Post operative complications.

Question 1

Whats the parameter for surgical fever?

A true srgical fever invilves?

Answer 1

101.5f or 38.6c
repeat temps due to fever spikes, if over 101.5 at 4hr intervals then make ouder for temp recording every 2hrs.
core tempm is higher at night.

Question 2

What are the 5 “W’s”

Answer 2

Wind (resp)
Water (urine out put)
Walking (DVT)
Wound
Wonder drugs

Question 3

Its about timing, what happens in firsy 24hrs, 48hrs, 72hrs, 7-10 days?

Answer 3

First 24 hours consider atelectasis; also consider necrotizing wound bacterial process such as clostridium or strep
Next 48 hours, consider pneumonia, DVT and IV site related infections
72 to five days, consider UTI and DVT
Seven to ten days, consider wound infection of non-necrotizing bacterial origin or C. diff

Question 4

how to Evaluate Fever?

Answer 4

HISTORY
Presenting signs and symptoms
Onset of symptoms and time since procedure
Any medications?
History of blood transfusions?
What foreign objects present?

Question 5

Fver work up?

Answer 5

CBC w/ diff, chem 20, amylase if indicated
CXR
Wound gram stain, culture and sensitivity
Sputum if indicated
Blood cultures times 2 sites
C diff. if suspicious
Other as indicated: CT, Ultrasound, arteriogram, X-rays

Question 6

What does wind mean?

Answer 6

ATELECTASIS
Signs and symptoms: fever pod #1, mild tachycardia, mild hypoxia, may or may not hear crackles on exam and CXR may not show any changes
Treatment: Incentive spirometry, adequate pain control, mobilization, may or may not need respiratory treatments if an element of asthma present

Question 7

What else does wind include?

Answer 7

PNEUMONIA
Signs and Symptoms: fever between 24-96 hours post operatively, dyspnea, chest pain, productive cough, tachycardia and hypoxia
Atelectasis is a precursor: CXR
Treatment: Usually need polymicrobial antibiotic coverage especially if pt has been in ICU or on ventilator for prolonged stay. Narrow coverage based on sputum culture and sensitivity

Question 8

What does water mean?

Answer 8

UTI
Signs and symptoms: Fever 3-5 days post operatively, dysuria, UA positive nitrites and esterase. Elderly males may also have urinary retention
Treatment: Ecoli is number one cause. Others include Staph aureus, klebsiella and enterococci. Levaquin or cefoxitin and adjust based on C and S

Question 9

Foley cath, pros and cons?

Answer 9

Pros: urinary retention post op (anesthesia), pain control, low anteriors/surg site issues
Cons: gotta come out ASAP, infection, sepsis, shock

Question 10

What do you know about urinary retention?

What tools does the hops have to assist?

Answer 10

A word about urinary retention: common
Ask about BPH, meds
Fullness, incomplete voiding
Bladder scan PVR 300-400 needs foley

Question 11

Waht does walking entail?

Answer 11

PULMONARY EMBOLISM
Signs and Symptoms: Sudden onset of SOB, chest pain, cough, anxiety. May have tachycardia but often no other change including normal oxygenation
Treatment: confirm with CT angio (used more often than VQ), determine source and treat with heparin or lovenox depending on risk of post-op bleed. Heparin more easily monitored and quickly reversed

Question 12

“Wound” How long before the pain gets better?

signs and symptoms of infection?

Answer 12

In 1wk is when the pain should be getting better

INFECTION
Signs and symptoms: Fever first 24 to 48 hours consider strept or clostridium. Skin bright red +/- blister and bullae.
Other microbial wound infections usually show 5-7 days later with fever, dull erythema, induration, fluctuance and purulent drainage

Question 13

Incision Complications?

SEROMA

Answer 13

Signs and symptoms: Painless swelling at surgical site, usually seen in incisions that evacuated or created a space such as mastectomy, incisional hernia with mesh ect. Natures way of “filling in.” LEAVE IT STERILE
Treatment: Don’t aspirate unless you feel the need to culture the fluid or unless the swelling is causing extreme discomfort

Question 14

Incision Complications?

HEMATOMA

Answer 14

Signs and symptoms: Swelling, pain and ecchymosis at surgical site. Usually afebrile. Caused by inadequate hemostasis in OR or uncontrolled HTN. Occasional hemodynamic instability
Treatment: Bedside aspiration or removal of stitch/suture. If unsuccessful or hematoma re-accumulates, return to OR

Question 15

Incision Complications?
WOUND DEHISC/EVISCERATION?
and what is the difference?

Answer 15

Signs and Symptoms: Wound edges no longer approximated with SQ tissue exposed. Fascia intact (dehisce) or not (evisceration)

DEHISC=fascia is closed
EVISCERATION=your looking at intestines= ring the alarm

Question 16

MEDICATIONS ASSOCIATED WITH DRUG FEVER

“She calls them wonder drugs”

Answer 16

Allopurinol, amphetamines, amphotericin B, azathioprine, barbituates, benztropine, bleomycin sulfate, carbamazepine, cephalosporins, cimetidine, clofibrate, cocaine derivatives, folate, haldol, hydralazine hctz, ibuprofen, interferon, iodides, isoniazid

Question 17

Other Complications?

Bowel obstruction:

Answer 17

s+s, PE findings – tinkles, rushes
workup: XR, CT
Management: NG?  Hydration? Bowel rest? 
Motility agents?
TPN, may need return to OR
(Tinkles=as if a metal shavings falling on a metal table “tinkle, tinkle”)

Question 18

Other Complications?

PSEUDOMEMBRANOUS COLITIS

Answer 18

Signs and symptoms: mild abd pain, +/- nausea, fever (sometimes out of proportion to the abd pain), leukocytosis.
Treatment: Verify by stool culture using 3 specimens. Usually able to treat with oral Flagyl; some Flagyl resistant varieties require admission for ID evaluation

Question 19

Other Complications?

POST OP INTRAABDOMINAL ABSCESS

Answer 19

Signs and symptoms: fever 2-4 weeks post operatively, abd pain, ileus or obstruction.
Treatment: Usually seen in patients S/P perforated viscous or in contaminated elective cases. Can also represent a leak that was contained. Confirm by CT and attempt conservative treatment with IR drainage and broad spectrum antibiotics. May need OR!!