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SURGERY
Post-op
| Question | Answer |
|---|---|
| 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
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