S&P Lecture 3: Post-op

What belongs in the preop note?

Brief summary of the workup, Diagnosis and planned procedure, H&P complete, Labs and CXR and EKG, Blood typed and crossmatched, NPO after midnight, Consent signed and on chart

What belongs in the op note?

Preop and postop diagnoses, Procedure performed, Findings, Fluids and blood products given, Estimated blood loss (EBL), Surgeons and anesthesia, Drains and tubes, Complications, Disposition

What are the components of admission orders (ADC VAAN DIML)?

Admit to, Diagnosis, Condition, Vitals, Allergies, Activity, Nursing, Diet, IV fluids, Meds, Labs

What goes in the S of a postop progress note?

Pain, Complaints, Bowel movement

Besides vitals what else goes in the O of a postop progress note?

I&O (24 hr and 8 hr), Urine output, Drain output, NG tube output, Exam of heart and lungs and abdomen and wound

How long after the procedure are PACU discharge criteria usually met?

1 to 3 hours

What are the core elements of an ERAS protocol?

Early mobilization, Early feeding, Multimodal pain management, DVT prophylaxis, Early catheter removal

What is healing by secondary intention?

Wound left open with the fascia closed

Which wounds are typically left to heal by secondary intention?

Chronic or infected wounds

Which wound solutions are cytotoxic?

Acetic acid, Dakin's solution, Povidone-iodine

How long should a surgical dressing be left intact?

3 to 4 days unless wet

When is it OK to change a surgical dressing before day 3?

Dressing is wet, Signs or symptoms of infection, Excessive drainage

What does a negative pressure (vacuum) dressing do?

Pulls exudate from the wound, Speeds wound healing, Helps debride the wound

When can patients usually shower after wound closure?

After 24 to 48 hours

What should patients avoid after wound closure?

Submerging the wound in water, Strenuous movement of the wound area, Hydrogen peroxide, Sun exposure, Smoking, Alcohol

Which surgical complications does CMS tie to reimbursement?

Iatrogenic pneumothorax, Respiratory failure, Pulmonary embolism, Unrecognized abdominopelvic puncture or laceration, Acute kidney injury, Sepsis, Deep vein thrombosis, Perioperative hematoma or hemorrhage, Wound dehiscence, In-hospital fall, Pressure ulcers

What is a seroma and how is it treated if it does not self-resolve?

Fluid collection (not pus or blood) in empty space - aspiration then compression

What is the classic dangerous hematoma that compresses an adjacent structure?

Neck hematoma after thyroid surgery

How are surgical site infections prevented?

Aseptic technique, Preop antibiotics, Meticulous wound care, Proper scrub technique, Minimizing dead space in the wound

What findings support a clinical diagnosis of SSI?

Warm, Red, Painful, Swollen surgical site, With or without pus

What should be done if an incision line infection is suspected?

Remove the sutures

Does redness only at a suture insertion site equal infection?

No

What is the most common SSI pathogen?

Staphylococcus aureus

Which comorbidities increase the risk of wound dehiscence?

Diabetes, Uremia, Impaired immune function, Steroid use, Jaundice, Sepsis, Poor nutritional status, Cancer, Obesity, Smoking

What is the most important modifiable risk factor for wound dehiscence?

Proper closure of the fascia (the strength layer)

When does wound dehiscence most commonly occur?

Postop days 5 to 8

What is an anastomotic leak?

A form of dehiscence from disrupted healing at a connection (anastomosis)

What signs suggest pain in an ICU patient?

Facial expressions, Hypertension, Tachycardia

Which IV opioid delivery method carries less likelihood of overdose?

Patient-controlled analgesia (PCA)

What is the most common postop pulmonary complication?

Atelectasis

When does postop atelectasis most commonly occur?

First 48 hours

Atelectasis causes what percentage of postop fevers?

90%

What are the obstructive causes of atelectasis?

Secretions, Blood clot, Sedation (loss of tone), ET tube placement

What are the non-obstructive causes of atelectasis?

Compression (effusion or abdominal distention), Lack of deep breathing, Decreased effort

What are the signs and symptoms of atelectasis?

Fever, Tachypnea, Tachycardia, Elevated diaphragm, Rales, Decreased breath sounds

How is atelectasis prevented?

Early mobilization, Position changes, Coughing, Incentive spirometer

What is the single best treatment for atelectasis?

Lung expansion techniques

Which factors suggest an infectious cause of postop fever?

ASA greater than 2, Preop trauma, T greater than 38.6 C, WBC greater than 10k, BUN greater than 15

How many infectious-origin risk factors predict nearly 100% chance of bacterial infection?

3 or more

What are the 5 W's of postop fever?

Wind (atelectasis), Water (UTI), Wound (wound infection), Walking (DVT), Wonder drug (drug fever)

What are the signs and symptoms of postop ileus?

Nausea, Bloating, Burping, No flatus or bowel movements, Decreased bowel sounds, Distention, Tympany, Dilated bowel loops or air-fluid levels on x-ray

How is postop ileus treated?

Supportive care, NG tube if needed, Antiemetics, Early feeding

What is a normal bladder (intra-abdominal) pressure?

Less than 12 mmHg

What bladder pressure plus organ dysfunction indicates laparotomy for abdominal compartment syndrome?

Greater than 20 to 30 mmHg

What is the mortality of postop pancreatitis after surgery near the pancreas?

30 to 40%

What are the features of postop cholecystitis?

