Post Op Complications Flashcards

1
Q

What are the complications post op

A
Bleeding 
Surgical site infection 
Urinary retention 
VTE
Pulmonary atelectasis 
Wound dishiscence 
Pain
Nausea and vomiting
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2
Q

When does bleeding occur post op

A

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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3
Q

What are the signs of haemorrhagic shock

A
Drop in BP and tachycardia - late signs 
dizziness 
Increased pain 
New nausea 
Decreased urine output 
Increased RR
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4
Q

How is haemorrhagic shock managed

A

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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5
Q

What is wound dehiscence

A

failure of a wound to close properly

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6
Q

What is simple dehiscence

A

The skin wound alone fails

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7
Q

What may cause a wound to fail to close

A

Diabetes
Infection
poor nutrition

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8
Q

What is a burst abdomen

A

Separation of abdominal wall closure with protrusion of the abdominal contents

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9
Q

What is the most common cause of wound dehiscence

A

Infection therefore early identification and treatment of SSI are important

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10
Q

What are the risk factors for wound dehiscence

A
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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11
Q

What are the clinical features of wound dehiscence

A
Visible opening 
typically happens around day 6 post op 
bleeding 
inflammation 
increasing pain
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12
Q

How is wound dehiscence managed

A

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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13
Q

How is sudden full dehiscence managed

A
Analgesia 
IV fluids 
Broad spectrum IV abx 
Cover wound in saline soaked gauze 
Urgent return to theatre
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14
Q

What is an abscess

A

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

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15
Q

When do post op wound abscesses present

A

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

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16
Q

What are the cardinal signs of inflammation

A
Rubor - redness
Calor - heat 
Dolor - Pain 
Tumor - swelling 
Loss of function
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17
Q

How are abscesses managed

A

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

18
Q

What is ARDS

A

Acute respiratory distress syndrome

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

19
Q

What happens to the lung tissue in ARDS

A

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

20
Q

What is the Berlin definition

A

4 criteria which define ARDS

  1. Acute onset (within 7 days of inciting event)
  2. PaO2:FiO2 ration of <300
  3. Bilateral infiltrates on CXR
  4. Alveolar oedema not explained by cardiogenic cause or fluid overload
21
Q

What are the causes of ARDS

A

Direct causes

  • Pneumonia
  • Smoke inhalation
  • Aspiration
  • Fat embolus

Indirect causes

  • Severe Pancreatitis
  • Sepsis
  • Polytrauma
22
Q

How does ARDS present?

A
Dyspneoa 
Can lead to 
Cyanosis 
Tachycardia 
Tachypneoa 
Fine inspiratory crackles
23
Q

If ARDS is suspected how is it investigated?

A

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

24
Q

How is ARDS managed?

A
  1. supportive treatment with ventilation
  2. 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

25
Q

What is the prognosis for ARDS

A

high mortality of 40% - dependent on patient factors

26
Q

What are the complications of ARDS

A

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

27
Q

What are the causes of constipation in a post op patient

A

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

28
Q

What the risk factors for constipation

A
poor fibre intake 
poor fluid intake 
intra-operative factors - e.g. excessive bowel handling
Age 
reduced mobility 
Medications
29
Q

What examination should be performed in patients with constipation

A

DRE to assess degree of faecal impaction

30
Q

how is constipation managed

A

Increase fluid intake
Sufficient dietary fibre
early mobilising
laxatives

31
Q

What are the different type of laxatives

A

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)

32
Q

Which patients will benefit from a stimulant laxative

A

post op ileus
Opioid induced constipation
Soft Stool

33
Q

When should prophylactic laxatives be used and which one?

A

Senna used in elderly patients on opioid analgesia

34
Q

What is dumping syndrome and when may it occur

A

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

35
Q

What is atelectasis

A

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

36
Q

What are the clinical features of atelectasisi

A
Increased respiratory rate 
decreased sats 
increased need for oxygen 
on examination may have fine crackles 
Some cases there may be a low grade fever
37
Q

What are the risk factors for atelectasis

A

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

38
Q

How is atelectasis investigated

A

Normally a clinical diagnosis

Can perform a CXR - can reveal small areas of collapse

39
Q

How is atelectasis managed

A

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

40
Q

How can atelectasis be prevented

A

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