Post-op complications Flashcards
Respiratory Complications
Anaphylaxis
Atelectasis
Hypoxemia
Aspiration
Pneumonia
Sepsis
What causes buildup of mucous in the lungs = lung infection?
general anesthesia decreases normal breathing and removes urge to cough after surgery, hurts to breath
Anaphylaxis
affects AIRWAY, swells up, loose capacity to breathe
Atelectasis
hypoventilation and excessive retained secretions
happens when the air sacs of alveoli deflate (can cause collapse of the lungs)
most common cause of hypoxemia
What are signs and symptoms of atelectasis?
agitation
hypo/hypertension, tachycardia (compensation)
absent or decreased A/E to that lobe of the lung
diminished/absent breath sounds
dullness in percussion
reduced chest expansion, tachypnea
fever
pt has just gotten out of surgery and is in acute rep distress. What might cause this?
the tongue. Wake pt up or put in oral airway
Hypoxemia
reduction in the oxygen tension in arterial blood that leads to a reduction at the tissue level (which is hypoxia)
aspiration
foreign material that enters trachea instead of esophagus
what is the normal value of PaO2?
80mmhg, less than that is hypoxemia (need blood gas analysis to confirm)
what causes hypoxemia?
reduced ability of oxygen to diffuse across alveoli
reduce perfusion of ventilated alveoli
reduced ventilation of perfused alveoli
reduce oxygen tension of inspired air
reduced volume of inspired air
what can aspiration cause?
pneumonia
what are interventions for atelectasis?
DB and cough q1h when awake
incentive spirometer
reposition HOB
apply o2
What is the mechanism of swallowing?
involves 5 cranial nerves and 26 muscles (motor, cognitive and behavioral processes)
an abnormality of any of these can cause ineffective swallowing= aspiration
what prevents aspiration?
gag/cough reflex
who does not have gag/cough reflex?
Older adults, people with stroke, anesthesia
What do we do for people that do not have gag/cough reflex?
intubate, NPO
PPI preop in those who are obese or pregnant
Pneumonia signs and symptoms
sudden onset of chills, shaking, high fever
dyspnea, tachypnea, sharp chest pain (increased w inspiration)
productive cough
decreased breath sounds
cyanosis w hypoxemia (PaO2 <80)
Pneumonia intervetions
DB and C q1h
incentive spirometry
early ambulation
HOB >30 degrees
oral hygiene
maintain airway
apply o2
contact MRP/RT
labs and diagnostics (sputum cultures, CXR, blood cultures)
abx
fluids
SEPSIS
systemic response to overwhelming infection, when a pts immune system fails to control pathogens or their toxins from a site of infection (SIRS criteria)
Systemic illness caused by microbial invasion to sterile parts of the body
leading cause of death and hospitalization
What are the most common populations for SEPSIS?
aging pop
chronic disease
artificial joints, heart valves, CVCs
Cancer, autoimmune diseases, immunocompromised
organ transplants
increased use of antibiotics and antimicrobials
What are the most frequents sites of infection for SEPSIS?
lungs
urinary tract
abdo
soft tissue skin
Symptoms of SEPSIS
early on, organ hypo perfused despite good BP
blood flow/oxygen prioritized to brain and heart, thus shunted away from kidneys, skin, GI tract, lungs = organ disfunction
altered LOC
confusion
psychosis
sao2<90
jaundice
decreased albumin
tachycardia
hypotension
CVP
oliguria
anuria
creatinine
decreased platelets
PT
decreased protein C D-dimer
What does severe SEPSIS have…?
NO SYMTPOMS
What is SIRS criteria?
2 or more of…
altered LOC
HR>90
emp >38 or <36
Resp >20
WBC count >12 (normal 4-11)
+
suspected infection
SEPSIS interventions
thorough assessment and VS (keep Sao2>92%)
advise MD, PCC (GET HELP)
contact ICU team (lab work and diagnostics - cultures and lactate, abx - after diagnostics and blood work, IV fluids- bolus, monitor - VS, urine output)
When do you have to be careful with bolus?
HF and renal patients
Septic shock
BP not greater than 90mmhg systolic or MAP 65 despite IV fluids
Diagnostics for SEPSIS
blood culture
CBC, coagulation profile, D-dimer
ABGs
lactate level
C-reactive protein
serum proteins
blood sugar
serum cr and u
liver function
Cardiovascular complications
VTE: DVT/PE
Pulmonary embolism
Peri-operative stroke
Fluid overload
Dehydration
Hypovolemia
Post-op bleeding
Electrolyte imbalance
Who is at risk for VTE?
pts without prophylaxis
obesity
acute illness
>40 y/o
cancer (hypercoagulation) use low molecular heparin
What do VTEs lead to?
PE!!!!!! if not treated
Why does PE need immediate intervention?
blocks O2 in bloodstream, leading to hypoxemia, lead to tissue hypoxia
Who is most at risk for PE?
joint replacement surgeries (immobility!!!!)
What is used to prevent PE?
Prophylaxis…
detect those at risk
education
early/frequent mobilization
hydration
post op symptom assessment
treatment advocacy (do they have decreased sensation?)
