Surgery - Post op complications Flashcards
1
Q
Incidence of post-op. complication
A
- Highest incidence 0-3 days post-op
- Specific complications in 3 patterns
- Immediate
- Early post-op
- Late post-operative period
2
Q
Miscellaneous in OT
A
ANAESTHETIC- anaphylaxis, malignant hyperpyrexia, suxamethonium apnoea, dislodged teeth, cut tongue/lips/sore throat. Unrecognised medical condition eg myasthenia gravis. Malfunctioning apparatus, impurities in gas
DAMAGE TO PATIENT- corneal abrasions, pressure points-nerve damage-positioning ( arm boards, lithotomy, DO NOT abduct arms beyond 90 degrees ), tissue necrosis ( prolonged pressure on nose ( ET tube ) hip abduction ( Lloyd Davis ), nerve damage from sharp needles, pressure sores, hypothermia. Wrong drug
BURNS from diathermy, lasers in ENT
ADJACENT structures, hepatic artery, ureter ( in gynae ), perforation of bowel in laparoscopy
Wrong operation, wrong side ‘ Never event ’.
3
Q
Immediate complications
A
- Haemorrhage
- Basal atelectasis-minor lung collapse
- Shock- MI, septicaemia (GU cases), continuing blood loss
- Low urine output-careful assessment of fluid balance-CVP
- Anaesthetic related complications
- Inadvertent damage to adjacent organs
- Wrong operation-’Never Event’
*
4
Q
Early post-operative complications-1
A
- 1st week
- Confusion ESPECIALLY in the elderly- ( exclude hypoxia, dehydration, sepsis, full bladder )
- Fever
- Secondary haemorrhage -usually infection
- Wound infection
- Wound breakdown ( dehiscence )-after about a week
- Anastomotic leak-can be very early
5
Q
Early complications -2
A
- Basal atelectasis/ chest infection ( hypoxia )
- DVT and PE
- Urinary complications- infection and retention
- Slow return of bowel function ( paralytic ileus ) –normal, but check electrolytes. ?Rx
- Bed sores-pressure necrosis
- Complications specific to surgical specialty
6
Q
Haemorrhage
A
- PRIMARY-occurs during the operation-should be corrected at the time-though not always
- REACTIONARY-occurs at the end of the operation when the wound initially looked dry but bleeding started in recovery/on ward as BP and CO rise to normal levels-? poor haemostasis/anaesthetic input
- SECONDARY-occurs several days after operation-usually infection that erodes into a vessel
7
Q
Treatment of surgical bleeding
A
- Good surgical technique-adequate haemostasis
- Check bp adequate at end of op. to see bleeding vessels ( induced hypotension )
- May need early re-exploration
- Find the bleeder and tie/cauterise
- Ooze
- Late post-op haemorrhage usually due to infection at operation site.-treat infection +/- re-explore
- Treat with iv fluids-plasma expanders/blood
8
Q
Treatment of medical bleeding
A
- Consumptive coagulopathy if a LARGE RAPID transfusion/sepsis
- Don’t forget bleeding diathesis or pre-op anticoagulants-warfarin, heparin, aspirin
- Aspirin bleeding-bruising/haematoma-pressure over part
- Check Hb/platelets/clotting screen
- Order x-matched blood
- Ensure good iv access (14g venflon)
- Invasive monitoring/HDU
- May need FFP or platelets ( talk to haematologist )
- ? Re-exploration
9
Q
Wound infection
A
- Commonly staph.aureus but coliforms important
- Wound infections more likely if:-
- ‘Dirty’ operation- ( GI )
- Long duration >2hrs )
- Susceptible patient-,old age, immunosuppression, DM
- Minor infection–red, c discharge-dressing, stitch out,?antibs
- More severe infection-cellulitis, localised abscess - as above but may need probing to let pus out ? further surgery . Heal by secondary intention
10
Q
Wound dehiscence
is one of the most common complications of surgical wounds, involving the breaking open of the surgical incision along the suture. Typically, the sutures or closures aroundwound edges should stay intact while new tissue, known as “granulation tissue,” starts forming to help heal the wound.
A
- Uncommon-about a week post op.
