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Surgery > Surgical Complications > Flashcards

Surgical Complications Flashcards

1
Q

RFs for wound infections?

A
  • wound infections increase hosp stay on avg 1 wk and 20% increase in cost
  • when taken b/f procedure, may prevent bacteria being released into blood stream
  • RFs:
    systemic factors:
    DM
    corticosteroid use
    obesity
    age
    local factors:
    fb
    electrocautery
    wound drains
    injection w/ epi
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2
Q

Selection of abx?

A
  • active against most likely organism w/ good tissue penetration
  • should be admin 60 min b/f incision
  • most commonly given:
    cefazolin (ancef, kefzol)
  • gram neg and anaerobic pathogens can be covered by:
    cefotetan
    cefoxitin
    ceftizoxime
  • each w/ or w/o metronidazole (flagyl) - esp w/ GI procedure
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3
Q

Eval of diabetic pt b/f surgery? What are these pts at higher risk for?

A
  • surgical stress induces a neuroendocrine response which results in insulin resistance, increased hepatic glucose production, and impaired insulin production
  • pre-op eval includes assessment of metabolic control and any diabetes-assoc complications
  • PE:
    feet
    minor injuries
    poor hygiene
    ulcers
  • cardiac: men have 2x teh risk, women have 4x risk, can have hypotension from cardiac neuropathy
  • gastroparesis: delay gastric emptying and aspiration
  • infection: hyperglycemia has effect on immune system, reduced blood flow decreases healing
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4
Q

RFs for thromboembolic disease?

A
  • PE remains MC preventable cause of death
  • 150,000 to 200,000 deaths/yr in US
  • RFs:
    extent of surgery or trauma
    duration of hosp stay
    previous VTE
    immobility
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5
Q

Risk model/caprini score for VTE?

A
  • very low risk: general and abdominal pelvic surgery w/ caprini score of 0, plastic and reconstructive surgery w/ caprini score 0-2
  • low risk: general and abdominal-pelvic surgery w/ caprini score of 1-2, plastic and reconstructive surgery w/ caprini score 3-4
  • moderate risk: general and abdominal pelvic surgery w/ caprini score of 3-4, plastic and reconstructive surger w/ score 5-6
  • high risk: general and abd. pelvic-surgery w/ caprini score of 5 or more, plastic and reconstructive surgery w/ caprini score of 7-8
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6
Q

Prevention of VTE? Process of selecting appropriate option?

A 
prevention:
- primary prophylaxis:
easy to admin
safe and effective
no need for lab monitoring
cost effective

selecting approp. option:

  • early and frequent ambulation for pts at very low risk
  • mechanical methods for pts w/ CI to pharm prophylaxis at low risk
  • pharm for pts at moderate and high risk
  • combo for pts at very high risk
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7
Q

Meds used in VTE prophylaxis?

A
  • LMWH: preferred in high risk pts - SQ once or twice daily
  • low dose UFH alt: 5000 units 2 hrs pre-op then 8-12 hrs post op SQ
  • warfarin:
    alt to LMWH/UFH
  • aspirin
  • timing: usually given b/f or after surgery and continued until pt is fully ambulatory
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8
Q

Mechanical methods for VTE prophylaxis?

A
  • intermittent pneumatic compression (IPC)
  • graduated compression stockings (GCS)
  • venous foot pump (VFP)
  • inferior vena cava filter: if
    absolute CI to anticoagulation, or failure to adequate anticoagulation
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9
Q

What is an SSI?

A
  • CDC has defined an infection related to an operation that occurs at or near the surgical incision w/in 30 days of the procedure, or w/in 90 days if an implant is used
  • MC nosocomial infection
  • impact: increase in mortality, increase cost to pt and hospital
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10
Q

Epidemiology and RFs for SSI?

A
  • epidemiology:
    depend on pop
    size of hosp
    experience of surgeon
RFs:
-surgical technique
-prolonged surgery time
-instrument sterilization
-preop prep 
-thermoregulation/gylcemic control
-medical condition of pt
-surgical enviro: 
personnel traffic, excessive use of electrosurgical cautery units, prosthesis or fb, need for blood transfusion
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11
Q

Presentation of SSI?

A
  • localized erythema
  • induration
  • warmth
  • pain at incision site
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12
Q

Tx of SSI?

