Postoperative Care and Complications Flashcards
When in the OR, who is managing the patients care?
When does this change?
Does this qualify as a transfer of care?
Jointly being managed by anesthesia and surgery together
Once surgery is over transferred PACU care is resumed by surgerical team
Yes
When should you use post-op order sets?
Whenever possible, in order not to omit necessary details
In a post-op patient what criteria is required for an ICU admission?
Who makes this decision?
If the patient requires ventilator assistance or circulatory support (vasopressors) and more intensive staffing require admission to ICU
Critical Care Provider (Attending)
What is another name for pulmonary toilet?
What is the goal?
Pulmonary hygiene, previously known as pulmonary toileting, refers to exercises and procedures that help to clear your airways (trachea and bronchial tree) of mucus and other secretions. Ensures pulmonary function and that alveolies are filled appropriately.
What is a low residue diet?
Low fiber diet; used often in many GI post-op patients
What considerations should be taken account for in a post-operative patient?
Considerations for:
* Level of consciousness
* Dangers of aspirations
* Presence of NGT or OGT
* teeth/dentures
* Intra-op degree of manipulation of bowels
Evaluation by provider from the surgical team should be completed within how many hours of surgery?
Post-op check within 4-6 hours
Surgical drains can allow for early detection of what complication?
Early warning of a surgical leak
Surgical drains allow for collapse in what space?
Surgical dead space
What are the common drain types?
- Jackson-Pratt
- Blake
- Penrose
- Wound Vac
What are some rules of thumb for drains?
- All drains are potentially dangerous (infection risk)
- For every drain, there must be a reason
- When the reason is gone, the drain should be gone
- Drain should not exit through the surgical incision
- Drain should be firmly secured
What are some factors affecting severity of pain post-operatively?
Can patient anxiety cause pain?
- Duration of surgery
- Type of anesthesia
- Degree of operative trauma
- Type and location of incision
- Organ manipulation
- Magnitude of intra-operative retraction
Yes
Why can inadequate pain management lead to pneumonia post-operatively?
Due to pain patient does take deep breaths/cough to move bacteria
What are some objective ways to measure pain?
- Increased HR
- Increased RR
- Does patient appear to be uncomfortable and does it match report
What opioid is considered the gold standard?
Morphine
When prescribing opioids what should be ordered along side it?
Naloxone for reversibility if there is an urgent need
What are side effects of all opioids?
- Sedation
- Confusion
- Respiratory depression
- Delayed gastric emptying
- N/V
- Pruritius
- Constipation
- Urinary retention
What receptors do opioids work on?
MU Receptors in the brain and spinal cord
MU 1 receptors are responsible for analgesia
MU 2 receptors are responsible for respiratory depression
When utilizing a patient-controlled analgesia (PCA) who can push the button?
ONLY THE PATIENT
What are some benefits to epidural anesthesia?
What are some risks/complications to consider?
- Better pain control than IV narcotics
- Earlier recovery of bowel function vs. systemic opioids
- Less need for systemic opioids (narcotics) and less nausea
- Easier breathing resulting from better pain control
- Easier and earlier participation in PT
Hypotension, headache, and leg weakness
How often should a fentanyl patch be changed/removed?
What about Lidoderm patches?
Every 72 hours
Every 12 hours (on 12 hours, off for 12)
When used for > 5 days what are the associated side effects of NSAIDs?
- Gastric irritation, peptic ulcer, GI bleeding
- Precipitation of bronchospasm in asthmatics
- Renal dysfunction
- Platelet dysfunction, bleeding
There is increased efficacy if Acetaminophen is taken when and how?
Taken via a scheduled dose within the 1st few days post-op (vs PRN)
What are the Five W’s of Post-Op Fever?
Wind: atelectasis
Wound: infections
Water: UTI
Walking (lack thereof): DVT
Wonder drug: medciation reactions
How should a peri-operative CVA be worked up?
Stat noncontrast CT to check for ischemia vs hemorrhage
Should also rule out metabolic cause for AMS
What are some pulmonary complications in the peri-operative phase?
- Atelectasis
- Aspiration pneumonia
- Nosocomial pneumonia
- Pulmonary edema (CHF or ARDS)
- Pulmonary embolus
A 59-year old is being seen for his pre-operative evaluation. He has a history significant for hypertension and a 30 year pack hisotry. What can his surgeon advise to reduce his risk for pulmonary complications post-operatively?
Smoking Cessation
3-4x risk reduction if smoking cessation >/= 8 weeks before surgery
What respiratory complication accounts for 90% of posteroperative pulmonary complications?
What is the etiology?
Atelectasis
- Obstruction of the tracheobronchial airway with leads to changes in bronchial secretions, defects in expuslion mechanism (aka cough) and alveoli collapse
- Pulmonary insufficiency
What are some predisoposing factors for respiratory complications in the post-operative period?
- Smoking
- Pulmonary problem
- Anesthesia (general anesthesia and postop narcotics)
- Infrequent/inadequate coughing/deep breathing
What is the number one risk for aspiration postoperatively?
Non-NPO patient undergoing emergency surgery
What is the presentation of a DVT?
Presents as swelling of leg, tenderness of calf, increased warmth with calf pain on passive dorsiflexion of foot
A 49 year old post-operative patient develops swelling in the right lower extremity. She complains of pain and tenderness in the calf. On exam there is tenderness, erythema, and calf measures 1cm greater than left calf on exam. What is the appropriate treatment and treatment duration for the suspected diagnosis?
Anticoagulation (m/c coumadin or Lovenox) for 3 months because it is a provoked DVT
Indefinite treatment with anticoagulation if this was an unprovoked DVT
What are some cardiac complications associated with post-operative complications?
- Hemorrhage
- Hypotension
- Hypertension
- Ischemia/Infarction
- Dysrhythmia/Heart Block
What are some treatments for post-operative hypertension?
What is a risk of hypertension?
- Treat underlying cause
- Can treat with beta blockers, diuretics, treat pain, or Foley placement if bladder is distended
Stroke if SBP is elevated
Are males or females at a higher risk for urinary retention in the post-operative period?
What are some symptoms?
Males
Urgency, discomfort, fullness, enlarged bladder, oliguria, anuria
What are the risk factors for PONV in a post-operative patient?
- Increased starvation
- Gastric irritation
- Effects of anesthetics
- Postoperative pain
What are the side effects of Scopolamine patch?
- Sedation
- CNS excitation
- Dry mouth
- Urinary retention
- Blurred vision
- Confusion
- Disorientation
- Hallucinations
What are the side effects of Ondansetron?
- Headache
- Dizziness
- Flushing
- Elevated liver enzymes
- Constipation
- QT prolongation
What is the treatment of illeus post-op?
What has been found to stimulate return of bowel function?
- NPO
- NG decompression if necessary
- Treat underlying cause
- Good pain control
- Frequent ambulation
- TPN or PPN if unable to take PO longer term
Chewing gum
What is the presentation of an anastomotic leak?
What is the gold standard for diagnosing?
- Typically around day 5 post-op
- Fever
- Tachycardia
- Abdominal pain
- Peritonitis
- Prolonged ileus
- Absent BS
- Oliguria
- Anuria
- Feces leak from drain/wound
CT scan with PO contrast
Is an anastomotic leak an emergency?
What is the treatment?
Yes
OR Right Away!!
