Post-op complications

Question 1

Pneumonia: RFs, Fx, differentials, Ix, Mx

Answer 1

• Predisposing Factors: Reduced chest expansion, change in commensals, debilitation, intubation, ventilator-associated pneumonia (VAP).
  * Risk Factors: Age, smoking, known respiratory disease, poor mobility, mechanical ventilation, immunosuppression.
• Clinical Features: Cough, dyspnea, chest pain.
• Differential Diagnosis: Acute HF, PE, ACS, COPD/Asthma exacerbation.
• Investigations: Routine bloods, possibly ABG, sputum sample if productive cough, CXR to confirm.
• Management: Oxygen as needed, antibiotics (co-amoxiclav 625mg TDS if mild to moderate, tazocin 4.5g TDS IV if severe).

Question 2

ARDS

Answer 2

• Definition: Severe hypoxemia in the absence of a cardiogenic cause.
• Causes:
• Direct: Pneumonia, smoke inhalation, aspiration, fat embolus.
• Indirect: Sepsis, pancreatitis, polytrauma, burns.
• Criteria: Acute onset within 7 days, PaO2:FiO2 ratio <300, bilateral infiltrates on CXR, alveolar edema not explained by fluid overload or cardiogenic cause causing hypoxemia.
• Pathophysiology: Inflammatory damage to alveoli → pulmonary edema, respiratory compromise, acute respiratory failure.
• Features: Worsening dyspnea, acute onset, hypoxia, tachypnea, inspiratory crackles.
• Investigations: ABG, bloods (U&Es, amylase, CRP), CXR, ECG (rule out cardiogenic cause).
• Management: Chest physiotherapy, encourage mobility, supportive ventilation, focused treatment of underlying cause, intensive care unit (ITU) management, positive end-expiratory pressure (PEEP).

Question 3

Fat embolus

Answer 3

• Description: Rare but serious condition, occurs when fat enters systemic circulation, often associated with long bone fractures.
• Risk Factors: Young age, long bone fractures, closed fractures, multiple fractures.
• Features:
• Occurs within 24-72 hours following trauma.
• Worsening shortness of breath, confusion, drowsiness, petechial rash.
• Clinical examination: Tachypnea, tachycardia, hypoxia, non-specific neurological signs, low-grade fever, organ dysfunction.
• Differential Diagnosis: Pulmonary embolism, meningococcal septicaemia.
• Investigations: Routine bloods, ABG (type 1 respiratory failure), CXR (diffuse bilateral pulmonary infiltrates), CTPA (ground glass appearance).
• Management: Supportive care, may lead to ARDS, often requires mechanical ventilation.
• Prevention: Early fixation of long bone fractures, close monitoring in intramedullary nailing procedures.

Question 4

Atelecatasis

Answer 4

• Partial collapse of small airways - alveolar gas reabsorption intraoperatively and impairment of surfactant production
• Reduced airway expansion -> accumulation of pulmonary secretions → increased risk of complications e.g. hypoxaemia, infection
• RFs:
• Age, smoking, GA, duration of surgery, poor-post op pain control, prolonged bed rest
• Fx:
• Increased respiratory rate, reduced O2 sats, fine crackles, low grade fever
• Dx:
• Clinical, CXR
• Mx:
• Chest physio, breathing exercises, analgesia, if severe bronchoscopy to aspirate secretions
  *

Question 5

Haemorrhage

Answer 5

Classification
* Primary bleeding - within intra-operative period, resolve during operation
* Reactive bleeding - within 24 hours - ligature slips or a missed vessel, these can be missed due to intraoperative hypotension and vasoconstriction
* Secondary bleeding - occurs 7-10 days post op - due to erosion of a vessel from a spreading infection
Features:
* Tachycardia, dizziness, agitaiton, raised respiratory rate, decreased urine output
Management
* A-E, major haemorrhage protocol, ensure adequate IV access and rapid fluid resuscitation,
* If visible bleeding site add direct pressure, get urgent senior surgical review

Question 6

PONV: RFs, when it occurs, complications of it, pathophysiology

Answer 6

Occurrence: Typically within the first 24-48 hours, affects around 20-30% of patients.
Complications: Increased recovery time/hospital stay, aspiration pneumonia, metabolic alkalosis.
Risk Factors:
Patient: Female, young age, previous PONV, opioid use, non-smoker.
Surgical: Intra-abdominal laparoscopic surgery, intracranial surgery, squint surgery, gynecological surgery, prolonged operative times, poor pain control.
Anaesthetic: Opiate or spinal analgesia, inhalation agents, prolonged anesthesia time, intra-operative dehydration or bleeding, overuse of bag and mask ventilation.
Pathophysiology: Involves the vomiting center in the lateral reticular formation of the medulla oblongata and the chemoreceptor trigger zone (CTZ) in the area postrema.

