Post-Op Complications

Question 1

What is primary bleeding?

Answer 1

During the intraoperative period; should be resolved during the operation, any major haemorrhages recorded in the operative notes

Question 2

What is reactive bleeding?

Answer 2

Occurs within 24 hours of the operation
Mostly due to ligature that slips or misses a vessel

Question 3

What is secondary bleeding?

Answer 3

Occurs 7-10 days postoperatively
Often seen when a heavily contaminated wound is closed primarily

Question 4

What is the classification of haemorrhagic shock?

Answer 4

Class I <750ml, <15% blood loss, normal BP
Class II 750-1000ml, <15-30% blood loss, normal BP
Class III 1500-2000ml, 30-40% blood loss, decreased BP
Class IV >2000ml, >40% blood loss, decreased BP

Question 5

What are the clinical features of haemorrhagic shock?

Answer 5

Tachycardia, dizziness, agitation, decreased urine output
Raised respiratory rate

Hypotension is often a late sign, do not assume patient stable if blood pressure is normal

Examination - exposure for bleeding, palpation of surgical area, discolouration, tenderness, peritonism.

Question 6

What is the general management of post op bleeding?

Answer 6

A to E approach, rapid fluid resuscitation
Direct pressure if bleeding site visible
Urgent senior surgical review, urgent blood transfusion

Question 7

What is important post neck surgery in post op bleeding?

Answer 7

Primary sign is likely airway obstruction as pretracheal fascia will only distend so far
Remove skin clips, deep layer sutures and suction haematoma beneath. Urgent senior surgical opinion.

Question 8

What are the risk factors of PONV?

Answer 8

Female, age, previous PONV, non-smoker
Intra-abdominal surgery, gynae surgery, long surgery
Opiate analgesia, overuse of bag and mask

Question 9

What are the neurotransmitters involved in the vomiting process?

Answer 9

Chemoreceptor trigger zone - dopamine and 5HT3
Vestibular apparatus - acetylcholine, histamine
GI tract - dopamine
Vomiting centre - histamine and 5HT3

Question 10

What is the management of PONV?

Answer 10

Anaesthetic measures, prophylactic antiemetics, dexamethasone at induction of anaesthesia
Conservative - fluid hydrate, analgesia, NG tube insertion
Pharmaceutical - those with impaired gastric emptying given prokinetic, metoclopramide for biochemical imbalance
Opioid induced N&V responds to ondansetron, cyclizine

Question 11

What are the side effects of NSAIDs?

Answer 11

Interactions with other medications e.g. warfarin
Gastric ulceration - add a PPI
Renal impairment
Asthma sensitivity
Bleeding risk

Question 12

What are the Ws of post-op pyrexia?

Answer 12

Day 0 - wave - rule out myocardial infarction, fluid overload
Day 1 - Wind - atelectasis, pneumonia
Day 3 - Water - UTI, anastomotic leak
Day 5 - Walking - DVT/PE
Day 7 - Wound - infection, abscess
Day X - Wonder - drugs/what did we do?

Question 13

What are the common sources of pyrexia/sepsis in a surgical patient?

Answer 13

Chest - infection
Cut - wound infection
Catheter - UTI
Collections
Calves
Cannula
Central line

Question 14

What is ARDS?

Answer 14

Acute lung injury, severe hypoxaemia in the absence of a cardiogenic cause

Acute onset within 7 days
Bilateral infiltrates on CXR
Alveolar oedema not explained by fluid overload or cardiogenic causes

Question 15

What are some of the causes of ARDS?

Answer 15

Direct - pneumonia, smoke inhalation, aspiration, fat embolus
Indirect - sepsis, acute pancreatitis, polytrauma, burns

Question 16

What is the pathophysiology of ARDS?

Answer 16

Exudative - diffuse alveolar damage due to tissue injury, inflammatory mediators released
Proliferative - new surfactant produced, restoration of alveolar capillary membrane integrity
Fibrotic - extensive fibrin deposition and scarring

Question 17

What are the clinical features of ARDS?

Answer 17

Worsening dyspnoea, in presence of a related risk factor
Hypoxia, tachypnoea, inspiratory crackles, acute onset

Question 18

What is the management of ARDS?

Answer 18

Supportive treatment, ventilation, treat underlying cause
Highly likely need early intubation and ITU admission
Limit inflammatory cascade, reduce alveolar injury
Lower tidal volumes in ventilation, PEEP

Question 19

What are the risk factors for developing atelectasis post op?

Answer 19

Age, smoking, use of GA, duration of surgery, pre-existing lung or neuromuscular disease, prolonged bed rest, poor post op pain control

Question 20

What are the clinical features of atelectasis?

Answer 20

Small airway collapse, features of resp compromise
Increased respiratory rate, reduced oxygen saturations
Low grade fever