Post Op Complications Flashcards by Marie Harrison

What are the complications post op

Bleeding 
Surgical site infection 
Urinary retention 
VTE
Pulmonary atelectasis 
Wound dishiscence 
Pain
Nausea and vomiting

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When does bleeding occur post op

During surgery - continuous bleeding due to vessel damage
Reactive - bleeding at the end of surgery or early post op (within 24hrs)
Secondary bleeding - 7-10 days post op

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What are the signs of haemorrhagic shock

Drop in BP and tachycardia - late signs 
dizziness 
Increased pain 
New nausea 
Decreased urine output 
Increased RR

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How is haemorrhagic shock managed

A-e assessment
Read notes and know which surgery was performed, if there are drains and where the wound is
Wide bore cannula
IV fluid resuscitation
Urgent senior review
Urgent blood transfusion
Direct pressure applied to bleeding site if seen

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What is wound dehiscence

failure of a wound to close properly

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What is simple dehiscence

The skin wound alone fails

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What may cause a wound to fail to close

Diabetes
Infection
poor nutrition

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What is a burst abdomen

Separation of abdominal wall closure with protrusion of the abdominal contents

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What is the most common cause of wound dehiscence

Infection therefore early identification and treatment of SSI are important

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What are the risk factors for wound dehiscence

Patient factors 
- age 
- male 
- diabetes 
- steroids
- smoking 
- obesity/malnutrition 
Intra-operative factors 
- emergency surgery 
- abdo surgery 
- length of operation (>6hr)
- wound infection
- poor surgical technique

Post operative factors

prolonged ventilation
post op blood transfusion
poor tissue perfusion
excessive patient coughing
radiotherapy

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What are the clinical features of wound dehiscence

Visible opening 
typically happens around day 6 post op 
bleeding 
inflammation 
increasing pain

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How is wound dehiscence managed

Swabs taken for infection
Bloods taken to look for infection markers
May require return to theatre
contaminated or dead tissue should be surgically debrided and prophylactic abx administered
Resuture wound using deep retention sutures
if immediate close not possible saline -soaked gauze packing

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How is sudden full dehiscence managed

Analgesia 
IV fluids 
Broad spectrum IV abx 
Cover wound in saline soaked gauze 
Urgent return to theatre

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What is an abscess

A mass of necrotic tissue containing dead and viable neutrophils suspended in liquefied tissue necrosis

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When do post op wound abscesses present

Within 7 days post op with signs of inflammation, pus or a punctum

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What are the cardinal signs of inflammation

Rubor - redness
Calor - heat 
Dolor - Pain 
Tumor - swelling 
Loss of function

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How are abscesses managed

They are drained
Antibiotics prescribed
Sterile dressings changed regularly
Surgery may be needed to re explore

What is ARDS

Acute respiratory distress syndrome

Acute lung injury caused by hypoxaemia in the absence of a cardiogenic cause

What happens to the lung tissue in ARDS

Severe inflammatory cascade causes damage to the alveoli leading to breakdown of the alveoli-capillary barrier. Increasing permeability leding to fluid infiltration and pulmonary oedema.
Fluid infiltration leads to impaired gas exchange leading to hypoxaemia
Damage to type II alveolar cells leads to reduction in surfactant production reducing lung compliance and worsening ventilation

What is the Berlin definition

4 criteria which define ARDS

Acute onset (within 7 days of inciting event)
PaO2:FiO2 ration of <300
Bilateral infiltrates on CXR
Alveolar oedema not explained by cardiogenic cause or fluid overload

What are the causes of ARDS

Direct causes

Pneumonia
Smoke inhalation
Aspiration
Fat embolus

Indirect causes

Severe Pancreatitis
Sepsis
Polytrauma

How does ARDS present?

Dyspneoa 
Can lead to 
Cyanosis 
Tachycardia 
Tachypneoa 
Fine inspiratory crackles

If ARDS is suspected how is it investigated?

bedside obs
Bloods: FBC, U+Es, CRP, amylase
CXR
ABG

How is ARDS managed?

supportive treatment with ventilation
focused treatment of underlying cause
Respiratory support
- Prone ventilation
- CPAP in early stages (40-60% O2)
- APRV
- ECMO

Diuresis or fluid restriction

Manage underlying cause

What is the prognosis for ARDS

high mortality of 40% - dependent on patient factors

What are the complications of ARDS

Pulmonary: PE, barotrauma, Pulmonary fibrosis, ventilatory ssociated pneumonia GI: ulcer, dysmotility, pneumoperitoneum Cardiac: MI, arrhythmias Renal: AKI Mechanical: vascular injury, pneumothorax, tracheal injury/stenosis Nutritional: malnutrition, electrolyte deficiency

What are the causes of constipation in a post op patient

Post op ileus Physiological - low fibre, poor fluid intake Iatrogenic - Opioids, anticonvulsants, antihistamine Pathological - bowel obstruction, hypercalcaemia, hypothyroidism

What the risk factors for constipation

``` poor fibre intake poor fluid intake intra-operative factors - e.g. excessive bowel handling Age reduced mobility Medications ```

What examination should be performed in patients with constipation

DRE to assess degree of faecal impaction

how is constipation managed

Increase fluid intake Sufficient dietary fibre early mobilising laxatives

What are the different type of laxatives

Bulk forming laxatives - help stool retain water and softens the stool e.g.ispaghula husk Osmotic laxatives - increase the amount of fluid in the bowel softening the stool e.g. Movicol, lactulose Stimulant laxatives - stimulate the bowel to contract so expelling faeces e.g. senna, picolax Rectal medications - glycerin suppository (stool softener) and Phospahet enema (stimulant)

Which patients will benefit from a stimulant laxative

post op ileus Opioid induced constipation Soft Stool

When should prophylactic laxatives be used and which one?

Senna used in elderly patients on opioid analgesia

What is dumping syndrome and when may it occur

Dumping syndrome is a complication of gastric bypass surgery EARLY 10-30 mins post prandial - Sudden large amounts of hypertonic contents move into the small intestine resulting in movement of fluid in the luminal space causing subsequent distension --> vomiting, nausea, diarhoea and hypovolaemia --> sympathetic response LATE 1-3hrs post prandial - Surge in insulin production following 'dumping' of food results in hypoglycaemia

What is atelectasis

Partial collapse of the small airways. often a contributor or precursor to more severe post op pulmonary complications e.g. pneumonia typically develops within 24hrs post op

What are the clinical features of atelectasisi

``` Increased respiratory rate decreased sats increased need for oxygen on examination may have fine crackles Some cases there may be a low grade fever ```

What are the risk factors for atelectasis

Age Smoking Use of GA Duration of surgery underlying lung or neuromuscular disease Prolonged bed rest Poor post op pain control - resulting in shallow breathing

How is atelectasis investigated

Normally a clinical diagnosis | Can perform a CXR - can reveal small areas of collapse

How is atelectasis managed

deep breathing exercises and chest physio - ensures the airways are opened maximally and coughing can be performd effectively Ensure there is adequate pain control if no improvement with physio then bronchoscopy may be needed to get rid of pulmonary secretions

How can atelectasis be prevented

Use chest physio as a preventative measure in patients who have had major surgery