Post-operative Complications - Anastomotic Leak, Flashcards
Early causes of post-op pyrexia (0-5days)
Physiological systemic inflammatory reactions - within 24hrs
Blood transfusion
Cellulitis
UTI
Late causes of post-op (5+days)
VTE
Pneumonia
Wound infection
Anastomotic leak
Wind
Water
Walking
Wound
1
Wind - pneumonia
3
Water - UTI
5
Walking - VTE
7
Wound - Surgical infection
Post-operative ileus
-what is it
-presentation
-management
Inhibitory sympathetic input
Inflammatory reaction
Effect of analgesics
Deranged electrolytes can also contribute
Abdo distention
Abdo pain
N/V
Inability to pass gas
Inability to tolerate oral diet
NBM => small sips of clear fluid
NG tube if vomiting => suck
IV fluids with electrolytes to correct any abnormalities
TPN for severe, prolonged cases
Anastomotic leak
-what surgery poses this risk
-presentation
-investigations
-management
Surgeries involving the formation of an anastomosis
Presents 3-5days post-op
Diffuse abdo tenderness and pain
Fever
Guarding
May have fecal matter in abdominal wound drain
Abdo CT
Return to theatre urgently
Delirium
-what is this
-types
-risk factors
Acute confusional state - disturbed consciousness, reduced cognitive function
Hypoactive - lethargy, reduced motor activity
Hyperactive - agitation, increased motor activity
Mixed - fluctuations throughout the day
Hypoxia
Infection - UTI, LRTI
Drug induced - BZ, diuretics, opioids, CS
Drug withdrawal - BZ, ETOH
Dehydration
Pain
Electrolyte abnormalities
Constipation, urinary retention
Delirium
-assessment
-investigations
-management
History may be tricky, take a collateral
-onset, course
-symptoms of a possible underlying cause
-comorbidities, baseline cognition
-past episodes
-DHx
AMT or MMSE
Confusion screen
Bloods
-FBC, U&E, Ca, TFT, glucose, B12, folate
Focus of infection?
-urinalysis, blood cultures, wound swabs, CXR
-consider CT head
Manage underlying causes
Encourage PO fluids, analgesia, monitor bowel movements
Quiet ward, regular routines, clock to orientate to time and place
Sedatives as a last resort
1st line - haloperidol
2nd line - lorazepam
Post-operative hemorrhage
-types of bleeding
-physiological response to bleeding
Primary bleeding - during surgery
Reactive bleeding - within 24hrs of op
-intraoperative hypotension and vasocontriction stopped vessel from bleeding during op but bleeds when BP normalises
Secondary bleeding - 7-10days postop
-erosion of vessel from a spreading infection (heavily contaminated wound closed primarily)
Physiological response
-localised splanchnic VC => RAAS activation to maintain BP
-but this ability is lost if too much blood lost
Classification of hemorrhagic shock
Class I
Blood loss - U750ml (U15%)
HR - U100
BP - normal
RR - U20
UOP - 30+
Class II
Blood loss - 750-1500ml (15-30%)
HR - 100-120
BP - normal
RR - 20-30
UOP - 20-30
Class III
Blood loss - 1500-2000ml (30-40%)
HR 120-140
BP - low
RR 30-40
UOP 5-20
Class IV
Blood loss - 2000ml+ (40%+)
HR 140+
BP - low
RR - 40+
UOP U5
Hemorrhagic shock
-presentation
-management
Tachycardia
Dizzy
Agitation
High RR, low UOP
Swelling discolouration, disproportionate tenderness of surgical area
A-E assessment
-direct pressure to bleeding sites
-urgent transfusion if needed (RBC, PLT, FFP, major hemorrhage protocol)
Presentation of hemorrhagic shock in
-neck surgery
-inferior epigastric artery injury
Thyroidectomy, parathyroidectomy
-pretracheal fascia does not distend => airway obstruction
Resp distress => suction hematoma at bedside
URGENT SENIOR SURFICAL OPINION
IEA injury - from laparoscopic ports
Postop nausea and vomiting
-risk factors
Patient factors
-Female
-PHx of PONV or motion sickness
-Opioid analgesia use
-Non smoker
Surgical factors
-Abdo laparoscopic surgery
-Intracranial/middle ear surgery
-Squint surgery
-Gynae surgery
-Prolonged op times
-Poor post-op pain control
Anaesthetic factors
-Opiate/spinal anaesthesia
-Inhaled agents
-Polonged anaesthetic time
-Intraoperative dehydration, bleeding
-Overuse of bag mask ventilation => gastric dilation
Pathophysiology behind vomiting and nausea
Chemoreceptor trigger zone - in 4th ventricle with no BBB, so responds to stimuli in circulation
CTZ, GI tract, vestibular system, higher cortical structures (sight, smell, pain) can all act on the vomiting center
=> acts on diaphragm, stomach, abdo musculature to initiate vomiting
CTZ
-dopamine (metaclopramide, domperidone does not cross BBB)
-5HT3 (ondansetron)
Vestibules
-ACh (hyoscine hydrobromide)
-histamine (cyclizine)
GI
-dopamine (metaclopramide)
Vomiting center
-Histamine (cyclizine)
-5HT3 (ondansetron)
Surgical site infection
-preop steps taken to reduce this risk
Body hair removal only if needed
-electrical clippers with single use head
ABx prophylaxis if
-placement of prosthesis/valve
-clean-contaminated surgery
-contaminated surgery
Give single dose IV ABx on anaesthesia
Surgical site infection
-intraoperative steps taken to reduce the risk
Prepare skin with alcoholic chlorhexidine
Cover site with dressing
