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MD2 Surgery > Post-Operative Care > Flashcards

Post-Operative Care Flashcards

1
Q

What should be looked for O/E when assessing the post-surgery patient?

A
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2
Q

What Ix may be performed on the post-surgery patient?

A

Blood tests: usually Hb, electrolytes

Imaging

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3
Q

What medications may be required in the post-surgery patient?

A

VTE prophylaxis

Abx (consider ceasing)

Analgesia (consider ceasing)

Aperients

Antiemetics

Regular Rx

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4
Q

What kinds of supplemental nutrition may need to be considered in the post-surgery patient?

A

Multivitamins

High-calorie and protein drinks

Nasogastric feeding

TPN

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5
Q

When is it especially critical to monitor fluid balance?

A

Major abdominal surgery, especially GI

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6
Q

What is not included in total daily fluid balance?

A

Insensible losses

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7
Q

What does UO measure? What should it ideally be maintained at in the post-surgical patient?

A

Measure of tissue perfusion

Maintain UO >30 mL/hr or >0.5 mL/kg/hr (beware in CCF and renal impairment!)

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8
Q

How should fluid balance be approached in the post-surgical patient in the days following surgery?

A

Day 1: increased ADH, do not give excessive fluids

Day 2: mobilisation often shifts fluid from interstitium back in IV space (decrease IV fluid rate in anticipation)

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9
Q

What are some other clinical markers of fluid balance besides UO?

A

HR, BP, JVP

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10
Q

What fluid regimes may be run in the post-surgical patient?

A

Replacement vs maintenance (typically 12/24-8/24)

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11
Q

What should be done in the post-surgical patient with low UO?

A

If anuria: check for blocked IDC

Assess patient for hypovolaemia, ensure patient is not bleeding

Give fluid challenge: 500mL-1L stat crystalloid

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12
Q

What complications does adequate analgesia help to prevent?

A

Pneumonia (reduces atelectasis)

DVT/PE

Atrophy

Pressure sores

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13
Q

What methods of analgesia delivery are possible in the surgical patient?

A

Regional

Spinal

Epidural

Patient-controlled analgesia

NB Can refer to acute pain service if pain not well-controlled

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14
Q

What actions are important to prevent complications in the post-surgical patient?

A

Encourage early mobilisation: aim for out of bed and walking by day 2

Chest physiotherapy

VTE prophylaxis: mechanical and chemical

Adequate analgesia

Adequate nutrition and fluids

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15
Q

What does a post-operative fever on day 1 suggest?

A

Usually drug fever

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16
Q

What possible cause should be considered if a post-operative patient develops fever on day 3?

A

Lungs! (E.g. pneumonia)

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17
Q

What possible causes should be considered if a post-operative patient develops fever on day 5+?

A

Infection: urinary tract, surgical site

Leaks

DVT/PE

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18
Q

What are the components of a “septic screen”?

A

CXR

MSU

Blood cultures

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19
Q

When should subcuticular sutures be removed?

A

Never; there is nothing to remove (unless prolene)

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20
Q

When should interrupted sutures or staples be removed?

A

In 1-2 weeks (depending on region; consider areas of tension, healing ability i.e. blood supply and nutrition)

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21
Q

What is a suture/staple reaction? Should they be removed in this circumstance?

A

Erythema around sutures/staples (more common with staples and braided sutures)

Consider removal if redness or purlent discharge present

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22
Q

What should be done if a wound infection occurs?

A

Cellulitis around a wound will spread outside the boundaries of the wound and staples

Consider opening suture line over infeced area to drain underlying abscess, swab for MCS and allow healing by secondary intent

Also give Abx (which ones??)

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23
Q

When does superficial wound dehiscence commonly occur and what should be done?

A

May occur if skin poorly apposed; suture/staples may have cut through

Healing by secondary intention

24
Q

What is deep wound dehiscence? How is it treated?

A

Burst abdomen due to dehiscence of fascial layer (sutures pulled through/slipped knot/poor tension); excessive haemoserous discharge from suture line or bowel on view

Usually return to theatre; consider tension sutures

25
Q

What might contribute to incisional hernia?

