Postoperative Complications

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Postoperative Complications

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

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