Postop Complications ABCs Flashcards
Postoperative Complications (10)
Atelectasis
Aspiration
Pneumonia/Sepsis
VTE (DVT, PE, Stroke)
Hypovolemia (bleeding and dehydration)
Paralytic Ileus
PONV (post-op nausea and vomiting)
Urine Retention
UTI/HAUTI
Surgical site infection
How does anesthesia affect breathing
General anesthesia hampers your normal breathing and stifles your urge to cough
After chest or abdo surgery it could hurt to breathe in deeply or push air out - mucous builds up in the lungs
Anaphylaxis (airways can swell)
Atelectasis/pneumonia = hypoxemia
What can cause acute respiratory distress post op
Tongue falling back because of decreased LOC (snoring)
Retained thick secretions
Laryngospasm
Laryngeal edema
How to respond to acute resp distress
assess if the tongue has fallen back. look for sternal retraction. wake the patient up. oral airway. sit them up. supplemental oxygen. check O2
if anaphylaxis has occurred we are immediately going to give Epi IM q5min
what is hypoxemia
reduction in the oxygen tension in arterial blood which will lead to a reduction in oxygen at the tissue level referred to as hypoxia
want it to be 80-100
hypoxema is a PaO2 of less than 80 mmHg
need blood gas analysis to confirm.
The “gold standard” diagnostic test for hypoxemia is arterial blood gas taken from radial artery.
what causes hypoxemia
Hypoxemia is a result of conditions or diseases that reduce the ability of oxygen to diffuse across the alveoli, reduce perfusion of ventilated alveoli, reduce the ventilation of perfused alveoli, reduce the oxygen tension of inspired air, reduce the volume of inspired air
happens when the air sacs in the lungs become deflated. can cause partial or complete colapse of a lung or lobe of a lung which is going to sound like decreased air entry.
what is the most common cause of hypoxemia in the post-op patient:
Atelectasis
S&S of hypoxemia (HATT)
Hyper/hypotension
Agitation
Tachycardia (compensate)
Tachypnea (unless being suppressed by opioids)
What is atelectasis
hypoventilation and excessive retained secretions
collapse of the alveoli
S&S of Atelectasis (7)
Diminished or absent breath sounds
Dullness on percussion
Reduced chest expansion, tachypnea
Fever
Restlessness/confusion
Hypertension, tachycardia
Interventions for Atelectasis
DB&C q1h while awake, incentive spirometer
Reposition patient, HOB> 30
Apply oxygen
Notify surgeon
Aspiration; what is it?
foreign material that enters the trachea instead of the esophagus and can then enter the lungs.
What causes aspiration?
Abnormality of any of the nerves, muscles, or processes required for swallowing can result in ineffective swallowing or GI reflux, as a result saliva or ingested materials can be aspirated.
happens in 45% of healthy individuals but most can clear the aspirate from the pulmonary tree by intact cough and gag reflex
not having these reflexes: unconscious, pts with stroke or other neuromuscular degenerative conditions.
how does anesthesia affect aspiration risk?
when patients dont have cough or gag reflexes such as intraoperatively, they cant claer secretions. because of this, patients are often intubated to protect the airway from GI reflux.
