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SURGERY

Post-op

QuestionAnswer
What is the best management for post-operative complications? prevention
differential diagnosis of a patient having postoperative fever 5 W’s: wound (wound infxn), wind (atelectasis), walk (PE), water (UTI), wonder drugs (any drug rxn)
intraoperative fever Intraoperative fever 2/2 inherited predisposition to reaction to anesthetics (esp succinyl choline) --> causes uncoupling of excitation-contraction system in skeletal muscle --> Malignant hyperthermia
Sx's of Malignant hyperthermia fever, hypoxia, acidosis, tachycardia, death
Tx for Malignant hyperthermia IV dantrolene, body cooling, stop anesthetic
post-op fever 2/2 Wound Within 24-48 hr; 1. response to surgical trauma OR 2. Necrotizing wound infections OR 3. Leakage of bowel anastomosis
What is the most common cause of post-op fever? Wind - atelectasis, occurs Within 24-48 hr
Organisms that cause post-op necrotizing wound infections often clostridial (invades muscle) or Group A Strep.
Organisms that cause post-op wound infections Staph or strep
Sx's in post-op necrotizing wound infections fever, leukocytosis, serosanguinous exudate, necrotic fascia w. extensive undermining
How to diagnose post-op necrotizing wound infections Gram stain
How to tx post-op necrotizing wound infections w. aggressive debridement or emergent amputation, & Abx
Sx's of post-op fever 2/2 leakage of bowel anastomosis tachycardia, hypotension, decreased u/o, diffuse abd tenderness
Causes of post-op fever that occur within 24 to 48 hrs (4) 1. Wind - atalectasis (most common), WOUND: 2. response to trauma, 3. necrotizing wound infxn, 4. leakage of bowel content p anastomosis
Causes of post-op fever that occur within 24 to 72 hrs (4) PULM: atelectasis, aspiration PNA, CATHETER: phlebitis at IV site --> can lead to sepsis, UTI from Foley
By POD 3, what is the most likely cause of post-op fever? by POD
Phlebitis inflammation of a vein
How to tx IV phlebitis; what if pt develops septic thrombophlebitis? removal of IV, blood cx, start IV abx if fever persists; may have to surgically remove the affected vein
How diagnose UTI 2/2 Foley? U/A & Cx
Causes of post-op fever that occur after 3 days 1. Wound infection, 2. DVT (7 to 10 days post op), 3. intra-abdominal abscess (POD 5-10)
Timeframe of development of DVT post-op 7-10 days
Timeframe of development of intra-abdominal abscess post-op 5-10 days
Factors that predispose a pt to wound infection/decreased wound healing DM (inadequate blood supply), chemo/radiation, anemia (hypoperfusion), immunosuppression, malnutrition, obesity, concurrent infection, steroids, wound tension/inc intra-abdominal pressure, long operation, long hospital stay
Types of wound complications 1. infxn (POD 3-7), 2. Hematoma/seroma, 3. Dehiscence (POD 5-8), 4. Incisional hernia
Timeframe for development of wound infection post-op POD 3-7
Timeframe for development of evisceration post-op POD 5-8
How to prevent hematoma/seroma closed-suction drains when flaps are created
How to tx a hematoma evacuate expanding hematomas, resuture if clean
Tx for wound infxn open wound & debride as necessary; Abx
Types of dehiscence superficial (skin edges) or fascial
What is evisceration? when bowels/organs come out of dehisced wound
How does evisceration initially present in a dehiscing wound? appears POD
Tx for superficial dehiscence reclose if not infected
tx for bowel evisceration cover evisceration w. sterile saline-soaked towels; place retention sutures to reclose fascia in OR, remove on POD
In what circumstances would you have an incisional hernia? How would you tx? Incisional hernia happens at the site of a prior fascial closure. Primary repair of fascial defect aiming for minimal tension (wide mobilization above and below the fascia)
Post op pt with Fever, dec breath sounds w. rales, tachypnea, tachycardia, inc density on CXR atelectasis - Collapse of alveoli from inadequate alveolar expansion (poor ventilation, secondary to pain, excessive sputum, etc.)
