Post-operative complications

Question 1

Potential complications

Answer 1

1. Respiratory failure->heart and lungs
2. Wound failure->check wound site
3. Confusion->orientation
4. Pyrexia->vitals
5. Deep vein thrombosis->painful calves, mobilising, DVT prophylaxis
6. Oliguria->urine output
7. Hyponatremia->bloods
8. Hypernatremia
9. Hypo/hyperkalemia
10. Hemorrhage
11. Vomiting

Question 2

Causes of respiratory failure

Answer 2

1. Pulmonary embolism
2. Acute lung injury/ARDS
3. Abdominal distension
4. Opiate overdose

Question 3

Potential wound failures

Answer 3

1. Discharge of fluid
(serous, blood, serosanguinous,
infected fluid)
2. Collection of fluid
(blood, pus, seroma--> large incision in SC or lymphatic damage-->lift skin off tissues and impede wound healing
3. Disruption of the wound

Question 4

Risk factors for wound breakdown

Answer 4

1. General
DM
Immunosuppression
Malignancy
Malnutrition
2. Local
Wound closure
Infection
Foreign body
Mechanical stress

Question 5

Serous versus serosnguinous from wound

Answer 5

1. serous may be little significance
2. Serosanguinous–> 5-8 days post may be due to dehiscience
   with evisceration. Sterile dressing
   consider taking back to surgery

Question 6

Causes of post-operative confusion

Answer 6

1. Hypoxia->pneumonia, PE, cariac
2. Sepsis
3. Drug withdrawal, drug effects
4. Metabolic/electrolyte
5. Urinary retention

Question 7

Management of confusion

Answer 7

1. Study charts
2. Co-morbidities
3. Drug/alcohol
4. History and examine
5. Consider oxygen
   Consider ABG, FBC/UEC/LFTs,
   blood/urine culture, CXR, echo?
6. May need sedation->midazolam, haloperidol

Question 8

Define normal temperature

Answer 8

A normal temperature is 36.5-37.5

Question 9

What considerations with post-op pyrexia

Answer 9

1. Type of fever
2. Procedure
3. Temporal relationship

Question 10

Fever within 24 hours

Answer 10

1. ATELECTASIS

2. Metabolic response

Question 11

Fever days 5-7

Answer 11

Usually infection
Pulmonary can
Consider: infection of the wound, operative site or urinary tract
Cannula and DVT!

Question 12

Fever >7 days post op

Answer 12

Abscess
Also remember–> drugs, transfusion, brainstem as cause of
+temperature

Question 13

Causes of oliguria

Answer 13

Diminished output

most commonly hypovolemia
2. Intra-renal (ATN)
3. Post renal failure: Need accurate matching input and output
Most ensure not in acute urinary retention

Question 14

Common causes of oliguria in terms of procedure and ileus

Answer 14

1. Underestimating fluid loss in procedure

2. Ileus->fluid becomes sequestered in the gut

Question 15

Cause of hyponatremia and management

Answer 15

1. Mostly dilutional
2. +ADH

Fluid restriction 2L until diuresis settles

Question 16

Causes of hypernatremia and management

Answer 16

Usually secondary to
reduced water intake
1. Administer water by mouth or
IV dextrose
2. Max reduction 10mmol/L in 24
hours redution/L dextrose= sodium concentration/ (TBW +1)

Question 17

Types of hemorrhage related to surgery

Answer 17

Localised
1. Primary- 
within procedure
2. Reactionary- w/i
24 hours of procedure,
most commonly from
poorly ligated blood vessel
3. Secondary 7-10 days 
after operation-->most often erosion of vessel from spreading infetion, intraperitoneal bleeding, GIT hemorrhage, disordered hemostasis

Question 18

Causes of vomiting

Answer 18

1. Drugs->immediate
2. Gut atony->self limiting
3. If >7 days->consider mechanical course

Question 19

Causes of post-op fever and timeframe

Answer 19

1. Wind
Pulmonary 1-3 days
Atelectasis, pneumonia
Exacerbate pre-existing
2. Water
UTI day 3-5
3. Wound
Infection day 5-8
4. Walk
Venous->DVT, PE, Thrombophlebitis
5. Wonder drugs
Any drug can cause

Question 20

Timing of post-op fever to identify cause

Answer 20

1. Hours after POD 1
Inflammatory
Blood reaction
Malignant hyperthermia
2. POD 1-2
!Atelectasis
Early wound
Aspiration pneumonitis
Addisonian, thyroid storm
Transfusion reaction
3. POD 3-7
UTI
Surgical site infection
Septic thrombophlebitis
Leaked anastamosis
4. POD 8
Intra-abdo abscess
DVT/PE, drug fever
Cholecystitis, peri-rectal
abscess, URTI, 
seroma/hematoma/biloma that's
infected
C dif colitis, Endocarditis

Question 21

Immediate post-operative management

Answer 21

1. Pain and other medications
   a. analgesia,
   b. antibiotics
   (prophylactic or therapeutic),
   c. sedatives,
   d. antiemetics and
   e. anticoagulants/DVT prophylaxis–>
   ensure charted and being
   administered where relevant
2. Monitoring
   vitals, (may include cVP),
   Fluid input and output
   Normal fluids noted
   If fluid shifts/renal reduce–>
   catheter and review hourly
   Check UEC, CRP, eGFR, haem regularly
3. Mobilisation
   as early/much as can (not in
   epidural catheter,
   multiple injuries)
   Physio–> help flow, reduce
   DVT risks
4. Communication
5. Respiratory
6. Fluid balance
7. Gut function
8. Drain and catheter care

Question 22

Respiratory considerations

Answer 22

1. Control of pain
2. Regular hyperinflation with inhalation spirometry
3. Early mobilisation

Question 23

Gut function considerations

Answer 23

1. Gastric dilitation: 2-3 days post-->massive fluid secretion, risk of regurg and aspiration
Insert NGT and decompress
2. Paralytic ileus: first post op
following peritonitis or 5 days post. Abdominal distention and vomiting
a. Oral fluid restriction
b. IV replacement
c. Most resolve spontaneousl
d. May consider pro-kinetic agents
3. Pseudo-obstruction:
elderly who has surgery
for fractures NOF
a. If not resolving spontaneously, 
colonoscopic decompression

Question 24

Principles of fluid balance

Answer 24

1. Correct abnormalities
2. Provide the daily requirements
3. Replace any abnormal/ongoing losses

Question 25

Daily requirements

Answer 25

``` basic requirements 45-60% TBW 2/3 intracellular 1/3 plasma water (25% of extracellular fluid) and interstitial fluid (75% of extracellular fluid). Na and potassium daily requirements: 100–150 mmol and 60–90 mmol-->will balance loss in urine Daily requirement for maintenence 2-3L: Loss: 1500 mL in the urine and about 500 mL from the skin, lungs and stool ```

Question 26

What do you need to do prior to potassium supplementation

Answer 26

Need to ensure kidneys are functioning

Question 27

Approximting losses from gastric, duodenal, diarrhea, upper GI, lower

Answer 27

``` Gastric--> +chloride, sodium, small potassium Duodenal/biliary/ pancreat/jejuno/feces--> mostly Na, Cl and bicarb Diarrhea--> Na, Cl, potassium and bicarb Upper GI-->acid lost (metabolic alkalosis) Lower-->sodium and bicarb ```

Question 28

Management of wound dishiscience and evisceration of the ward after laparotomy

Answer 28

1. Assume defect involvles whole of the wound 2. Put guts in abdomen, sterile dressing 3. IV cannula, IV antibiotics, IVF 4. Get senior help 5. Let theatre know 6. Analgesia