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Medicine II: Surgery > Post Operative Care and Complications > Flashcards

Post Operative Care and Complications Flashcards

1
Q

What is considered the clinically significant indication of a fever?

A

Temp at or above 38.5 C, 101.3 F

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2
Q

What are the main cytokine releasing cells?

A

monocytes, macrophages, neutrophils

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3
Q

What are the main fever associated cytokines?

A

IL-1, IL-6, TNF-alpha, inteferon gamma

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4
Q

Why is a fever higher in a burn patient?

A

They have a higher basal metabolic rate

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5
Q

Most common DDX: (5 Ws)

A 
wind
water
wound
walking
wonder drug
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6
Q

What are examples of wind?

A

atelectasis, pneumonia

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7
Q

What are examples of water?

A

UTI, anastomotic leak

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8
Q

What are examples of wound?

A

wound infection, abscess

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9
Q

What are examples of walking?

A

DVT/PE

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10
Q

What is the most common source of a fever in the first 24 hours?

A

atelectasis

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11
Q

What is the main cause atelectasis in the OR?

A

collapse part of lungs because of artificial ventilation during anesthesia

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12
Q

The fever is from a cytokine release by alveolar macrophages, what will help resolve some of this?

A

deep breathing

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13
Q

What can severely complicate atelectasis?

A

pneumonia

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14
Q

What is the definition of an immediate fever?

A

onset is in the OR or in the immediate post-op period

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15
Q

What are though to be the causes of an immediate fever?

A

medications

necrotizing infection

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16
Q

When medications cause an immediate fever what does it often present with?

A

Hypotension

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17
Q

What are the causative agents of necrotizing fascitis?

A

c. preferinges, group a strep

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18
Q

What is the tx for necrotizing fascitis?

A

ABC, resuscitate, abx (pip/tazo and clindamycin), surgical debridement

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19
Q

What is the definition of an acute fever?

A

fever 1 week after surgery

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20
Q

What are the possible causes of an acute fever?

A 
necrotizing infection
anastomatic leak
pulmonary embolism
MI
pneumonia
aspiration
UTI
SSI
EtOH withdrawal
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21
Q

What is the definition of a subacute fever?

A

fever that occurs greater than 1 week after surgery

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22
Q

What goes into the ddx for a subacute fever?

A 
SSI
UTI
Line infection
abx-associated edema
febrile drug reactions
thrombophlebitis
sinusitis
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23
Q

What is the most common cause of a subacute fever?

A

IV was left in the arm to long causing thrombophlebitis

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24
Q

What is the main cause of a delayed (late) fever?

A

typically a secondary infectious cause

25
Q

What do we look at during a post op fever evaluation?

A

abc’s
resuscitate
HPI- anesthesia record, op note, nursing report, flow chart
PE: look at wounds, look at back for decubitus ulcers, look at drain output
check PIV sites, CVL, foley, tubes

26
Q

What labs should you order if you are concerned about an infection?

A 
CBC w/diff, sputum, Cx, UCx, Blood Cx x 2
Lumbar puncture (if ams, neck pain, fever)
RUQ US (cholecystitis)
27
Q

What is a bronchoscope?

A

a fiber optic scope that looks into airways to assess issues and suction if needed, can also take samples

28
Q

What is the management of a post op fever patient?

A

removal of infection (foley cath, central lines, peripheral IVs)
open, debride and drain infected wounds

29
Q

What values do we look at for a post-op bleeding patient?

A

VS, labs, drain output

30
Q

What do we need to find out about the blood?

A

where is it going?: thorax, pelvis, abdomen, extremities, floor

31
Q

What do we check if they are slowly bleeding?

A

CBC

32
Q

What is the number one reason the patient is bleeding post op?

A

inadequate hemostasis

could also be caused by coagulopathy drugs (coumadin, heparin, plavix)

33
Q

What do you do if you notice the patient is bleeding post-op?

A

notify the team immediately, may need trip to OR

34
Q

What do we need to do once the bleeding has been identified in the patient? How?

A

stop the damn bleeding

  1. direct manual pressure!!!!!
  2. correct coagulopathy (ff plasma, fibrinogen, platelets, vit k)
  3. Get labs (HGB/HCT, PT/INR, PTT, iSTAT, rapid TEG, type and cross)
  4. resuscitate
  5. OR
35
Q

What is a common post op pulmonary complication?

A

Excessive sedation caused by decreased respiratory drive; want to reverse opiods

36
Q

What post op pulmonary complication is a big killer? What do you do about it?

A

PE, give heparin and monitor closely

37
Q

What is the main cause of a pulmonary embolism?

A

DVT

38
Q

What are the symptoms of a PE?

A 
tachypnea
tachycardia
new onset of atrial fib
hypoxia
hyperventilation
39
Q

How do we diagnose a PE post op?

A

exam, abg, CT angiogram
US to look for DVT
NO D-DIMERS, theirs are too high already

40
Q

What are risk factors for DVT?

A 
cancer
obesity
smoking
old age
pregnancy
estrogen
heart disease
immobilization
central line
surgery
41
Q

What is the work up for a hypercoagulable state?

A 
antithrombin III def
Protein c or protein s def
lupus anticoag
homocystinuria
occult neoplasm
connective tissue disorders
42
Q

What is the treatment for a DVT?

A

heparin

43
Q

What are complications of heparin?

A

HIT- heparin induced thrombocytopenia

caused by and antibody that causes platelet aggregation

44
Q

How do we diagnose HIT?

A

Send HIT antibody

45
Q

Tx of HIT

A

Stop heparin, use atixtra or argatroban

for large emboli need emergent surgical embolectomy by thoracic surgery

46
Q

What are common post op cardiac complications?

A

MI
bradycardia
arrhythmia

47
Q

What is a main cause or the post op cardiac complications?

A

stress from surgery, mostly from fluid shift

48
Q

What are common post op GI complications?

A

Ileus
bowel obstruction
c. difficule colitis

49
Q

How do we treat ileus?

A

minimize narcotics
correct electrolytes, K is most important
early ambulation

50
Q

What is significant about a post op bowel obstruction complication?

A

due to adhesions from surgery, can occur years after abdominal surgery

51
Q

Who commonly gets c. diff?

A

patients on abx

52
Q

What do we look at to diagnose c. diff?

A

WBC, can be as high as 50,000

53
Q

How do we treat c. diff?

A

IV flagyl PO or PR vancomycin

54
Q

How do you treat each of the 5 W’s?

A

Wind – Incentive Spirometry, Nebulizer
Water – UA & Culture – Cipro/Nitrofurantoin
Walking – Extremity Duplex US - Anticoagulation
Wound – Open wound – Wet to Dry Dressings
Weird Drugs – D/C drugs

55
Q

What are the basic pincipals for post-op management?

A
  1. Early mobilization
  2. Pulmonary therapy
  3. Early nutrition - Enteral > Parenteral
  4. Adequate fluid & electrolyte administration
  5. Manage cardiac risk factors
  6. Control blood sugar
56
Q

How do you control blood sugar post-op?

A

Use sliding scale insulin to maintain regimen

57
Q

How do you manage cardiac risk in post-op?

A

Pre-existing CAD requires BBs to keep HR < 70

58
Q

How do you push for pulmonary therapy post-op?

A

incentive spirometry to prevent/correct atelectasis and prevent pneumonia

59
Q

How do you promote early mobilization post op?

A

OOB on Day 1 to prevent muscle wasting, risk of DVT and return bowel function

Medicine II: Surgery (14 decks)

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