Postoperative care - Complications & Management

Question 1

T/F n if everything before and during the surgery go exactly as planned, no postoperative complications will occur.

Answer 1

F

Question 2

Mechanical complications are
those that arise as a direct
problem of _______

Answer 2

the surgical wound and may be a result of
poor technique

Question 3

Mechanical complications

Answer 3

○ Hematoma
○ Hemoperitoneum
○ Seroma
○ Wound Dehiscence
○ Anastomotic Leak
○ Retained Foreign Bodies

Question 4

Hematoma

Answer 4

○ A collection of blood and clot in the wound.
○ Common and usually a result of inadequate
hemostasis in the surgical bed before closure.
○ Risks: Some medications and coagulopathies.

Question 5

These often require drainage as they increase the risk of wound infection or dehiscence

Answer 5

Hematoma

Question 6

Hemoperitoneum

Answer 6

○ Bleeding into the peritoneum after abdominal surgery.
○ Life-threatening and manifests as hypovolemic shock within the first 24 hours post op. Return to OR.

Question 7

Life-threatening and manifests as hypovolemic shock within the first 24 hours post op.

Answer 7

Hemoperitoneum

Question 8

Seroma

Answer 8

○ Collection of serous fluid in the surgical
bed; Usually not “serious”.
○ Increases risk of infection and may slow
wound healing or cause dehiscence.
○ May require drainage, but can recur.
○ Adequate deep tissue closure helps to
prevent the development of seromas

Question 9

Wound Dehiscence

Answer 9

○ Partial or total disruption of any or all layers of the operative wound.
○ Please see the “Wound Management and Wound Healing” lecture

Question 10

Adequate deep tissue closure helps to
prevent the development of ______

Answer 10

seromas

Question 11

Anastomotic Leak

Answer 11

○ A very serious complication of
intestinal anastomoses.
○ Occurs in up to a quarter of cases
to some degree.
○ Same risk factors that can apply
to wound dehiscence apply here.
○ Results in significant peritonitis,
fever, and can cause septic shock.
○ Often requires emergent surgery.
○ High risk of mortality.

Question 12

A very serious complication of
intestinal anastomoses.

Answer 12

Anastomotic Leak

Question 13

Retained Foreign Bodies

Answer 13

○ Rarely objects are accidentally left in the surgical
wound (sponges, instruments, etc).
○ While mortality is low, morbidity is
high because it essentially always
requires return to the OR
○ The most common body cavity
involved is the abdomen, followed by
the thoracic cavity.
○ “Final counts,” possible x-ray, and
scanning counters decrease the rate

Question 14

Postoperative- Stroke risks

Answer 14

● Underlying medical conditions
● Elderly
● Types of surgery
○ Valve replacement
○ Endarterectomy
○ Needed anticoagulants
● Patients can have a stroke just
from general anesthesia alone,
regardless of surgery location

Question 15

Postoperative Cerebrovascular Attack (Stroke)

Answer 15

○ Almost always due to intraoperative or
immediate postoperative hypoperfusion
resulting in ischemic injury.
○ Elderly patients with atherosclerotic disease
that experience perioperative hypotension are
the most common victims.
○ Embolic-type strokes can occur with some
surgeries, such as Carotid Endarterectomies &
heart surgery with extracorporeal circulation

Question 16

Seizures

Answer 16

○ Metabolic derangements, some
medications, and a history of epilepsy all
can lead to a seizure in the postoperative
period. Risk is hard to calculate for most.
○ Treat rapidly with anticonvulsants.

Question 17

Extensive stays in the ICU can also
result in something called _____

Answer 17

ICU Psychosis (the ICU syndrome).

Question 18

a state of confusion most often caused by an acute metabolic
derangement and is more common in elderly patients

Answer 18

Delirium

Question 19

s may accompany delirium or may occur suddenly without any
apparent confusion

Answer 19

Psychosis
■ Manifests as “losing touch with reality” and/or hallucinations
■ Also often caused by medications or metabolic derangement

Question 20

Most commonly manifest after POD #3

Answer 20

Psychiatric Complications

Question 21

Delirium Tremens (DTs), six and treatment

Answer 21

○ Occurs in alcoholic patients who stop drinking
suddenly
○ Re-adaptation to ethanol-free metabolism
requires about 2 weeks.
○ Symptoms include personality changes,
anxiety, tremor, hallucinations, confusion,
agitation, and occasionally seizures.
○ Benzodiazepine and Thiamine (B1) are the
treatments of choice

