Postoperative Care & Complications Flashcards
What are the three postoperative phases
Immediate postoperative phase: Post anesthetic
Intermediate postoperative phase: Hospitalization period
Convalescent phase: From hospital discharge to full recovery
Immediate postoperative period
Patient is transferred from operating room to either PACU or ICU to monitor.
Discharged from PACU when cardio, pulmonary, & neurologic function is back to baseline (~1-3 hours after operation)
Immediate postoperative period: Monitoring
Vital signs, central venous pressure, intake & output, Intracranial pressure (in cranial surgery), pulses (vascular surgery)
Immediate postoperative period: Respiratory orders
Intubated: Vent settings, CXR to check tube placement
Extubated: Supplemental oxygen PRN, IS, deep breathing, out of bed if no limitations.
Immediate postoperative period: Position in bed
Elevate head of bed: Indicate minimal degrees of elevation
Elevate designated extremity
Specialty mattress for pressure relief if indicated
Immediate postoperative period: activity orders
Bed rest: Consider DVT prophylaxis such as anticoagulant or sequential compression device (SCD):
Up in chair
Ambulate: Nursing &physical therapy
Immediate postoperative period: diet
NPO vs clear liquids vs regular vs speciality diet
Immediate postoperative period: Fluids and electrolytes
Fluids: Maintenance needs and replacement of losses
Electrolytes: Replace GI loss
Immediate postoperative period: Drainage tubes
Specify type, amount of suction, irrigation fluid & frequency if indicated, and
Site care
Immediate postoperative period: Medications
Analgesics: minimize in geriatric patients
Gastric acid suppression (selective use)
Deep vein thrombosis prophylaxis
Anxiolytic (selective use): use only when absolutely necessary and avoid in geriatric patients.
Hypnotics: lower dose in geriatric patients.
Antibiotics when indicated
Antipyretic prn
Stool softeners
Previous medications when indicated
Immediate postoperative period: Laboratory testing
Depends on the patient and operation performed:
Significant blood loss: CBC
Significant fluids administered: BMP
Diabetic patient: Glucose checks q2-4h
When is a CXR indicated postoperatively?
If patient is intubated, s/p central venous catheter placement, s/p tracheostomy, s/p cardiothoracic surgery.
Intermediate postoperative period: Wound care
Sterile dressing should be applied in the OR.
Unless complications should remove dressing after 2 days (using aseptic technique –> gloves worn and wash hands before and after) to see if would edges have epithelialized.
Remove earlier if: Open wound Original dressing is wet Suspect infection: fever and increasing pain
Intermediate postoperative period: suture/staple removal
Face wounds: remove sutures at post op day 2-3 & steri-strip
Most other wound closures: Remove sutures or staples by post-op day 5-7 and steri-strip wound ???? Slide 18
When might wounds require more time prior to suture or staple removal?
Incisions that cross a crease line Incisions closed under tension Some incisions on extremities, especially incisions on feet Incisions in debilitated patients Scalp incisions
What is the purpose of drain placement post op?
To evacuate fluid (pus, blood, serum) and air (from pleural cavity)
Where should a drain be brought out?
Through a separative incision in order to prevent increasing the risk of wound infection.
Intermediate postoperative period: Drain management
Use aseptic technique
Remove drain as soon as it is no longer useful
What are the different types of drains?
Open, closed, and sump
Open drains
eg Penrose
Increase rate of infection in surgical wounds. Use only in wounds already infected
Closed drains
Connect to suction device
Sump drains
Connect to suction device
Airflow system keeps lumen open. Useful when drainage is likely to plug other types of drains.
What is the process of removing large bore drains?
After infection is controlled and large bore drain is to be removed:
consider slowly withdrawing drain over several days, progressively replace drain with smaller catheters as it closes.
Intermediate postoperative period: Changes in pulmonary function following surgery
Decreased vital capacity
Decreased functional residual capacity –> both can lead to alveolar collapse and atelectasis
What are some common causes of pulmonary edema postoperatively?
Increased hydrostatic pressure (left ventricular failure and fluid overload)
Increased capillary permeability: Due to systemic sepsis or SIRS
Decreased plasma oncotic pressure
What patients are at increased risk for pulmonary complications?
Smokers
Those with underlying pulmonary disease (COPD)
Elderly
Intermediate postoperative period: Early respiratory failure (< 48 hours)
Associated with major operations and develops in short time span.
Chest or upper abdomen
Severe trauma
Preexisting lung disorder
Intermediate postoperative period: Late respiratory failure (> 48 hours postoperative)
Triggered by postoperative event:
Pulmonary embolism
Abdominal distension
Opioid overdose
What are signs of respiratory failure?
Tachypnea Decreased tidal volume PCO2 > 45 mm Hg Po2 < 60 mm Hg Low cardiac output
Respiratory failure treatment
- Intubate and ventilate
2. Determine etiology
Respiratory failure prevention
Anticipate potential problems
Postoperative pulmonary care: IS, elevate head of bed, mobilize early if possible
Hypovolemia can lead to dry secretions and risk for pneumonia –> fluids, fluids, fluids!
Hypoventilation: avoid high FIO2 (with supplemental oxygen) because it removes stabilizing gas (nitrogen) for alveoli and causes over sedation. Control pain!
Intermediate postoperative period: Maintenance fluids
24 hrs = wt (kg) x 30
or
4 mL/kg/hr for 1st 10 kg
2 mL/kg/her for 2nd 10 kg
1 mL/kg/hr for every kg above 20 kg
Why do patients need maintenance fluids after surgery?
Systemic factors (fever, burns)
Loses from drains
Increased capillary permeability
Fluids: Dextrose 5% in H2O
50 g/ dL of glucose
Given in the case of evaporative loss postoperatively
Fluids: Dextrose 5% & NaCl .45 %
50 g/dl of glucose + 77 meq/L of both Na and Cl.
