1
Q
Name three cardiovascular post-op complications
A
- Hypotension
- HTN
- Myocardial infarction
- Venous thromboembolism
- Arrhythmias
2
Q
List three precipitating factors for post-op myocardial infarction
A
- Stress response to major surgery: anxiety; pain
- Fluid overload post-op
- Profound hypotension
- Failure to restart anti-angina medication
3
Q
What is the commonest post-op arrhythmia?
A
Atrial fibrillation
4
Q
Why should pre-operative B-blockers be continued?
A
Sudden cessation in existing IHD:
- Rebound angina
- Infarction
5
Q
How does pain affect post-op complications?
A
- CVS:
- Tachycardia
- HTN
- Increased myocardial O2 demand
- Resp: Basal atelectasis; chest infections
- GI: PONV, ileus
- Urinary retention
- Immobility; VTE
6
Q
Give three causes of post-op breathlessness
A
- Upper airway obstruction; anaphylaxis
- Respiratory failure
- Basal atelectasis (24h)
- Pneumonia (3-5d)
- Pulmonary embolism (5-7d)
- Exacerbation of COPD
7
Q
Define respiratory failure
A
Inadequate gas exchange in the respiratory system:
- Type I: PaO2 <8.0kPa on air
- Type II: PaO2 <8.0kPa and PaCO2 >6.0kPa
8
Q
Outline the initial management of respiratory failure
A
- Sit patient up
- 15L high flow O2 in non-rebreathe mask
- Treat bronchospasm with neb salbutamol 5mg
- CXR
9
Q
Why are post-op chest infections common?
A
Pain reduces:
- Breathing ➔ basal atelectasis
- Coughing ➔ decreases mucus clearance
10
Q
Name three risk factors for post-op atelectasis
A
- Age
- Smoking
- General anaesthesia
- Longer duration of surgery
- Pre-existing lung or neuromuscular disease
- Prolonged bed rest
- Uncontrolled pain
11
Q
How does post-op atelectasis present?
A
- Respiratory compromise
- Tachypnoea
- Reduced SaO2
- Fine crackles
- Low-grade fever
12
Q
Outline the causes of post-op atelectasis
A
- Airway obstruction by bronchial secretions
- Hypoventilation
- Pain
13
Q
Outline the management of post-op atelectasis
A
- Chest physiotherapy; deep breathing exercises
- Pain control
- CPAP if severe
14
Q
Classify the types of post-op haemorrhage
A
Arterial (rare): rapid, bright red, pulsatile
Venous: low pressure, dark red, non-pulsatile
- Primary: immediately post-op or continuation of intra-op
- Reactionary: within 24hr
- Unsecured blood vessels; slipped ligature
- Secondary: 7-10 days post-op
- Vessel erosion from spreading wound infection
15
Q
Outline the emergency management of post-op haemorrhage
A
- A-E assessment
- IV access >18G + fluid resuscitation
- Read operation notes: determine site; important info
- Direct compression of superficial bleeding
- Urgent senior surgical review + imaging
- Clotting, platelets, X-match 2+ units
- RBC; platelets; and FFP if severe
- Protamine sulfate to reverse heparin
- Consider activating major haemorrhage protocol
16
Q
What blood products are available for managing haemorrhage?
A
- RBCs
- Fresh frozen plasma: all coagulation factors
- Platelets
- Cryoprecipitate: fibrinogen, Factor VII and VIII
- Tranexamic acid: inhibit plasminogen and plasmin
- Prophylatic use in cardiovascular surgery
17
Q
What measures can be used to reduce the need for blood transfusion?
A
- Treating pre-operative anaemia and coagulopathies
- Stopping
- Warfarin (5d): may need ‘bridging’ LWMH till 24h pre-op
- Clopidogrel (7d)
- LMWH (24h)
18
Q
List five causes of post-up pyrexia
A
- Infection: days indicate most likely period
- ‘Wind’: LRTI (1-2d)
- ‘Water’: UTI (3-5d)
- ‘Wound’: Surgical site infections; abscess (5-7d)
- Infected lines (any day)
- ‘Walk’: VTE (4-6d)
- Iatrogenic: eg. transfusion, ‘Wonder’ about drugs (7+d)
- Prosthetic implantation: eg. Hip replacement; valve; stent
- Pyrexia of unknown origin
19
Q
What is pyrexia of unknown origin?
