POST-OP COMPLICATIONS

Question 1

If a patient just had surgery and you see delirium, fluid overload, hyponatremia, tachycardia, bradycardia, or afib – what should you think?

Answer 1

Those are NOT NORMAL in a post-op patient

Question 2

What’s the main endogenous pyrogen released with a fever?

Answer 2

Interleukin 6 (most commonly associated with post-op fever)

Question 3

What’s a normal temp in Celsius?

Answer 3

37

Question 4

At what point are we concerned about fever in a post op patient?

Answer 4

Temp greater than 38.0

Question 5

What do the 5 W’s explain?

Answer 5

Potential causes of fever

Question 6

What are the 5 W’s?

Answer 6

Wind = atelectasis (without air)

Water = UTI

Walking = DVT

Wound = Infection

Wonder drugs

Question 7

When would someone develop atelectasis?

Answer 7

POD 1-2

Question 8

Why does atelectasis develop?

Answer 8

Compression (positional)
Absorptive (pain with deep inspiration)
Or combo of the two with surfactant dysfunction (anesthesia/ventilator)

Question 9

How do we prevent atelectasis?

Answer 9

Incentive spirometry and mobility

Question 10

How often should they use the incentive spirometer, what do we want them to do?

Answer 10

10x/day

We want then to take a good deep breath

Question 11

If you get a call POD one that a patient has a fever – what do you do?

Answer 11

Encourage ambulation and use incentive spirometry

Question 12

When does atelectasis typically resolve?

Answer 12

Within 48 hours

Question 13

: If we see a fever in a patient, what should we make sure to see if they have?

Answer 13

A foley catheter!

Question 14

When do UTI’s typically present in post-op patients?

Answer 14

POD 3-5

Question 15

When do DVT’s typically present in post-op patients?

Answer 15

POD 4-6

Question 16

How do we prevent DVT?

Answer 16

Walking on POD 1

Mechanical: Pneumatic compression or Antiembolism stockings

Chemical: LMWH, warfarin, aspirin

Question 17

If a patient has a fever 5-7 days after surgery, what are you concerned about?

Answer 17

Wound infection or are drugs causing fever

Question 18

What are some potential etiologies for respiratory failure?

Answer 18

Atelectasis, pulmonary edema, alveolar hypoventilation, aspiration, and pneumonia

Question 19

If our post-op patient has a cough, SOB, fever, and gradual decline in their O2’s – what do you think of?

Answer 19

Post-op pneumonia

Question 20

How do we confirm diagnosis of post-op pneumonia?How do we confirm diagnosis of post-op pneumonia?

Answer 20

Auscultation, CXR, and WBC

Question 21

How do we treat post-op pneumonia?

Answer 21

Chest PT and Abx

Question 22

How could we have prevented post-op pneumonia?

Answer 22

Ambulation, cough, and incentive spirometry

Question 23

What are some common pathogens of ventilator associated pneumonitis?

Answer 23

Gram - = Pseudomonas, Serratia

Gram + = MRSA (oxacillin resistance)

Question 24

How do patients acquire ventilator associated pneumonitis?

Answer 24

Ventilator tube, ET tube, and humidification fluid

Question 25

How do we prevent ventilator pneumonitis?

Answer 25

Aseptic technique and Avoid prolonged intubation

Question 26

How do we treat ventilator pneumonitis?

Answer 26

Support (fluid/suction) Abx

Question 27

How do we diagnose a DVT in a post-op patient?

Answer 27

Venous Doppler

Question 28

Is a d-dimer helpful in a post-op patient?

Answer 28

NO!

Question 29

How do we prevent VTE’s?

Answer 29

Mobility, stockings, pneumatic pressure devices, Anticoag (Heparin, warfarin, aspirin)

Question 30

If a post-op patient has pleuritic chest pain with sudden SOB, fever, sudden hypoxemia, and tachycardia – what should jump to the top of your DDx?

Answer 30

PE

Question 31

If your patient had an O2 sat of 98% at 8AM and now at 10AM their O2 sat is 89% - what do you need to do?

Answer 31

Confirm the change yourself See if their rate is Tachycardia Don’t ignore these changes! *Think PE

Question 32

How do you treat a PE?

Answer 32

Heparin, warfarin, or NOAC’s (factor 10A inhibitors - maybe)

Question 33

Can you ever use tPA in a post-op patient?

Answer 33

NO!

Question 34

When do we most commonly see arrhythmias occur in post-op patients?

Answer 34

After cardiac and thoracic surgery

Question 35

What are some causes of post-op arrhythmias? (think ACLS)

Answer 35

H’s and T’s!! Hypoxia Hypovolemia Hyperthermia Hypoglycemia HTN Electrolytes Infection Medications

Question 36

How should we approach a post-op arrhythmia?

Answer 36

Reverse cause (can often resolve when we treat the cause) Consider cardioversion Don’t stop the beta blocker – even if they are hypotensive! (they can have reflex tachycardia)

Question 37

What’s the most common cause of morbidity and mortality after non-cardiac surgery?

Answer 37

Myocardial Infarction

Question 38

If a post-op patient has unexplained SOB, tachycardic, hypotension, with possible HF – what do we think of?