- Poor blood supply, long term steroids, infection, malnutrition, excessively tight sutures
- Often sero-sanguinous discharge a few days before
- Wound bursts open and bowel protrudes
- Cover with swabs and operate
11
Q
Common post-op problems
A
- Junior staff commonly asked to see patients because
- ↓Blood pressure (sometimes high )
- Pyrexia
- Poor urine output
12
Q
Post op hypotension-1
A
1.Residual effect anaesthetic drugs ( eliminate other causes first)
- ? Spinal anaesthetic, OR epidural may be in situ
- Systolic BP 80-90 mm hg OK except in elderly/CV disease
- Elevate legs +- fluid challenge ( care )
- Often warm with slow pulse
2.HYPOVOLAEMIA -?pre-op, intra-op, post op.
- Signs of poor peripheral circulation ( Cold, clammy, anxious )
- B blockers may mask tachycardia
- Watch urine output
- Raise legs, O2, fluid challenge, blood tests, CVP, HDU, clotting studies, ?re-operate
13
Q
Post-op hypotension -2
A
3.LVF
- History/exam for MI-poor peripheral circulation,
- ECG, bloods, CXR
- Small fluid load ( 250ml )
- CVP, PA catheter , arterial line
- Rx, O2,restrict fluid, diuretics, inotrope support,
4.SEPTIC SHOCK-often warm
- c ↑CO, followed by fall in CO as fluid lost-biliary surgery and urology
- Rx O2, colloids , inotropes , antibiotics, CVP
(systemic inflammatory response syndrome SIRS)
14
Q
Shock
A
- Definition-Inadequate perfusion and oxygenation of vital organs
- HAEMORRHAGIC
- Normal blood vol 70ml/kg –say 5 litres
- Stage 1. 15% blood loss-pt well c minimal signs.
- Stage 2. 15-30% loss. Anxious , HR, RR, Syst BP→ ( pulse pressure ↓)
- Stage 3. 30-40% loss. Classic signs of shock, confusion.
- Stage 4. Loss >40%.Life threatening
15
Q
Shock-2
A
- Non-Haemorrhagic causes of shock
- Cardiogenic
- Anaphylactic
- Septic
- Tension p’thorax
- Mediastinal shift and ↓venous return
16
Q
Post –operative hypertension
A
- Common
- Pain
- Existing hypertension
- Hypoxaemia
- Hypercapnia
- Vasopressors
- Needs urgent Rx WHY?
- O2, vasodilators labetolol, hydrallazine ( SNP ), ANALGESIA
- CARE +++++ in case you unmask hypovolaemia )
17
Q
Post-operative pyrexia
A
Small rise in temperature common
If it rises above 38C then consider and check the 7 Cs
- 1.CANNULA-presence of thrombophlebitis-remove/replace/cult.
- 2.CVP line ? Infected- remove/replace
- 3.CHEST-Hx, Examine, sputum→lab , physio, ?CXR
- 4.CATHETER-UTI,check urine-lab.
- 5.CUT-wound infection
- 6.COLLECTION ( pus )-abscess, failure of anastomosis
- 7.CALVES-DVT ( 2nd week post op c.low grade pyrexia)
18
Q
Chest infection
A
- Not uncommon in those at risk, smokers, COPD, obesity.
- Coughing ineffective and sputum blocks small airways →atelectasis distally. Inhaled organisms then → infection
- Basal atelectasis –after GA but can be sorted by deep breathing
- Thoracic and upper abdominal incisions
- In fit patients, usually not a problem.In at risk patients, control pain ( epidural anaesthesia ), regular deep breathing and coughing( physiotherapy ), early mobilisation , good hydration
- Physio, sputum, antibiotics, whatever necessary
19
Q
Collection of pus
A
- Deep collection- SUBPHRENIC . 7-21/7 post op.
- PELVIC abscess 5-10/7 post-op
- Usually after perforation/ peritonitis
- Pts appear to be doing well then, general malaise, nausea/vomiting, pain ( referred )
- ↑WCC, ultrasound or CT
- Drainage by open operation or percutaneously c US
20
Q
Anastomotic leak
A
- Anastomosis may LEAK → abscess formation →sealed off by omentum/bowel
- Pt slow to recover but improves with drip/suck/antibiotics
- LARGE leak or breakdown ( dehiscence )→severe illness, peritonits/septicaemia
- Operation asap, washout abdomen post-op care as required
- Bring out two ends as temporary stomas
21
Q
DVT
A
- DVT- clinical diagnosis in first instance-calf tenderness/pain, nagging pyrexia and ? red, swollen calf 10-14 days post op.
