Surgery Flashcards
When do most post-op complications occur?
1-3 days after
Atelectasis
Partial or complete lung collapse. Lack of gas exchange in alveoli, due to alveolar collapse or fluid consolidation.
Basal atelectasis
The collapse of basally oriented lung tissue, a common post-operative complication, which is associated with mucus retention due to poor pulmonary clearance, and secondary infection.
Clinical findings
Dyspnoea, tachycardia, pyrexia, cyanosis, pain on coughing, reduced expectoration, secondary bacterial infection, reduced chest movement especially on affected side, basal dullness, crepitation on breathing.
Imaging
Opacity of involved segment, mediastinal shift to affected side.
Risk factors
Abdominal distension, emphysema, intubation, irritation from anaesthetics, mechanical trauma to airways, muscle weakness, obesity, opiate use for pain, post-operative drowsiness, pregnancy, smoking, wound pain.
Complications that tend to happen immediately following surgery
Primary haemorrhage
Basal atelectasis
Shock
Low urine output
Complications that tend to occur early after surgery
Acute confusion Nausea, vomiting Fever 2° haemorrhage Pneumonia Dihescence DVT Acute urinary retention UTI Infection Bowel obstruction Paralytic ileus
Paralytic ileus
Paralytic ileus is the occurrence of intestinal blockage in the absence of an actual physical obstruction. This type of blockage is caused by a malfunction in the nerves and muscles in the intestine that impairs digestive movement
Dihiscence
Rupture along anatomical line, fault
Wound dihescense
Two sides of incision come apart
2% of midline laparotomy wounds, usually 7-10 days post-op
Serious – up to 30% mortality
Anastomosis dihescence
Anastomoses are created by surgically attaching to previously unattached lumen-containing structures (ie intestines)
Dihescence is the separating of those structures.
Serious complication following intestinal surgery.
Post-surgical complications that occur late after the procedure
Bowel obstruction
Incisional hernia
Persistent sinus
Recurrence of original problem
Consumptive coagulopathy
Hemorrhagic disorder that occurs following the uncontrolled activation of clotting factors and fibrinolytic enzymes –> tissue necrosis and bleeding.
May result post op from large volume blood transfusion, anticoagulant meds, pre-existing/undiagnosed condition
Main cause of post-op morbidity following intestinal surgery
Infection.
Superficial often staph.
Keyhole vs laparoscopic sugary
Keyhole: small incision, use of fibre optic lights sources and little itty bitty instruments.
Laparoscopic: keyhole specifically inside the abdomen and peritoneal cavity.
Most common complication following abdominal surgery
Infection (especially staph)
Post-operative cellulitis/abscesses
Usually present within 1 week, but can manifest up to three weeks after.
Fever, spreading
Cellulitis: antibiotics
Abscesses: opened and cleaned and left to heal by 2nd intention
Gas Gangrene
Uncommon; potentially fatal
Bacterial gas-producing infection.
C perfringens
Spreads quickly.
Wound sinus
Late post-op complication from deep chronic abscess.
A wound sinus is a discharging blind-ended track that extends from the surface of an organ to an underlying area or abscess cavity
Usually caused by infection, liquefaction, or foreign body.
Factors which may affect wound healing
Poor blood supply Excess suture tension Long term steroid use Immunosuppressive therapy Radiotherapy Severe rheumatoid disease Malnutrition
Incisional hernia
Incompletely healed surgical wound through which intestines (or other viscera) protrude.
10-15% abdominal wounds. Usually within first year, but up to 15 years possible.
How many major surgeries/general anaesthetics result in respiratory complications?
15%
Aspiration pneumonitis
Sterile inflammation of
lungs from inhaling gastric contents
50% mortality
History of vomiting/regurgitation, or emergency surgery with full stomach.
Acute Respiratory Distress Syndrome
Surfactant dysfunction with resultant inflammation.
Results from direct or systemic insult to lung.
24-48 hours post-op
ICU – mechanical ventilation with positive-end pressure
Thrombo-embolism
Major cause of complications and mortality post-op
Obstruction of a blood vessel by a blood clot that has become dislodged from another site in the circulation.
Pulmonary embolism
Presents with sudden dyspnea, cardiovascular collapse, pleuritic chest pain, hemoptysis
Smaller PEs can present with confusion, breathlessness, chest pain.
