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
2
Q
Primary Goal of the first 2 phases of postop care
A
- Hemostasis
- Pain Control
- Prevention & early detection of complications
3
Q
during the Immediate Postoperative Period, who is the main provider
A
anesthesiologist
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
5
Q
admit orders components
A
- 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
6
Q
components of Post-Op Note / Procedure Note
A
- 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
7
Q
who mostly dictate the operative report
A
surgeon
8
Q
Who may provide a brief op note at physician request
A
PA
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
10
Q
instruction components for wound care
A
- 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
11
Q
Epithelialization of the wound occurs in the first ? hours
A
48h
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
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
14
Q
Pulmonary function depression worse in:
A
Elderly patients, smokers, obesity, pre-existing lung disease
15
Q
MC pulmonary risk after surgery
A
atelectasis
Other pulmonary risks - Pulmonary edema, pneumonia, respiratory failure, PE
16
Q
```
how to minimize risk of atelectasis complication from surgery
A
incentive spirometry and early mobilization
17
Q
factors in fluid replacement selection
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
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
19
Q
MC fluid selection
A
LR (balanced crystaloid) or D5/0.5%NS
20
Q
how to monitor blood loss during intermediate phase
A
- 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
21
Q
A Hemoglobin < 7 (in any patient) or < 8 in patients with cardiac, pulmonary, or cerebrovascular disease require ?
A
blood transfusion.
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!
23
Q
pain control during intermediate phase
A
- 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
24
Q
MC pain control
A
opioids
- IV or PCA (patient controlled analgesia)
- Morphine, Hydromorphone (Dilaudid), Fentanyl, Meperidine (Demerol)
25
non-opioid options for pain control during intermediate phase
* Ketorolac (Toradol) – NSAID
* Tylenol
26
Given in conjunction with opioids - reduce opioid requirements
non-opioids
Ketorolac (Toradol) - NSAID
Celecoxib (Celebrex) - Cox 2 inhibitor
Acetaminophen (IV, PO, rectal)
Gabapentin
27
Combination Approach and Alternatives/Adjuncts to Opioids
1. local anesthesia
2. spinal/epidural
3. nerve blocks
4. adjuvant therapy - Muscle relaxants, Anxiolytics
28
local anesthesia options for pain control
* Intraoperative injection
* Patches
* Pain-ball
29
Spinal/Epidural pain control is indicated for what
>5 rib fractures
30
nerve blocks for pain control is indicated for what
ORIF, external fixation, hemiarthroplasty of extremities in trauma cases
31
what happens to peristalsis after abdominal surgery?
diminished peristalsis
(first 24 hrs, slowly improves over 72 hrs)
32
diminished peristalsis after abd surgery can lead to what?
how to manage?
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
33
GI prophylaxis (stress ulcer) for intermediate care?
PPI/H2 blocker
34
what antiemetics can be given during intermediate care from abd surgery
Zofran, Phenergan
35
Intermediate Care - DVT Prophylaxis
* Medications - most commonly Lovenox (LMWH) or SQ Heparin
* Compression stockings/SCDs
* Early ambulation
36
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
37
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
38
other considerations for 5 W's
1. (W)Abscess (5-7d)
- organ or space, not necessarily incisional
-CT scan
2. Waterway “bloodstream’”
- bacteremia (within 24h)
- blood culture x2 two sites
39
Most common cause of fever in the first 24-48h after surgery
atelectasis
40
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
41
RF for atelectasis
1. Smokers, COPD - already have loss of elastic recoil
1. Increased secretions which can lead to obstructions
1. Elderly - loss of elastic recoil
42
complications of atelectasis
1. Decreased oxygenation of blood
1. Infection of atelectasis segment
- In general - If atelectasis persist for >72h - pneumonia will develop
43
tx atelectasis
* Deep breathing exercises/incentive spirometry/coughing
* Chest percussion, bronchodilators
* Bronchoscopy if severe
44
causes of pneumonia
❧ Aspiration
❧ Atelectasis
❧ Underlying pulmonary disease/smoking
❧ Increased pulmonary secretions
❧ Diminished defense mechanisms postoperatively
❧ Impaired cough reflex, loss of ciliary coordination
45
manifestations of penumonia
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
46
management/tx for postop hospital acquired pneumonia with no other risk factors or known resistance
Ceftriaxone (Rocephin), Ampicillin/Sulbactam (Unasyn), Levofloxacin (Levaquin), Ertapenem (Invanz)
47
tx for penumonia if concerns about resistant organisms or coverage for pseudomonas:
Piperacillin/Tazobactam (Zosyn), Cefepime (Maxipime), Imipenem
48
tx for MRSA pneumonia
Vancomycin, Linezolid
49
More significant effusions can present with ___ and ___
atelectasis and pneumonia
50
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)
51
tx for pleural effusion
* Small & causing no compromise - do nothing
* Causing respiratory compromise or associated with pneumonia - drain
52
Greatest risk of pneumothorax associated with what line or procedure
* subclavian central line placement
* after surgery where diaphragm may be punctured (adrenalectomy, nephrectomy)
53
presenation of pneumothorax
* Sudden SOB
* Chest pain/tightness
* Hypoxia
* Tachycardia
* Tachypnea
* Exam - Unequal breath sounds; Hyperresonance with percussion; Decreased wall expansion
54
tx for pneumothorax
thoracostomy (chest) tube
55
UTI Risk increases with
prolonged catheterization (>2 days)
56
MC pahtogen to cause UTI
E coli
57
s/s of UTI
Dysuria
Hematuria
Frequency
Fever/N/V
Malodorous urine
58
dx UTI
UA with cx
59
tx for UTI
Ciprofloxacin, Rocephin
60
MCC of postop fever after 48 hrs?