A
  • proph abx
  • infected wounds
  • abx: broad spectrum w/ coverage of gram + coci, culture and gram stain reports
  • surgical technique:
    limit electrocautery
    closure subq tissue
    skin closure
    delayed closure and heal by secondary intention
    limit hypothermia
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13
Q

What are hematomas and seromas? Presentation?

A
  • collectio of blood or serum under the incision
  • hematomas are more common
  • cause wound separation and infection
  • presentation:
    appear a few days after surgery
    swelling
    pain
    seeping fluid around incision site
    erythema, inflammation
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14
Q

Tx and prevention of hematomas and seromas?

A 
- tx:
percutaneous drains
wound exploration: packed and heal by secondary intention
- prevention:
closure of dead space
meticulous hemostasis
placement of drains controversial
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15
Q

What is fascial dehiscence? RFs?

A
  • abdominal wall tension overcoming tissue or suture strength
  • occur late or early post-op period
  • complications are incisional hernia
  • RFs:
    age
    male
    COPD
    ascites
    obesity
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16
Q

Main cause of fascial dehiscence? Presentation, tx, prevention?

A
  • suture: main cause is failure to remain anchored, knot failure, large stitch intervals
  • presentation: profuse serosanguinous drainage, popping sensation w/ abdominal bulge
  • tx: closure in OR
  • prevention: continuous mass closure or interrupted, internal or external retention sutures
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17
Q

Primary intention of wound healing?

A
  • wound closed w/ stitches or staples
  • covered w/ sterile dressing
  • may drain a small amt of blood or serosangueness fluid
  • generally kept protected from getting wet w/ a plastic cover for 2-10 days depending on wound site, if allowed to get wet - shower only, no bath or hot tub
  • monitor for erythema, swelling, warmth and drainage
  • note: wound intact, no erythema or drainage, dressing dry, wound redressed
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18
Q

Secondary intention of wound healing?

A
  • epidermis and dermis not closed, sometimes other layers not closed allowed to granulate in
  • usually if there has been contamination, an infected wound, peritonitis
  • has to be packed daily to q other day w/ saline moistened gauze or sponges and covered q/ a sterile dressing
  • note: wound - healing by secondary intention, size x by x, pink granulation tissue filling in well, repacked and dressed
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19
Q

Pulmonary complications? How common?

A
  • hypoventilation
  • infection (bronchitis, pneumonia)
  • atelectasis
  • prolonged mechanical ventilation and resp failure
  • exacerbation of underlying chronic lung dz
  • bronchospasm
  • occur in 1/3 of pts
  • accounts for 1/2 of perioperative mortality
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20
Q

physiology of surgical pulm complications?

A

-residual effects of anesthesia and post op opioids depress respiratory drive
- inhibition of cough, impairment of mucociliary clearance of respiratory secretions
- after abdominal and thoracic surgery:
vital capacity reduced by 50-60%, fxnl residual capacity reduced by 30%, due to diaphragmatic dysfxn and postop pain

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21
Q

RFs for pulm complications?

A
  • age: over 50 is independent RF
  • COPD or other chronic lung disease
  • asthma: if controlled not a higher risk
  • smoking: over 20 pack year hx higher incidence of postop pulm complications
  • general health status:
    CHF increases risk
    URI: best to postpone elective surgery until resolved

procedure related RFs:

  • surgical site: abdominal and thoracic (esp upper abdominal)
  • duration of surgery: lasting longer than 3-4 hrs
  • type of anesthesia: regional vs general - more complications w/ general
  • type of neuromuscular blockade: using long acting agent (pancuronium) higher risk then w/ short acting agents
22
Q

Goal for preop pulm risk assessment?

A
  • direct hx to recognize chronic lung disease:

reports of exercise intolerance, unexplained dyspnea or cough

23
Q

PE and testing for pulm risk assessment?

A

PE: note decreased breath sounds, rhonchi, wheezes, or prolonged expiratory phase
testing:
- all pts undergoing lung resection should have pre-op PFTs performed
- for all other procedures, lab tests are adjuncts to clinical eval
PFTs: obtain for pts w/ COPD or asthma if clinically can’t determine if pt at their best baseline, obtain for pts w/ dyspnea or exercise intolerance that remains unexplained
- ABGs: no data support use of pre-op ABGs as helpful to stratify risk for post-op pulm complications
- CXR: obtain in pts w/ known CVD, in those over 50 yo undergoing high risk surgical procedures

24
Q

What are the strategies to reduce post-op pulm complications?