Question 22

Most cardiac dysrhythmias appear during
_____

Answer 22

the operation or within the first 3
postoperative days (POD #0-3)

Question 22

Intraoperative dysrhythmias

Answer 22

Overall incidence is 20%
■ Higher incidence in those with known heart conditions (35%).
■ Usually related to the anesthesia meds

Question 23

Postoperative dysrhythmias

Answer 23

Overall incidence varies with type of surgery
■ Generally related to reversible factors such as hypokalemia, hypoxemia, alkalosis,
digitalis toxicity, and cardiac stress during anesthesia weaning.
■ Treatment- focused on any metabolic derangements and follows ACLS protocols

Question 24

Postoperative MI may be precipitated by factors such as _____

Answer 24

hypotension and hypoxemia

Question 25

Postoperative Heart Failure

Answer 25

Left ventricular failure and pulmonary edema appear in 4% of patients over the age of 40 years undergoing a surgery with general anesthesia ○ Fluid overload during and after surgery is the most common cause ○ Fluid restriction is needed; diuretics may be given, occasionally ventilation

Question 26

_____ are the most common single cause of morbidity after major surgical procedures and the second most common cause of postoperative deaths in patients over 60 years

Answer 26

Respiratory complications

Question 27

Atelectasis

Answer 27

○ The most common pulmonary complication affecting 25% of patients undergoing abdominal surgeries because of shallow breathing. ○ Appears most commonly in the first 48 hours after surgery. ○ Responsible for over 90% of fevers on POD #1 or 2.

Question 28

The most common pulmonary complication

Answer 28

Atelectasis

Question 29

Prevention of Atelectasis

Answer 29

Can usually be prevented with early mobilization, use of incentive spirometers, and encouragement to cough ○ Bronchodilators and mucolytics may be used. ○ Severe cases may need intrabronchial suction.

Question 30

_____ are particularly likely to aspirate regurgitated gastric contents when consciousness is depressed.

Answer 30

Trauma victims

Question 31

About 50% of aspirations result in _____

Answer 31

Pneumonia.

Question 32

Preventing Aspiration

Answer 32

○ Can be prevented by preoperative fasting, proper patient positioning, and careful intubation. ○ Bronchoscopy sometimes required for Tx, along with resp therapy.

Question 33

Postoperative Pneumonia

Answer 33

○ Pneumonia is the most common pulmonary complication among patients who die in the postoperative period. ○ Patients with peritoneal infection and those requiring prolonged ventilation after surgery are at the greatest risk ○ Often times the infecting pathogen is a hospital-borne, drug-resistant bacteria. ○ Tx consists of clearing secretions and IV Abx.

Question 34

Treatment for postopoerative pneumonia

Answer 34

Tx consists of clearing secretions and IV Abx

Question 35

Pneumothoraces may occur following the insertion of a ______

Answer 35

subclavian central catheter or after positive-pressure ventilation

Question 36

Gastrointestinal Complications:

Answer 36

○ Paralytic Ileus ○ Gastric Dilation ○ Bowel Obstruction ○ Fecal Impaction ○ Post Op Pancreatitis or Hepatic Dysfunction

Question 37

Paralytic Ileus

Answer 37

○ Anesthesia and surgical manipulation result in a decrease in enteric nervous system activity- Postoperative Ileus ○ Gastrointestinal peristalsis generally recovers to near normal within 24-48 hours after surgery

Question 38

Gastric Dilation

Answer 38

○ Rare, but life-threatening complication of massive distention of the stomach by gas and fluid, sometimes after failed intubation. ○ Intragastric pressure can cause ischemic necrosis and perforation, as well as pressure on intrathoracic or intra abdominal structure/organs

Question 39

Bowel Obstruction

Answer 39

○ Acute bowel obstruction is usually from constipation or paralytic ileus. ○ Delayed development of bowel obstructions can occur as the postoperative formation of adhesions or intussusception

Question 40

Delayed development of bowel obstructions can occur as the postoperative formation of ______

Answer 40

adhesions or intussusception

Question 41

Fecal Impaction

Answer 41

○ Fecal impaction can develop as a result of colonic ileus after surgery. ○ Most commonly a problem in elderly patients, although not always

Question 42

The use of postoperative opioid or anticholinergic medications is a common cause of _____

