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4/3: Surgery Y3/4 - Peri-Operative Care [16] (check ILOs) > Post-Op Pneumonia > Flashcards

Post-Op Pneumonia Flashcards

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1
Q

What is pneumonia defined as?

A

A lower respiratory tract infection with accompanying consolidation visible on CXR

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2
Q

What are the main types of pneumonia?

A
  • HAP
  • CAP
  • Aspiration
  • Immunocompromised (opportunistic)
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3
Q

What is the predominating type of pneumonia in a post-op setting?

A

HAP

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4
Q

What is HAP?

A

Pneumonia with onset >48 hours since hospital admission and was not present on admission

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5
Q

Why are surgical patients predisposed to developing lower respiratory tract infections?

A
  • Reduced chest ventilation
  • Change in commensals
  • Debilitation
  • Intubation
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6
Q

Why do post-op patients have reduced chest ventilation?

A

Reduced mobility in bedridden patients results in an inability to fully ventilate their lungs, leading to accumulation of fluid secretions which subsequently become infected

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7
Q

Why is there a change in commensals in post-op patients?

A

The hospital environment microflora will vary compared to what the patient may normally be exposed to, nor have immunity too

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8
Q

What are the common pathogens for HAP?

A
  • E. coli
  • S. aureus, including MRSA
  • S. pneumonia
  • Pseudomonas
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9
Q

What is meant by debilitation in post-op patients?

A

Many patients undergoing surgery are likely to be sick or have several co-morbidities, compromising their immune systems and predisposing to pulmonary infections

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10
Q

What is VAP?

A

Ventilator acquired pneumonia

HAP that occurs >48 hours after tracheal intubation

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11
Q

How common is VAP, compared to other healthcare infections?

A

It is the most common hospital acquired infection in patients receiving mechanical ventilation, accounting for around 50% of antibiotics given in an ICU setting

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12
Q

Who is VAP most common in?

A

Those with ET tube in situ

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13
Q

Why is VAP most common in those with ET tube in situ?

A

As the tube interferes with normal protective upper airway reflexes, prevents effective coughing, and encourages aspiration of contaminated pharyngeal contents

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14
Q

What are the risk factors for developing HAP?

A
  • Age
  • Smoking
  • Known respiratory disease or recent viral illness
  • Poor mobility
  • Mechanical ventilation
  • Immunosuppression
  • Underlying co-morbidities, e.g. diabetes, cardiac disease
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15
Q

What is the classical presentation of HAP?

A
  • Productive or non-productive cough
  • Dyspnoea
  • Chest pain
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16
Q

Why might patients with HAP not present in the classical way?

A
  • Intubation
  • Reduced consciousness
  • Other co-morbidities
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17
Q

What might be the only clinical features of HAP in some patients?

A
  • General malaise
  • Pyrexia
  • Impaired cognition
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18
Q

What may be found on examination in HAP?

A
  • Reduced O2 saturation
  • Increased RR or HR
  • Pyrexial
  • Features of septic response
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19
Q

What may be found on auscultation in HAP?

A
  • Bronchial breath sounds
  • Inspiratory crackles
  • Dull percussion notes
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20
Q

What are the differential diagnoses for HAP?

A
  • Acute heart failure
  • Acute coronary syndrome
  • PE
  • Asthma or COPD exacerbation
  • Pleural effusion or empyema
  • Psychological, e.g. anxiety disorder
21
Q

What investigations may be done in HAP?

A
  • Bloods
  • ABG
  • Sputum sample
  • Blood cultures
  • Imaging
22
Q

What bloods may be done in HAP?

A
  • FBC
  • CRP
  • U&Es
23
Q

When might an ABG be required in HAP?

A

In severe cases of oxygen desaturation

24
Q

When should blood cultures be done in HAP?

A

If there are any signs of severe infection or sepsis

25
Q

What imaging should be done in HAP?

A

CXR

26
Q

How does HAP present on CXR?

A

Consolidation, either lobar or bronchopneumonia

27
Q

What can be done if a sputum sample is unobtainable in severe or non-responding infections?

A

Bronchoalveolar lavage (ask specialist first tho)

28
Q

What is mild on CURB 65 score?

A

0-1

29
Q

What is moderate on CURB 65 score?

A

2

30
Q

What is severe on CURB 65 score?

A

3 or more

31
Q

What do you score points for in CURB 65?

A
  • Confusion
  • Urea >7.0
  • RR >30
  • Systolic <90 or diastolic <60
  • Age >65
32
Q

Describe the use of CURB 65 in HAP?

A

Applicability to HAP is limited and other parameters and factors should guide management

33
Q

How should patients with HAP be managed?

A
  • O2 therapy as indicated
  • Management of septic
  • Abx
34
Q

On what basis should antibiotics be given in AP?

A

Empirically, pending sensitivities

35
Q

What antibiotic should be given in mild HAP?

A

Co amox

36
Q

What antibiotic should be given in moderate HAP?

A

Co amox

37
Q

What antibiotic should be given in severe HAP?

A

Taz

38
Q

How should HAP be prevented?

A

Any post-op patients with prolonged bedrest or reduced mobility should have chest physio to increase lung ventilation and reduce fluid stasis

39
Q

What are the major complications of pneumonia?

A
  • Pleural effusion
  • Empyema
  • Respiratory failure
  • Sepsis
40
Q

What will aspiration of the gastric contents into the pulmonary tissue result in?

A

Chemical pneumonitis

41
Q

When will lung infection result from aspiration?

A

If any oropharyngeal bacteria are aspirated into the lung tissue as well

42
Q

What lobes of the lungs are classically affected in aspiration pneumonia?

A

Eight middle or lower lobes (due to anatomy of bronchi)

43
Q

What are the risk factors for aspiration in post-op patients?

A
  • Reduced GCS, e.g. due to anaesthesia
  • Iatrogenic interventions, e.g. misplaced NG tube
  • Prolonged vomiting without NG tube insertion
  • Underlying neurological disease
  • Oesophageal strictures or fistula
  • Post-abdominal surgery
44
Q

How do the clinical features and examination for aspiration pneumonia compare to HAP?

A

Much the same

45
Q

When should aspiration pneumonia be suspected over pneumonitis?

A

If there is evidence of an infective process developing

46
Q

What is involved in the management of aspiration pneumonia?

A

Mainly preventative

47
Q

How is aspiration pneumonia prevented?

A

Identifying patients at risk of aspirating and placing suitable precautions, e.g. NG tube placement, in place until suitable

48
Q

Who is involved in the prevention of aspiration pneumonia?

A
  • Nursing staff

- SALT

49
Q

How is pneumonitis caused by aspiration prevented?

A

Supportive measures

4/3: Surgery Y3/4 - Peri-Operative Care [16] (check ILOs) (20 decks)

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