A
  • COPD:
    combos of bronchodilators, abx and systemic steroids, all pts should receive daily inhaled ipratropium or tiotropium, beta agonists as needed
  • asthma:
    well controlled w/ beta-agonists, peri-operative systemic steroids if needed
  • URI: delay elective surgery in presence of viral URI
  • pt education:
    lung expansion maneuvers: coughing, incentive spirometry, and deep breathing should be taught prior to surgery
25
Q

Intra-op strategies to reduce pulm complications?

A
  • use spinal or epidural when possible
  • for neuromuscular blockade intermediate agents (vecuronium, atracurium) instead of pnacuronium
  • shorter procedures in high risk pts
26
Q

Post op strategies to reduce pulm complications?

A

lung expansion:

  • deep breathing exercises
  • incentive spirometry
  • adequate pain control
  • routine use of NG tube increases post-op pulm complications
27
Q

What is a post-op fever? Most caused by?

A
  • fever over 38 degrees is common in 1st few days after major surgery
  • most early post-op fever caused by inflammatory stimulus of surgery and resolves spontaneously
28
Q

5 W’s of post op fever?

A
  • wind: day 1-2 (pneumonia, aspiration, PE)
  • water: day 3-5 (UTIs, indwelling cath)
  • walking: day 4-6 (VTE)
  • wound: day 5-7 (SSI)
  • wonder drugs: day 7+ (drug fever, infection related to IV line)
29
Q

Tx of post-op fever?

A
  • remove unnecessary tx including meds and catheters
  • suppress fever w/ tylenol
  • abx per clinical judgement/culture results
30
Q

What is malignant hyperthermia? Causative agents?

A
  • uncommon and sometimes life-threatening rxn to some anesthetic agents
  • unsafe drugs:
    depolarizing muscle relaxants (anectine)
    potent inhalational agents:
    Halothane
    isoflurane
    enflurane
    desflurane
    sevoflurane
31
Q

Safe drugs to use in malignant hyperthermia susceptible pts?

A
  • barbiturates (thiopental)
  • benzos (midazolan, diazepam, lorazepan)
  • droperidol (inapsine)
  • ketamine
  • local anesthetics (lidocaine, bupivacaine)
  • nitrous oxide
  • nondepolarizing muscle relaxants (pancuronion, rocuronium, vecuronium)
  • opioids (morphine, demerol)
  • propofol
32
Q

Clinical manifestations of malignant hyperthermia?

A

signs of hypermetabolism:

  • hypercarbia (the most sensitive indicator of potential MH in the OR)
  • skeletal muscle rigidity (most specific sign)
  • tachycardia
  • tachypnea
  • high temp (usually a late sign of MH)
  • HTN
  • cardiac dysrhythmias
  • acidosis
  • hypoxemia
  • hyperkalemia
  • myoglobinuria
33
Q

PP of malignant hyperthermia?

A
  • genetic predisposition
  • increased intracellular Ca++
  • continuous muscle contraction
34
Q

What ?s should we ask pts during preop eval to assess for risk of malignant hyperthermia?

A
  • just b/c prior anesthetics have been uneventful doesn’t mean that MH won’t occur
  • ask about any muscle cramps, progressive weakness after prior surgeries
  • any family hx of muscle disease or anesthetic problems
35
Q

What is probably the most dangerous triggering agent for malignant hyperthermia?

A
  • Succinylcholine: needs to be avoided in pts that are suspected to have malignant hyperthermia
36
Q

Tx of malignant hyperthermia?

A
  1. call for help:management is involved and difficult for one person
  2. stop triggering agents
  3. hyperventilate pt w/ 100% O2
  4. finish or abort procedure
  5. admin dantrolene (2.5 mg/kg bolus, may repeat 2 mg/kg q 5 minutes, then 1-2 mg/kg/hr)
  6. cool pt (cold IV NS, cold body cavity lavage, ice bags to body, cold NG lavage, cooling blanket)
  7. monitor and tx acidosis (follow serial arterial blood gases and admin Na bicarb)
  8. promote urine outpt (maintain over 2 ml/kg/h management; furosemide, mannitol)
  9. tx hyperkalemia - w/ insulin and D50W
  10. tx dysrhythmias w/ procainamide and calcium chloride
  11. monitor Creatinine kinase, urine myoglobin, and coag for 24-48 hrs
37
Q

Surgical care improvement project - natl goal?

