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Surgical prep and care > Post-op problems > Flashcards

Post-op problems Flashcards

1
Q

Name three cardiovascular post-op complications

A
  • Hypotension
  • HTN
  • Myocardial infarction
  • Venous thromboembolism
  • Arrhythmias
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2
Q

List three precipitating factors for post-op myocardial infarction

A
  • Stress response to major surgery: anxiety; pain
  • Fluid overload post-op
  • Profound hypotension
  • Failure to restart anti-angina medication
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3
Q

What is the commonest post-op arrhythmia?

A

Atrial fibrillation

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4
Q

Why should pre-operative B-blockers be continued?

A

Sudden cessation in existing IHD:

  • Rebound angina
  • Infarction
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5
Q

How does pain affect post-op complications?

A
  • CVS:
    • Tachycardia
    • HTN
    • Increased myocardial O2 demand
  • Resp: Basal atelectasis; chest infections
  • GI: PONV, ileus
  • Urinary retention
  • Immobility; VTE
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6
Q

Give three causes of post-op breathlessness

A
  • Upper airway obstruction; anaphylaxis
  • Respiratory failure
  • Basal atelectasis (24h)
  • Pneumonia (3-5d)
  • Pulmonary embolism (5-7d)
  • Exacerbation of COPD
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7
Q

Define respiratory failure

A

Inadequate gas exchange in the respiratory system:

  • Type I: PaO2 <8.0kPa on air
  • Type II: PaO2 <8.0kPa and PaCO2 >6.0kPa
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8
Q

Outline the initial management of respiratory failure

A
  • Sit patient up
  • 15L high flow O2 in non-rebreathe mask
  • Treat bronchospasm with neb salbutamol 5mg
  • CXR
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9
Q

Why are post-op chest infections common?

A

Pain reduces:

  • Breathing ➔ basal atelectasis
  • Coughing ➔ decreases mucus clearance
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10
Q

Name three risk factors for post-op atelectasis

A
  • Age
  • Smoking
  • General anaesthesia
  • Longer duration of surgery
  • Pre-existing lung or neuromuscular disease
  • Prolonged bed rest
  • Uncontrolled pain
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11
Q

How does post-op atelectasis present?

A
  • Respiratory compromise
    • Tachypnoea
    • Reduced SaO2
  • Fine crackles
  • Low-grade fever
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12
Q

Outline the causes of post-op atelectasis

A
  • Airway obstruction by bronchial secretions
  • Hypoventilation
  • Pain
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13
Q

Outline the management of post-op atelectasis

A
  • Chest physiotherapy; deep breathing exercises
  • Pain control
  • CPAP if severe
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14
Q

Classify the types of post-op haemorrhage

A

Arterial (rare): rapid, bright red, pulsatile

Venous: low pressure, dark red, non-pulsatile

  • Primary: immediately post-op or continuation of intra-op
  • Reactionary: within 24hr
    • Unsecured blood vessels; slipped ligature
  • Secondary: 7-10 days post-op
    • Vessel erosion from spreading wound infection
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15
Q

Outline the emergency management of post-op haemorrhage

A
  • A-E assessment
  • IV access >18G + fluid resuscitation
  • Read operation notes: determine site; important info
  • Direct compression of superficial bleeding
  • Urgent senior surgical review + imaging
  • Clotting, platelets, X-match 2+ units
    • RBC; platelets; and FFP if severe
    • Protamine sulfate to reverse heparin
    • Consider activating major haemorrhage protocol
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16
Q

What blood products are available for managing haemorrhage?

A
  • RBCs
  • Fresh frozen plasma: all coagulation factors
  • Platelets
  • Cryoprecipitate: fibrinogen, Factor VII and VIII
  • Tranexamic acid: inhibit plasminogen and plasmin
    • Prophylatic use in cardiovascular surgery
17
Q

What measures can be used to reduce the need for blood transfusion?

A
  • Treating pre-operative anaemia and coagulopathies
  • Stopping
    • Warfarin (5d): may need ‘bridging’ LWMH till 24h pre-op
    • Clopidogrel (7d)
    • LMWH (24h)
18
Q

List five causes of post-up pyrexia

A
  • Infection: days indicate most likely period
    • ‘Wind’: LRTI (1-2d)
    • ‘Water’: UTI (3-5d)
    • ‘Wound’: Surgical site infections; abscess (5-7d)
    • Infected lines (any day)
  • ‘Walk’: VTE (4-6d)
  • Iatrogenic: eg. transfusion, ‘Wonder’ about drugs (7+d)
  • Prosthetic implantation: eg. Hip replacement; valve; stent
  • Pyrexia of unknown origin
19
Q

What is pyrexia of unknown origin?

