Surgery: Post-op

Question 1

what is included in “early mobilization” to prevent complications of post-op? (5)

Answer 1

1. Deep breathing and coughing
2. Active daily exercise
3. Joint range of motion
4. Muscular strengthening
5. Make walking aids such as canes, crutches and walkers available

Question 2

what is ASA physical status?

Answer 2

score 1-6

from “normal healthy patient” to “mild systemic dz” to “declared brain dead”

Question 3

infection is usually confined to what?

Answer 3

SubQ tissues

Question 4

surgical wound classification 1-4

Answer 4

(1) Clean : no gross contamination from exogenous or endogenous sources
1. 5%

(2) Lightly contaminated: clean-contaminated
2–5%

(3) Heavily contaminated: 5–30%
(4) Infected: in which obvious infection has been encountered during operation

Question 5

two types of surgical site infections (SSIs)

Answer 5

Incisional SSIs
Superficial: Incisional (skin and subcutaneous tissues)
Deep: Incisional (deeper soft deep fascia, muscles, and tissues beneath subcutaneous tissue of the incision)

Organ/space SSIs
Any part of the anatomy other than body wall layers that was manipulated during the procedure

Question 6

2 types of factors that contribute to surgical infections

Answer 6

1. host : (DM, hypoxia, malnutrition, etc)

2. perioperative factors: ( operative shaving, breaks in sterility, etc)

Question 7

prophylactic abx are indicated for what two types of “surgical classification”s ? when are they discontinued?
(kinda weeds)

Answer 7

clean/light contaminated or contaminated cases

• use for just about for any big surgery (b/c most will be clean-contam.)
• discontinue usually within 24 hours of operation

Question 8

risk of Abx resistance (kinda weeds)

Answer 8

Immunodeficient / compromised
Implants/invasive devices
Elderly patients
Illness severity
Extended LOS (length of surgery) 
Exposure to broad spectrum antibiotics 

*but wont really change how we prophylax

Question 9

one of the most common wound complications and is almost always caused by imperfect hemostasis ( wound is not DRY/ properly closed)

Answer 9

hematoma (collection of blood and clot in the wound)

Question 10

why are hematomas bad for post-op? how to avoid?

Answer 10

Increased chance of dehiscence (opening up of the wound) and infection.
-give anti-coags

Question 11

what is a seroma? why are they bad?

Answer 11

Fluid collection in the wound other than pus or blood. Seromas delay healing and increase the risk of wound infection.

Question 12

what is wound dehiscence? when is it most commonly seen?

Answer 12

Wound dehiscence is partial or total disruption of any or all layers of the operative wound.
(in abd procedures, can be BAD)
most commonly observed between the fifth and eighth postoperative days, when the strength of the wound is at a minimum

Question 13

MOST important factor in preventing wound dehiscence ?

Answer 13

adequacy of closure: performing a neat incision, avoiding devitalization of the fascial edges by careful handling of tissues during the operation, placing and tying sutures correctly, and selecting the proper suture material.

Question 14

what gives “strength “ to a closure?

Answer 14

The fascial layers give strength to a closure, and when fascia disrupts, the wound separates.

Question 15

the most common single cause of morbidity after major surgical procedures and the second most common cause of postoperative deaths in patients older than 60 years.

Answer 15

pulmonary complication

Question 16

what type of operations are pulmonary complications most common?

Answer 16

emergency operations

Question 17

most common pulmonary complication, affects 25% of patients who have abdominal surgery. how is it fixed?

Answer 17

atelectasis (lung collapse)

-self- limited

Question 18

fever within 48 hours post-op MOST likley means what?

Answer 18

atelectasis

Question 19

pts who die after surgery, what is the most likely cause?

Answer 19

post-op Pneumonia

Question 20

who gets fat embolisms?

Answer 20

• fractures of long bones or joint replacements.

- exogenous sources of fat, such as blood transfusions, intravenous fat emulsion, or bone marrow transplantation.

Question 21

fat embolism syndrome

Answer 21

consists of neurologic dysfunction, respiratory insufficiency, and petechiae of the axillae, chest, and proximal arms.

Question 22

how do we want the blood to be during surgery and then after?

Answer 22

sticky/thicker during surgery, Thin after

-Oral anticoagulant drugs should be stopped 3–5 days before surgery, put back on after

Question 23

what is bridging anti-coag? who might need this?