Answer 38

MI!

Question 39

How do you treat the MI in your post-op patient?

Answer 39

Consult surgeon and cardiology

Question 40

If a post-op patient has dyspnea, hypoxemia with normal CO2 tension, and CXR with increased markings – what do you think of?

Answer 40

Heart Failure

Question 41

How do you treat heart failure in your post-op patient?

Answer 41

diuretic, inotropic support, ventilator support (if needed)

Question 42

What are some early causes of perioperative stroke?

Answer 42

Manipulation of heart and aorta Particulate release from ECMO

Question 43

What are some late causes of perioperative stroke?

Answer 43

Emboli from Afib, supply/demand MI, coagulopathy

Question 44

What are the 7 risk factors to a perioperative stroke?

Answer 44

Advanced age, Non-elective surgery, Female sex, EF less than 40%, Vascular disease, DM, and Cr greater than 2

Question 45

How do we prevent a perioperative stroke?

Answer 45

Avoid acute or aggressive BB (don’t increase doses, or start people not on BB on them) Statins

Question 46

How do we treat a perioperative stroke?

Answer 46

ASA, embolectomy, and intra-arterial tPA

Question 47

What would cause a wound to dehiscence?

Answer 47

Mechanical force, tissue ischemia due to tight suturing, poor suturing technique, and local infection

Question 48

What are some of the signs we look for wound infection?

Answer 48

Redness, swelling, localized heat/erythema, increased/worsening pain (at incision site), dehiscence, tachycardia, and fever (late)

Question 49

What are the 4 classifications of risks for wound infections?

Answer 49

Clean Clean-contaminated Contaminated Dirty

Question 50

How do we prevent wound infections?

Answer 50

Limit pre-op hospitalization Pre-op shower and/or Chorhexadine bath Hair removal immediately before surgery Avoidance of adhesive drapes Decreased op time

Question 51

What is the source of a clean-contaminated wound? What type of bacteria?

Answer 51

Source = endogenous colonization (elective GI surgeries) Contaminate = Polymicrobial (gram neg)

Question 52

What is the source of a contaminated wound infection?

Answer 52

Gross-contamination (the gallbladder spills out every time it’s touched during removal)

Question 53

How do we prevent contaminated wound infections?

Answer 53

Give pre-op Abx less than 60 minutes before procedure

Question 54

What is the source for a dirty wound infection?

Answer 54

Established post-op infection

Question 55

What’s a common nosocomial infection?

Answer 55

C. diff (CDAD)

Question 56

What’s the MOST common nosocomial infection?

Answer 56

UTI

Question 57

What abx are C. diff most commonly associated with?

Answer 57

Clinda and Floro

Question 58

What should we always remember about C. diff?

Answer 58

Spores are resistant to heat, acid, alcohol, and abx → we must wash it down the drain

Question 59

If you see a patient with diarrhea, what must you ALWAYS DO? Why?

Answer 59

WASH YOUR HANDS! C. diff is resistance to hand sanitizer!! → we must wash it down the drain

Question 60

How do we treat C. diff?

Answer 60

Metronidazole and/or Vanco PO → because C. diff is in the gut! Not in the veins

Question 61

If a patient has dysuria with a mild fever – what do we think of?

Answer 61

Cystitis

Question 62

If we see high fever, flank tenderness – what do we think of?

Answer 62

Pyelo

Question 63

How do we prevent UTI’s?

Answer 63

Get the catheter out ASAP!!

Question 64

How do we treat UTI’s?

Answer 64

Specific Abx, bladder drainage, and hydration

Question 65

If a patient has temporary paralysis of a portion of the bowels (often after surgery/great stress) – what is it known as? When do we see this occur?

Answer 65

Post-operative Ileus Occurs after abd surgery

Question 66

If a patient has N/V with vague abdominal discomfort. On PE you note quiet bowel sounds – what do you think of? What diagnostic study should you get?

Answer 66

Post-op ileus Get Abd Xray

Question 67

How do we treat paralytic ileus?

Answer 67

NPO, NG tube, IVF

Question 68

If a patient has an abrupt increase in ETCO2, increased body temp, with muscle rigidity – what do you think of?

Answer 68

Malignant Hyperthermia

Question 69

What is malignant hyperthermia?

Answer 69

Hypermetabolic condition of muscle – intracellular Ca binding to sarcoplasmic reticulum (violent/sustained muscle contractions) → leads to muscle necrosis and Rhabdo

Question 70

What are some late effects of malignant hyperthermia?

Answer 70

Compartment syndrome, rhabdo, acidosis (metabolic and respiratory), and arrhythmias (due to increased K)

Question 71

How do we treat Malignant Hyperthermia?

Answer 71

D/C triggering agent, dantroline, cooling blankets (don’t want them to shiver, because it will make it worse!), renal and respiratory support

Question 72

What are some other aberrancies we will see in post-op patients?

Answer 72

Delirium (elderly with new environment), orthostasis (due to volume depleted prior to surgery + Narcotics), tachycardia, bradycardia, hyponatremia (volume depleted, stress from surgery cause increase in ADH + LR fluids have low sodium levels), and Afib