Most common after GI procedures, Frequently acalculous, More common in males, Progresses rapidly to gallbladder necrosis, Unlikely to respond to conservative therapy

Which criteria define acute kidney injury (any one)?

Creatinine rise greater than 0.3 mg per dL within 48 hr, Creatinine greater than 1.5x baseline within 7 days, Urine output less than 0.5 mL per kg per hr for 6 hr

When is a urinary catheter used for surgery?

Procedure longer than 3 hr or large-volume fluids anticipated

After which surgery is the catheter left 4 to 5 days because of sacral plexus trauma?

Abdominoperineal resection

What makes up Virchow's triad?

Venous stasis, Hypercoagulable state, Endothelial damage

How is postop VTE prevented?

Early mobilization, Heparin or LMWH, Sequential compression device

How often is SQ heparin given for VTE prophylaxis?

Every 12 hours

How often is SQ enoxaparin given for VTE prophylaxis?

Every 24 hours

Per the cited study when can chemoprophylaxis start after elective major abdominal surgery?

Any time within 24 hr of skin closure without changing bleeding or VTE risk

Which factors make up the intrinsic pathway?

XII, XI, IX, VIII

Which factors make up the common pathway?

X, V, II (prothrombin), I (fibrinogen)

Deficiency of which clotting factor does NOT cause bleeding?

Factor XII

Which bleeding history findings suggest a bleeding disorder?

Prolonged bleeding after dental procedures, Prolonged bleeding after minor cuts, Bleeding with previous operations, Long or frequent menses, Easy bruising, Family bleeders

Which pathways does PT measure and which anticoagulant does PT and INR monitor?

Extrinsic and common - warfarin

Which pathways does aPTT measure and which anticoagulant does it monitor?

Intrinsic and common - unfractionated heparin (not LMWH)

What are the acquired causes of surgical bleeding?

Liver disease, Thrombocytopenia, Anticoagulation, DIC, ITP, HIT, Trauma

How is hemophilia treated perioperatively?

Factor replacement (factor VIII or IX) as bolus or continuous infusion

What is the treatment for von Willebrand disease?

Desmopressin (IV or intranasal) and possibly factor concentrate

How is immune thrombocytopenia (ITP) treated?

Maintain an effective hemostatic platelet count, Corticosteroids, IVIG, Platelet transfusion if life-threatening bleed

How is heparin-induced thrombocytopenia (HIT) treated?

Stop all heparin and heparin products, Start a non-heparin anticoagulant (argatroban)

What must be documented for a patient with HIT?

Lifelong heparin allergy

How is trauma-induced coagulopathy treated?

1:1:1 transfusion of RBC to FFP to platelets, Avoid further dilution, Tranexamic acid (TXA)

What is the traditional vicious triad of trauma coagulopathy?

Acidosis, Hypothermia, Hemodilution

Which point-of-care test best identifies which part of the cascade is deficient?

TEG or ROTEM

How is aspirin reversed?

Platelet transfusion, Desmopressin

How is heparin reversed?

Protamine sulfate

How is warfarin reversed?

4-factor prothrombin complex concentrate (PCC), Vitamin K (with or without)

Which lab is used to work up DOACs and LMWH?

Anti-Xa

How is dabigatran reversed?

Idarucizumab, Hemodialysis

How are apixaban and rivaroxaban and edoxaban reversed?

Andexanet alfa, 4-factor PCC

How is LMWH reversed?

Protamine sulfate may help (partial reversal)

Who is the universal donor?

O negative

What must always be obtained before giving a transfusion?

Written informed consent

How are PRBCs stored?

1 to 6 °C for 42 days

How are platelets stored?

22 °C (room temp - not refrigerated) with gentle agitation for 3 to 5 days

Why are platelets the product most susceptible to bacterial growth?

They are stored at room temperature

What is cryoprecipitate rich in?

Factor VIII, Fibrinogen, Fibronectin

Acute hemorrhage with what blood volume loss likely needs 1:1:1?

More than 30%

What is ordered preop if transfusion is expected within 48 hr postop?

Type and crossmatch

What is the transfusion threshold for hemoglobin?

Hgb less than 7 (less than 8 in cardiac patients)

When is FFP given?

Coagulopathy with INR above 1.5 or active bleeding

Below what platelet count are platelets transfused before a procedure?

Less than 50k

When is cryoprecipitate used for acute bleeding with acquired hypofibrinogenemia?

Major trauma, Cardiac surgery, OB hemorrhage

What is the most common cause of a major hemolytic transfusion reaction?

Clerical error (mislabeled specimen or wrong patient)

Which complications commonly follow a hemolytic transfusion reaction?

DIC, Renal failure, Death

How is an allergic transfusion reaction (to plasma proteins) treated?

Antihistamine, Epinephrine if anaphylaxis

What are the symptoms of a febrile transfusion reaction?

Chills and a temperature rise greater than 1 °C

Which blood products most often cause TRALI?

Plasma-containing products such as FFP

What are the signs of TRALI?

Hypoxemia, Bilateral infiltrates, Tachycardia, Hypotension

How is TRALI treated?

Supportive care with ventilatory support

What are the signs of TACO?

Respiratory distress, Hypertension, Pulmonary edema

Which blood pressure finding separates TRALI from TACO?

TRALI = hypotension and TACO = hypertension

How is TACO treated?

Stop the transfusion, Diuretics, Oxygen, Supportive care

How is a bacterially contaminated transfusion treated?

Stop the transfusion, Broad-spectrum antibiotics with gram-negative coverage

When are vitals checked during any transfusion?

Immediately before then 15 min after starting then hourly