A
  • to reduce preventable surgical morbidity and mortality
38
Q

SCIP: surgical infection prevention?

A
  • abx: admin within 1 hr b/f incision, use of antimicrobrial recommended in guideline, d/c w/in 24 hrs of surgery end
  • glucose control in cardiac surgery pts
  • proper hair removal
  • normothermia in surgery pts
39
Q

SCIP - concerns about pre-op shaving? What type of hair removal is part of guidelines?

A

shaving the surgical site w/ a razor induces small skin lacerations:

  • potential sites for infections
  • disturbs hair follicles which are often colonized w/ S. aureus
  • risk greatest when done the night before
  • pt education: be sure pts know that they shouldn’t do you a favor and shave b/f they come to the hosp
  • hair removal by clippers in OR only, no other option
40
Q

Prevention of cardiac events (SCIP)?

A
  • periop bbs in pts who are on bbs prior to admission
41
Q

Prevention of VTE (SCIP)?

A
  • VTE prophylaxis is a must!!
42
Q

Acquired risk factors for VTE?

A
  • hosp/nursing home** (61.2)
  • active malignant neoplasm (19.8)
  • trauma
  • CHF
  • CV catheter
  • neurologic disease w/ paresis
  • superficial vein thrombosis
  • varicose vein/stripping
43
Q

SCIP 1-2-3 abx admin?

A
  1. given on time: 1 hr b/f incision, 2 hrs: vanco and levaquin
  2. appropriate selection of abx (usually Ancef, vanco, clindamycin)
  3. d/c w/in 24 hrs after anesthesia end time (exception 48 hrs for CV surgery)
    - provider must document reason to extend if applicable - ex: infection, suspected infection
44
Q

If using vanco - what needs to be documented?

A
  • if vanco is marked on physician order and pt doesn’t have any allergies - one of the following needs to be documented:
  • MRSA: colonization or infection
  • Pt w/ an acute inpt hospitalization w/in last yr
  • pt residing in a nursing home w/in the last yr
  • pt w/ chronic wound care or dialysis
  • pt w/ continuous inpt stay more than 24 hrs prior to the principal procedure
  • pt transferred from another inpt hospitalization after a 3 day stay
  • pt undergoing valve surgery
45
Q

SCIP - blood glucose guidelines?

A
  • cardiac surgery pts: controlled 6am postop serum glucose (less than 200 mg/dl postop day 1 and 2)
46
Q

SCIP-9 foley d/c guidelines?

A
  • urinary cath: d/c by postop day 2
  • or Physician, PA, NP documented reason to continue beyond day 2
    ex: pts w/ urologic, gyn, perineal op, I and O
47
Q

SCIP-cardiac-2 BB recommendations?

A
  • continue if pt on home BB therapy
  • BB may be given 24 hrs, prior to op or day of procedure ( up to midnight) HR must be 50 or greater and systolic BP 100 or higher
    (if held according to parameters, physician, PA, APN reason must be documented)
  • then BB continued postop days 1 and 2: have to document reason if help postop
48
Q

SCIP-VTE-2 timing of prophylaxis?

A
  • mechanical and/or pharm prophylaxis is ordered according to VTE risk assessment tool and type of surgery
  • prophylaxis is given 24hrs prior to surgery or within 24 hrs after anesthesia end time
  • provider documentation reqd if CI: ex - open wound, bleeding risk
49
Q

SCIP-10 normothermia guidelines?

A
  • at least 96.8F or higher w/in 15 min of anesthesia end time or warmer used in OR
  • exception: provider documentation of intentional hypothermia
  • if at lower temp: have 3x risk of infection
50
Q

Current SCIP measurements?

A
  • SCIP 1: pre-op abx given w/in 1 hr b/f incision
  • 2: must receive SCIP recommended prophylactic abx
  • 3: d/c abx w/in 24 hrs of anesthesia end time (cardiac op exception)
  • 4: controlled 6 am postop serum glucose (cardiac only)
  • 6: appropriate hair removal
  • CARD-2: periop BB therapy for pre BB rx
  • VTE-2: VTE prophylaxis w/in 24 hrs prior to or after anesthesia end time
  • 9: remove urinary catheter by postop day 2
  • 10: temp over 96.8 F 15 min after anesethesia end time

Surgery (19 decks)

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