Surgical Complications

Question 1

List the causes of post-operative fever

Answer 1

Immediate:
- POD1 have pulmonary atelectasis or inflammatory reaction to surgery
Acute:
- POD1-2 have early wound infection 
Sub-acute
- POD3-7 most likely from surgical site infection
- leakage from anastomosis
- UTI
Delayed
- POD >8 due to DVT or PE
- abscess

Question 2

List the 5 W’s of post-operative fever

Answer 2

Wind: POD1-2 (pulmonary atelectasis, aspiration, pneumonia)
Water: POD3-5 (UTI)
Weins POD4-6 (DVT or PE)
Wound POD5-7 (surgical site infection)
What did we do POD>7 (drugs, reaction to blood products)

Question 3

List the risk factors for a surgical site infection

Answer 3

Procedure Sterility:
- procedure >2hrs
- break in sterility
- drains
Patient risk factors:
- age
- obesity
- immune suppression, chemo, radiation
- diabetes
Wound factors:
- reduced blood supply

Question 4

What are the most common bacterial surgical site infections

Answer 4

• Staph aureus
• Strep spp
• Clostridium spp
• E coli
• Enterococcus

Question 5

Discuss the management of surgical site infection

Answer 5

• source control with incision and drainage
• heal by secondary intention
• Ancef if not GI, GU, or perineum
• Ancef+Cipro+Flagyl if GI, GU, perineum

Question 6

Describe wound dehiscence and its management

Answer 6

• is a disruption in the fascial layer of the tissue at the site of closure that usually begins POD1-3
• Can attempt to approximate the wound for closure or bring to OR if there is evisceration of contents

Question 7

Discuss acute gastric dilatation as a surgical complication

Answer 7

• is a delayed gastric emptying without evidence of obstruction
  Presentation
• nausea, vomiting
• post-prandial bloating
• epigastric distention and tenderness
  Treatment
• conservative through dietary modification (low fat and fiber)
• pro kinetics (metoclopramide) 10-15 minutes before meals

Question 8

Discuss post-operative ileus as a surgical complication

Answer 8

• is slowed or absent peristalsis of small and large bowel without obstruction
  Pathophysiology
• physiologic following abdominal surgery
• pathologic is from metabolic or physical insult to GI (electrolyte disturbance, opiates, anticholinergics, inflammation or hemorrhage)
  Presentation:
• nausea, vomiting, constipation, obstipation
  Investigations:
• X-ray show dilated small and large bowel without transition zone and air in the rectum
  Treatment:
• usually have return to normal function by POD3
• NG tube and bowel rest

Question 9

Discuss post-operative urinary retention

Answer 9

Risk Factors:
- age >50
- pre-existing urinary retention
- neurologic disease
- BPH
- anti-cholinergics
Pathophysiology
- anesthesia lead to detrusor dysfunction, urethral obstruction or failure of pelvic floor relaxation
Presentation
- FUNSHED
Investigation
- post-void residual of >100mL
Management
- foley catheter to relieve bladder
- trial of void

Question 10

Discuss post-operative urosepsis

Answer 10

Pathophysiology:
- urinary tract infection from PPEEAKS (pseudomonas, proteus, e coli, enterococcus, acinobacter, kliebsella, staph saprophyticus) leading to sepsis
Presentation:
- urinary frequency, urgency, dysuria
- catheter may just be associated with mental status change, fever and chills
Investigations
- urine culture
- positive nitrites and leukocytes
Management
- UTI: nitrofurantoin for 5-7 or septra for 3
- pyelonephritis: IV gentamicin + ampicilin for 7 days or IV cefotaxime for 7 days

Question 11

Discuss post-operative bleeding

Answer 11

Pathophysiology:
- POD0-2 reactionary hemorrhage
- POD8-14 from secondary hemorrhage from a infection leading to bleeding
Presentation
- visible bleeding from wound
- pain from hematoma along with distention of tissue and skin bruising
- have anemia and hypovolemia leading to pre-syncope, increase in HR, decreased BP
Investigations
- CBC, type and cross
- INR, PTT
Treatment
- stabilize
- fluid resuscitation and if still refractory consider blood transfusion
- achieve hemostasis