UTI
61
RF for urinary retention
Pelvic/Perineal Surgery, Spinal Anesthesia, Over distention of Urinary Bladder (not catheterized), h/o BPH/prostate tumor
62
s/s of urinary retention
* Oliguria/anuria
* Abdominal/pelvic pain discomfort
* Palpation of lower abdomen may demonstrate distended bladder
63
dx for urinary retention
Bladder scan with PVR of >400mL
64
tx for urinary retention
Bladder catheterization (Foley)
65
4 wound complications
1. Hematoma
1. Seroma
1. Wound Dehiscence
1. Surgical Site Infection (SSI)
66
Collection of blood caused by inadequate hemostasis
hematoma
67
RF hematoma
Anticoagulants, Coagulopathies, Marked post-op HTN, Vigorous coughing/straining after surgery
68
appearance of hematoma
Swelling, discoloration, bruising, pain/discomfort, blood leaking through incision
69
tx hematoma
* Small hematomas may resorb on own
* Compression Dressing
* Evacuation of hematoma, ligation of bleeding vessels
70
common sites for hematoma
Breast, Joints, Thyroid
71
complications with hematoma
Compress nearby structures, reduced perfusion to site (poor healing - tissue necrosis), infections
72
most serious complications of hematoma
Neck: cut off air supply, Spine: compress spinal cord
73
hematoma prevention
* Stop anticoagulants
* Drain placement intraoperatively
74
Collection of serous fluid
Typically from lymphatics
Not pus or blood
Caused by transection of lymphatics
seroma
75
appearance of seroma
* Swelling, discomfort
* Leakage of serous fluid from incision
76
common sites for seroma
Axilla & Breast (post-mastectomy)
Inguinal region
77
tx for seroma
* Needle aspiration, compression dressings
* If recurrent or severe = surgical wound exploration
78
complications of seroma
* Compression of nearby structures
* Delay wound healing
* Increase risk of infection
79
Complete or partial disruption of any or all layers of incision
Wound Dehiscence
80
Rupture of all layers exposing internal organs
Evisceration
81
common site for wound dehiscence
abdominal
82
RF for wound dehiscence
* Age > 60
* DM, immunosuppression, liver ds, sepsis, cancer, obesity, inadequacy of closure, increased intra-abdominal pressure, infection
83
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
84
tx for dehiscence
1. Moist towels and binder until surgical consult –return to OR
1. 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
MC pathogen for wound infection
s. aureus
86
Types of SSI’s
* Superficial - skin and subcutaneous tissues
* Deep - fascia, muscles, tissues
* Organ/Open Space
87
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
88
host RF for SSI
* DM
* Hypoxemia
* Immunosuppressive drugs
* Cigarette smoking
* Malnutrition
* Poor skin hygiene/contaminated or infected wounds
89
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
90
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
91
management for tx for SSI
* Culture
* Abx
* Surgical debridement
92
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.
