Post-op complications part 2

Question 1

what is the term for acute mechanical failure of wound closure?

Answer 1

wound dehiscence

Question 2

what percentage of all post-op infections in hospitalized patients are wound infections?

Answer 2

14-16 percent

Question 3

most post-op wound infections require _________

Answer 3

surgical debridement

Question 4

is induration a normal sign of healing or a sign of infection?

Answer 4

induration = normal

Question 5

signs of wound infection?

Answer 5

1) redness
2) swelling
3) localized heat and erythema
4) worsening pain (esp after day)
5) dehiscence
6) tachycardia
7) fever (late)

Question 6

what types of procedures typically cause clean (no gross contamination) wound infections?

Answer 6

non-abdominal (like a hand surgery)

Question 7

what is the source of infection of a “clean” wound infection?

Answer 7

patient skin OR environment, surgical team

Question 8

are the contaminants seen in “clean” wound infections typically gram negative or gram positive?

Answer 8

gram positive (thats what we have living on our skin!)

Question 9

clean-contaminated (lightly contaminated) wound infections are most likely due to what?

Answer 9

endogenous colonization during an elective GI surgery (gallbladder we picked at starts to leak contents)

Question 10

what type of organisms typically cause “clean-contaminated” infections?

Answer 10

polymicrobial, typically gram negative (so tx differently than clean!)

Question 11

this type of infection is typically caused by a “spill” during elective surgery; ie you go in and poke the gallbladder and its so friable it starts spewing its contents everywhere

Answer 11

contaminated wound infection

Question 12

a perforated gastric ulcer is an example of what type of wound infection?

Answer 12

contaminated wound infection

Question 13

how do we prevent wound infection?

Answer 13

ABX must be PRESENT at time of the contamination (given less than 60 minutes from time of incision) active against anticipated pathogens

re-dose 4-6 hours later, no more than 3 post-op doses

Question 14

an intestinal infarction is most likely to cause what type of wound infection?

Answer 14

dirty (infected)

spillage of intestinal contents into the gut

Question 15

an intra-abdominal abscess drainage will cause what type of wound infection?

Answer 15

dirty

Question 16

which two antibiotics have the strongest association with C. difficile?

Answer 16

clindamycin and fluoroquinolones

Question 17

is c. difficile gram negative or gram positive?

Answer 17

gram positive spore forming anaerobic bacillus

Question 18

c. difficile is carried by _____ percent of adults in hospitals or LTC facilities

Answer 18

20-50 percent

Question 19

what are 5 common facultative anaerobes?

Answer 19

1) staph
2) strep
3) enterococcus
4) e. coli
5) listeria

Question 20

how is c. diff transmitted? why do we have such a hard time eliminating it?

Answer 20

fecal/oral

spores are resistant to heat, acid, alcohol, and antibiotics! hand sanitizer alone will not kill c.diff!

Question 21

treatment of c. diff colitis?

Answer 21

PO metronidazole
PO vancomycin (not IV!)

or PO vancomycin PLUS IV metronidazole

Question 22

you may recommend your patient coming in for surgery washes in a _______

Answer 22

chlorhexadine bath (broad spectrum topical ABX)

Question 23

are dressings of much help in preventing post operative infection?

Answer 23

nope!

Question 24

should we used an open or a closed drain system if we want to prevent post-op infection?

Answer 24

closed!

separate stab for exit

Question 25

what is the most frequently acquired nosocomial infection?

Answer 25

urinary tract infection

Question 26

what are the 3 biggest risk factors for UTI?

Answer 26

1) pre-existing urinary tract contamination 2) urine retention (like BPH) -- anesthesia also causes urinary retention! 3) instrumentation

Question 27

what percentage of patients will have bacteriuria less than 48 hours after cath is placed?

Answer 27

5 percent develop bacteriuria 1 percent develop UTI

Question 28

this type of UTI presents with dysuria and mild fever

Answer 28

cystitis

Question 29

this type of UTI presents with high fever, flank tenderness, and occasionally ileus

Answer 29

pyelonephritis

Question 30

what is the best way to prevent UTI in surgical patient?

Answer 30

get catheter out ASAP!

Question 31

treatment of UTI in post-op patient?

Answer 31

hydration, bladder drainage, specific antibiotics

Question 32

temporary paralysis of a portion of the bowels is known as what?

Answer 32

postoperative ileus

Question 33

signs and symptoms of postoperative ileus?

Answer 33

nausea, vomiting, vague abdominal discomfort

Question 34

diagnostic modality for postoperative ileus?

Answer 34

abdominal x-ray

Question 35

what will we hear on auscultation of a patient's abdomen with ileus?

Answer 35

quiet bowel sounds

Question 36

treatment of postoperative ileus? (3)

Answer 36

1) NPO 2) NG tube 3) IVF/nutrition: D5IV -- don't jump to TPN support and wait!

Question 37

what is the name of the autosomal dominant genetic hypermetabolic condition of muscle?

Answer 37

malignant hyperthermia

Question 38

how will a patient with malignant hyperthermia present?

Answer 38

1) violent sustained muscle contractions 2) possible masseter rigidity 3) increased body temp (maybe delayed up to 36 hours following trigger) 4) tachycardia 5) cyanosis 6) muscle rigidity

Question 39

what are the two known triggers of malignant hyperthermia?

Answer 39

1) extreme stress | 2) anesthetic agents (inhaled halothane, succinylcholine)

Question 40

what are 4 life-threatening late effects of malignant hyperthermia?

Answer 40

1) compartment syndrome 2) rhabdomyolysis 3) acidosis (metabolic and respiratory) 4) arrhythmias/sudden cardiac arrest (associated with hyperkalemia)

Question 41

an abrupt ______ in ETCO2 may be your first sign of malignant hyperthermia

Answer 41

INCREASE in ETCO2

Question 42

how do we prevent malignant hyperthermia?

Answer 42

check family history! a muscle biopsy with stimulated contraction studies may be ordered

Question 43

what is the DOC for treating malignant hyperthermia?

Answer 43

DANTROLENE (muscle relaxer which blocks Ca release from sarcoplasmic reticulum, disrupts excitation-contraction coupling)

Question 44

what other two body systems should you provide support for in a malignant hyperthermia episode?

Answer 44

renal support respiratory support

Question 45

you should provide _____ when your patient is in malignant hyperthermia

Answer 45

cooling blankets

Question 46

always be sure to search for ________ in your patient with malignant hyperthermia

Answer 46

occult compartment syndrome

Question 47

why do we worry so much about patients with renal disease developing bradycardic with volume depletion?

Answer 47

their kidneys can't increase the volume bc they aren't working they can go into PEA!

Question 48

is our patient following volume depletion more likely to go into hypernatremia or hyponatremia?

Answer 48

hyponatremia; once we volume deplete them they have a surge of ADH production (retain water)

Question 49

how do we fix hyponatremia in our patient?

Answer 49

normal saline! has a higher level of sodium in it