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Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
Postoperative Complications
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Postoperative Complications

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  • 1. Postoperative complications www.hi-dentfinishingschool.blogspot.com
  • 2. Pick well Cut well They will do well
  • 3. Case 1-SOB/ Chest pain
    • 78 year old male who is 3 days s/p LAR. You are called to see him for SOB and chest pain. T- 38, P-102, BP- 170/90, R- 30
    • History- What do you want to know?
    • Physical exam- What do you check?
  • 4. Case 1- SOB and chest pain
    • Differential diagnosis
    • MI
    • Heart failure
    • Arrhythmia
    • Pulmonary embolus
    • Pneumonia
    • Airway obstruction
    • Chest pain
  • 5. Case 1- SOB and Chest Pain
    • Immediate work up and management
    • Is the airway OK?
    • Does he need to be intubated?
    • Apply supplemental O2
    • ABG
    • EKG (troponins)
    • Order CXR
  • 6. Myocardial infarction
    • Can it be predicted pre-operatively?
    • yes, Eagle criteria-Q waves, hx of angina, ventricular ectopy, DM needing meds, >70
    • What medications will lessen incidence?
    • Beta blockers
    • What is the immediate treatment?
    • MONA (if blood pressure acceptable)
    • What is the ultimate treatment, operative implication
    • Catheterization, thrombolytics- consider time since surgery.
  • 7. Heart failure
    • What are the risk factors for increased incidence in post op period?
    • CAD, Heart failure, valvular heart dse, DM, renal failure
    • What are effective measures pre-op?
    • Optimal management of heart failure, ECHO, PAC not terribly helpful
    • How do you manage HF post op?
    • ACE inhibitors, diuretics,+/- Beta blocker, w/u for ischemia, LV function
    • What is the challenge of volume management
    • Need enough for myocardial contractility, but not too much.
  • 8. Arrhythmias
    • What are the causes of sinus tachycardia?
    • Volume, fever, pain, anxiety, anemia
    • What is the initial management of SVT?
    • Adenosine if re-entrant, amiodarone, verapamil, diltiazem, O2
    • What heart blocks require pacers?
    • Mobitz 2, third degree block
    • Can you have a BP, awake pt with V tach?
    • Yes
  • 9. Pulmonary embolus
    • What is the death rate in the US?
    • 150-200 thousand deaths per year
    • What is the most common origin of PE?
    • Ileofemoral vein thrombosis
    • What are the various diagnostic modalities? Which is the gold standard?
    • V/Q scan, CT, pulmonary angiogram. US of leg
    • What are the treatment options?
    • Heparin drip, LMW heparin, warfarin, thrombolytic therapy, IVC filter
  • 10. Pneumonia
    • What are the sequelae from gastric aspiration? Who is at risk?
    • May have pneumonitis, chemical injury. At risk- full stomach, emergency OR, male, >60
    • How do you treat aspiration?
    • Maintain airway, adequate ventilation, no steroids or prophylactic antibiotics
    • What is the definition of nosococomial pneumonia?
    • Pneumonia occuring 48 hours after admission
  • 11. Pneumonia
    • What else causes fever and CXR infiltrates? When does it occur
    • Acute lung injury, pulmonary edema, atelect. Occurs first 5 days.
    • What common organisms are involved?
    • Gram negative (enterobacter, acinetobacter, pseudomonas), staph aureus)
    • What organisms are involved in trauma?
    • H.flu, s. pneumoniae, s aureus (neurosurg)
  • 12. Atelectasis
    • What are the causes of atelectasis?
    • Obstructive and non obstructive
    • Why are abdominal surgical pts at risk?
    • Pain, decreased tidal volumes
    • Is atelectasis a cause of fever?
    • No, but may be coincident with it
    • What are strategies for treating atelectasis?
    • Ambulation, incentive spirometry, CPAP, bronchoscopy, chest PT
    • Does mucomyst work?
    • Not in randomized trials
  • 13. Airway obstruction/bronchospasm
    • What are the initial manuevers to treat airway obstruction?
    • Positioning, check for foreign body, O2
    • How do you differentiate between the two?
    • Airway obstruction shows stridor, bronchospasm has wheezing.
    • How would you try to establish an airway?
    • Oral intubation, fibro-optic, consider surgical airway
    • What medications could you use
    • Racemic epinephrine for airway obstr, albuterol for bronchospasm.
  • 14. Pleural effusion/pneumothorax
    • How to you differentiate on exam?
    • PTX has decreased breath sounds and tympany, effusion, decreased breath sounds. Remember clinical context.
    • What clinical dx associated with massive pleural effusion?
    • Cancer, trauma, pulmonary surgery, lymph duct injury
    • Are there differences in the chest tube?
    • Air alone can have a smaller tube- 20-28; fluid should be larger 32, 36 or up to 40 for blood
  • 15. Case 2-Post op fever
    • A 35 year old female had an appendectomy for perforated appendicitis 6 days ago. She has been febrile throughout, but now has a temperature of 102. P- 115, BP 90/60, R 27
    • Hx- What do you want to know?
    • P/E- Where to you focus on exam?
  • 16. Case 2- Post op fever-What is your differential?
    • Wound
    • Intra-abdominal abscess
    • Pneumonia
    • UTI
    • Catheters
    • Medications
    • Endocrine abnormalities
    • Pancreatitis
    • DVT
    • Transfusion reaction
  • 17. Case 2- Post op fever
    • What is your immediate work up and treatment plans
    • Fluid resuscitation
    • Tylenol, Motrin
    • Focused work-up
    • Review of medications
    • Consideration of antibiotics
  • 18. Wound
    • How does the class of the surgery affect incidence of SSI? What does it add to LOS
    • The higher? the class, the higher the incidence. Adds 7 days to LOS
    • What are features of necrotizing fasciitis that are not present in a simple SSI
    • Illness of patient, crepitance, extensive cellulitis, polymicrobial organisms
    • What is the treatment of a SSI?