Answer 42

Fecal impaction

Question 43

Postoperative Pancreatitis

Answer 43

○ Postoperative pancreatitis accounts for 10% of all acute pancreatitis cases. ○ Occurs in 1-3% of patients having surgery near to the pancreas. ○ Can complicate surgeries of bilary system, ERCP ○ Post Op pancreatitis is a severe (necrotizing) type, mortality rate is 30-40%

Question 44

Postoperative Hepatic Dysfunction

Answer 44

○ Hepatic dysfunction ranging from mild jaundice to life-threatening hepatic failure develops after 1% of general anesthesia operations. ○ The cause may be medications, transfusions, sickle cell crisis, resorption of hematomas (bilirubin overload with hemolysis), ischemia, sepsis, biliary obstruction etc. Can be pre-, intra-, posthepatic source.

Question 45

Postoperative Urinary Retention

Answer 45

○ The inability to void after surgery is common, especially after pelvic/perineal operations, or operations conducted under spinal anesthesia. ○ The narcotics used during anesthesia in general can also induce inability to void urine. ○ Foley should be removed as soon as possible. ○ Within a few hours, they will hopefully start voiding, but if not, a Foley should be placed again, for 4-5 days to allow recovery

Question 46

Postoperative Urinary Tract Infection

Answer 46

○ UTI is the most frequently acquired nosocomial infection. ○ The strongest risk factor for postoperative urinary tract infection is the placement of a Foley catheter ○ Prevention involves prompt treatment of urinary retention and avoidance of unnecessary prolonged urinary catheter use. ○ Treatment with antibiotics

Question 47

___ is the most frequently acquired nosocomial infection

Answer 47

UTI

Question 48

______ are perhaps the most common postoperative complication.

Answer 48

Infectious complications

Question 49

Meticulous surgical technique and giving an appropriate perioperative antibiotics are the best ways to prevent _____

Answer 49

SSIs.

Question 50

Treatment for surgical site infections

Answer 50

Antibiotics, debridement, irrigation, and healing by secondary intention are the usual treatments.

Question 51

Clostridium Difficile Colitis

Answer 51

○ Excessive (or even normal) perioperative antibiotic use can result in the postoperative diarrhea of Clostridium difficile (C Diff Colitis). ○ Spectrum of severity ranges from mild to severe toxic colitis (rare). ○ Tx-DC the antibiotic, and treat with PO Vancomycin or IV metronidazole

Question 52

Drug-Resistant Infections

Answer 52

○ Drug-resistant organisms, such as MRSA and VRE, are present as asymptomatic colonization in about 30% of the community. ○ Nosocomial spread of these bacteria to postoperative patients can result drug-resistant pneumonia, UTIs, surgical site infections, sepsis, etc. ○ Prevention involves contact precautions and limited Abx use

Question 53

Venous Thromboembolism

Answer 53

○ Because of the vessel damage that occurs in surgery, and the increased incidence of “laying around” during recovery, surgical patients are at increased risk of developing DVTs and PEs ○ Prevention strategies are required postoperatively and may involve Sequential Compression Devices, SC Heparin/LMWH, early ambulation, DOAC ○ If VTE is suspected, Duplex Ultrasound and/or CT Pulmonary Angiography are the Dx tests of choice. ○ Systemic anticoagulation (IV then PO) is required, and other Txs may be needed (such as IVC filter

Question 54

Prevention strategies for Venous Thromboembolism

Answer 54

may involve Sequential Compression Devices, SC Heparin/LMWH, early ambulation, DOAC

Question 55

What to do If VTE is suspected post-surgery

Answer 55

Duplex Ultrasound and/or CT Pulmonary Angiography are the Dx tests of choice

Question 56

What should be on your differential diagnosis if your postoperative patient develops a fever

Answer 56

Remember the 6Ws!○ Wind- Lungs. Does the patient have Atelectasis or Pneumonia? ○ Water- Urine. Does the patient have a Urinary Tract Infection? ○ Wound- Incision or anastomosis. Does the patient have a SSI? ○ Wonder drugs - certain anesthetics ○ Walking- DVT ○ Wires- Access Lines. Infection of the IV or Arterial lines?

Question 57

What are the 6Ws for?

Answer 57

The Postoperative Fever ○ Wind- Lungs. Does the patient have Atelectasis or Pneumonia? ○ Water- Urine. Does the patient have a Urinary Tract Infection? ○ Wound- Incision or anastomosis. Does the patient have a SSI? ○ Wonder drugs - certain anesthetics ○ Walking- DVT ○ Wires- Access Lines. Infection of the IV or Arterial lines?