Answer 23

use of a short-acting parenteral agent to reduce the interval without anticoagulation
-patients on warfarin with an especially high thromboembolic risk

Question 24

cardiac complications:General anesthesia depresses the _______, and some anesthetic agents predispose to what?
what do you do about this?

Answer 24

General anesthesia depresses the myocardium, and some anesthetic agents predispose to dysrhythmias by sensitizing the myocardium to catecholamines.

-Monitoring of cardiac activity and blood pressure during the operation detects dysrhythmias and hypotension early.

Question 25

cardiac complications: In patients with a high cardiac risk, _______may be safer than _________for procedures below the umbilicus.

Answer 25

regional anesthesia (e.g. nerve block) may be safer than general anesthesia

Question 26

three main concerns for cardiac complications post-op

Answer 26

silent MI, fluid overload and resultant left ventricular failure, monitor electrolyte levels

Question 27

post-op ileus

Answer 27

Anesthesia and surgical manipulation result in a decrease of the normal propulsive activity of the gut

Question 28

GI peristalsis returns when after post-op ileus?

Answer 28

within 24 hours after most operations that do not involve the abdominal cavity

Question 29

what is gastric dilation? how does it present?

Answer 29

a rare life-threatening complication, consists of massive distention of the stomach by gas and fluid
-patient appears ill, with abdominal distention and hiccup

Question 30

txt of gastric dilation?

Answer 30

gastric decompression with a nasogastric tube.

In the late stage, gastric necrosis may require gastrectomy.

Question 31

how to differentiate between ileus and obstruction?

Answer 31

plain film (xray) 
- obstruction will show lots of gas stuck in there

Question 32

bowel obstruction is most often caused by what?

how does it present?

Answer 32

Mechanical obstruction is most often caused by postoperative adhesions or an internal (mesenteric) hernia

-patients experience a short period of apparently normal intestinal function before manifestations of obstruction supervene.

Question 33

post-op fecal impaction presentation

Answer 33

Early manifestations are anorexia and obstipation or diarrhea. In advanced cases, marked distention may cause colonic perforation.
- results from ileus and impaired perception of rectal fullness

Question 34

how common is post-op fever? how bad is it?

Answer 34

Fever occurs in about 40% of patients after major surgery.
In most patients the temperature elevation resolves without specific treatment.
BUT important, if there are other symptoms as well, evaluate clinically cause could be significant

Question 35

Features often associated with an infectious origin of the fever include… how many of these must be present for the chance of a bact. infection to be near 100%

Answer 35

preoperative trauma,
ASA class above 2
fever onset after the second postoperative day,
initial temperature elevation above 38.6 °C,
postoperative white blood cell count greater than 10,000/L
postoperative serum urea nitrogen of 15 mg/dL or greater.

If three or more of the above are present, the likelihood of associated bacterial infection is nearly 100%.

Question 36

fever after 5th post-op day may indicate what?

Answer 36

Fever this late suggests wound infection or, less often, anastomotic breakdown and intra-abdominal abscesses.

Question 37

Dx test for wound infections/ intra abd abscess?

Answer 37

CT scan of the abdomen and pelvis is the test of choice and should be performed early, before overt organ failure occurs.

Question 38

The 5 Ws

Answer 38

Wind: pneumonia, aspiration, PE
Water: UTI, (foley)
Walking: DVT PE
Wound:  SSI (surgical site infection)
Wonder drugs /What did we do? drug reaction, infection from vascular access, blood product reactions

Question 39

post-op fluid replacement is based on what 4 things

Answer 39

(1) maintenance requirements
(2) extra needs resulting from systemic factors (eg, fever, burns)
(3) losses from drains
(4) requirements resulting from tissue edema and ileus (third space losses).

Question 40

best test for renal fxn

Answer 40

how much urine is produced

Question 41

how much fluid do you replace?

Answer 41

multiplying the patient’s weight in kilograms times 30

(eg, 1800 mL/24 h in a 60-kg patient

Question 42

fluid requirements are increased by what 3 factors?

Answer 42

Maintenance requirements are increased by fever, hyperventilation, and conditions that increase the catabolic rate.

Question 43

Assessment of the status of fluid balance requires accurate records of what?

Answer 43

fluid intake and output and is aided by weighing the patient daily.