A
  • Recurrent fever (>38oC)
  • Persisting for >3/52
  • Without an obvious cause
  • Despite >1/52 of inpt investigations

Causes: infection of unknown source; malignancy eg. lymphoma; connective tissue disease; vasculitis; drug reactions

20
Q

Discuss the different types of surgical site infection

A
  • Superficial surgical site infection: within the first week
    • Localised pain, redness, and discharge
    • Staph aureus
    • Tx: Flucloxacillin 500mg PO QDS 5/7
  • Abscess: most present within first week
    • Usually after bowel surgery
    • Pyrexia and spreading cellulitis or abscess
    • Tx: Cefuroxime 1.5g IV TDS + Metro 500mg IV TDS
21
Q

What peri-operative measures can reduce the risk of renal dysfunction?

A
  • Pre-op: adequate hydration
  • Eliminate nephrotoxic drugs where possible
  • Postoperative: maintain satisfactory CO; fluids
22
Q

Define oliguria and anuria

A
  • Oliguria: urine output <0.5ml/kg/h
  • Anuria: no measurable urine output
23
Q

How does pulmonary oedema present following renal failure?

A
  • Deteriorating blood gases
    • Despite increasing respiratory support
  • Hyperkalaemia
  • Acidosis
24
Q

Name two risk factors for post-op acute urinary retention

A
  • Aged >50
  • Male
  • PMH of retention
  • Abdomino-pelvic or urological surgery
  • Spinal or epidural
  • Neurological or urological co-morbidites
  • Drugs eg. Opioids; anticholinergics
25
Q

List three clinical features of acute urinary retention

A
  • Little or no urine passed
  • Suprapubic pain
    • May be painless if previous chronic urinary retention
  • Sensation of needing to void; inability to initiate micturition
  • Suprapubic mass; dull percussion
26
Q

Name two causes of post-op acute urinary retention

A
  • Uncontrolled pain
  • Constipation
  • UTI
  • Spinal or epidural
27
Q

Describe the management of post-op acute urinary retention

A
  • Reverse underlying factor
    • Improve analgesia
    • Treat constipation
    • Mobilise
  • Warm bath ➔ encourages micturition
  • Restart any pre-op tamsulosin for BPH
    • Relaxes prostate and bladder muscles
  • Catheterisation
28
Q

Name three post-op GI complications

A
  • Post-op nausea and vomiting (PONV)
  • Paralytic ileus
  • Post-op mechanical small-bowel obstruction
  • Constipation; diarrhoea
29
Q

Give three patient risk factors for PONV

A

Patient factors:

  • Female
  • Younger age
  • Previous PONV; motion sickness
  • Opiods
  • Non-smoker
30
Q

Give three surgical risk factors for PONV

A

Surgical factors:

  • Intra-abdominal laparoscopic surgery
  • Intracranial or middle ear surgery
  • Squint surgery
  • Gynaecological surgery
  • Prolonged operations
  • Poor post-op pain control
31
Q

Give two anaesthetic risk factors for PONV

A

Anaesthetic factors:

  • Opioids or spinal
  • Inhalation agents eg. isoflurane; nitrous oxide
  • Prolonged anaesthesia
  • Intraoperative dehydration/bleeding
  • Excessive bag mask ventilation: gastric dilatation
32
Q

Name three consequences of PONV

A
  • Increased bleeding
  • Incisional hernias; wound dehiscence
  • Aspiration pneumonia
  • Decreased absorption of oral medication
  • Poor nutrition
  • Hypokalaemia; metabolic alkalosis
33
Q

How is PONV managed?

A
  • Adequate hydration; analgesia
  • Identify and treat any obstruction
  • Cause-specific anti-emetic therapy:
    • Impaired gastric emptying: Metoclopramide
    • Bowel obstruction: Hyoscine
    • Opioid-induced: Ondansetron; cyclizine
34
Q

Name two intra-abdominal anastomoses with high risk of leak

A

Oesophageal and rectal anastomosis

35
Q

Name three risk factors for anastomotic leak

A

Patient factors:

  • Medication eg. steroids; immunosuppressants
  • Smoking; alcohol excess
  • Diabetes
  • Obesity; malnutrition

Surgical factors:

  • Emergency surgery
  • Longer operation
  • Peritoneal contamination
36
Q

Request three investigation in suspected anastomotic leakage

A
  • Gastrografin enema
  • CT abdomen and pelvis with contrast
  • FBC; CRP; U+Es; LFTs; clotting
  • VBG
  • G+S
37
Q

Request three investigations for suspected post-op ileus

A
  • FBC; CRP: U+Es
  • CT abdomen and pelvis
38
Q

Outline the management of post-op ileus

A

Must exclude serious pathology eg. anastomotic leak

  • Daily bloods including U+Es
  • Encourage mobilisation
  • Reduce opiod usage
  • Drip and suck: NBM + IV fluids ± NG tube
  • Catheterisation
39
Q

Differentiate post-op ileus from mechanical obstruction

A

Post-op ileus is a functional bowel obstruction

Absent bowel sounds rather than ‘tinkling’ bowel sounds

Surgical prep and care (10 decks)

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