Post-Op Complications Flashcards by Stephanie Escobar

3 possible complications of pain

Atelectasis
Delirium
SIADH

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Intra-operatively pt begins to have Early signs
Tachycardia, Cyanosis, Rigidity and an elevated body temperature +/- arrhythmia or other signs of organ dmg. Next best step in management.

Malignant Hyperthermia

Discontinuation triggering agent (Anesthesia)
Administer Dantrolene (ryanodine receptor antagonist)
Cooling measures (Cold Blankets, Ice packs, etc.)

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Patient begins to have fevers and chills within an hour of an invasive procedure. Next best step in management.

Bacteremia

Blood Cultures
Empiric Abxs

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Patient begins to have fevers and extreme pain within hours after surgery? What is the worst possible thing that could be happening?

Gas Gangrene in the surgical wound

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Post op fever (usually from 101º – 103ºF) is caused sequentially in time by (7):

Atelectasis (POD# 1–2)
Pneumonia (POD# 1–3)
UTI (POD# 3–5)
Deep Vein Thrombophlebitis (POD#  5+)
Infection: Cellulitis  (POD# 7+)
Abscess (POD# 8+)
Drug Reaction (POD# 8+)
(A PUDICAD)

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2 causes of Post-Op chest pain:

MI (POD# 2–3)

PE (POD# 7+)

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Is a risk in awake intubations in combative patients or elderly with impaired swallowing/neurocognitive disorders.

Aspiration PNA

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Management of Aspiration pneumonia includes

Bronchoscopy to remove debri and lavage
+/- bronchodilators & O2 treatment
—————
Prevent via NPO +/- PPIs

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Intra-Op Tension Pneumothorax usually 2/2

Pt with recent blunt trauma to lungs or broken ribs put on PPV

(become harder to bag, BP steadily declines)

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Most common cause of post-op delirium?

Hypoxia
(give O2 & get an ABG)
*may be 2/2 sepsis so r/o

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Causes of Post-Op Altered Mental Status

Hypoxia (POD# 1) 
ARDS (POD# 1–2)
Delirium Tremens (POD# 2–3) 
Hyponatremia 
Hypernatremia 
Ammonemia
Hypercarbia → COPDers

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4 causes of decreased post-op Urine Output

Urinary retention → (elderly, h/o BPH)
Kinked/clotted catheter → ZERO UOP since surgery
Dehydration → less than 0.5 ml/kg/hr of UOP
Acute Renal Failure → low UOP

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3 causes of post-op Abdominal Distention

Paralytic Ileus → Anesthesia
Adhesions → Bowel Obstruction
Ogilvie (pseudo obstruction) → Dilated Colon

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4 Post- op wound or infection complications:

Wound

Dehiscence
Evisceration

Infection

GI Fistulas → contaminating leaks
Cellulitis of sx incision

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TPN must be initiated after ____ of failed enteral nutrition.

TPN is initiated automatically in cases of severe
___ or ___

2–3 days (no longer than 1 week)

Burns or Brain Injury

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Management of post-op Atelectasis (3)

——

get CXR
Improve Ventilation (postural drainage, incentive spirometry)
Bronchoscopy (if no improvement)

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Management of post-op Pneumonia (3)

CXR
Sputum Culture
ABxs (Vanc & Pip-Tazo)

Management of post-op UTI (2)

UA (+/- urine culture)
## AntibioticsUncomplicated lower UTI
Nitrofurantoin, TMP/SMX, Fosfomycin

Complicated lower UTIs (Men, anatomic d/o, kids)
Ciprofloxacin (Floroquinolone)

Men → Ciprofloxacin or TMP/SMX

Management of post-op Thrombophlebitis (3)

IV site infection

Replace IV
Doppler imaging
Heparin bridge → Warfarin

Management of post-op Cellulitis Infection (3)

red/warm/painful skin

Antibiotics (if it’s cellulitis)
U/S (if it could be an abscess)
I&D (if it’s an abscess)

Management of post-op Deep Abscess (2)

CT imaging

2. Percutaneous Drain (radiographically guided)

Management of post-op MI (2)

