Postop Fever and Complications

Question 1

Fever within 48 hours post op is likely due to

Answer 1

inflammation

Question 2

In the early post op period (48 hours post op), when do you not ignore the fever?

Answer 2

over 39C or 38C with symptoms (38 alone is likely wound healing)

symptoms= signs of sepsis or necrotizing fascitis

Bacteremia and nec fasc can cause fever post op day 0-1

Question 3

After 48 hours post op, fever over 38 should be worked up how?

Answer 3

Fever work up:

UA and cultures
Blood culture
CXR
DVT US

Question 4

What are the 5 Ws?

Answer 4

Wind: Pneumonia
Water: UTI
Walking: DVT
Wonder drugs: malignant hyperthermia
Wound

Question 5

3 day post op, pt presents with cough and dyspnea and 2L O2 cannula, how do you work them up?

Answer 5

CXR, they might have pneumonia (Wind)

Question 6

How do we prevent pneumonia post op?

Answer 6

Incestive spirometry and ambulation

Question 7

How do we prevent post op UTIs?

Answer 7

Foley out soon

Question 8

How do we prevent post op DVTs?

Answer 8

Ambulation
LMWH
SCDs (leg sqeezers)

Question 9

AUtosomal dominant mutation in ryanidine ca receptors

Answer 9

malignant hyperthermia

Question 10

What drugs may result in malignant hyperthermia?

Answer 10

Succinylcholine or halothane

Question 11

When are prophylactic ‘skinbiotics’ warranted?

Answer 11

Clean contaminated and contaminated procedures and dirty procedures

Question 12

What antibiotics are normally used for prophylactics before surg?

Answer 12

second gen cephalosporins like cefelexin

Question 13

What organisms are most commonly associated with nec fasc?

Answer 13

C pyferinges and s pyogenes

Question 14

What are the signs/features of nec fasc?

Answer 14

High fever, lots of pain, skin change, bullae (late)

Question 15

What skin layer is cellulitis?

Answer 15

hypodermis

Question 16

How do you get a deep peritoneal infection post op?

Answer 16

contents that are ‘dirty’ end up in the peritoneum and can either form abscess or cause diffuse peritonitis

Abscess= there was spillage with inadequate washout
Leak=diffuse perotinitis and high fever

Question 17

What drug do you give to counter malignant hyperthermia?

Answer 17

Dantrolene

Question 18

What is post op fever and when do we work it up?

Answer 18

Early postoperative fever is an elevation in body temperature during the first 48 hours after surgery. Unless extremely elevated, an elevated temperature is likely not due to infection (contrary to what we all learned and is still routinely taught). The American College of Surgeons has recommended (level B) that if there is only an elevated temperature (no signs of hemodynamic instability or symptoms of infection) in the 48 hours after surgery, fever should not be worked up. Practically, this means that an isolated elevated temperature of 38 °C (100.4 °F), which would normally trigger a “fever work-up,” does not need a work-up. An isolated elevated temperature of ≥ 39 °C (102.2 °F), or an isolated elevated temperature of 38 °C (100.4 °F) concomitant with symptoms of infection, does.

Question 19

What are general causes of elevated temperature?

Answer 19

Question 20

What do we mean by clean, clean contaminted, contaminated, and dirty for surgical wounds?

Answer 20

Question 21

Answer 21

I just wanted you to remember what nec fasc looked like

Question 22

To reduce the risk of aspiration, when should patients go NPO in relation to surgery?

Answer 22

8 hours prior

Question 23

Where do conents tend to go when aspirate?

Answer 23

Right lower lobe

Question 24

Small bowel obstruction (SBO) is discussed in Surgical Small Bowel. SBO is most commonly caused by ______________

Answer 24

by adhesions from a previous surgery.

Question 25

What are the inital interventions for post surgical SBO?

Answer 25

Ambulation, intravenous fluids, and electrolytes.

Question 26

________________is a failure of primary wound closure—the sutures don’t hold, the scar tissue doesn’t form, or the tissue dies. This can occur in the skin layer, deep fascia, or both

Answer 26

Dehiscence

Question 27

What can contribute to poor wound healing?

Answer 27

poor nutrition, increased stress on the wound, vascular compromise, and infection (cellulitis, abscess)

Question 28

What do we use as a cursory/gestlt for nutritional status?

Answer 28

Albumin

Question 29

What are major contributing factors for vascular compromise?

Answer 29

Vascular compromise comes from a number of sources. Diabetesand hypertension, causes of arteriolosclerosis (arteriolar disease), are modifiable risk factors, but the vascular damage is already done, even if glucose and blood pressure are controlled in the postoperative setting. SMOKING is also another risk factor.

Question 30

How long before surgery should a person stop smoking?

Answer 30

30 days

Question 31

Why does intubation protect the airway from aspiration?