How to tx post-op atelectasis? Post-op deep breathing, pain meds, coughing, pulm toilet & suctioning, chest PT, incentive spirometry
How to prevent post-op atelectasis? Pre-op smoking cessation, incentive spirometry, good pain control
Post-op pt with Resp failure, CP, inc sputum prodxn, fever, cough, mental status changes, cyanosis, tachycardia, CXR infiltrate Aspiration Pneumonia
What are risk factors that increase risk of aspiration PNA? (5) 1. intubation/extubation, 2. impaired consciousness, 3. dysphagia, 4. nonfunctioning NGT, 5. Trendelenburg position
How to diagnose aspiration PNA (4) 1. CXR, 2. Cx of sputum, 3. Gram stain, 4. bronchoalveolar lavage
How to treat aspiration PNA (6) 1. bronchoscopy, 2. Abx, 3. O2, 4. pulm toilet, 5. percussion, 6. postural drainage
How to prevent aspiration PNA (4) 1. Keep IVF to minimum; 2. clear mucus/sputum; 3. frequent change of position; 4. prolong intubation until pt alert
What is the cause of pulmonary edema in post-op pts? 1. Hemodynamic (L heart failure --> inc hydrostatic P) 2. infection/inflammation --> microvascular injury or inc vascular permeability
Tx of pulmonary edema 1. O2, 2. diuresis, 3. negative fluid balance, 4. inotropes, 5. pulm artery catheterization
How to prevent pulmonary edema 1. IVF to minimum, 2. if CHF --> use inotropes
Pt with acute onset of severe life-threatening respiratory insufficiency, cyanosis, severe arterial hypoxemia refractory to O2 ARDS
What is the cause of ARDS in a post-op pt? diffuse alveolar capillary damage; associated with hypovolemia, PE, impaired resp drive, atelectasis, pneumonia, inc intraabd press, PTX, chylothorax, hemothorax, narcotic OD, mucus plug, pulm edema
Tx for ARDS (6) 1. O2 2. intubation 3. ventilation (PEEP) PRN; 4. chest PT, 5. suctioning, 6. pulm artery catheter
Pt with Dyspnea, low BP, tachypnea, CP, +/- fever, tender LE, loud P2, hemoptysis; abnl ECG and CXR PE
What factors increase a person's risk for PE? 1. immobility, 2. OCP's, 3. elderly, 4. MI, 5. hypercoagulable, 6. long bone fracture (fat embolization), 7. trauma
How to diagnose pulmonary embolism? V-Q scan; pulm A-gram is gold standard
How to tx pulmonary embolism heparin anticoagulation, Greenfield filter, long-term warfarin
What is Homan's sign? calf pain --> suggests PE
What is Bergman's triad? mental status changes, petechiae, dyspnea --> suggests fat embolism (usu from long bone fracture)
Tx for fat embolism Ventilatory support w. PEEP PRN; +/- steroids, treat DIC if it develops
How to prevent fat embolism Immobilization of Fx prior to transport, early OR fixation of Fx; O2, ABG monitoring
Dyspnea, rapid, shallow breaths, sharp CP worse w. coughing or deep breath, abd pain, fever, cough, hiccups Pleural Effusion
Tx for pleural effusion Thoracentesis, tube thoracotomy, surgical decortication, pleurodesis
What is the definition of post-op oliguria? u/o < 25 ml/hr, increased creatinine & BUN
pre-renal causes of post-op oliguria inadequate fluids, hypotension, CHF
renal causes of post-op oliguria ATN, nephrotoxic dyes or drugs
post-renal causes of post-op oliguria Foley catheter obstruction/stone, ureteral/urethral injury, BPH, bladder dysfunction (meds, spinal anesthesia)
In post-op oliguria, when would you consider dialysis? fluid overload, refractory hyperkalemia, BUN > 130, acidosis, uremic encephalopathy
How do you manage post-op oliguria? Optimize volume status & CO, discontinue nephrotoxic drugs, maintain u/o > 40cc/hr w. low dose dopamine, furosemide, ethacrynic acid
DDx of post-op hypotension 1. hypovolemia, 2. sepsis, 3. cardiogenic shock, 4. meds
what are some causes of hypovolemic post-op hypotension? blood loss, dehydration, third spacing, adrenal insufficiency
What is the tx for hypovolemic post-op hypotension? IVF, blood PRN
What are some causes for post-op sepsis --> hypotension? infection spreading from wound, spillage of bowel contents, infxn of lines & tubes, etc.