    • Open wound, debride dead tissue- usually at bedside
    • What is the treatment of necrotizing fasciitis?
    • Emergent operative debridement, broad spectrum antibiotic coverage, volume resuscitation
  • 19. Intra-abdominal abscess
    • What is the cause of an IAA, and how is it diagnosed?
    • Either anastomotic leak, or residual bacteria, infected hematoma. Diagnosed by CT, occasionally exam
    • What is the predominate organism?
    • Anaerobes, but depends on surgery
    • How does IAA differ from peritonitis- clinically and treatment?
    • Peritonitis is process which is not contained. Treated by exploration. IAA often approached percutaneously, unless multiple or intraloop
  • 20. UTI/Catheters
    • What is the definitive diagnosis of a UTI?
    • Change foley if applicable, U/A as well as cx
    • How long should a peripheral IV stay in?
    • 72 hours
    • What contributes to central line infections?
    • Technique on placement, dressings, number of accesses, duration of lines, ?guidewire change
    • What procedure should be followed for guidewire change?
    • Cx tip of line, if positive, new stick. If cellulitis, new stick
  • 21. Medication
    • What is the most common drug associated with drug fever?
    • Phenytoin
    • What drugs are associated with neuroleptic malignant syndrome? Malignant hyperthermia
    • Phenothiazines,haloperidol, reglan; succinylcholine, halothane.
    • What drugs are most common in post op fever?
    • Antimicrobials, heparin
  • 22. Endocrine Abnormalities
    • What abn is associated with fever, increased volume needs, occ electrolyte abnormalities? How do you check for it?
    • Adrenal insufficiency. ACTH stimulation
    • What abnormality is associated with tachycardia, hypertension, skin changes and fever?
    • Hyperthyroidism
  • 23. Transfusion Reaction
    • What are the causes of transfusion reactions?
    • Immunological, infectious, chemical, physical
    • How do you work up a transfusion reaction?
    • Stop the transfusion, ASA, possibly meperidine
    • What are the signs of an ABO incompatible reaction? What treatment
    • Acute hemolytic reaction- fever, flank pain, bloody urine or DIC. NS resuscitation, save blood for evaluation. Recross pt, hgb, AB test
  • 24. Case 3- Swollen leg
    • A 55 year old woman was noticed to have a swollen leg. T- 38.2, P- 90, B/P 130/70,R-20
    • Hx- what do you want to know
    • P/E- what do you need to evaluate on exam
  • 25. Case 3- Swollen leg
    • Differential diagnosis
    • DVT
    • Peripheral arterial insufficiency
    • Phlegmacia cerulea- dolens, albicans
    • Cellulitis
    • Lymphangitis
    • Necrotizing fasciitis
  • 26. Case 3- Swollen leg
    • What do you need to do immediately, what work up do you need?
    • Start resuscitation, Ab if patient is toxic
    • Call vascular if sudden loss of perfusion
    • Elevate limb if decent pulse
    • Ultrasound of limb- venous compression doppler
  • 27. DVT
    • What are the modalities to make the diagnosis of DVT?
    • Venogram, U/S, impedance plethysmography
    • Does a normal extremity exam r/o DVT?
    • No
    • What are effective means of primary prophylaxis?
    • Low dose heparin, LMW heparin, warfarin
  • 28. DVT- Treatment options
    • Anticoagulation
    • IVC filter, rarely SVC filter
    • Thrombolytic therapy
      • Not as effective if obstructing thrombus
      • Recombinant TPA
      • Systemic or catheter directed
    • Venous thrombectomy- +/- correction of venous stenosis
  • 29. Peripheral arterial insufficiency
    • What are the causes?
    • Embolus, thrombosis, failed graft, compartment syndrome
    • What are the signs?
    • Cold foot, numbness, dependent rubor, absent pulses, inability to move toes
    • What are treatment options?
    • Surgery for arterial exploration
    • Angiography, thrombolytic therapy
  • 30. Infectious causes
    • What is the work up and treatment of cellulitis?
    • If abscess in question, consider CT,US, MRI
    • Antibiotics, elevation. Examine first!
    • What is the work up and treatment of lymphangitis?
    • Lymphangiogram would be difficult, treat with elevation and antibiotics
    • What is the treatment of necrotizing fasciitis?
    • Surgery, broad spectrum antibiotics
  • 31. Case 4- Change in mental status
    • You are called to see an 87 year old woman with a change in mental status. She is now somnolent, T-37, P-65, B/P-150/80,R -10
    • Hx- What do you need to know?
    • P/E- How to you focus your exam?
  • 32. Case 4- Change in mental status
    • Differential diagnosis
    • Medications
    • Infection
    • CVA/ TIA
    • Hypoxia, hypercarbia
    • Hypoglycemia
    • “ Sundowning”
    • Was there a fall?
  • 33. Case 4- Change in mental status
    • What do you need to do immediately?
    • O2, decide if patient needs to be intubated
    • Get an ABG
    • If not focal, stop all sedation, analgesia, consider reversal
    • Give an amp of D50
    • Consider head CT once patient stable
  • 34. CVA / TIA
    • What could be cause in perioperative period?
    • Pre-existing cerebral vascular disease
    • Hypotension in OR or post operatively
    • Bleeding disorder
    • Why is a CT important?
    • Allows you to know if it is hemorrhagic or ischemic which will alter treatment
  • 35. Medications
    • All sedatives
    • All analgesics- Beware the PCA
    • Reglan
    • H2 blockers
    • Seizure medications
    • Antiarrhythmics

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