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
GI Complications:Paralytic ileus
Paralytic ileus
def: no peristalsis
Prevalence: 24-72 hours post-op
Causes:
-GI tract innervation is disrupted from intestinal manipulation
-Hypokalemia
-Wound infection
-Narcotics
Symptoms:
-Severe abdominal distension
-Nausea and/or vomiting
-Decreased or absent bowel sounds
-Severe constipation or passage of flatus and small liquid stools
Interventions:
-Ambulate, ambulate, ambulate
-Hold food and fluids (per order)
-NG tube to decompress the stomach (prevent intestinal perforation)
-Anti-emetics with or before food
-Notify surgeon
GI Complications:Postoperative Nausea and Vomiting (PONV)
s/s
Pallor, tachycardia, diaphoresis, and salivation
Retching: rhythmic contractions of the diaphragm, adnominal wall, and chest wall muscles that follows nausea
Vomiting: a reflexive, rapid, and forceful oral expulsion of the upper GI tract contents
Risk Factors:
-Female
-hx of PONV
-hx of motion sickness
-Nonsmoker
-Postoperative use/administration of opioids
-Use of volatile anaesthetics
-Use of nitrous oxide
-Age
-Duration/type of surgery
-High anxiety level prior to surgery
-Postoperative pain
-Dizziness on ambulation
-Timing of oral intake
interventions:
-Administer anti-emetics preventively if high risk.
-Modify analgesic routine if necessary
-Change to alternate opioid.
GU Complications:Urinary Retention
normal output 30cc/hr
Retention dt: Stress response, ADH increase
s/s
-Absence of voiding
-Bladder distention
-Complaints of discomfort
-Anxiety and restlessness
-Diaphoresis
-HTN
-Urinary frequency/ urgency/ sensation that bladder isn’t fully emptied with voiding
Interventions:
-Help patient ambulate as soon as possible post-surgery to commode or bathroom (unless contraindicated)
-Bladder scan (PVR) – look at volumes in OR/PACU
200 cc in first 8 hrs is good for post-op pt.
-we want them to collect 400ml in bladder to stretch before inserting i/o cath
TOV 3., then PVR. Important: try to pee first, then PVR. If over 400cc, get doc order for I/O cath. Normal pt will recover ability to pee.
GU: Healthcare Associated Urinary Tract Infection (HAUTI)
Most common hospital acquired infection
Risks:
-Duration of catheter – biofilm develops allowing bacteria to track up into the bladder
-Catheter management techniques
-Female sex
-Older age
-Diabetes mellitus, immunosuppressed
-Malnourished, frail
-chronic illness
Complications
-Acute delirium
-Decreased mobility
-Infection – which can lead to sepsis
-Increase LOS (morbidity, mortality)
Asymptomatic bacteriuria:
+ urine culture WITHOUT signs or symptoms of a UTI
We do not treat this!
Symptomatic UTI:
+ urine culture (≥ 100,000 CFU, < 2 organisms)
+ at least one of following signs or symptoms of UTI (with IUC) With no other recognized cause: fever, suprapubic tenderness, CVA tenderness
+ at least one of the following signs or symptoms of UTI (48 hrs post removal) With no other recognized cause:– above symptoms plus urgency/ frequency/dysuria
Indications for an Indwelling Urinary Catheter
-Acute/chronic urinary retention &/obstruction that cannot be relieved by use of intermittent catheterization
-Short-term monitoring of urinary output in critically ill patient
-Peri-operative use for selected surgical procedures
-Intra-operative monitoring of urinary output
-Facilitate healing in advanced (Stage III or IV) pressure ulcers in incontinent patients
-Requires prolonged immobilization with inability to void with alternative measures
-Improve comfort for end of life care
HAUTI prevention
-Hand Hygiene
-Avoid unnecessary urinary catheters through nursing and physician education (CPG)
-Insert using aseptic two person technique
-Cleanse with CHG sponges prior to insertion
-Maintain catheters based on recommended hygiene guidelines
-Promotion of one-way urine flow
-Review of catheter necessity daily and removal promptly
-Elimination of re-usable plastic measuring basins
-Utilization of Foley tracking tool in physicians orders
-Meditech tracking and auditing
-Bag off of floor
-Single use Vernacare container to discard urine as required
-Use routine precautions during any manipulation of the catheter or drainage system
-If breaks in aseptic technique, disconnection or leakage occur – replace catheter and drainage system
-Maintain a continuously closed system
-Maintain meticulous hygiene at the catheter-urethral interface – BID & PRN
Advocate for your Patient!
Q: Why does this patient have a catheter?
Q: Do they meet the criteria to keep it in?
If they don’t – contact MRP & get it out
Q: Any s/s of a UTI?
Fever, urgency, frequency, dysuria, CVA or supra-pubic tenderness
If suspected ~ send a C&S and notify MRP.
After-Removal Nursing Care: (catheter)
Mobilize – at least twice per shift (check mobility orders)
Get patient up to commode or bathroom to void q2h while awake
Avoid bedpans
Optimize bowel function
If unable to void in 4 hours =Follow bladder scanning protocol
Surgical Site Infections (SSIs)
Four Pillars for Prevention:
1. Normothermia
-Average temperature drop for a patient in the OR is 1oC
-Anaesthetics inhibit the body’s ability to thermoregulate (you cannot shiver).
-Preventative measure is preop warming. We achieve this by using the Bair Paws gowns. Minimum 30 mins preop. Patient must understand to not turn it off, to adjust the temperature knob, and that there is no battery so they need to be switched to a regular gown to go for a walk around the unit.
- Antibiotic Timing
-Antibiotics need time to absorb, but the goal is to have them at peak levels from time of inicision to time of close.
-Antibiotics goal is infusion starting 30 – 60 mins before cut time.
-We achieve this by sending our antibiotics to the OR. There are a few antibiotics the OR might ask us to start preoperatively (i.e. cefazolin). - Glycemic Control
-High blood sugars during and following an operation predispose patients to SSIs as they promote growth of bugs.
-To prevent this, we are starting glycemic control measures. Patients with high blood sugars will receive an insulin infusion during the OR and PACU stays. They will be switched to subcutaneous insulin for their stay on the inpatient unit.
-Highest risk factor group is undiagnosed diabetics. First we will work out this process, and then expand our screening criteria to catch these patients. - Skin Prep
-Patients who receive shaving prior to an operation are at higher risk for infection as shaving causes opening in the skin’s protective barrier.
-To Prevent this, patients are sent to the OR without shaving. If necessary, the OR will perform clipping on a patient.
-We also prep patients preoperatively with at least one wash (two preferred) with CHG (chlorhexidine gluconate) wipes to help prevent infections.
Interventions:
Local: Wound culture and PO abx
Systemic: Same as for sepsis.
Wound Dehiscence and Evisceration
-Wound edges fail to join
-A portion of the viscera protrudes through the incision
-Peritonitis and septic shock
s/s
-Serosanguinous exudate
-Visible intestine
-Popping sensation felt by patient after retching, forceful vomiting, coughing or straining
Interventions:
-Keep patient in bed
-Notify surgeon
-Withhold food and fluids
-Patent IV
-Apply sterile dressing
-Analgesics (fast acting)