Fluids: NaCl 0.9%
154 meq/L of Na and Cl
Fluids: NaCl 0.45%
77 meq/L of Na and Cl
Fluids: Lactated Ringers
103 meq/L of Na, 109 meq/L Cl, 28 meq/L of bicarb, and 4 meq/L of potassium.
Most commonly given as initial maintenance fluids and in the case of loss due to increased capillary permeability.
Fluids: Plasmalyte
140 meq/L of Na, 98 meq/L of Cl, 5 meq/L K, + magnesium, and buffers
Intermediate postoperative period: Potassium replacement
Usually potassium is not added to IV fluids for first 24 hours postop because levels may already be increased secondary to intraoperative trauma.
After 24 hours –> add 20 meq/L
When do you need to measure electrolyte levels postoperatively?
In patients requiring IV fluids for short postoperative period it is not indicated.
For complicated patients it may be needed daily in order to continue to evaluate fluid and electrolyte requirements.
What is in the process of evaluating fluid needs?
Vital signs Mental status I&O Central pressure monitoring Lab- acid-base status (ABG and BMP)
Intermediate postoperative period: postoperative ileus
S/p laparotomy peristalsis is decreased and slowly returns over 3-4 days.
Small intestine –> 24 h
stomach –> 48 h
large intestine –> 3-4 days
Intermediate postoperative period: Nasogastric tube indications
Esophageal & gastric resections
Marked ileus (bowel obstruction, diffuse peritonitis)
Acute gastric distension postoperative
Potential complications associated with nasogastric tube
Postoperative atelectasis
Postoperative pneumonia
Gastric reflux/ aspiration
When should you remove NG tubes?
When output is decreased
Or when peristalsis is returned.
Intermediate postoperative period: hyperglycemia
Monitor blood sugar and maintain in appropraite range (140-180)
Return to preadmission regimen once diet has resumed.
Transfusion therapy: Whole blood
Contains 400-500 mL of donor blood with RBCs, Plasma, and clotting factors.
Platelets and granulocytes are not functions. Not routinely available.
Transfusion therapy: Fresh whole blood
Active clotting factors and functional platelets.
This is the ideal blood for massive trauma and availability is usually lacking.
Transfusion therapy: Packed red blood cells (RBCs)
One unit-300-350 mL of blood with plasma removed.
One unit should increase hemoglobin by 1 g/dL
Indications for blood transfusion
Hemoglobin < 7 g/dL
Patients with cardiac, pulm, cerebrovascular disease may require transfusion at higher hemoglobin.
Transfusion therapy: Leukocyte-reduced RBCs
Filters remove more than 99.9% of contaminating leukocytes.
This is more expensive but may be indicated for those with previous transfusion reactions, chronically transfused, and immunosuppressed.
Transfusion therapy: Apheresis platelets
Platelets collected from a single donor by aphaeresis procedure.
Typically takes ~ 1-2 hours for collection.
Indications for platelet transfusion
Plateles count < 10,000/ uL
Active bleeding and count < 50,000
Prophylactic prior ot invasive procedure & platelet cound < 50,000
Prior to neurosurgical and ocular procedures and platelet count < 100,000
Active bleeding & patients has required 10 unites packed RBCs
Transfusion therapy: Renal failure
Platelet dysfunction in renal failure can cause bleeding issues.
Should: administer desmopressin (DDAVP)
for active bleeding and immediately prior to surgical incision.
Transfusion therapy: Fresh frozen plasma
Prepared from centrifugation of whole blood and apheresis.
Contains clotting factors, albumin, and fibrinogen
Can be used in patients with deficiency of coagulation factors (congenital, liver disease, DIC, warfarin overdose, massive transfusion, prior to invasive surgery with INR > 1.6)
Only give in circumstance of active bleeding or risk of bleeding from emergency procedure.
Fresh frozen plasma (FFP) usage
Monitor PT/ aPTT and INR
Contraindicated in INR < 1.5
For patients on warfarin consider holding medication and monitoring.
Transfusion therapy: Cryoprecipitate components
Fibrinogen
Factor VIII
Von Wildebrand factor
Factor XIII
Used to correct hypofirinogenemia & factor XIII deficiency
Postoperative Pain: pain control
Document pain control in daily chart
Control the patients pain while also trying to limit amount of opioid use.
Do not over sedate the patient.
Postoperative pain: pain management options
Parenteral opioids Nonopioid parenteral analgesics Oral analgesics Patient-controlled analgesia Continuous epidural analgesia Intercostal block
Postoperative pain: Parenteral opioids
Bind to opioid receptors in CNS. Intravenous route preferred to intramuscular route.
Side effects: Respiratory depression Nausea & vomiting Ileus Clouded senorium
Especially see side effects in the geriatric patient!
Parenteral opioids examples
Morphine
+/- acetaminophen
Meperidine (Demerol)
Hydromorphone (Dilaudid)
Postoperative pain: nonopioid parental analgesics
NSAID drug (Toradol)
Available in injectable form
30 mg q6h
Want to limit use to 5 days.
Advantages: No respiratory depression
Side effects: GI, renal, impaired coagulation
**Avoid in orthopedic procedures
Postoperative pain: Oral analgesics
Indicated once pain level is decreased options include: Codeine + acetaminophen Hydrocodone + acetaminophen Oxycodone + acetaminophen Oxycodone + ASA
Postoperative pain: Patient-controlled analgesia (PCA)
Consists of timing unit, pump, and analgesic. Patient can deliver predetermined dose of analgesic by pressing the button. Timing unit interposes an inactivation period between doses.
