Hypoxic
  • Chest pain
137
Q

dx and tx for pulmonary embolism

A
  • Dx - Stat CTA PE protocol
  • Tx - Anticoagulation therapy, ?embolectomy
138
Q

when to DC pt

A
  1. afebrile >24 h
  2. tolerating oral intake
  3. returned bowel function
  4. ambulatory
  5. colled with PO meds
  6. voiding spontaneously
  7. remains hemodynamically stable
  8. safe disposition

may require LTAC or SNF placement

139
Q

what is the Convalescent Phase

A

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
140
Q

f/u instructions during convalescent phase

A

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

Surgery (7 decks)

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