Question 7

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PONV Management

Answer 7

Prophylaxis:
* Anaesthetic: Reduce opiates/volatile gases, avoid spinal anesthesia.
* Prophylactic antiemetics, dexamethasone at induction.
Conservative:
* Fluid hydration, analgesia, consider NG tube for decompression.
Pharmaceutical:
* Impaired gastric emptying: Trial prokinetic agents like metoclopramide or domperidone.
* Metabolic or biochemical imbalance: Trial metoclopramide.
* Opioid-induced: Cyclizine or ondansetron.

Question 8

Pyrexia at how many days post surgery indicates what

Answer 8

1-2 days - respiratory
3-5 days - respiratory or urinary
5-7 days - surgical site infection
Any day - infective IV or central lines

Question 9

delerium

Answer 9

Hypoactive (most common) - lethargy and reduced motor activity
Hyperactive (most recognised) - agitation and increased motor activity
Delirium is an acute confusional state, characterised by a disturbed consciousness and reduced cognitive function.
Risk factors:
Age >65, multiple co-morbidities, underlying dementia, renal impairment, male gender, sensory impairment
Cause:
Hypoxia, infection, drug induced/withdrawal, dehydration or pain, constipaiton or urinary retention, electrolyte abnormality
Assessment:
Obtain collateral history, onset and course, underlying cause, previous episodes, alcohol, baseline cognition
AMT: (age, time, address, year, recognition of two people / objects, date of birth, year of 1st/2nd world war, name of current monarch, count backwards 20-1)
Investigations:
Concussion screen: bloods (FBC, U&E, Ca2+, TFTs, glucose, B12, folate), blood cultures/wound swabs, urinalysis, CXR, CT head if relevant
Management -
Treat underlying cause, nursed in quiet area with clocks and lighting
Sedatives only if have to, haloperidol

Question 10

Bile leak

Answer 10

Happen post cholecystectomy when the clips used to seal cystic duct slip off
Causes peritonism, sepsis, pain
Ix: bloods, CT with contrast maybe, antibiotics, contact surgeon, start sepsis 6

Question 11

Anastamotic leak RFs, Fx, what is it

Answer 11

• 3-5 days but can occur at any time
• Leak of luminal contents from a surgical join - significant contamination of abdominal cavity
• Any patient not progressing as expected or who deteriorates after surgery should be considered to have an anastomotic leak until proven otherwise
  RFs:
  Patient - medication, smoking/alcohol excess, DM, obesity, malnutrition
  Surgical - emergency surgery, extended operative time, peritoneal contamination, oesophageal-gastric anastomosis
  Features:
• Worsening abdominal pain, signs of sepsis, can be more subtile signs such as prolonged ileus,
• Any patient nor progressing appropriately post of with an anastomosis is considered to have leak until proven
• OE - tender abdomen, either localised and generalised with or without signs or peritoneum, depending on degree of contamination

Question 12

Anastamotic leak: Ix, Mx

Answer 12

Ix:
* Urgent bloods (FBC, CRP, clotting), ABG, CT with IV contrast (presence of gas and enteric comments outside lumen)
Mx:
* NBM, IV broad spectrum antibiotics, resuscitation fluids, urinary catheter for fluid balance
* Minor leak - conservative with antibiotics and bowel and possible percutaneous drain
* Large leak / Systemically unwell with peritonism - surgical intervention - laparotomy, washout of contamination and refashioning of anastomosis

Answer 13

Deceleration or arrest in intestinal motility - function bowel obstruction
RF:
* Patient - increasing age, electrolyte derangement, neurological disorder, anticholinergic medication
* Surgical - opioid use, pelvic surgery, extensive intra-operative intestinal handling, peritoneal contamination, intestinal resection
Features:
* Failure to pass flatus or faeces, Bloating and distension, N+V, Absent bowel sounds
Ix:
* Routine bloods (FBC, CRP, U&Es, Ca2+, PO43-, MG2+), CT abdomen with oral contrast
Mx:
* Rule out serious underlying pathology
* NBM, IV fluids, monitor fluid balance, NG tube
* Daily bloods - correct any electrolyte abnormality
* Encourage mobilisation, reduce opioid analgesia
*

Question 14

what laxatives for different types of psot op constipation

Answer 14

• Patients with a hard stool and chronic constipation issues will benefit from a stool-softening laxative, such as movicol or lactulose, but may require glycerine suppositories to help soften the rectal stool initially.
• Patients with post-operative ileus, opioid-induced constipation, or a soft stool will benefit from a stimulant laxative, such as senna or picosulphate