Post-op Complications Flashcards
What is the timeframe of post-op ileus according to the organ involved?
Small bowel (0-24hrs)
Stomach (24-48hrs)
Colon (48-72hrs) - ask pt if they have passed flatus to check for colon ileus
note: post-op ileus delayed by opiates
What are the most common wound contaminants in abdominal surgery?
Bacteroides fragilis (anaerobe)
Gram-ve bacteria:
- E. coli
- Pseudomonas
- Proteus
- Klebsiella
Staph. aureus (skin)
Define a surgical site infection.
Type of healthcare associated infection which occurs after an invasive surgical procedure.
- 3rd most common nosocomial infection
- majority caused by contamination of incision with patient’s microbes
- inc. post-op resp. infections, UTIs,
Why are post-op respiratory infections common?
- wound pain makes pt reluctant to breathe deeply/cough (tell pt to cough)
- intubation introduces dry air —> irritation —> increased mucus production
- opiates are anti-tussive —> mucus not coughed up
What are the pre-op measures taken to reduce the risk of surgical infection?
- shower before surgery
- hair removal using electric clippers (razors cause skin abrasion)
- Abx prophylaxis indicated: prosthesis/implant surgery, clean-contaminated surgery, or contaminated surgery
What are the intra-op measures taken to reduce the risk of surgical infection?
- skin preparation using antiseptic (povidone-iodine or chlorhexidine)
- hand decontamination
- sterile gowns/gloves
- cover wounds with appropriate dressings (2-3days for skin closure; do not keep removing dressing - risk of infection; weeping wound indicates skin has not closed)
- Abx at induction and removal of anaesthesia
What are the post-op measures taken to reduce the risk of surgical infection?
- avoid unnecessary contact with wound for 48-72hrs
- clean hands & PPE
- involve tissue viability team when wound is not healing well/shows sign of infection
- empirical Abx in suspected wound infection/prophylactic 2-3days post-op
What are the most common organisms implicated in surgical site infections?
Bacteria (depends on organs involved)
- Staphylococcus (coagulase -ve) (25%)
- Enterococcus (D) (11.5%)
- Staph. aureus (9%)
- Candida albicans (6.5%)
- E. coli (6.3%)
- Pseudomonas aeruginosa (6%)
What are some risk factors for poor wound healing?
- chronic renal failure
- jaundice
- diabetes mellitus
- smoking
- obesity
- advanced age
- steroids/immunosuppressants
- chemo/radiotherapy
- alcoholism
- poor nutrition
What are the features of clean surgery?
Elective/non-emergency surgery
Non-traumatic
Primarily closed
No acute inflammation
Internal tracts not entered
What are the features of clean-contaminated surgery?
Clean urgent/emergency
Elective entering of internal tracts with minimal spillage
No infected internal fluids
Abx req.
What are the features of contaminated surgery?
Penetrating trauma
What are the features of dirty surgery?
Penetrating trauma > 4hrs
Purulent inflammation
Pre-op entry of internal tracts
Abx req.
What is the patient zone?
Everything within curtain has microbes unique to the patient
What are the most likely surgical infections according to the post-op timeline?
24hrs + fever = respiratory infection (atelectasis)
1-2days = pneumonia
4-5days = UTI, surgical site infection
What is the general management of surgical site infections?
- have high index of suspicion: timing, drains/catheters/lines, presence of risk factors, signs of infection
- appropriate Ix
- appropriate Abx (guided by micro. dept)
- may req. opening of wound, debridement, or other surgical procedure
- risk of sepsis = sepsis care pathway, higher level of monitoring, phone ITU
What is the general management for post-op chest infections?
- Hx of chest disease
- ensure good post-op analgesia to encourage breathing and coughing
- chest physio (bd) + nebulisers
- Abx
What is the prevention of post-op UTIs?
- prevent by avoiding unnecessary catheterisation, good aseptic technique, remove at earliest opportunity, do not leave same one in for 2-3days
Give examples of sources of post-op bacteraemia.
Cannulas CVP lines (sepsis causes death within hrs) Anastomotic breakdown/abdominal sepsis (3-7day post-op + abdo. tenderness)
What are the risk factors for C. difficile infection?
- current or recent Abx
- 65yrs
Give some examples of post-op neurological complications.
- not waking up: unconsciousness/drowsiness; caused by inhalational anaesthesia, opioids, benzodiazepines, longer ops., hypoglycaemia, neuro. surgery
- pain: increased symp. stimulation, reduced vital capacity, reduced tidal volume, reduced forced reserve capacity, basal atelectasis, chest infections, N&V, ileus, urinary retention, DVT/PE
- confusion/agitation: brain insult, dementia, hypoglycaemia, extremes of age, drug users, alcoholics, urinary retention, hypo/hyperthermia
- hypothermia/shivering: thin/elderly, children; caused by paralysis, lower threshold for hypothalamic heat redistribution/muscle movement; causes increased O2 demand and reduced wound healing
Give some examples of post-op respiratory complications.
- upper airway obstruction
- hypoventilation: resp. depression, oedema, reduced consciousness
- reduced resp. rate OR reduced tidal volume = reduced minute volume
- hypoxia; V/Q mismatch, shunt, increased O2 demand, pain, reduced saturation, increased resp. rate, tachycardia, unconsciousness/restlessness/agitation
- atelectasis
- fluid overload
Give some examples of post-op cardiac complications.
- hypotension: caused by anti-hypertensive overdose, haemorrhage, shock
- hypertension: neurosurgery, spinal surgery, adrenal surgery, pain, pre-op hypertension, acute brain insult (Cushing’s reflex), N&V
- MI
- venous thromboembolism
Give some examples of post-op GI complications.
- N&V: aspiration, cannot take usual meds, reduced wound adhiscence
- ileus —> constipation
- distension
- abdo. pain
