Postoperative Complications Flashcards
RESP
general: hypoxia, hypoxemia
1. Atelectasis
2. Aspiration
3. Pneumonia/ Sepsis
CVS
1. VTE
2. DVT
3. PE
4. Stroke
5. Hypovolemia
6. Bleeding
GI
1. Paralytic Ileus
2. PONV
GU
1. Urine Retention
2. UTI/ HAUTI
Surgical Site Infections (SSI)
pressure sores
RESP - hypoxia/hypoxemia
PaO2 < 80mmHg
Need blood gas analysis to confirm
caused by conditions that:
-Reduce the ability of oxygen to diffuse across the alveoli
-reduce perfusion of ventilated alveoli
-reduce ventilation of perfused alveoli
-reduce O2 tension of inspired air
-reduce volume of inspired air
Atelectasis is the most common cause of hypoxemia in the postop patient.
Atelectasis
def
s/s
interventions
def:
Hypoventilation and excessive retained secretions
s/s
-Diminished or absent breath sounds
-Dullness on percussion
-Reduced chest expansion, tachypnea
-Fever
-Restlessness/confusion
-Hypertension, tachycardia
Interventions:
-DB&C q1h while awake, Incentive spirometer
-Reposition patient, HOB >30
-Apply oxygen
-Notify surgeon
Aspiration
Prevention is key and involves the administration of __anticholinergic ex atropine_____________ prior to surgery
Pneumonia
def
s/s
interventions
def
lung inflammation caused by bacterial or viral infection, in which the air sacs fill with pus and may become solid
s/s
-Sudden onset of chills, shaking, with high fever
-Dyspnea, tachypnea, sharp chest pain exacerbated by inspiration
-Productive cough
-Diminished breath sounds
-Cyanosis with hypoxemia
interventions
-Maintain airway (acute)
-Apply oxygen (acute)
-Contact MRP/RT
-Labs/ diagnostics
-Sputum cultures
-CXR
-Blood cultures (if septic)
-Antibiotics
-Fluids
Sepsis
def
The systemic response to overwhelming infection, when a patient’s immune system fails to control pathogens or their toxins, from a site of infection
Systemic illness caused by microbial invasion to normally sterile parts of the body
Usually in blood and often bacterial, but can be any class:
Virus
Fungus
Parasite
Yeast
risk:
Aging population
Chronic diseases
↑ artificial joints, heart valves, CVCs
↑ people living with cancer, autoimmune diseases, immuno-compromised
↑ organ transplants
Indiscriminate use of antibiotics and antimicrobials
NOTE: Needs early detection and aggressive treatment
Most frequent sites of infection:
Lungs
Urinary Tract
Abdomen
Skin/Soft tissue
s/s
-Early on: organs can be hypo-perfused despite a reasonable BP
-Blood flow/oxygen prioritized to the brain and heart, thus shunted away from the kidneys, skin, GI tract, lungs. Resulting in organ dysfunction
Altered Consciousness Confusion Psychosis
Tachypnea, SaO2 <90%
Tachycardia, Hypotension, CVP
Oliguria, Anuria, Creatinine
Jaundice, Enzymes, ↓ albumin
↓ Platelets, PT, ↓ Protein C, D-dimer
interventions
- Labs – blood culture, serum lactate to trend anaerobic metabolism. Above 4 = poor outcome. Anything over 2 is rough
- Abx. Broad spectrum
- IV fluids – dt increased metabolic needs, maintain BP to SBP >90 or MAP > 65
- Monitor VS, U/o, LOC. U/o to watch end-organ perfusion of kidneys to tell if blood is shunting
Thorough assessment and VS (keep 02 saturation ≥ 92%)
Advise MD, PCC/Charge Nurse → GET HELP!
