postoperative complications- QUESTIONS Flashcards
A)pulmonary edema B) pulmonary embus C)pleural effusion D)pneumonia E)Myocardial infarction F)basal atelectasis G)asthma H)angina pectoris
Choose the most likely complication from above
A 40-year-old lady was admitted with pelvic mass, ascites and shortness of breath. At laparotomy she was found to have a solid ovarian tumor, the results of which was benign. What is the most likely cause of her shortness of breath?
A 75-year-old woman had vaginal hysterectomy for pelvic organ prolapse. She woke up feeling short of breath in the morning on postoperative day 1. There are crackles on auscultation bibasally.
A 62-year-old woman with a raised BMI had a laparotomy to remove a solid ovarian mass. She has been reluctant to mobilise due to occasional crampy pain in her legs. On postoperative day 3, she complained of chest pain and difficulty breathing.
A 50-year-old woman had laparoscopic hysterectomy. She is a known heavy smoker. On the evening following surgery, she complained of central chest pain and shortness of breath which lasted for more than a few minutes.
1 - The answer is pleural effusion. She has Meig’s syndrome which typically presents with a triad of solid benign ovarian tumour, ascites and pleural effusion.
2 - The answer is pulmonary oedema. She could have been given too much intravenous fluids. Pneumonia usually presents a few days later and rarely immediately on Day 1.
3 - The answer is pulmonary embolus. Calf pain can be a presentation of DVT, the presence of a pelvic mass could contribute to sluggish venous return and clot formation. The clot has embolised to her pulmonary circulation.
4 - The answer is myocardial infarction. Angina pectoris does not usually last long and happens on exertion although unstable angina can happen in women with a history of diabetes.
- Colloids,
- Cryoprecipitate
- Crystalooids
- FFP
- Group specific blood
- Irradiated group specific blood
- O Rhesus neative blood
- Human albumin solution
A 30-year-old woman developed DIC following major obstetric haemorrhage. Following resuscitation and blood products, her results are as follows: Hb 7.0 platelets, 50 APTT, PT prolonged, reduced fibrinogen. Haemostasis has been achieved.
A 38-year-old woman with a history of renal transplant had a trial of instrumental delivery in theatre. She sustained a blood loss of 2.0 litres. Hb returned at 6.5.
A 28-year-old woman collapsed on the floor in the toilet of the delivery suite following an emergency caesarean section. There was blood in the bed pan and all over the floor.
A 40-year-old woman had a mid urethral tape inserted 3 days ago. She presented to the emergency department feeling unwell. She was tachycardic, tachypnoeic with a temperature of 39°C. Her blood results showed Hb 7.5 (8.5), platelets 140, normal clotting screen, normal renal function and CRP 200.
1 - The answer is cryoprecipitate. There is hypofibrinogenaemia which needs treatment. Platelet transfusion is not necessary when there is no further ongoing bleeding
2 - The answer is irradiated group specific blood. She is a transplant patient hence the need for irradiated blood product.
3 - The answer is O Rhesus negative blood. In the event of an emergency, where group specific blood may take a few minutes and the diagnosis is obvious, replacement must take place urgently whilst awaiting further group specific crossmatched product.
4 - The answer is crystalloid. This woman has sepsis and requires initial fluid resuscitation
A 26-year-old woman had diagnostic laparoscopy as a day case procedure. She went home the same day and returned 4 days later with vomiting, abdominal pain and rigors.
What is the most important diagnosis of exclusion?
Bladder injury Pelvic inflammatory disease Small bowel injury Urinary tract infection Wound infection
The answer is small bowel injury. Bladder injury could be a potential differential diagnosis, however it is relatively rare that this would happen at laparoscopy as the ancillary ports at the suprapubic region are inserted under direct vision. The bladder is also emptied at the beginning of the procedure.
Urinary tract infection rarely presents with vomiting.
Small bowel injury can happen especially with multiple attempts at insertion of the Veress needle. It is therefore important not to skip safety checks for Palmer’s test and entry pressure when CO2 is introduced.
Pelvic inflammatory disease is not a recognised complication following laparoscopy.
Wound infection is a possibility but it is usually associated with less severe symptoms and can easily be diagnosed on abdominal inspection and palpation.
A 33-year-old woman had a tension free vaginal tape inserted. At follow-up she is complaining of a recurrent urinary tract infection and urgency to urinate. Her consultant wants to ensure there is no evidence of bladder wall perforation which was missed at her initial surgery.
