Surgical Complications Flashcards
RFs for wound infections?
- 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
Selection of abx?
- 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
Eval of diabetic pt b/f surgery? What are these pts at higher risk for?
- 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
RFs for thromboembolic disease?
- 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
Risk model/caprini score for VTE?
- 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
Prevention of VTE? Process of selecting appropriate option?
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
Meds used in VTE prophylaxis?
- 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
Mechanical methods for VTE prophylaxis?
- 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
What is an SSI?
- 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
Epidemiology and RFs for SSI?
- 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
Presentation of SSI?
- localized erythema
- induration
- warmth
- pain at incision site
Tx of SSI?
- 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
What are hematomas and seromas? Presentation?
- 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
Tx and prevention of hematomas and seromas?
- tx: percutaneous drains wound exploration: packed and heal by secondary intention - prevention: closure of dead space meticulous hemostasis placement of drains controversial
What is fascial dehiscence? RFs?
- 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
Main cause of fascial dehiscence? Presentation, tx, prevention?
- 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
Primary intention of wound healing?
- 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
Secondary intention of wound healing?
- 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
Pulmonary complications? How common?
- 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
physiology of surgical pulm complications?
-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
RFs for pulm complications?
- 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
Goal for preop pulm risk assessment?
- direct hx to recognize chronic lung disease:
reports of exercise intolerance, unexplained dyspnea or cough
PE and testing for pulm risk assessment?
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
What are the strategies to reduce post-op pulm complications?
- 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
Intra-op strategies to reduce pulm complications?
- use spinal or epidural when possible
- for neuromuscular blockade intermediate agents (vecuronium, atracurium) instead of pnacuronium
- shorter procedures in high risk pts
Post op strategies to reduce pulm complications?
lung expansion:
- deep breathing exercises
- incentive spirometry
- adequate pain control
- routine use of NG tube increases post-op pulm complications
What is a post-op fever? Most caused by?
- 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
5 W’s of post op fever?
- 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)
Tx of post-op fever?
- remove unnecessary tx including meds and catheters
- suppress fever w/ tylenol
- abx per clinical judgement/culture results
What is malignant hyperthermia? Causative agents?
- uncommon and sometimes life-threatening rxn to some anesthetic agents
- unsafe drugs:
depolarizing muscle relaxants (anectine)
potent inhalational agents:
Halothane
isoflurane
enflurane
desflurane
sevoflurane
Safe drugs to use in malignant hyperthermia susceptible pts?
- 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
Clinical manifestations of malignant hyperthermia?
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
PP of malignant hyperthermia?
- genetic predisposition
- increased intracellular Ca++
- continuous muscle contraction
What ?s should we ask pts during preop eval to assess for risk of malignant hyperthermia?
- 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
What is probably the most dangerous triggering agent for malignant hyperthermia?
- Succinylcholine: needs to be avoided in pts that are suspected to have malignant hyperthermia
Tx of malignant hyperthermia?
- call for help:management is involved and difficult for one person
- stop triggering agents
- hyperventilate pt w/ 100% O2
- finish or abort procedure
- admin dantrolene (2.5 mg/kg bolus, may repeat 2 mg/kg q 5 minutes, then 1-2 mg/kg/hr)
- cool pt (cold IV NS, cold body cavity lavage, ice bags to body, cold NG lavage, cooling blanket)
- monitor and tx acidosis (follow serial arterial blood gases and admin Na bicarb)
- promote urine outpt (maintain over 2 ml/kg/h management; furosemide, mannitol)
- tx hyperkalemia - w/ insulin and D50W
- tx dysrhythmias w/ procainamide and calcium chloride
- monitor Creatinine kinase, urine myoglobin, and coag for 24-48 hrs
Surgical care improvement project - natl goal?
- to reduce preventable surgical morbidity and mortality
SCIP: surgical infection prevention?
- 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
SCIP - concerns about pre-op shaving? What type of hair removal is part of guidelines?
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
Prevention of cardiac events (SCIP)?
- periop bbs in pts who are on bbs prior to admission
Prevention of VTE (SCIP)?
- VTE prophylaxis is a must!!
Acquired risk factors for VTE?
- hosp/nursing home** (61.2)
- active malignant neoplasm (19.8)
- trauma
- CHF
- CV catheter
- neurologic disease w/ paresis
- superficial vein thrombosis
- varicose vein/stripping
SCIP 1-2-3 abx admin?
- given on time: 1 hr b/f incision, 2 hrs: vanco and levaquin
- appropriate selection of abx (usually Ancef, vanco, clindamycin)
- 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
If using vanco - what needs to be documented?
- 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
SCIP - blood glucose guidelines?
- cardiac surgery pts: controlled 6am postop serum glucose (less than 200 mg/dl postop day 1 and 2)
SCIP-9 foley d/c guidelines?
- 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
SCIP-cardiac-2 BB recommendations?
- 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
SCIP-VTE-2 timing of prophylaxis?
- 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
SCIP-10 normothermia guidelines?
- 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
Current SCIP measurements?
- 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
