Postoperative Care Flashcards
What is post-op fluid management?
Replace blood lost during surgery + provide maintenance IVF + make up for fluid loss in drains/NG tubes/fistulas
How do you replace surgical blood loss?
Replace in a 3:1 ratio with IVF
How do you replace maintenance IVF?
Administer D5 1/2 NS + KCl using the 100/50/20 rule for daily fluid requirements, or the 4/2/1 rule for hourly fluids
What is the third space?
Fluid sequestered into ISF due to inflammation or injury, mobilized 3-5 days after recovery –> requires decrease in IVF rate
What is malignant hyperthermia?
T>104 following anesthesia with high risk of myoglobinuria; tx dantrolene, 100% oxygen, and cooling blankets
What is bacteremia?
T>104 and chills within 1 hour or an invasive procedure; get blood Cx x3 and start empiric abx
What are the complications of aspiration?
Complication of awake intubations; leads to sudden death, chemical pneumonitis, or secondary pneumonia
How do you manage aspiration?
Prevent via NPO and antacids before intubating, Tx BAL and bronchodilators
How do you manage a tension pneumothorax?
Complication of intubation in weak or traumatized lungs, presents as “difficult to bag”, progressive hypotension and JVD; Tx is emergent needle decompression + chest tube
What is normal urine output post-op?
At least 0.5-1 mL/h/kg
What is post-op urine retention?
Presents as a need to void, but inability to do so; Tx is straight cath at 6 hours post-op and Foley after 2nd straight cath
UOP = 0 is likely due to a kinked or plugged Foley
UOP < 0.5 is either due to fluid deficit or acute renal failure; give a bolus of 500 mL IVF and if UOP responds, then it’s due to a fluid deficit
What are the potential causes of post-op hematuria?
Consider bladder overdistention, cancer, infection, kidney stones, trauma, prostatitis, and cyclophosphamide; get urology consult
What do you consider with post-op fever?
Consider the five W's: Wind (atelectasis POD 1) Water (UTI POD 3) Walking (DVT POD 5) Wound infection (POD 7) Wonder Drug (drug-induced fever)
How do you treat post-op atelectasis?
Partial lung collapse, dx bilateral inspiratory crackles, prevent with pulmonary toilet and incentive spirometry
Can develop into pneumonia POD 3 if left untreated
What is urosepsis?
UTI + septic shock; presents as cloudy urine, fever, hypotension, and a change in mental status; dx by urinalysis and urine Cx, tx with empiric abx + IVF
How do you treat a wound infection?
Dx examine wound site for erythema and fluctuance; if cellulitis –> abx only
if abscess –> drain pus and BID dressing changes
What is suppurative phlebitis?
Infected thrombus at site of venipuncture; Tx is to remove catheter and surgical excision of infected vein to the first non-infected branch, leave wound open, and give IV abx
How do you treat a GI fistula?
GI fistula causes leakage of GI contents from wound site; tx is NPO, TPN, and protect abdominal wall until body can heal itself
What prevents the healing of a fistula?
FRIEND: foreign body, radiation, infection, epithelialization, neoplasm, distal obstruction
Fistula x peritonitis = requires surgical exploration
Fistula x abscess = percutaneous drainage
Post-op chest pain concerns
MI : presents as acute chest pain +/- other classic signs; Dx CK-MB or troponin I, treat the complications
PE: presents as chest pain, hypoxia, and prominent JVD; Dx is V/Q scan, Tx is heparin –> IVC filter if PE recur while anticoagulated
How do you treat ARDS?
Presents as hypoxia due to septic shock
Tx intubation with high PEEP and permissive hypercarbia, then look for source of sepsis
When do you see delirium tremens?
Presents as hallucinations in an alcoholic POD 2-3, prevention is key and tx is controversial
What is hepatic encephalopathy?
Presents as coma in a liver failure patient s/p TIPS due to ammonia toxicity
How does wound dehiscence present?
Presents as salmon-colored fluid soaking dressings s/p open laparotomy POD 5; stabilize wound site, surgical closure at a later date
What is evisceration?
Wound dehiscence + intestines spilling out; keep patient in bed and cover bowel with sterile dressings, emergency surgical closure necessary
How does hypernatremia present?
Every 3 Na over 140 indicates 1 L of water loss, presents as volume depletion (slow) or altered MS (rapid); give D5 1/2 NS to correct imbalance
How does hyponatremia present?
Due to SIADH or isotonic fluid loss with free water resorption, presents as coma and convulsions; tx is water restriction and LR/NS
What causes hypokalemia?
Due to diarrhea or vomiting, give K+ at a rate of <10 mEq/hr
What causes hyperkalemia?
Renal failure, aldosterone blockers, or release from dead tissue (crush injury, ischemic bowel, etc.); tx C BIG K Die – calcium gluconate, bicarb-insulin-glucose, kayexalate, and dialysis
What is primary intention?
Close approximation of wound edges via sutures or staples
Timing: epithelialized by POD 2, max collagen in 5-7 days, avoid weight-lifting for 4-6 weeks, complete healing by 6 months
What is secondary intention?
Contaminated wounds left open to prevent abscess formation; granulation tissue forms first, then comes contraction via myofibroblasts, then finally a delayed epithelialization
What is third intention?
Wound initially left open, then delayed primary closure afterwards
What is an incisional hernia?
Presents as bulging at wound site with increased abdominal pressure, needs to be repaired surgically
What is a hypertrophic scar?
Raised scar within site of incision, observe until scar is stable, then steroids + excision
What is keloid?
Raised scar that extends beyond site of incision; will grow back if excised
How do you treat a wound infection?
Red and tender area on incision site; Tx is drainage and BID wet-to-dry dressing changes
No abx unless cellulitis is spreading
When do you use prophylactic antiobiotics with a wound?
Recommended for any clean-contaminated or contaminated procedures, insertion of prosthetic material, immunosuppression, or poor blood supply;
give single dose 1 hour pre-op and single dose post-op
What are the wound types?
Clean wound: no entry into GI, GU, or respiratory tracts; <10% infection rate, Tx is primary closure
Contaminated wound: major wound contamination (e.g. bowel spillage or stab wounds) ; Tx is secondary closure