What would be the best modality to confirm or exclude this finding?
CT urogram Cystourethroscopy Intravenous urogram Micturating cystogram Ultrasound KUB
The correct answer is cystourethroscopy. Ultrasound KUB is not a sensitive imaging technique to identify bladder injury. It is a good modality to diagnose hydronephrosis, large bladder or kidney lesions. However, some tertiary centres can identify the position of synthetic mid urethral slings using transperineal ultrasound. There is limited experience with this technique hence it is not a standard modality used in most centres.
Micturating cystogram can be used to identify bladder injury however the perforated site might be very small to be detected on imaging.
Intravenous urogram or IVU is best used to identify anatomical anomalies and calculi.
A CT urogram is a modality which can be considered, however the risk of radiation and contrast exposure as well as cost effectiveness to identify a small perforation must be taken into account.
Cystourethroscopy under local or general anaesthesia should be carried out. A repair by an experienced surgeon could be done at the same time.
Early (less than 36 hours) postoperative complications
within 1 and half day.
Fluid management
Pain
Primary surgical haemorrhage (within 24 hours postop)
Revealed haemorrhage
Concealed haemorrhage
Superficial wound haematoma
Atelectasis
Ureteric/bladder injury
Ureteric obstruction
Wound infection (streptococcal/clostridial)
Late (later than 36 hours) postoperative complications
after 1 and half day.
Any early causes as above
Urinary tract infection
Chest infection
Wound dehiscence and incisional hernia
Abdominal/pelvic abscess
Secondary haemorrhage
Thromboembolic deterrent
Bowel injury
Bowel obstruction
Paralytic ileus
Diarrhoea
Fistula
48 year old
laparoscopic hysterectomy 8 hours ago
EWS: 7
EXAM: airway: clear, RR: 20bpm SO2: 96 % Capillary refil l> 5sec Pulse: 120bpm BP: 90/60 D- AVPU Abdomen: tender, distended I/O: 2200/200ml
What immediate action is required?
Arrange for the woman to return to theatre Blood transfusion Pressure dressing Intravenous fluids Facial oxygen
Relevant blood test required
- FBC
- U&E
- LFT
- Clotting screen
- Group and save
- Group and crossmatch
- Hb: 7 (preop 11)
- WCC:15
- Platelet: 70 (preop 180)
- Na: 130
- K: 3.5
- Urea: 4
- Creat : 50
- eGFR: >60
- ALT: 50
- ALP:83
- GGT:40
- Albumin:30
- APTT:37
- PT: 1.0
- INR: 1,0
- O positive
Intravenous fluids
- FBC
- U&E
- LFT
- Clotting screen
- Group and crossmatch
48 year old
laparoscopic hysterectomy 8 hours ago
EWS: 7
EXAM: airway: clear, RR: 20bpm SO2: 96 % Capillary refil l> 5sec Pulse: 120bpm BP: 90/60 D- AVPU Abdomen: tender, distended I/O: 2200/200ml
Immediate action: Intravenous fluids
Relevant blood test required
- Hb: 7 (preop 11)
- WCC:15
- Platelet: 70 (preop 180)
- Na: 130
- K: 3.5
- Urea: 4
- Creat : 50
- eGFR: >60
- ALT: 50
- ALP:83
- GGT:40
- Albumin:30
- APTT:37
- PT: 1.0
- INR: 1,0
- O positive
Arrange for theatre
Part 3
At laparotomy, the bleeding point was identified and ligated. However the woman is now bleeding from the surface of raw edges and diathermy is not successful at achieving haemostasis.
The area appears to be oozy and SURGICEL® or Floseal® is used. The former provides a network upon which fibrin and platelets can be deposited and the latter consists of patented gelatin granules and human thrombin to provide haemostasis. The woman is not clotting well.
Part 3
At laparotomy, the bleeding point was identified and ligated. However the woman is now bleeding from the surface of raw edges and diathermy is not successful at achieving haemostasis.
The area appears to be oozy and SURGICEL® or Floseal® is used. The former provides a network upon which fibrin and platelets can be deposited and the latter consists of patented gelatin granules and human thrombin to provide haemostasis. The woman is not clotting well.
What is the diagnosis?