A
- Recurrent fever (>38oC)
- Persisting for >3/52
- Without an obvious cause
- Despite >1/52 of inpt investigations
Causes: infection of unknown source; malignancy eg. lymphoma; connective tissue disease; vasculitis; drug reactions
20
Q
Discuss the different types of surgical site infection
A
- Superficial surgical site infection: within the first week
- Localised pain, redness, and discharge
- Staph aureus
- Tx: Flucloxacillin 500mg PO QDS 5/7
- Abscess: most present within first week
- Usually after bowel surgery
- Pyrexia and spreading cellulitis or abscess
- Tx: Cefuroxime 1.5g IV TDS + Metro 500mg IV TDS
21
Q
What peri-operative measures can reduce the risk of renal dysfunction?
A
- Pre-op: adequate hydration
- Eliminate nephrotoxic drugs where possible
- Postoperative: maintain satisfactory CO; fluids
22
Q
Define oliguria and anuria
A
- Oliguria: urine output <0.5ml/kg/h
- Anuria: no measurable urine output
23
Q
How does pulmonary oedema present following renal failure?
A
- Deteriorating blood gases
- Despite increasing respiratory support
- Hyperkalaemia
- Acidosis
24
Q
Name two risk factors for post-op acute urinary retention
A
- Aged >50
- Male
- PMH of retention
- Abdomino-pelvic or urological surgery
- Spinal or epidural
- Neurological or urological co-morbidites
- Drugs eg. Opioids; anticholinergics
25
List three clinical features of acute urinary retention
* Little or no urine passed
* Suprapubic pain
* May be painless if previous chronic urinary retention
* Sensation of needing to void; inability to initiate micturition
* Suprapubic mass; dull percussion
26
Name two causes of post-op acute urinary retention
* Uncontrolled pain
* Constipation
* UTI
* Spinal or epidural
27
Describe the management of post-op acute urinary retention
* Reverse underlying factor
* Improve analgesia
* Treat constipation
* Mobilise
* Warm bath ➔ encourages micturition
* Restart any pre-op tamsulosin for BPH
* Relaxes prostate and bladder muscles
* Catheterisation
28
Name three post-op GI complications
* Post-op nausea and vomiting (PONV)
* Paralytic ileus
* Post-op mechanical small-bowel obstruction
* Constipation; diarrhoea
29
Give three patient risk factors for PONV
Patient factors:
* Female
* Younger age
* Previous PONV; motion sickness
* Opiods
* Non-smoker
30
Give three surgical risk factors for PONV
Surgical factors:
* Intra-abdominal laparoscopic surgery
* Intracranial or middle ear surgery
* Squint surgery
* Gynaecological surgery
* Prolonged operations
* Poor post-op pain control
31
Give two anaesthetic risk factors for PONV
Anaesthetic factors:
* Opioids or spinal
* Inhalation agents eg. isoflurane; nitrous oxide
* Prolonged anaesthesia
* Intraoperative dehydration/bleeding
* Excessive bag mask ventilation: gastric dilatation
32
Name three consequences of PONV
* Increased bleeding
* Incisional hernias; wound dehiscence
* Aspiration pneumonia
* Decreased absorption of oral medication
* Poor nutrition
* Hypokalaemia; metabolic alkalosis
33
How is PONV managed?
* Adequate hydration; analgesia
* Identify and treat any obstruction
* Cause-specific anti-emetic therapy:
* Impaired gastric emptying: Metoclopramide
* Bowel obstruction: Hyoscine
* Opioid-induced: Ondansetron; cyclizine
34
Name two intra-abdominal anastomoses with high risk of leak
Oesophageal and rectal anastomosis
35
Name three risk factors for anastomotic leak
Patient factors:
* Medication eg. steroids; immunosuppressants
* Smoking; alcohol excess
* Diabetes
* Obesity; malnutrition
Surgical factors:
* Emergency surgery
* Longer operation
* Peritoneal contamination
36
Request three investigation in suspected anastomotic leakage
* Gastrografin enema
* CT abdomen and pelvis with contrast
* FBC; CRP; U+Es; LFTs; clotting
* VBG
* G+S
37
Request three investigations for suspected post-op ileus
* FBC; CRP: U+Es
* CT abdomen and pelvis
38
Outline the management of post-op ileus
Must exclude serious pathology eg. anastomotic leak
* Daily bloods including U+Es
* Encourage mobilisation
* Reduce opiod usage
* **Drip and suck**: NBM + IV fluids ± NG tube
* Catheterisation
39
Differentiate post-op ileus from mechanical obstruction
Post-op ileus is a functional bowel obstruction
Absent bowel sounds rather than 'tinkling' bowel sounds
Surgical prep and care
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