Contact ICU Outreach (if available at your site)
Diagnostics (from sepsis order set)
Blood and other cultures
CBC with diff, Coagulation profile, d-Dimer
ABGs
Lactate level
C-reactive protein – maker of vascular inflammation
Serum proteins
Blood sugar
Serum Creatinine and Urea
Liver function
Venous Thromboembolism (VTE): DVT/PE
VTE is a foreseeable risk without prophylaxis in hospitalized patients
Hip replacement 51%
Knee replacement 47%
General surgery 25%
Neurosurgery 22%
Populations at risk:
-Obesity
-Acute medical illness
-Increasing age over 40
-Cancer diagnosis
Prevention/Prophylaxis:
-Detection of added risk
-Proactive education
-mobility, weight, medication adherence
-Medical optimization
-Early frequent mobilization
-Hydration
-Post-op symptom assessment
-Treatment advocacy
Heparin
prevent clotting within blood vessels
Cancer patients cant take heparin. Cancer makes them hypercoaguable. So they need the things that go on their legs
Peri-Operative Stroke
Incidence:
-Depends on type and complexity of surgery
-Vascular surgeries ++ high risk
-Urgent surgeries
-Predominantly ischemic and embolic
-45% of perioperative strokes occur by POD#1
Risk Factors (preoperative):
-70+ years (decreased cerebrovascular reserve and multiple coexisting conditions)
-Female
-History: HTN, Diabetes, Renal Insufficiency, smoking, COPD, PVD, cardiac disease, systolic dysfunction, previous stroke or TIA
-Abrupt discontinuation of antithrombotic therapy before surgery
Risk Factors (procedure-related):
-Type and nature of surgery
-Anesthesia
-Duration of surgery
-Arrhythmias, hyperglycemia, hypotension, or hypertension
Risk Factors (post-operative):
-Heart failure, low ejection fraction, MI, arrhythmias (ie atrial fibrillation)
-Dehydration and blood loss
-Hyperglycemia
-Stasis in the post-operative period
-Bed rest
-Withholding of antiplatelet or anticoagulant agents (aggravate surgery-induced hypercoagulability)
-Prevention & treatment of inflammation and infections (High WBC correlates with an increased incidence of stroke)
Procedures with higher risk:
Carotid endarterectomy 5.5-6.1%
Peripheral vascular surgery 0.8-3.0%
General surgery 0.08-0.7%
peri-op stroke
Interventions:
CALL THE PHYSICIAN and encourage Neurology consultation
If they are eligible for thrombolytics, there is a 3 hour window from the onset of symptoms (tenectaplase or tPA)
TIA/Stroke Pre-Printed Physician Orders
Swallowing Screen
Early mobilization
Glucose control
Blood pressure control
Fever control
No indwelling foley catheters (unless absolutely necessary)
Post Stroke Care Diagnostics:
-ECG
-Chest X-Ray
-Holter Monitor
-Carotid Doppler
-Echocardiogram
Cardiovascular Complications
Fluid Overload
Dehydration/ Hypovolemia
Electrolyte Imbalance
Fluid Overload
causes
-Stress response in postoperative patients initiates increase of antidiuretic hormone (ADH) secretion and water retention.
-CHF
-Rapid, high volume IV infusions intra-operatively
s/s
-Increased BP, heart rate or shortness of breath
-Abnormal breath sounds (crackles/ decreased A/E)
-Peripheral Edema
-Decreased urinary output (less than 30 cc/hr) should be > 120cc in 4 hours
Prevention
-Monitor IV fluids /blood products rate and amount
-Monitor output – note 24hr balance (Include OR intake and output!)
-Assess for signs of overload – report and record them
-Meds as ordered e.g. diuretics, ACE inhibitors, Digoxin
Dehydration
def :
Excessive loss of water from the tissues.
s/s:
Hypotension/Tachycardia
Dry lips and mucous membranes
Lack of skin turgor
Muscle weakness, dizziness, restlessness, headache
Less than 350 cc of urine in 12 hours
Prevention:
-Monitoring of urine output/oral/IV intake
-Being aware of blood loss during surgery
-Monitoring of vital signs/including temperature
SYMPTOMS SIMILAR TO ANAEMIA!! CORRECT DEHYDRATION AND POSSIBLY AVOID UNNECESSARY TRANSFUSION
Hypovolemia
Total blood volume loss of 15 to 25%
Possible Causes:
-Blood loss from surgical site
-Severe dehydration
-Third-spacing
-Fluid loss from excessive vomiting, diarrhea
s/s:
-Lethargy
-Hypotension
-Rapid shallow respirations
-Rapid, weak pulse
-Cool, clammy skin
-Oliguria or anuria
Interventions
-Vitals, oxygen, IV fluids
-Contact MRP, ICU outreach
Postoperative Bleeding
s/s:
-Excessive bleeding for what is “normal” for the surgery
-Low hemoglobin
-Hypotension, tachycardia
-Pale, cool
Interventions:
-Vitals
-Notify surgeon
-Patent IV
-Apply pressure, call for help
-Try to keep the pt warm
-Have team there for support
-Lie pt flat (to reduce cardiac workload)
Electrolyte Imbalance
-Imbalance of normal electrolyte levels (sodium, potassium chloride, bicarbonate, calcium, phosphorus & magnesium)
-Hypokalemia (low potassium can affect heart function)
Increased risks:
-Preoperative NPO status
-Fluid loss during surgery
-Nausea, vomiting, diarrhea (decreased intake, increased output)
Interventions:
-Monitor lab values postoperatively
-Report/record abnormal values
-Medications – IV/PO
-Prevent c-diff – probiotics if antibiotics
-Treat and prevent nausea & vomiting
