Post operative care Flashcards
DDX for post op fever
24-48 Hr can be normal response to trauma and surgery
Hrs after surgery - normal response, Reaction to blood products, malignant hyperthermia
Day 1-2 - atelectasis (most common), early wound infection eg clostridium, GAS (Crepitus and look for dishwater drainage), aspiration pneumonitis, other (addisonian crisis, thyroid storm, transfusion reaction.)
Day 3-7 - Likely infection - UTI, surgical site infection, IV site or line,septic thrombophlebitis, leakage of bowel anastomoses (Tachycardia, hypotension, oliguria, abdominal pain)
Day 8 or more - Intraabdominal abscess, DVT/PE, drug fever, Other (Cholecystitis, peri-rectal abscess, URTI, infected seroma/Biloma/Hematoma, parotitis, C.difficile colitis, endocarditis.
The 5 Ws of post operative fever
Wind day 1-2 pulmonary - atelectasis, pneumonia
Water day 3-5 Urine - UTI
Wound Day 5-8 if earlier think GAS of C.Diff
Walk Day 8 or more - thrombosis, DVT/PE
Wonder drugs Day 1 drug reaction.
Post surgical wound care
Shower Day 2-3 after epithelialization
Dressing removed day 2 and left uncovered if dry. If wet examine for infection - fever, tachycardia, pain.
Skin sutures and staples removed day 7-10 except if crossing groin crease, closed under tension, in extremities or pt is elderly, corticosteroid or immunosuppressed then remove on day 14.
Negative pressure dressing consist of foam and suction, promote granulation.
Surgical site infections
Cause - S.aureus, E.coli, Enterococcus, Strept spp, Clostridium Spp
Presentation - Fever on day 5-8 unless Strep and Clostridium. Pain, blanchable erythema, induration, purulent discharge, warmth.
Complication - fistula, sinus tracts, sepsis, abscess, suppressed wound healing, superinfection, spreading infection to myonecrosis, or facial necrosis (necrotising fasciitis), wound dehiscence, evisceration, hernia.
Prophylaxis - Sterile procedure, ABx (cefazolin, metronidazole) 1hr pre surgery, and repeat if long procedure.
Tx - swab MCS, re open incision, drain, pack and heal by secondary intent. Debrief for deeper or necrotic. ABx if cellulitis.
Wound Hemorrhage or Hematoma
Presentation - pain, swelling, discolouration of wound edges, leakage, if in neck surgical emergency
Tx - Pressure dressing, open drainage and wound packing for large Hematoma. May need to reoperate to find source.
Seroma
Fluid collection other then Pus or blood due to transaction of lymph vessels which delays healing and increases risk of infection.
Tx - Consider pressure dressing with or without needle drainage. May need to reopen.
Wound dehiscence
Defined as disruption of facial layer allowing abdominal content to be in contact with skin only. 95% caused by intact suture tearing through fascia.
Presentation: Typical day 1-3 with serosanguinous drainage from wound with or without evisceration. Palpate of wound edge to feel for healing ridge from abdominal wall closure
Tx - place moist dressing over wound with binder around abdomen and transfer to OR, If evisceration (burst abdomen) it is a surgical emergency.
Urinary retention
Presentation: abdominal discomfort, palpable bladder, overflow incontinence, post-void residual urine volume greater than 100ml.
Tx Foley catheter to rest bladder, then trial of voiding
Oliguria/Anuria
Most common post operative cause is pre renal with or without ATN. Cause may be external fluid loss (Hemorrhage, dehydration, diarrhoea. Internal fluid loss (third spacing due to bowel obstruction, pancreatitis)
Presentation: Urine output less then 0.5cc/Kg/H increasing Cr, increasing BUN
Tx - according to underlying cause, fluid deficit is treated with crystalloid.
DDX for Post op Dyspnea
Respiratory: atelectasis, pneumonia, pulmonary embolus, ARDS, Asthma, pleural effusion
Cardiac: MI, arrhythmia, CHF
Inadequate pain control.
Atelectasis
Common - 90% of post op Cx
Presentation - low grade fever on day 1 post op, tachycardia, crackles, decreased BS, Bronchial breathing, Increase RR
RF - COPD, smoking obesity, elderly persons, Upper abdominal or thoracic surgery, over sedation, significant post operative pain, poor inspiratory effort.
Tx - Prophylaxis (stop smoking 8 wk prior), Post prophylaxis - Incentive spirometry, deep breathing exercises, chest physiotherapy, intermittent PP breathing, Selective NGT decompression after abdo surgery. Short acting neuromuscular blocking agents, Minimise use of resp depressive drug, good pain control and early mobilisation.
Pneumonia/pneuonitis
May be secondary to aspiration of gastric contents during anesthetic induction or extubation causing a chemical pneumonitis
RF for aspiration - GA, Decreased LOC, GORD, Full stomach. bowel/gastric outlet obstruction and non-functioning NGT, Pregnancy, seizure
RF for others - atelectasis, immobility, PmHX of resp conditions.
Presention - Productive cough, fever, tachycardia, cyanosis, resp failure Decrease LOC, CXR of pulmonary infiltrates
Tx - Prophylaxis: (stop smoking 8 wk prior), Post prophylaxis - Incentive spirometry, deep breathing exercises, chest physiotherapy, intermittent PP breathing, Selective NGT decompression after abdo surgery. Short acting neuromuscular blocking agents, Minimise use of resp depressive drug, good pain control and early mobilisation.
- Remove debris and fluid from airway
- Consider intubation or flexible bronchoscopic aspiration
- IV Abx- nosocomial aerobes and anaerobes (Ceftriaxone, metronidazole.)
Pulomary oedema
Causes - pre existing cardiac: Increase BV, LV HF,
- Resp: negative airway pressure due to breathing against a closed epiglottitis upon waking, alveolar injury
Presentation: SOB, basal crackles, CXR
Tx LMNOP
- Lasix - Frusemide
- Morphine - decreases symptoms of dyspnea, venodilator and afterload reduction.
- Nitrates - Venodilators
- Oxygen + non-invasive ventilation
- Position - sit patient up.
Respiratory failure
Presentation: Dyspnea, cyanosisi, evidence of obstructive lung disease, Earliest menifations are tachypnea above 25 and hypoxemia less than 60. Pulmonary oedema and SpO2 drop
Tx
- ABC
- Sit pt up and assess airways, is breathing asymetrical?
- Auscultate chest:
- Assess circulation and tx shock
- Intubation may be required
- Bronchodilators and diuretics to treat CHF
- CXR: consolidation, oedema, effusion and pneumothoraces.
- Adequate BP to maintain pulmonary perfusion
If these measure fail to PaO2 above 60 it might be ARDS.
Post operative care of pt
Pain management
Monitoring: vitals, fluid balance, bloods(FBC, U and E),
Mobilisation: Early is best.
DVT prophylaxis: TEDS, Scuds, Heparin
Communication: To inform the patient on everything.
Wound care
Respiratory care: Simple breathing exercises, Incentive spirometry, Oxygen and intubation
Fluid balance: Correct any abnormalities, provide daily requirment, replace any abnormal and ongoing loss.
Exam: Resp and GI, Pressure sore, calves, Crains and wounds
Plan
- Mobilisation
- Daily bloods
- When to remove drain less then 100-50ml per day
- Dressing requirements.