What is the tx of post-op sepsis --> hypotension? IVFs, blood Cx, Abx, surgical drainage of abscess, pressors PRN
What is the tx for cardiogenic shock? start dopamine to maintain BP, & treat underlying condition
Who is at high risk for post-op cardiogenic shock? Pts w. h/o MI within 6 mos before operation
How to manage cardiogenic shock 2/2 MI? Dopamine; EKG, cardiac isoenzymes, troponin I; treat w. nitrates, aspirin, O2, pain control w. morphine, beta blocker, monitoring
Causes of cardiogenic shock 1. MI, 2. fluid overload, 3. arrhythmia, 4. cardiac tamponade, 5. valvular dysfunction
What meds can cause post-op hypotension? antihypertensives, nitrates, phenothiazines, tranquilizers, tricyclics, hypoglycemia, autonomic dysfunction
How do you tx post-op hypotension if 2/2 meds? adjust dosage or d/c meds; if narcotics give Narcan 2 mg
Initial management of post-op CP? a. Start O2, obtain vitals b. If in acute distress start D5 TKO 18 gauge c. Obtain ABG, EKG (correct arrhythmia), CXR d. Give morphine sulfate
In post-op CP, what do you do if EKG shows ST-segment depression, or T-wave inversion a. Obtain medicine consult, CPK-MB isoenzymes, lytes w. Ca, Mg, PO4 b. Give O2 2-4L/min by NC, nitroglycerin PRN up to 3 doses c. Nitro paste, more morphine sulfate, d. If ischemic changes continue, start Nitro drip
If post-op pt has ischemic changes on EKG and is hypertensive and tachycardic, what do you do? use metoprolol IV to keep HR < 20% baseline
Do you give ASA in post-op CP? Yes - for prevention of future events
Factors that can lead to abnl post-op bleeding Bleeding at the surgical site (coag factor deficiencies - inher/acquir, DIC, transfusion rxns, operative techniques; Gastroduodenal ulcer (from stress)
Name some coag factor deficiencies that could cause abnl post-op bleeding hemophilia, von Willebrand dz
Name some meds that could cause abnl post-op bleeding heparin, warfarin, aspirin, NSAIDs, Abx, valproic acids, ethanol, garlic, ginkgo, ginger, ginseng
How would DIC cause abnl post-op bleeding? activation of coagulation cascade --> thrombosis & consumption of clotting factors
How could operative procedure affect probably of post-op bleeding? prolonged operation, inadequate closure, certain procedures have greater incidence of post op bleed (cardio-pulmonary bypass, neurosurg, ophthalmic surgery, prostate surgery, & surgery to stop bleeding)
Most common cause of post-op bleeding inadequate hemostasis during the operation
Other factors that can cause abnl post-op bleeding skin edema, hypothermia, connective tissue dz, vasculitides, uremia, hepatic dysfunction, DM, hyperlipidemia
In which pts are gastroduodenal ulders a common cause of post-op bleeding? Why is this? victims of major trauma, burns, ARDS, renal failure, sepsis; defect in mucosal membrane protection
How to prevent abnl post-op bleeding? Screen for coagulation disorders prior to operation (Hx, PT, PTT, plts), Type & cross blood
What do you do if pre-operatively, a pt is found to have anemia? thrombocytopenia? Significantly elevated PT/PPT? anemia - transfuse; thrombocytopenia - plts or DDAVP; elevated PT/PTT - FFP (short term) or Vitamin K (long term)
What meds should you hold preoperatively? hold aspirin, NSAIDs, heparin, warfarin
How to prevent stress ulcers pre-operatively? H2 blockers or antacids
Causes of post-op ileus adynamic ileus normal after laparotomy; also caused by hypokalemia, narcotics, intraperitoneal infxn
Post-op pt presents w nausea, vomiting, abdominal distention. What is the differential? Ileus, acute gastric dilation, intestinal obstruction, fecal impaction
How to tx actue gastric dilation? NGT decompression
What are causes of post-op intestinal obstruction? from adhesions (most resolve), incarcerated hernia (internal or fascial dehiscence), intussusception
Who is most likely to get fecal impaction post-op? Those who use narcotics post-operatively.
