Post-Op Complications Flashcards
3 possible complications of pain
Atelectasis
Delirium
SIADH
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.)
Patient begins to have fevers and chills within an hour of an invasive procedure. Next best step in management.
Bacteremia
- Blood Cultures
- Empiric Abxs
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
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)
2 causes of Post-Op chest pain:
MI (POD# 2–3)
PE (POD# 7+)
Is a risk in awake intubations in combative patients or elderly with impaired swallowing/neurocognitive disorders.
Aspiration PNA
Management of Aspiration pneumonia includes
Bronchoscopy to remove debri and lavage
+/- bronchodilators & O2 treatment
—————
Prevent via NPO +/- PPIs
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)
Most common cause of post-op delirium?
Hypoxia
(give O2 & get an ABG)
*may be 2/2 sepsis so r/o
Causes of Post-Op Altered Mental Status
7
Hypoxia (POD# 1) ARDS (POD# 1–2) Delirium Tremens (POD# 2–3) Hyponatremia Hypernatremia Ammonemia Hypercarbia → COPDers
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
3 causes of post-op Abdominal Distention
Paralytic Ileus → Anesthesia
Adhesions → Bowel Obstruction
Ogilvie (pseudo obstruction) → Dilated Colon
4 Post- op wound or infection complications:
Wound
- Dehiscence
- Evisceration
Infection
- GI Fistulas → contaminating leaks
- Cellulitis of sx incision
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
Management of post-op Atelectasis (3)
——
- get CXR
- Improve Ventilation (postural drainage, incentive spirometry)
- Bronchoscopy (if no improvement)
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)
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?
- 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?
- Bolus 500ml IVF over 10m (H2O challenge) → if ↑UOP → dehydration
- 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