Answer 31

It blocks the airway from anything that could come up from the esophagus

Question 32

What would you see on CXR for gastric acid pneumonitis?

Answer 32

Diffuse patchy opacities NOT lobar

Question 33

How long does bowel function take to return post op?

Answer 33

Depends on the procedure: the more the bowel is messed with the longer it will take

Question 34

What is our work up for post op ileus?

Answer 34

POD2: XR look for propotional and diffuse distention
POD5: CT w/IV contrast

Question 35

How does Post Op ileus differ from SBO?

Answer 35

Post Op Ileus has diffuse distention

Question 36

What number do we normally use as the cutoff for bladder volume to dx urinary retention?

Answer 36

Over 500 ccs

Question 37

What does over 500 cc’s on bladder scan mean?

Answer 37

There is urinary retention

Question 38

Under production of urine is caused by what major categories of kidney probelms?

Answer 38

Prerenal and infrarenal

Question 39

What are ways we can get ischemia in a surgical wound?

Answer 39

Smoking, htn, DM, ASVD–> vascular probelm

Stitches to tight

Question 40

“distension of the proximal colon through the splenic flexure, and then return of normal distal colonic function” is characteristic of…

Answer 40

acute colonic pseudo-obstruction (ACPO, Ogilvie’s syndrome)

Suspect acute colonic pseudo-obstruction (ACPO, Ogilvie’s syndrome) in elderly, postop patients with abdominal distension. Confirm by CT with IV contrast, which will show dysfunctional distal vagus innervation—distension of the proximal colon through the splenic flexure, and then return of normal distal colonic function.

Question 41

In the case of evisceration, first step is

Answer 41

If evisceration occurs, keep the bowel alive with warm, moist dressings, and keep the patient alive by emergently cleaning and closing the wound in the OR.
The goal is to return to the operating room. Not in a minute, not in an hour, NOW. On the way, you should soak dressings in sterile saline and cover the bowel. The correct answer is wet sterile dressing, emergent return to the OR.

Question 42

How do we approach obstructive uropathy?

Answer 42

Obstructive uropathy presents with either the urge to void and suprapelvic pain or elevated creatinine and a suprapelvic mass, diagnosed by bladder scan and treated with catheterization.

Question 43

What are we concerned for in the case of an edematous abdomen and abdominal wall that are open and have the wound edges forced apart from one another, you would need some pretty tight tension to close the abdomen…

Answer 43

Compartment syndrome, do a wound vac

Question 44

What do you expect on x ray for someone with a SBO?

Answer 44

Small Bowel Obstruction:
In small bowel obstruction, there will be no colonic gas. In large bowel obstruction, there will be no small bowel gas (because the ileocecal valve prevents the reflux of air). This X-ray shows centrally located loops, moderate distension, mucosal infoldings, and absent colonic and rectal gas. Thus, this is a small bowel obstruction.

Question 45

What do you expect on x ray for someone with a LBO?

Answer 45

Large bowel obstruction will have either no gas in the small bowel or an appropriate amount (because the ileocecal valve prevents the reflux of gas into the small bowel) and a distended colon. There could be haustrations, depending on the extent of the distension. The proximal large bowel will be distended, and the distal bowel will be decompressed or absent. Whether caused by colon cancer (in the US) or sigmoid volvulus (the rest of the world), large bowel obstruction typically occurs near or within the sigmoid colon. Therefore, the gas pattern should show a distended ascending colon, distended transverse colon, distended descending colon, and nothing after the sigmoid colon. This is a major distinction between LBO and ACPO (also the history, but in terms of a licensing exam question about bowel gas patterns, WHAT is distended is important).

Question 46

What do you expect on x ray for someone with an ACPO?

Answer 46

ACPO is the result of some undiscovered pathology of the terminal vagus nerve innervations. The vagus nerve is responsible for the proximal colon up to the splenic flexure. S2–S4 autonomics take care of the rest. Thus, there will be a large bowel obstruction pattern—only the large bowel is distended, the small bowel will be normal—up to the splenic flexure. Distally, there will either be normal or decompressed bowel. In the context of a focused radiology question like this one, there would be no way to differentiate between a LBO at the splenic flexure and ACPO without context. But we want you to learn that LBOs typically happen at the sigmoid colon, and ACPO is the pattern that demonstrates dilation up to the splenic flexure. Many sources erroneously call distension of the entire colon ACPO

Question 47

What do you expect on x ray for someone with a post op paralytic ileus?

Answer 47

Paralytic ileus (adynamic ileus, postoperative ileus) represents the normal physiological response to anesthesia—the entire GI tract waking back up. Paralytic ileus is normal and expected after any surgery. Defecation should occur by day 3 if all is well. Before that, X-ray will show gaseous distension of the whole bowel that is proportional to the normal segment sizes. There will be colonic gas on the flanks and rectal gas “within” the pelvic bones.