CPSS E1- Pre-op/Post-op & Complications

What is the immediate phase of post-op care?

post-anesthesia phase; pt transferred from OR → PACU

What is the intermediate phase of post-op care?

hospitalization period; pt transferred from PACU → inpt floor

What is the convalescent phase of post-op care?

transition period from time of hospital d/c to full recovery

What is PACU phase 1?

initial handoff from anesthesia team to PACU nurse, pt is monitored for recovery of anesthesia

What is PACU phase 2?

prepares pts for discharge, provides post-op care instructions, discharge meds

What are the major causes of early complication & death following major surgery?

- Acute pulmonary derangements

- CV derangements

- Fluid derangements

What are common complications of the intermediate post-op phase?

wound infections, drain issues, respiratory complications, fluid or electrolyte imbalance, GI issues, inadequate pain control

What is the MCC of post-op fever within 48 hrs of surgery?

Atelectasis

What is the MC post-op pulm complication?

Atelectasis

What will atelectasis progress to within 72-96 hours if left untreated?

Pneumonia

What will a CXR show if there is atelectasis?

area of collapsed lung parenchyma

What post-op care can help tx and prevent atelectasis?

- Incentive spirometry

- Clear airway with chest physiotherapy, coughing, suctioning

- Bronchodilators + mucolytics for COPD pts

What respiratory complication MC occurs during intubation for emergency surgery?

Aspiration pneumonitis

*can progress to ARDS

What is the tx for aspiration pneumonitis?

bronchoscopy, tracheobronchial toileting, chest physiotherapy, empiric abx

What would a CXR of aspiration pneumonitis show?

patchy infiltrates

What are causes of early respiratory failure (occurs w/in 1-2 hrs)?

- major abdominal or chest surgery

- severe chest trauma

- preexisting lung disease

- excessive anesthetic agents

What are causes of late respiratory failure (occurs beyond 48 hrs)?

- cardiac failure, pulmonary edema

- PE

- abdominal distention

- narcotic overdose

What is the MCC of death from pulmonary complications?

Pneumonia

*majority G-

What is one of the MC preventable causes of post-op death?

VTE

What is the MC source of a PE?

LE venous thrombosis

When do most blood clots from surgery form?

on the OR table or immediately post-op

What imaging & lab findings would indicate a PE is present?

CXR: Hampton's hump, Westermark sign

EKG: S1Q3T3 pattern

elevated D-dimer

What are contraindications to PE tx with Heparin?

*TOC

- active bleeding

- severe bleeding diathesis

- immediately post-op

- severe trauma (multiple fractures)

- acute intracranial hemorrhage

What is the tx for a PE if anticoaguation is contraindicated or recurrent PE?

Vena cava filter (Greenfield filter0

What is the best prophylaxis for post-op PE?

Early mobilization post-op

What can cause a fat embolism?

fx of shafts of long bones (femur MC)

severe soft tissue injuries

intramedullary instrumentation (hip/knee arthroplasty)

What are sx of a fat embolism?

delayed 24-72 hrs

neuro findings are common

acute dyspnea

petechial rash (conjunctival, oral mucosa, axillary)

What lab values indicate a fat embolism?

thrombocytopenia

severe hypoexmia

fat in the urine & sputum

How can you prevent an air embolism when placing a central venous line?

place the patient in Trendelenburg position (head down) & the right side elevated to dislodge air from the right atrium

What are the MC cardiac complications after operation under general anesthetic?

- dysrhythmias/arrhythmias (PVCs)

- MI

- HF

What are the common causes of post-op PVCs?

hypoxia, hypokalemia, digitalis toxicity, alkalosis

What is a hematoma?

collection of blood & clot in the wound

What is post-op hematoma/bleeding most commonly due to?

inadequate hemostasis

What is a seroma?

collection of clear fluid in the wound; occurs s/p surgery involving elevation of skin flaps & transection of numerous lymphatic channels (eg. mastectomy, operations in the groin)

What is a lymphocele?

collection of lymph fluid in the operative wound

What are the MCC of wound dehiscence?

- excess wound tension

- ischemia

- improper suturing or knot tying technique

Wound dehiscence is MC on what post-op days?

POD #5-8

Wound infection typically occurs on what post-op days?

POD #5-10

What are the MC organisms causing wound infection 12-24 hours post-op?

Clostridium & Streptococcus

What are the MC organisms causing wound infection >2 days post-op?

Enteric anaerobes/aerobes & Staph

What are considered clean wounds?

Uninfected operative wounds that does not enter a viscus

Ex- hernia repair, soft tissue biopsy

What are considered clean contaminated wounds?

Operation in which a viscus is entered and there is potential exposure to bacteria

Ex- gastric & biliary surgery

What are considered contaminated wounds?

Open, fresh wounds or operations involving breaks in sterility or gross spillage from a viscus

Ex- colorectal or vaginal surgery

What are considered dirty wounds?

Massively contaminated traumatic wound, devitalized tissue, foreign bodies or fecal contamination

Ex- intraabdominal abscess, necrotic tissue

What is considered a fever post-op?

38C or 100.4F

What commonly causes a fever on post-op day 1-3?

Wind (atelectasis, PNA)

What commonly causes a fever on post-op day 3-5?

Water (UTIs)

What commonly causes a fever on post-op day 3-7?

Walking (DVT/PE) or

Wound (SSIs, anastomotic leak)

What commonly causes a fever on post-op day 7+?

drug-related (sulfa drugs), central line infection, transfusion rxn

What are common pathogens of post-op pneumonia?

Pseudomonas & MRSA

What is the MCC of central venous line infection?

Staph

How does malignant hyperthermia present?

fever occurs immediately aft surgery, hx of halogenated gas, labs show metabolic acidosis and hypercalcemia

What is the tx for malignant hyperthermia?

IV Dantrolene, cooling measures

What is the gold standard for dx Intraabdominal abscess?

CT

How much blood loss does a saturated 4×4 gauze (Ray-Tec) indicate?

10-20 mL

How much blood loss does a saturated Laparotomy ("Lap") sponge indicate?

50-100 mL