interventions for aspiration
Prevention is key and involves administration of PPIs prior to surgery such as those who are obese or pregnant, pts with decreased LOC coming out of general anesthetic. pts with stroke
Aspiration can lead to pneumonia
Sit the patient up
Dont feed when asleep
Pneumonia S&S
Sudden onset of chills, shaking, with high fever
Dyspnea, tachypnea, sharp chest pain exacerbated by inspiration
Productive cough
Diminished breath sounds
Cyanosis with hypoxemia
What measures can we implement to prevent Post-op pneumonia
- DB & C q1h while awake along with incentive spirometry
- Early ambulation which includes good pain control
- HOB elevated > 30 degrees at all times or patient is sitting up for all meals
- Oral hygiene at least BID with mouthwash
Interventions for Pneumonia
maintain airway
apply oxygen
labs/diagnostics
- sputum cultures (best to get right in the morning)
- CXR (diagnostic)
- blood cultures (if septic)
- antibiotics
- fluids
Sepsis
The systemic response to overwhelming infection, when a patient’s immune system fails to control pathogens or their toxins, from a site of infection
See it in surgery all the time because we cut into someone
Systemic illness caused by microbial invasion to normally sterile parts of the body
usually in the blood and often bacterial (can be viral, fungal, parasitic, yeast)
Prevalence of Sepsis
First line of defense has been broken
One of the leading causes of death
Common reason for admission to hospital
Is prevalent and on the rise in aging population, chronic diseases, artificial joints, heart valves, central venous catheters, people living with cancer, autoimmune diseases, immune-compromised, organ transplants, indiscriminate use of antibiotics and antimicrobials
SIRS Criteria
H - heart rate > 90
R - RR > 20
T - temp greater than or equal to 38 or less than 36
W - WBC count greater than 12 or less than 4
A - altered mental status (GCS score < 15)
Sepsis = Suspected source + 2 of the SIRS criteria
QSOFA (quick sepsis-related organ failure assessment)
Resp rate > 22
Systolic BP < 100
Altered mental status
Lactate greater than 4
If the patient develops two or three QSOFA criterial call MRP and inform him/her the patient has SEPSIS and possible SEPTIC SHOCK and needs immediate assessment
Most frequent sites of infection
Lungs
Urinary tract
Abdomen
Skin/soft tissue
Symptoms of Infection
Early on, organs can be hypo-perfused
Blood flow/oxygen is shunted away from the kidneys, skin, GI tract, lungs
Altered consciousness, confusion, psychosis, tachypnea, SaO2 < 90%, jaundice, creatinine, decreased platelets, PT, decreased protein C, D-dimer. Severe sepsis is sepsis that doesn’t respond to aggressive fluid rehydration
Assessment/Interventions Sepsis
Lactate (tells about anerobic metabolism)
Thorough assessment and VS
EARLY IDENTIFICATION
Advise MD, PCC/Charge nurse
Contact ICU outreach team
- Lab work & diagnostics (incl cultures and lactacte)
- Antibiotics (ideally after blood cultures but don’t delay more than 30 minutes)
- IV fluids
- Monitor (VS, urine output - tells you about organ perfusion. and LOC)
Ultimately monitoring for septic shock and if systolic BP doesnt stay about 90 or MAP is less than 65 despite the IV fluids the patient is oging to need vasopressors
Diagnostics for sepsis
Blood and other cultures
CBC with diff, coagulation profile, d-dimer
ABGs
Lactate level
C-reactive protein (markre of vascular inflammation)
Serum proteins
Blood sugar
Serum Cr and U
Liver function
Populations at risk for VTE
Obesity
Acute medical illness
Increasing age over 40
Cancer diagnosis (pt with cancer can be hypercoagulable)
What is PE
life threatening and needs immediate treatment. because it is a clot blocking oxygenation. blocks the diffusion of oxygen across into the blood stream. this is a big deal depending on where it is and how much of the lung it is obstructing.
which surgeries pose the greatest risk of PE
joint replacements of the hip and knee because of immobility after surgery
S&S of pulmonary embolism (6) CHLDSS
Coughing, including a cough that produces bloody mucus.
Heart palpitations (heart racing or pounding)
Leg pain or swelling
Dizziness.
Shortness of breath that worsens with exertion
Sharp sudden chest pain
what can you assess to help prevent the clot from entering the lungs?
Always asking if they have pain in calves on dorsiflexion, looking for swelling, pedal pulses, warmth. find the clot before it gets to the lungs
Prevention/Prophylaxis of DVT and PE
Detection of added risk
Proactive education (mobility, weight, medication adherence)
VTE prophylaxis OD or BID subcut injection
Medical optimization
Early frequent mobilization
Hydration
Post-op system assessment
Treatment advocacy
Sensation (diabetic patients) might not feel the pain of a blood clot the same way patients with normal sensation would
Heparin
Treatment of choice for PE and DVT
Primary use: prevent clotting within blood vessels
Adverse effects:BLEEDING
do PTT lab test.