Most frequently arise from DVTs
Urinary Retention
Common immediate post-op complication.
Can result from pain, drugs, over distension
Acute renal failure
May be cause by severe or prolonged hypotension, drugs, obstructive jaundice, aortic surgery.
Sx: bloody stools. breath odor. slow, sluggish movements. generalized swelling or fluid retention. fatigue. pain between ribs and hips. hand tremor. bruising easily.
Haemofiltration or dialysis
Acute renal failure: DDx
PRErenal faiure due to hypovolemia (in which case rehydrate)
Ileus
Hypomobility of the GI tract in the absence of mechanical obstruction.
Expected consequence of abdominal surgery.
Physiologic ileus spontaneously resolves within 2-3 days, after sigmoid motility returns to normal.
Ileus that persists for more than 3 days following surgery is termed postoperative adynamic ileus or paralytic ileus.
Adynamic ileus
loss of peristalsis with consequent dilatation of the colon in the absence of an obstructing lesion.
Early mechanical obstruction
One week after surgery
Twisted or trapped loop of bowel, or adhesions
Late mechanical obstruction
Adhesions can organize and persist, causing small bowel obstructions months or years post-op
Anastomotic leakage/breakdown
Common but may lead to peritonitis, sepsis.
Absolute general CIs
Medical emergencies Advanced organ failure Unstable diabetes complications Hemorrhage Fever Shock Fever above 38.5° Systemic contagious or infectious condition.
Absolute local CI’s
DVTs Thrombophlebitis Arteritis Post-op life-threatening aneurysms Local irritable skin conditions Open wound Pain syndromes Sepsis
Relative CIs
Congestive heart failure Chronic kidney disease Immunosupression General debilitation Drug withdrawal Hypo/hypertension
Physiologic pain
Results from high intensity sensation
Comes and goes
Safety mechanism
Clinical pain
Hypersensitivity to stimuli
Not always localized to injury sure.
Hematoma/seroma
Collection of fluid beneath the skin
Post-op complications relating to massage
Loss of CT tensile strength Muscle weakness Nerve damage Lesions, scars Loss of function
Four phases of wound healing
- Inflammatory
- Migratory
- Proliferative
- Maturation/remodelling
Inflammatory phase of healing
1
Begins immediately; peaks at 3-5 days.
Clot formation
Inflammatory response clears debris and organisms
Migratory phase of healing
2
AKA re-epithelization phase
2-5 days
Clot becomes scan
Epithelial cells begin to bridge wound
Proliferative phase of healing
3
AKA collagen and fibroblastic phase
Collagen synthesis, increased tensile strength
Granulation tissue formed with neovascularization
Maturation phase of healing
4
AKA remodelling phase
6 weeks onward
Collagen forms cross-links, scars flatten
Strength increases for 6 months, plateaus at 80%
Hypertrophic scars
Red, raised, pruiritic (itchy)
Amenable to surgical revision
Keloid scars
Tissue extends beyond scar boundaries
More frequent in darker skin
Treated with topical steroids
Primary healing
By first intention
Closure by direct approximation
Used in clean wounds
Secondary healing
Second intention
Wound is allowed to close by granulation, epitheliation, contraction
Infection, delay in care, loss of skin
Not as pretty
Tertiary healing
Third intention
Contaminated wounds
Allows inflammatory phase to continue, reducing chance of infection.
Closed 4-10 days post injury
Anti-asthma meds
Increased SNS
If high BP, vigorous, deep, painful methods, plus heat, are CId
Anticoagulants
Slow clotting.
Deep techniques may cause bruising.
Antidepressants, anti-anxiety meds
May alter temperature perception
Moderate, local hydrotherapy. Monitor visually and physically for adverse reaction.
No full body hydro
Anti-inflammatories
Frictions CId
May affect assessment
Corticosteroids
Repeated use may lead to tissue breakdown and poor healing at injection site
Muscle relaxants
Palpation: muscle feels loose, stretchy, hypotoned
Deep techniques, extreme stretches, full body hydro CId
Hydro: moderate and local
Watch for postural hypotension and dizziness
Barrier Phenomenon
Barrier of first resistance normally softens; when pathological does not spring or shift
Characteristics of active scars
Increased drag
Decreased stretch
Thicker skin fold
May adhere to underlying structures
