American society of anaesthetic score 1. Normal healthy pt 2. Mild systemic disease (e.g. asthma) 3. Severe systemic disease 4. Severe systemic disease that is a constant threat to life 5. Moribund pt, not expected to survive without operation 6. Declared brain dead pt - organ removal for donor purposes 4 or above usually traumatic/emergency

Post-op Complications Flashcards by Hemanshu Monga

What are the post-op complications classes?

Immediate - <24 hrs after surgery
Early - 24-72 hrs post-op
Intermediate - 4-14 days post op
Late - >14 days post-op

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What are the immediate complications for surgery?

Anaphylaxis - from anaesthesia or pain relief
Anaesthetic complications - hyperkalemia
Primary haemorrhage - bleeding continues after surgery
Pyrexia
Renal failure - pre-renal failure (hypovolemia)

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What are early complications of surgery?

Atelectasis - due to pain post-op, pts tend not to take deep breaths - can also lead to pneumonia
Secondary haemorrhage - increased BP after surgery = leaking vessels
MI
N/V
Post-op ileus
Sepsis (resp, urinary, wound, arterial or venous cannulae)

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What are the intermediate complications of surgery?

Anastomotic leak - approx 4 days - colonic surgery 
Collection 
Wound infection/dehiscence 
Pneumonia/UTI - more common later on 
VTE

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What are late complications of surgery?

VTE
Incisional hernia
Adhesive obstruction - small bowel surgery, can be quite a while after
Delayed/non-union for fractures

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What is the most common cause of morality post-op?

IHD

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Which patients factors make pt a high risk of surgery?

Increasing age
Smoking
Inability to perform ADLS
Obesity

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What pre-existing morbities make pt high risk for surgery?

Infection 
Anaemia
CCF/IHD
COPD/resp disease 
Diabetes 
Immunosuppression
Malignancy - chemo/radiotherapy

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What is ASA score?

American society of anaesthetic score

Normal healthy pt
Mild systemic disease (e.g. asthma)
Severe systemic disease
Severe systemic disease that is a constant threat to life
Moribund pt, not expected to survive without operation
Declared brain dead pt - organ removal for donor purposes

4 or above usually traumatic/emergency

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What is the surgical severity score?

Grade 1 - diagnostic endoscopy, laparoscopy, breast biopsy
Grade 2 - inguinal hernia, varicose veins, adenotonsillectomy, knee arthroscopy
Grade 3 - total abdominal hysterectomy, TURP, thyroidectomy
Grade 4 - total joint replacement, artery reconstruction, colonic resection, neck dissection

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How many g/L of Hb does one unit of RBC increase Hb by?

10 g/L

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What are common post-op complications?

Fever
Resp distress 
Hypotension 
N/V 
Wound complication 
BNO - bowels not open

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What are the causes of post-op haemorrhage?

Primary - vessel damage during surgery
Reactionary - rise in BP at end of operation causes bleeding
Secondary - normally due to infection which causes damage to vessels days after surgery

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What is the management of post-op bleeding?

Urgent resuscitation + senior assessment
Bloods - high urea can indicate bleeding as metabolised in the GI tract.
Relevant imaging includes CT
May require re-operation

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What is paralytic ileus?

Transiently impaired propulsion of intestinal contents.

Most common cause of delayed discharge from hospital

Causes are unclear

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What are clinical features of paralytic ileus?

Distended, tympanic abdomen - dilated loop do bowel on x-ray with air

Abdominal pain, N/V, BNO
Absence of bowel sounds

What is the management of paralytic ileus?

Not usually dangerous

NBM 
Treat underlying cause - hypokalaemia, reduce opioids, rationalise anticholinergics, dehydration
NG drainage if vomiting 
Encourage mobilisation 
Rehydrate

Usually resolves within 3 days - CT if ongoing

What should be don about immediate post -op fever?

Common

Assess medication and blood products as may be sign of reaction
VTE
MI
Septic screen and ensure haemodynamically stable

What is the septic screen?

Routine bloods, G&S, coagulation 
Lactate 
Cultures 
CXR - chest infection very common 
Contact senior

Discuss ceiling of care - ward based, NIV, ITU

What can be the cause of acute (< 7 days) post-op fever?

Usually infection - surgical site, UTI, pneumonia, C.diff

VTE/MI
Blood transfusion reaction
Pancreatitis - steroid use

What are the causes of subacute (1-4 weeks) post-op fever?

Surgical site infection, deep abscess, prosthesis, UTI, pneumonia

VTE

What are the 5 Ws of post-op fever?

Wind - resp - 1-2 days 
Water - UTI - 3-5 days 
Walk - VTE - 4-6 days 
Wound - 5-7 days 
Wonder about drugs - 7+ days - anaesthesia +antibiotics

When is post-op escalation required?

Septic shock - still experiencing hypotension despite fluid resuscitation
Lactate > 4
No response to current management

How would you check for post-op AKI?

Bloods - inflammatory markers + U&Es - creatinine+urea

What is the management of post-op N/V that has no obvious underlying cause?

Stop/reduce opioids Optimise pain control - NSAIDs instead of opioids Ensure adequate hydration Consider NG decompression if vomiting profusely Prescribe anti-emetic

Which pt factors put pt at higher risk of post-op N/V?

Female gender <50yrs Previous PONV Smoking

What operative risk factors put pts at higher risk of PONV?

``` Intra-abdo laparoscopic surgery Gynaecology surgery Middle/inner ear surgery Poor pain control Opiate/spinal analgesia Nitrous oxide, isoflurane ```

What are the potential underlying causes of PONV?

``` Post-op ileus, bowel obstruction Infection Metabolic - hypercalceamia, uraemia, DKA Medications - antibiotic, opioids Raised ICP Anxiety ```

Which anti-emetic should be avoided in post-op pts and why?

Dopamine antagonist - metoclopramide or domperidone - avoid in bowel obstruction

What are the anti-emetics of choice for post-op N/V and what are some S/E?

Ondansetron(5-HT3 antagonist) - constipation, risk of long QT interval Cyclizine - avoid IV as can cause addiction, anticholinergic properties - caution in elderly

What is the main cause of shortness of breath that must be ruled out post-op and what investigations should be ordered?

VTE Bloods + ABG, CXR, CTPA, ECG

What is the management of VTE post-op?

Do not delay anticoagulation Discuss with seniors - risk of bleeding LMWH or UFH in renal failure Oral anticoagulation: - 4-6 weeks for temporary risk factors - 3 months for first idiopathic - at least 6 months for other/no clear cause

What is post-op fever defined as?

Core body temp >38 for 2 consecutive days or >39 for 1 day

What is SIRS?

Systemic inflammatory response syndrome - response to any insult E.g. surgery and infection Temp > 38 or < 36 Heart rate >90 RR >20 WCC > 12x10ª9/L or <4x10ª9 Need two SIRs criteria to confirm

How is sepsis confirmed?

SIRS criteria + source of infection

How is severe sepsis identified?

SIRS criteria + source of infection + organ dysfunction ``` SBP <90mmg or MAP < 65mmg Drop in BP >40mmg Lactate >2 - lack of organ perfusion Urine output <0.5ml/kg/hr for 2 consecutive hours Drop in GCS or AMTS score ```

What is septic shock?

Severe sepsis that has resistant hypotension despite fluid resuscitation