What is the tx of PE?
heparin
Heparin
increased risk of bleeding
check lab values (PT)
route: SubQ
what is the antidote of heparin?
protamine sulfate
Peri-operative stroke risks
vascular surgeries
longer surgeries
HF, low ejection fraction, MI
dehydration
hyperglycemia
stasis in postop, bed rest
withholding antiplatelet/anticoagulant
Peri-op stroke
ischemic and embolic
happens POD1
Periop stroke interventions
Call MD!! (facial droop, slurring, sudden neurologic changes)
neurology consultation
Pts are eligible for thrombolytics within 3 hour window of onset of symptoms
- Doctor
- CT scan (tPA)
- thrombolytics
swallowing screening
early mobilization
glucose control
BP control
no indwelling catheter (high risk of bleeding with tPA)
diagnostics (CXR, holter monitor, carotid doppler, echocardiogram)
Fluid overload prec factors
stress response (increase ADH and water retention)
CHP
rapid high volume IV intra op
Fluid overload detection
decreased urine output (<30ml/hr)
Increased BP, HR or SOB
abnormal breath sounds (crackles/decreased A/E)
Peripheral edema
Fluid overload prevention
monitor IV fluids/blood products rate and amount
monitor output - note 24 hour balance
assess for signs of overload
meds as ordered (diuretics, ACE inhibitors, digoxin)
Dehydration
Excessive loss of water from tissues
Dehydration detection
less than 350cc of urine in 12 hours
Hypotension/tachycardia
dry lips and mucous membranes
lack of skin turgor
muscle weakness, dizziness, headache, restlessness
Prevention of dehydration
monitoring urine output oral/IV intake
blood loss during surgery
VS including temp
correct dehydration and avoid unnecessary transfusion
(similar to anemia)
hypovolemia causes
total blood volume loss of 15-24%
blood loss from surgical site
severe dehydration
third spacing (not enough albumin, liver disease, fluid loss from vomiting/diarrhea, N/G tube suction)
What are symptoms of hypovolemia?
lethargy
hypotension
rapid/weak pulse
cool/clammy skin
rapid shallow resps
oliguria/anuria
MOST CONCERNED ABOUT BP
Hypovolemia interventions
VS, o2, IV fluids
MRP, ICU outreach
Post op bleeding symptoms
excessive bleeding
low hgb
hypotension, tachycardia
pale, cool
Post op bleeding interventions
VS
notify surgeon
Patent IV (1,2)
apply pressure
keep pt warm
lie pt flat (decreased card. work)
warfarin? INR?
Electrolyte imbalance common electrolytes
NA, KCl, bicarbonate, Ca, phosphorus, Mg
what affects heart function?
hypokalemia
What causes electrolyte imbalance?
N/V
fluid loss during surgery
preop NPO status
Electrolyte imbalance prevention
monitor lab values
report/record abnormal
meds (IV/PO)
prevent c-diff
tx and prevent N/V
GI complications
Paralytic ileus
Post op N and V (PONV)
Paralytic ileus
decreased motility of intestines beyond 24 hours
when does paralytic ileus happen?
24-48 hours postop
What causes paralytic ileus ?
Gi tract innervation is dusrupted from intestinal manipulation
hypokalemia
wound infection (increased stress, decreased wound healing)
narcotics
symptoms of paralytic ileus
severe abdo distension
N/V
decreased or absent BS
severe constipation or passage of flatus and small liquid stools
interventions for paralytic ileus
ambulate!
Pain management
hold fluids and food
NG tube to decompress stomach (prevent intestinal preformation)
anti-emetic
notify surgeon (abd X ray)
Post op N/V (PONV)
administer anti-emetics
modify analgesic routine if necessary
change to alternate opioid
GU complications
Urinary retention
Healthcare associated UTI (HAUTI)
Urinary retention symptoms
absence of voiding
bladder distension
discomfort
anxiety/restlessness
diaphoresis
htn
urinary frequency/urgency/sensation that bladder isnt fully emptied with voiding
Urinary retention interventions
ambulate
bladder scan
HAUTI risks
most common type of infection
catheter (biofilm crawls up catheter)
female
catheter management techniques
older age
DM, immunosuppressed
malnourished
HAUTI complications
delirium
decreased mobility
infection
mobility, mortality
asymptomatic bacteriuria
urine culture positive without signs and symptoms of UTI
DO NOT TREAT W ABX
Symptomatic UTI
urine culture (+)
at least one positive with the following: fever, suprapubic tenderness, CVA tenderness)
+
at least one of the following: urgency/frequency, dysuria
Indications for a indwelling catheter
acute urinary retention +/ obstruction that cannot be relieved by use of intermittent catheterization
short term monitoring of urinary output in critically ill pt
per-op use
intra op monitoring of urinary output
facilitate healing in advanced pressure ulcers in incontinent pts
requires prolonged immobilization with inability yo void
improve comfort for end of life care
After removal of catheter…
mobilize at least BID
commode bathroom to void q2h
avoid bed pans
optimize bowel function
if unable to void for 4 hours - bladder scan
Surgical site infection prevention
4 pillars!!
1. homothermia (maintain temp)
2. antibiotic timing (given within 1 hour of surgery)
3. glycemic control (lower)
4. skin prep (preop) - with CHG
Interventions for surgical site infection
local: would culture and PO antibiotics
systemic: same as for sepsis
