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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