- 50% silent
- Tests essential, duplex scanning with Doppler ultrasound, D-dimer ( FDP present in blood after clot is degraded by fibrinolysis. So called because it contains 2 D domains and 1 E domain of fibrin molecule )
- D-dimer not normally present in plasma except where coagulation system has been activated-thrombosis, DIC,PE,
- Rx with heparin (APTT 1-1.5x ) and warfarin ( INR ) for 3-6/12
- Prophylaxis, heparin, TED stockings, ‘blue boots, rarely IVC filter.
22
Q
Pulmonary Embolism
A
- May be asymptomatic or pleuritic chest pain
- Pt may be tachypnoeic, appear anxious, have low grade fever, haemoptysis may be present
- ECG- sinus tachycardia ( S1Q3T3 occurs in large PE c severe R heart strain -RARE
- CXR may be show minor atelectasis –use to exclude other differentials
- ABG’s-↓PaO2, V/Q mismatch )↓PCO2 ( hyperventilation )
- V/Q scan or CT pulmonary angiography
- CARE ++ c anticoagulation if recent surgery ( recent MI )
Atelectasis (at-uh-LEK-tuh-sis) — a complete or partial collapse of a lung or lobe of a lung — develops when the tiny air sacs (alveoli) within the lung become deflated. It’s a breathing (respiratory) complication after surgery
23
Q
Poor urine output-1
A
- PRE-RENAL-hypovolaemia/ pump failure-Is the pt adequately hydrated
- So Hx, examination for signs of hypovolaemia, heart failure or distended bladder
- RENAL-atn, incompatible blood transfusion, prolonged hypotension
24
Q
Poor urine output-2
A
- POST RENAL-(usually males )- Enlarged prostate , blocked catheter, pain
- Check charts etc for nature of operation and fluid balance
- May need a fluid challenge, head down ? Hypovolaemic
- If no improvement-snr advice
- Biochemical workup and systems review
- Catheterise if bladder distended
25
Q
Examination of hydration status
A
- 1. General inspection, conscious level, observations, drains, incisions etc. Check paraphernalia around bed inc iv fluids, N/G tube,charts-esp urine output
- 2.Pulse, BP, temperature, respiration, JVP
- 3.? Sunken eyes, dry mouth, ↓capillary refill, ↓skin turgor
- Heart sounds ( 3rd HS ), basal creps ( rales ), peripheral oedema
26
Q
Factors influencing post-op complications
A
- General health of the patient and magnitude of surgery
- Significant pre-op morbity
- Obesity, cigarette smoking
- Important to optimise condition
- Various forms of prophylaxis, antibiotics, heparin—BNF/local guidelines
- Stop certain medications
- Careful selection
27
Q
Late complications
A
- Almost all surgical
- Urethral stricture ( following catheterisation )
- Failure of surgery-recurrence of reason for surgery
- Incisional hernias
- Cosmetic appearance-scars, aesthetics, keloid formation
- Pressure sores -geriatric population, obesity, poor tissues/ blood flow ( although develop early )
28
Q
Reduction/prevention of post-op complications
A
- Preoperative
- Pre-assessment Clinic-Hx, Ex, treatment/optimisation, risk assessment
- Peri-operatively
- Good technique, cleanliness/ sterility, antibiotics, right patient, right op. VTE prophylaxis
- Postoperative
- Good analgesia Early mobilisation Postoperative Intensive care / HDU / Regular Review,
29
Q
Post operative pain and nausea and vomiting
A
- PAIN-
- Analgesic ladder
- Regional/local
- NAUSEA and VOMITING-
- Strong risk factors , female, Hx ponv, Hx motion sickness, non smoker, opiate administration, GA
- Weaker evidence- age, duration of surgery
30
Q
Pain
A
- Should not be here but often a problem
- Acute pain service
- Anaesthetic technique-local/regional technique
- Use of indwelling catheter ( epidural, interscalene )
- Pain cascade
- Rx may be oral, im, iv, infusion devices –background + bolus
- Explanation to pts pre-op
31
Q
Analgesic advice
A
Basis of WHO advice-5 simple recommendations( initially cancer pain )
- 1.Oral administration
- 2.Regular administration