Get ECG & Troponin

2. Angioplasty or Stents (if needed)

Management of post-op Pulmonary Embolism (2)

tachy+ diaphoretic + pleuritic pain + anxious +JVD

Start Heparin
add IVC filter (if PE recurs or AC is c/i)
CTA confirms dx

Contraindications to Heparin/Warfarin → 
Active bleeding
recent Stoke/TIA
cranial trauma
recent neurosurgery
h/o HIT 
bleeding d/o

Management of post-op AMS 2/2 Hypoxia (2)

O2 supplementation

2. ABG

Management of post-op AMS 2/2 ARDS (1)

PEEP | keep TV low to avoid barotrauma

Management of post-op AMS 2/2 Delerium Tremens (1) | Pt is hallucinating + combative

Benzodiazepines

Management of post-op AMS 2/2 Hyponatremia (1)

Hypertonic NaCl aliquots to D5W saline (+/- osmotic diuretics to PREVENT) Hyponatremia → rapid drop of Na+ in hrs → s/t excess D5W post-op + stress induced SIADH

Post op pt day 1 presents with AMS. Notably larger volume UOP. Diagnosis and management?

½ D5W or ⅓ D5W + NS (AMS 2/2 Hypernatremia) Hypernatremia → large UOP → tx with ½ D5W or ⅓ D5W + NS

6hrs Post-op patient with urge to urinate, but is unable to what is the next best step in management?

Urinary retention: In-Out Catheter (indicated if pt can't pee after 6hrs) → Foley placement after 2-3 cath attempts and no spontaneous urine

KUB shows dilated bowel w/ air-fluid level | Diagnosis:

Bowel Obstruction

Ogilvie (pseudo obstruction) → dilated colon in elderly patient seen on KUB → next step is to ____ → then ___ & ____ placement → avoid _____ if possible (b/c it is fatal if not Pseudo obstruction)

Replete fluids and electrolytes Colonoscopy + Rectal tube placement Neostigmine (AchE inhibitor)

Dehiscence → skin closes, but fascia fails to close → | Next best step in management?

Abdominal Binder | while waiting to see if OR is needed

Evisceration → s/t dehiscence → bowel spills out of incision Next best step in management?

1. Cover bowel in warm saline wraps a | 2. Emergent OR

GI Fistulas → Gastric fluids leak out of incision or drain Next best step in management? If free draining (afebrile, no peritonitis) (3) If not freely draining (fever, peritonitis) (1)

If free draining (afebrile, no peritonitis): 1. IVFs & electrolyte replacement 2. nutritional support distal to fistula 3. suctions/–ostomy bags to protect abd wall Fistula will heal naturally in time If not freely draining (fever, peritonitis) 1. Complete drainage is required to prevent sepsis

Patient has had ZERO urine output since surgery or has had urine output which suddenly has ceased. Next best step in management?

check catheter's patency | it might be kinked or clotted

Post-op patient has had a low urinary output ( <0.5 ml/kg/hr) what are 2 possible explanations? (besides clotted catheter)

dehydration or acute renal failure

In a post-op patient with low urinary output ( <0.5 ml/kg/hr) how can you differentiate between dehydration or acute renal failure as the primary etiology?

1. Bolus 500ml IVF over 10m (H2O challenge) → if ↑UOP → dehydration 2. After H20 challenge there is no appreciable change in UOP get urinary labs → –FeNa<1% → dehydration –FeNA >1% → acute renal failure

``` Post-Op Complications (list as many as you can) Skin (6) Vascular (3) General (2) GI (6) Cardiac (2) Pulm (4) Renal (3) ```

Seromas, Site Infections, Dehiscence/Evisceration, pressure ulcers, Hernias (late) Hemorrhage, Hematomas, DVTs illeus, N/V, SBOs (s/t adhesions), leaks, fistulas MIs, Arrhythmias (A-fib) atelectasis, ARDS, PNA, PE AKI, urinary retention, UTI (s/t catheter)

Immediate or w/in hours causes of post-op fevers (3)

Febrile transfusion reaction malignant hyperthermia neuroleptic malignant synd (anti-emetics)

Risk factors for Post-Op urinary retention (5-7)

old, male, BPH, diabetes, neurological condition, opioids, anticholinergics