How to tx fecal impaction? laxative or softeners & rectal exam
Name some post-operative metabolic disorders Hyperglycemia & DKA; Adrenal insufficiency; Thyroid storm
What are some risk factors for post-op hyperglycemia/DKA? Pre-existing DM; overfeeding (TPN); infection, stress, drugs, lab error
How to tx post-op hyperglycemia/DKA? IVF, insulin, monitor glucose & lytes
What are some risk factors for post-op adrenal insufficiency? Chronic steroid use, autoimmune (assoc w. hyperthyroidism & DM), TB, females; occurs after ceasing steroids, stress, infxn, hemorrhage, Waterhouse-Friderichsen syndrome
How to tx post-op adrenal insufficiency? 100mg hydrocortisone, then chronic replacement
Waterhouse-Friderichsen syndrome dz of adrenal glands most commonly caused by Neisseria meningitidis. infxn leads to massive hemorag into (usually) both adrenal glands. Overwhelming bacterial infxn meningococcemia, low BP & shock, DIC w widespread purpura, and rapid adrenocortical insuf.
What are some risk factors for post-op thyroid storm? Pre-existing hyperthyroidism; infection, acute abdomen, surgery, trauma (any severe stressor)
How to tx post-op thyroid storm? IVF, propylthiouracil, propanolol, steroids
What contributes to the development of post-op enterocutaneous fistulas? anastomotic leak, trauma/injury to bowel/colon, Crohn’s disease, abscess, diverticulitis, inflammation & infection
How to manage Enterocutaneous Fistulas? NPO, TPN; r/o & correct underlying causes (eg – infxn), feed distally; half close spontaneously, the rest require operation & resection
What factors cause altered cognition in post-op pts? meds, preoperative stroke, functional delerium, Convulsions
How to manage new-onset post-op AMS? a. Obtain VS, review medications (H2 blockers, narcotics, benzos, antidiabetic agents); b. Examine CNS for lateralizing neurologic Sx or drug withdrawal, c. Consider Neurology consult
What is the w/u for new-onset post-op AMS? pulse ox & ABG (hypoxia, hypercapnea); FSBG (hypoglycemia), Chem 7, Ca2+, Mg2+ (hypo/hyperNa, hyperCa, uremia); CXR (PNA); head CT (mets, bleed, abscess), LP if CT neg (meningitis); LFTS and ammonia (hepatic coma); bld cx (sepsis); also thyrotoxicosis
What is the tx for convulsions? lorazepam & diphenylhydantoin
post op fever POD 1-2 WIND - lungs, PNA, atelectasis
post op fever POD 3-5 WATER - UTI, Foley
post op fever POD 4-6 WALKING - DVT, PE
post op fever POD 5-7 WOUND - Surg site infection, abscess
post op fever POD 7+ Wonder drugs - drug fever, IV's
Created by: christinapham