93
MC abx prophylaxis for SSI
Cefazolin (Ancef)
Ceftriaxone (Rocephin)
Cefoxitin (Mefoxin)
94
SSI abx prophylaxis with colorectal or appendix
add Metronidazole (Flagyl) or Clindamycin
95
GI postop complications
1. Stress Gastritis
1. N/V
1. Gastric Dilation
1. Bowel Obstruction
1. Fecal Impaction
1. Postoperative Pancreatitis
1. Postoperative Hepatic Dysfunction
1. Postoperative Cholecystitis
1. C. difficile colitis
96
Functional postop ileus are normal when?
for first 24-72 hrs
97
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
98
what is KUB XR
pronounced air fluid levels with distinct dilation above area of obstruction for bowel obstructions
98
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
99
tx ileus and obstruction
* Nasogastric tube decompression
* Bowel rest / NPO
* ?need for adhesiolysis
100
fecal impaction is MC in who?
elderly
101
fecal impaction is a result from a combination of:
Postoperative ileus, opioids, and reduced mobility
102
s/s of fecal impaction
anorexia, obstipation
103
dx fecal impaction
Rectal Exam
KUB XR
104
tx for fecal impaction
* Manual Removal
* Bowel regimen
105
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
106
Pancreatitis & Cholecystitis is more likely to develop which type of condition
infected necrotizing pancreatitis
107
s/s Pancreatitis & Cholecystitis
acute severe abdominal pain, N/V/D, fever
108
dx Pancreatitis and Cholecystitis
US/CT scan/MRI, elevated enzymes, leukocytosis
109
Post Op Hepatic Injury has increased risk with surgeries of?
upper abdomen, biliary tract, and/or pancreas
110
jaundice from postop hepatic injury can be d/t:
1. Drugs
1. Blood transfusion reactions
1. Damage to liver or liver resections
1. Obstruction due to injury of bile ducts
111
tx for postop hepatic injury
* DC drug
* DC blood transfusion, fluid replacement
* GI consult-ERCP, stenting
112
Main risk associated with postoperative antibiotic use
Can be transmitted person to person (healthcare providers)
C. diff
113
s/s of C. diff
malodorous diarrhea, abdominal distention, pain
114
Dx C. diff colitis
stool cx
115
complications with c. diff colitis
toxic megacolon
116
cardiac complications from surgery
* CVA
* Dysrhythmias
* MI
* DVT/Thromboembolism
* Phlebitis/Bacteremia
117
MCC of CVA
prolonged ischemia/poor perfusion
118
highest risk surgery to cause CVA
CEA (can also result from plaque being displaced), open heart surgery
119
RF for CVA
Elderly, Patients with severe known atherosclerosis, and severe hypotension during surgery (bleeding, sepsis, etc)
120
Cardiac complication that is common during induction of anesthesia and during surgery - typically self limiting
Dysrhythmias
121
postop Dysrhythmias d/t
* Electrolyte disturbances, drug toxicity
* May be first sign of MI
122
s/s of dysrhythmias
often asx, may have CP, palpitations, or dyspnea
tx depends on specific arrhythmia
123
RF for MI
* Duration & type of surgery, prolonged hypotension, prolonged hypoxemia
* Patients with known CAD, HTN, CHF, angina
123
s/s, dx and prevention for MI
* S/SX – CP, SOB
* dx – EKG, labs
* Prevention - Stabilize CV disorders prior to elective surgery
124
Caused by needle or catheter introduced into the vein causing inflammation of the vein
Phlebitis
125
Phlebitis can lead to ___ and ___
infection
thrombosis
126
MCC of fever after 72 h
phlebitis
127
s/s, tx, and prevention of phlebitis
1. S/Sx - induration, edema, and tenderness, erythema, drainage, pronounced pain with infection (suppurative phlebitis)
1. Tx - removal of catheter/warm compresses/NSAIDS
- Abx and excision of affected area of vein with suppurative phlebitis
1. Prevention - GOOD ASEPTIC TECHNIQUE, rotation of insertion site
128
RF for DVT
1. FHx
1. obesity
1. immobility
1. trauma
1. surgery
1. smoking
1. oral
1. contraceptives
1. age
129
s/s and dx for DVT
* S/SX: posterior calf pain, erythema, induration, tenderness
* dx: Venous Doppler
130
complication of DVT
embolism
131
tx and prevention for DVT
* Treatment: Anticoagulation therapy, ?Filter
* Prevention: Chemical/mechanical DVT prophylaxis, early mobilization
132
what is virchow's triad
endothelial injury, hypercoag, venous stasis
133
fat embolism is MC with what surgery?
orthopedic surgeries/long bone fractures
134
s/s of fat embolism
* mostly asx
* Onset - 12-72h after surgery
* rsp distress/hypoxemia, petechiae of axilla and chest, neurologic abnormalities
135
dx and tx for fat embolism
* Dx - clinical, MRI can show emboli in the brain
* Tx - Symptomatic respiratory support
136
s/s of pulm embolism
* Tachycardic
* Hypotensive
* Tachypneic
* Hypoxic
* Chest pain
137
dx and tx for pulmonary embolism
* Dx - Stat CTA PE protocol
* Tx - Anticoagulation therapy, ?embolectomy
138
when to DC pt
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
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
140
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