- Give according to pain intensity ( pain score )
- Adapt dose to individual
- 5.Constant concern for detail-esp keep pt fully informed
32
Q
Post Operative Nausea and Vomitting
A
33
Q
PONV prophylaxis
A
Usually by anaesthetist
- LOW risk, 0-1 points ( less than 20% ) No prophylaxis
- HIGH risk, 2-3 points ( 40-60 %) Dexamethasone 3.3mg iv PLUS Ondansetron 4mg iv
- VERY high risk 4 points ( 80% ) High risk PLUS Cyclizine 50mgIV
- NB-Patients with low risk points but emetogenic surgery ( gynae, ENT, squint and those whose op may be compromised by vomiting )
34
Q
PONV Rescue treatment
A
- FIRST LINE therapy- Ondansetron 4mg tds if not given within last 6 hrs ( or give second line therapy )
- SECOND LINE therapy-Cyclizine 25-50 mg iv tds if not given within last 8 hrs ( or give 3rd line therapy )
- THIRD LINE therapy- Metoclopramide 10mg IV tds OR Prochlorperazine 12.5 mg im tds OR Prochlorperazine 3-6 mg buccally
- Care with all of these ( do not use ondansetron on pts with QT interval prolongation, caution with cyclizine in IHD, heart failure. Metoclopramide with caution in pts under 20 )
- Allow ½ hr to assess efficacy and address pain,hypotension, sepsis, hypoxia etc
- See gloshospitals.nhs.uk
35
Q
Normal body temperature
A
- NBT 37.0 ( 98.6 )-varies over the course of a day
- Range of ‘ normal ‘ body temp 36.1-37.2. Lowest in early hrs
- Thermo-regulatory centre in hypothalamus
- In febrile individuals, daily swing may be 1 degree
- Site of measurement important. Oral>axilla<rectal-all>
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36
Q
Normal variations in temperature
A
- Menstruating women-rise of 0.6 degrees C c ovulation
- Elevation post-prandially
- Pregnancy and endocrine disorders affect temperature
- Older adults have impaired ability to develop fever
- Baseline temperature is lower in older patients
- Septic old patients may develop only a modest fever
37
Q
Post-operative fever
A
- Pyrexia 37-38C common post-operatively
- About 40% of post-op patients with a fever have an infectious process
- Pyrexia may be caused by surgical stimulus or be an important clinical sign of disease
- Post-op fever is a manifestation of cytokine release, including interleukin IL-1 and IL-6, TNF-alpha and interferon-gamma. ? IL-6 the most important
- Consider a broad range of differential diagnoses
- Fever may be attenuated in immuno-supressed patients, those on steroids, chemotherapy, the elderly, pts with CRF
40
Q
Post operative complications to remember
A
- Post-operative fever
- Haemorrhage
- Hypotension
- Decreased urinary output
- Respiratory complications
- Wound infection/disordered healing
- Ileus/breakdown of anastomosis
- Confusion
- DVT
42
Q
Nosocomial Infection
A
Greek:-Nosus-disease,-Komeion-take care of
- Should apply to disease acquired under medical care
- Usually taken to mean hospital acquired
- Nosocomial infection is one that was not present or incubating in the patient before admission, but occurred within 48 hrs of admission, 72 hrs of discharge
- Affect 1:10 patients, hospital stay x2.5 longer than non-infected pts
- Nosocomial rate in ITU’s 20% ( MRSA accts. for 60% nosoc. ITU infections
- NB, 1/3 preventable, hand washing important +++
- Staph aureus predominant pathogen
44
Q
Postoperative cognitive dysfunction & delirium ( POCD & POD )
A
- Deterioration in cognition after surgery-esp. memory and executive functions ( prob solving, memory, reasoning )
- Distinct from POD
- Diagnosis needs pre-op baseline- may last several months
- Commoner in pts >60 and pre-existing cognitive impairment, ↑ASA,↑C2H5OH, previous stroke, major ops (esp cardiac)
- Equally likely in GA or LA case. Seems independent of oygenation/cerebral blood flow
- ? Mediated by inflammatory response to surgery.?↑C-reactive protein in hip # cases
- bja.oxfordjournals.org/content/103/suppl_1/i41.full