heparin can be given subcut or IV
antidote is protamine sulfate
Incidence of Peri-Operative Stroke
Depends on the type and complexity of surgery
Vascular surgeries ++ high risk
Urgent surgeries
predominantly ischemic and embolic (a clot vs a hemorrhage)
45% occur by POD#1
Risk Factors for stroke
> 70 years
Female
history: HTN, diabetes, renal insufficiency, smoking, COPD, PVD, cardiac disease, systolic dysfunction, previous stroke or TIA
Abrupt discontinuation of antithrombotic therapy before surgery
Risk Factors (procedure related)
- type and nature of surgery (vascular increase risk)
- anesthesia (general anesthesia)
- duration of surgery (longer surgeries)
- arrhythmias, hyperglycemia, hypotension, or hypertension
Risk Factors: POST OP
- heart failure, low ejection fraction, MI, arrhythmias
- dehydration and blood loss
- hyperglycemia
- stasis in the post-operative period
- bed rest
- witholding of antiplatelet or anticoagulant agents (aggravate surgery-induced hypercoagulability)
Prevention & treatment of inflammation and infections (high WBC correlates with an increased incidence of stroke)
Interventions
CALL THE PHYSICIAN and encourage neurology consultation
Time matters: if they are eligible for thrombolytics there is a 3 hour window from onset of symptoms (tPA)
get them to CT and get it read then give them tpa in order for them to have the best outcomes
- TIA/Stroke pre-printed physician orders
- swallowing screen
- early mobilization
- glucose control
- BP control
- Fever control
- no subcut, IM or catheters while on tpa because of the risk of bleeding
S&S of stroke
- symptoms of stroke: facial droop, paralysis, abrupt inability to express themselves, slurring of speech, visual deficits sudden, sudden ambulation difficulty. Sudden acute, unexplained neurologic changes
Post Stroke Care Diagnostics
ECG
Chest X-ray
Holter monitor
carotid doppler
echo
Going to look for risk factors of the stroke. ECG and CXR happen quickly
Other cardiovascular complications
Fluid overload
Dehydration/Hypovolemia
Electrolyte Imbalance
Fluid overload: precipitating factors
Stress response in postoperative patients initiates increase of antidiuretic hormone and water retention
CHF - or renal patients
Rapid, high volume IV infusions intra-operatively
Fluid overload: Detection
Decreased urinary output (less than 30cc/hr) should be > 120 cc in 4 hours
Increased BP, HR and SOB
Abnormal breath sounds (crackles/decreased A/E)
Peripheral Edema
Fluid Overload: Prevention
Monitor IV fluids/blood products rate and amount
Monitor output - note 24hr balance (include OR intake and output)
Assess for signs of overload - report and record them
Meds as ordered (diuretics, ACE inhibitors, digoxin)
Dehydration: Detection
Less than 350cc of urine in 12 hrs
Hypotension/tachycardia
Dry lips and mucous membranes
Lack of skin turgor
Muscle weakness, dizziness, restlessness, headache
Dehydration: Prevention
Monitoring of urine output/oral/IV intake
Being aware of blood loss during surgery
Monitoring of vital signs/including temperature
Symptoms similar to anemia correct dehydration and possibly avoid unnecessary transfusion
Hypovolemia: Possible Causes
Total blood volume loss of 15-25%
Blood loss from surgical site (drain amount, wound seepage, how many layers is the output going through)
Severe dehydration
Third-spacing when pt doesnt have enough albumin
Fluid loss from excessive vomiting, diarrhea, or NG tube suction. This is why we have them on low intermittent suction
Hypovolemia: Symptoms
Lethargy
Hypotension
Rapid, weak pulse
Cool, clammy skin
Rapid shallow respirations
Oliguria or anuria
Hypovolemia: Interventions
Vitals, oxygen, IV fluids
Contact MRP, ICU outreach
We are most concerned about BP. the patient is in big trouble if their organs aren’t perfusing or their systolic BP is < 90 or MAP < 64
That is or red flag pt is going into hypovolemic shock
evidenced by poor urine output–> kidneys are not perfusing
Post-Op Bleeding: symptoms
Excessive bleeding for what is “normal” for the surgery
Low hemoglobin
Hypotension, tachycardia
Pale, cool
Post-Op Bleeding: Interventions
Vitals
Notify surgeon
Patent IV
Apply pressure, call for help
Try to keep the pt warm
Have team there for support
Lie pt flat or even in reverse trendelenburg
Hold heparin, trent INR if warfarin has been resumed
Electrolyte Imbalance: increased risks
Imbalance of normal electrolyte levels (sodium, potassium, chloride, bicarbonate, calcium, phosphorus & magnesium)
Hypokalemia (low potassium can affect heart function)
- preoperative NPO status
- fluid loss during surgery
- nausea/vomiting/diarrhea (decreased intake, increased output) - PONV
Electrolyte Imbalance: Prevention/detection
Monitor lab values postoperatively
Report/record abnormal values
Medications - IV/PO
Prevent C-diff - probiotics if on abx
Treat and prevent N&V
