Post Op Complications Flashcards
What are the three major stages for post op period?
a. Immediate post-op, 1-3 hours, PACU, or Recovery Room
b. Intermediate Phase : the remainder of hospitalization
c. Convalescent (late) Phase: discharge to full recovery
What are the most common causes of death in the immediate post-op period?
a. Acute pulmonary, CV and fluid derangements. Can be discharged from PACU after 1-3 hours , as those risks return to near baseline.
b. If there is a complication: then you want to support your patient, assess and treatment pain, detect and prevent complications
What Post-Op orders need to be considered?
ADC Van Diml
i. Admit to _____
ii. Diagnosis
iii. Condition
iv. Vitals
v. Activity
vi. Nursing orders
vii. Diet
viii. IV fluids
ix. Medications
x. Labs
What prophylaxis treatments do you need to consider post-op
DVT, wound, GI stress ulcer, Respiratory, Bowel
What should you use for DVT prophylaxis?
Sequential compression devides, LMWH, mobilize
What should you use for Wound prophylaxis?
a. Give 24 hours of IV antibiotics post-op
What should you use for GI stress ulcer prophylaxis
PPIs, H2Bs, antacids
What should be used for Resp phrophylaxis
Incentive spirometry 10x/hour, mobilized
What should be used for bowel prophylaxis?
Mobilize, stool softener, MOM
What are wound complications with fluid in the wound?
Hematoma: collection of blood and clot in close wound due to poor hemostais. creates a pressure effect
Seroma: thought to be due to a disruption in lymph fluid. Increases risk of infection
What is the number one preventing factor for wound complications
Hand washing
What are some of the signs of wound complications?
Warmth, spreading redness, induration, tenderness, pus/drainnage, increasing pain over time, foul smell.
Treatment is antibiotics and allowing for drainage, often will need to return to OR for irrigation and debridement
What is a dehiscence?
a. Partial or total disruption of wound layers (superficial skin/dermis vs deep fascia
- What is evisceration
all layers rupture and abdominal contents extrude. Can be due to closure issues by sutures, increased abdominal pressure, deficient wound healing.
What is the most common single cause of morbidity after major surgical procedures?
a. Respiratory complications
b. Second most common cause of post-op death in age >60. Much more common in patients with upper chest or upper abdominal surgeries.
What is the most common pulmonary complication
a. Atelectasis
b. First 48 hours: causes 90% of all episodes of fever. (other symptoms being tachypnea, tachycardia). Usually due to the collapse of dependent bronchioles due to SHALLOW BREATHING and FAILURE TO HYPERVENTILATE.
How can you prevent atelectasis?
Positive pressure, nebulized meds, percussion, NT suction
When is aspiration more likely
More likely with NG tube or ETT. Certain drugs, decreased LOC, trauma, pregnancy. Prevent this by causing NPO 6 hours pre-op.
How do you treat aspiration?
BAL, IVF, steroids, antibiotics, pulmonary consult.
What is the most common respiratory complication that cause people do DIE?
pneumonia.
signs include fever, tachypnea, hypoxia, CXR consolidation
tx= give abx, do suctions/mobilization/nebulizer
What are the risk factors for getting pneumonia postop?
prolonged vent support, peritoneal infections, atelectasis, aspiration
What are the organisms most frequently isolated?
GN bacilli: Klebisiella and Pseudomonas.
What is a pleural effusion?
collection of fluid or blood between parietal and visceral pleura, think “inflammation”.
How can you treat pleural effusion?
if large and compromising pulmonary function, place a chest tube for drainage.
PE and DVT are two manifestations of the same disease. The risk factors for the disease are the same…what are they?
- venous stasis
- injury to the vessel wall
- hypercoagulability
This is known as Virchow’s triad
Virchow’s triad:
- venous stasis
- injury to the vessel wall
- hypercoagulability
What are some of the symptoms of PE?
dyspnea, chest pain on inspiration, cough, LEG PAIN, increased heart rate, increased respirations.
What is a homan’s sign
its associated with DVT, although not clinically specific. a positive sign is a forceful dorsiflexion followed by calf pain.
What lab findings are present with PE?
ECG is abnormal in about 70% of patients, but sinus tachycardia and nonspecific ST and T wave changes are more common. ABG usually shows alkalosis due to hyperventilation. A neg Ddimer can rule out a Pe but if its positive, it cant diagnose it as PE. A CT with angiography is needed to diagnose a PE.
what imaging is needed to diagnose a PE
CT pulmonary angiography
What is the choice of imaging to detect DVT?
venous US
What is the treatment for PE?
start both heparin and warfarin together, then warfarin for 6 months after.
what are some risk factors for DVT?
female, smoker, obesity, immobility
What are some prophylaxis that we can do?
compression stockings, early post op ambulation, heparin
What are some cardiac complications that can arise?
- Dysrrhythmias : give pre-op BB to decrease risk. SVTs not usually serious, but if there is Afib/flutter with RVR then you need to get rate control. if in shock, then you need to convert them.
- MI–> increased with those who have CV risk factors. Can be asymptomatic.
- CHF –> may be a post op MI that was missed. More commonly caused by fluid overload.
What are some peritoneal complications?
A. Hemopertioneum= most common cause of shock in 1st 24 hours. patient will be:
- tachycardic
- hypotenisve
- decreased UOP
- abd exam will show distention, rigidity.
- decreased Hgb
B. drain complications
What are some GI complications?
- post op gastric distention
- tender distended abdomen with HICCUPS
- tx: NG decopmression - bowel obstruction
a. mechanical: adhesions, hernia, etc…
b. paralytic: await gas
c. you will see air fluid levels on X-ray
A patient has abrupt epigastric/back pain, increased amylase and lipase, and a CT scan shows an increased pancreatitis. How might this have happened
mechanical trauma after nearby surgery can upset the pancreas. usually from GB/biliary tract surgery. high mortality.
What is the most common cause of hepatic dysfunction?
hepatocellular insufficiency due to inflammation, drugs, or sepsis.
How will hepatic dysfunction appear?
mild jaundice to liver failure. look at skin and liver enzymes.
What should Cdiff be treated with?
- remove current abx
2. if needed, then metronidazole and vanco
Who needs a foley?
- surgery >3 hrs
- pelvic surgery
- unable to ambulate
untreated can lead to build up and hydronephrosis.
patient’s who have had a foley for longer than >3d are assumed to have?
a UTI
Describe how you should think of fevers in order of post-op days
wind water wound
- 0-2 days: atelectasis is highest concern.
- 2-5 days: IV sites, UTI, pneumonia
- > 5 days: infection at surgical site or intraabdominal abcess.