A

Poor wound healing

26
Q

List 10 RFs for poor wound healing and therefore incisional hernia

A

Poor nutrition

Obesity

Smoking

Steroids

DM

Uraemia

Jaundice

Malignancy

Tissue ischaemia

Infection

27
Q

How are surgical drains classified?

A

Tubed vs corrugated

28
Q

List 4 common surgical drains

A

Suction: Jackson Pratt, Redivac

No suction: Penrose, Yate’s

29
Q

How long do post-operative drains usually stay in?

A

Often stay in for a few days

30
Q

What causes should be considered in the setting of excessive drain output?

A

If blood, patient may need to return to theatre (may be damage to underlying structures)

Irrigiation fluid (if early)

More serious complication

Ascites (check albumin, optimise nutriton)

Urine (send for UEC)

Pancreatic fistula (send for amylase)

Bile leak (send for bilirubin)

Lymph leak

31
Q

What is a T-tube?

A

Special surgical drain placed after bile duct exploration

Never removed before T-tube cholangiogram (1/52 post-surgery)

May be left in to create fistulous tract (takes 6/52)

32
Q

When is an external ventricular drain used?

A

To relieve hydrocephalus (can also check CSF pressure via this)

Should be handled with care!)

33
Q

60 year old male, 2 days post-total gastrectomy, with UO 300mL in last 12/24 (concentrated)

Initial assessment?

A

At bedside: check BP, HR, temp, JVP, tongue for dryness, fluid balance chart, look at drain

34
Q

60 year old male, 2 days post-total gastrectomy, with UO 300mL in last 12/24 (concentrated); feels thirsty

O/E: HR 90, BP 160/90, temp 38

Fluid balance in last 24 hrs: intake 2L IV (nil orally), output 700mL urine + 400mL NG aspirate + 800mL abdominal drain

Therefore 1-2L behind

Mx?

A

Give IV fluids

NS 1L over 2/24, next bag over 4/24, then review

May need more fluid at this point but check obs, UO, JVP, etc first (and if worried ask your registrar)

Be careful if PHx includes CCF!

35
Q

50 year old male 4 days post-incisional hernia repair with findings of obstructed loop of small bowel, now vomiting ++

Possible causes?

A

Post-operative ileus

SBO

Ischaemic or infarcted segment of bowel

Gastric dilatation

Drugs (narcotics)

36
Q

50 year old male 4 days post-incisional hernia repair with findings of obstructed loop of small bowel, now vomiting ++

Mx?

A

Give anti-emetic (maxolon, stemetil, ondansetron)

Place NGT: free drainage and aspirate

Give IV fluids and check fluid balance

Order supine and erect AXR

37
Q

80 year old woman, 2 days post-open cholecystectomy, presents with confusion

Possible causes and contributing factors?

A

Hypoxia: atelectasis, pneumonia, over sedation with narcotics, CCF, MI, PE

Sepsis: chest, urine, wound, intra-abdominal (bile leak)

Medication: opiates, sedatives

DTs

Metabolic: uraemia, hyponatraemia, hypo- or hyper-glycaemia

Contributing factors: stroke, pain, anaemia, hypotension, dementia, sleep deprivation, change of environment

38
Q

80 year old woman, 2 days post-open cholecystectomy, presents with confusion

Mx and Ix?

A

Get Hx from nursing staff or family

Turn on lights

Check Hx for pre-op state, alcohol, drugs, DM

Check obs

Look at patient, give O2

Ix: ABG, RBG, UEC, FBE, blood cultures, MSU, CXR, ECG

39
Q

78 year old man returned to the ward after abdomino-perineal resection 6/24 ago

Lost 2L blood in theatre and was given 1.5L gelofusine and 2U packed RBCs

BP in recovery was 120/70

Epidural infusion in situ and patient reports no pain

IV running at 100 mL/hr

BP now 85/50

Possible causes?