Poor tissue perfusion Disseminated intravascular coagulation (DIC) Decreased platelets Bleeding point not identified Infection
Disseminated intravascular coagulation (DIC)
Part 4
The diagnosis is DIC. Massive haemorrhage protocol is initiated. The anaesthetist has given her tranexamic acid intravenously. Blood products have been organised prior to theatre as her clotting and platelets were deranged. The woman had fresh frozen plasma and cryoprecipitate. A unit of platelet was also given.
Blood loss was calculated, this included weighing of swabs and suction volume deducting any fluid used for washout. A drain, e.g. Robinsons, was left in situ in the pelvis along with a Redivac drain under the rectus sheath to monitor bleeding post-operatively.
Antibiotics
A 72-year-old woman who was previously fit and well underwent a laparoscopic hysterectomy for stage I endometrial cancer. The procedure was reported as routine and she was recovering well until four days postoperative when she developed a sudden onset of shortness of breath, with oxygen saturation 85% on air.
What is the differential diagnosis?
What would be your initial investigations?
MI
PE
atelectasis
chest infection.
ABGs FBC ECG CXR troponin.
key points of posoperative VTE
Women must be individually risk assessed for VTE preoperatively.
If in doubt, repeat investigation while maintaining patient on therapeutic anticoagulation.
Ventilation perfusion scan has less radiation dose to womens’ breasts.
CTPA is the gold standard for diagnosis of pulmonary embolus but has long term implications.
key points of posoperative Sepsis and infection
Genital tract sepsis is a polymicrobial infection.
Sepsis is treatable if the woman is resuscitated adequately and urgently.
The use of prophylactic antibiotics for selected gynaecological procedures reduces infection.
Pelvic abscesses need draining if there is a failed response to intravenous antibiotics.
Use invasive devices sparingly and if used remove as soon as practical.
A 24-year-old woman had an epidural for analgesia in labour. She had an emergency caesarean section for delayed progress in first stage. You go to see her the next day to debrief her, when she complains of a headache.
Typically, what is the most likely presenting complaint in post-dural puncture headache?
Blurred vision Epistaxis Severe frontal headache Severe vomiting Vertigo
What would be an important diagnosis of exclusion?
Encephalitis Meniere's disease Meningitis Pre-eclampsia Space occupying lesion
The answer is severe frontal headache. A headache is a common complaint in women with a post-dural puncture. The pathophysiology is not fully understood - it is either attributable to the traction on intracranial structures due to lowering of CSF pressure, or compensatory venodilatation (Monroe-Kellie doctrine). The headache is usually postural and can improve when lying down.
Severe vomiting is not a typical presentation of post-dural puncture headache. Patients can present with nausea and vomiting but a headache is more common.
There have been reported cases of diplopia and cortical blindness, again this is not a common presentation.
Epistaxis is not a common presentation of post-dural puncture headache.
Vertigo can be present. Again, note the question relates to the most likely presenting complaint.
___________________________________
The answer is meningitis. Meningitis is a mentioned complication following epidural anaesthesia. There should be additional findings apart from a headache in isolation. When considering other potential differential diagnosis, imaging and if necessary a lumbar puncture can be performed. Obstetricians should be guided by their anaesthetic colleagues and physicians.
Encephalitis is not a recognised complication following epidural insertion.
Space occupying lesion - vomiting and worsening symptoms with valsalva is a feature. Patients will also have an abnormal neurological examination depending on the area affected.
Meniere’s disease is a benign condition which rarely presents with a headache in isolation.
Pre-eclampsia will have other clinical features especially hypertension which gives rise to the headache.
Urinary complications case study
A 26-year-old woman was admitted for laparoscopic resection of the endometriotic fibrosis on the left uterosacral ligament. The procedure was difficult and resection of the fibrotic endometriotic tissue was performed.
The left ureter was dilated and as it was in the middle of the endometriotic nodule, it was difficult to pass a ureteric stent during cystoscopy. The ureter was dissected free and appeared intact at the end of the procedure. An IVU was arranged prior to her discharge home on day 3.
On day 8 she returned complaining of constant urinary leakage. Urine was demonstrated from the vault suture line and IVU confirmed the presence of a uretero–vaginal fistula.
A nephrostomy was inserted down, which passed a ureteric stent. Renal function was unaffected and there were no long-term sequlae from the occlusion.
Going forward, what would your considerations be in this case?
Write your answer in the reflective notes below before proceeding.
What would your considerations be in this case?
If there is any doubt in your mind, investigate.
If there has been difficult surgery or distorted anatomy, consider investigation to ensure that there is no damage.
Seek urological help if injury is suspected.