A

Hypovolaemia: bowel prep and fasted, long operation, behind in fluid replacement, bleeding, 3rd spacing, sepsis

Epidural causing peripheral vasodilation

MI, CCF

40
Q

78 year old man returned to the ward after abdomino-perineal resection 6/24 ago

Lost 2L blood in theatre and was given 1.5L gelofusine and 2U packed RBCs

BP in recovery was 120/70

Epidural infusion in situ and patient reports no pain

IV running at 100 mL/hr

BP now 85/50

Mx?

A

Decrease rate or stop epidural infusion

Check FBE, UEC, ECG

Give more IV fluid +/- blood: start with NS 1L over 30 mins then review, may need gelofusine 500 mL stat if does not respond

If Gram negative sepsis possible give IV Abx! (3rd gen cephalosporin or stat gentamicin)

41
Q

70 year old man, 5 days post-anterior resection, presents with fever of 38.5

Possible causes?

A

Wound infection

Pelvic abscess

UTI

Pneumonia

DVT/PE

Drip site infection

Others: transfusion reaction, Rx, brainstem disease, MI, gout

42
Q

Causes of post-op fever in first 48 hrs?

A

Basal atelectasis

Metabolic response to injury

Drug fever

43
Q

70 year old man, 5 days post-anterior resection, presents with fever of 38.5

Mx?

A

Identify site of infection: obtain pus (swab or aspirate), blood cultures, MSU, FBE, imaging (CXR, ECG, U/S, Duplex doppler, CT)

44
Q

How often should an IV cannula be changed to avoid infection and thrombosis?

A

Every 3 days

45
Q

How is a PICC line placed? What is it used for? What are the possible complications? How long can it remain in situ?

A

Placed by radiology under U/S control into basilic vein in upper arm with sterile technique

Can use for TPN or other infusions (almost equivalent to CVC)

Risk of venous thrombosis of basilic vein

Can be used for weeks

46
Q

Why is a CVC used? How is it placed? What are the risks? How long can it remain in situ?

A

Good for TPN or other infusions

Placed into IJV or subclavian vein with tip in SVC (can use femoral vein), usually inserted in theatre or recovery (clean and ECG monitored!)

Immediate risk of pneumothorax, arterial puncture, haematoma; later risk of thrombosis, stenosis, sepsis

Can leave in for 5-21 days as it is Abx-impregnated

47
Q

What is a vascath and why is it used? How and where is it inserted? How long can it remain in situ?

A

Temporary catheter used for haemodialysis

Inserted under local anaesthetic (and ideally U/S guidance) into the IJV or femoral vein (NOT the subclavian)

Can be left in a maximum of 5 days

48
Q

What is a Permcath? How is it inserted? What are the risks and benefits?

A

Long term catheter with dual lumen used for haemodialysis

Placed under general anaesthetic into the IJV or EJV (and tunnelled cuffed catheter to prevent infection and displacement)

Risk of infection and blockage

Benefit is that it can be replaced

49
Q

What is the Infusaport/Portocath and why is it used? How is it inserted? What is the main benefit?

A

Buried port on chest wall with line into SVC, used for long term central chemotherapy, IV drugs and blood taking

Inserted under GA

Reduced risk of infection

50
Q

What is a Hickman catheter? How is it inserted and what is it used for?

A

Single or dual lumen catheter

Inserted under GA and tunneled with cuff to prevent infection

Used for chemotherapy, bone marrow infusion, blood transfusions and long term TPN

51
Q

What additional tool is required when inserting a line in theatre?

A

Image intensifier

52
Q

What Ix should be ordered post-insertion of a line and why?

A

CXR

To exclude pneumothorax and check position of catheter

As always if there are any concerns, check with registrar!

53
Q

Name the lines seen in this picture and note their placement

A
54
Q

How should lines be accessed?

A

Carefully! Must use aseptic technique if changing dressings or accessing any lines

55
Q

How should cuffed lines be removed?

A

Need to use local anaesthetic, cut down over cuff and excise with line, then suture

MD2 Surgery (5 decks)

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