Post-OP Complications

Post-op fever

§  SSI¹: due to a group A Streptococcus (GAS) or Clostridium perfringens.
§  SSI²: due to other organisms ( NOT GAS or C perfringens).
§  SSI³: due to indolent organisms.
DVT: deep venous thrombosis; MI: myocardial infarction; PE: pulmonary embolism; SSI: surgical site infection
Causes of postoperative fever (the 5 Ws):
Wind
(lungs)
·       Pulmonary embolus
·       Pneumonia
·       Aspiration
Wound
·       Surgical site infection
Water
·       Urinary site infection
Walk
·       Deep venous thrombosis
Wonder
drugs/products
·       Drug fever
·       Blood products
·       Intravenous lines
·       Malignant Hyperthermia
o   INTRA-op
o   Dx: clx
o   Tx: IV Dantrolene, 100% O2, cooling blanket
·       Bactremia
o   shortly post op
o   do cultx 3 times
o   start emperic abx
·       Mnemonic: Wind – Water – Walking – Wound – Wounder
o   Atelectasis is the mcc of post-op fever on the first PO day.
path
·       AW obstruction (mucus, foreign body)→Air trapped in the alveoli (then it leaks out)→Lung collapse
·       Mediastinum shifts TOWARD
Clx
·       SOB/Hypoxia
·       ❌ breath sound/Dullness
Dx
·       CXR: opacification of affected lung/ Narrower rib spacing/ Mediastinal shift
Tx
·       PPx: incentive spirometry/ chest physiotherapy
·       Small: Chest physiotherapy
·       Large: Bronchoscopy (remove mucus plug)
o   listen to the lungs, do chest x-ray,
o   improve ventilation (deep breathing and coughing, postural drainage, incentive spirometry).
o   The ultimate therapy if needed is bronchoscopy.
o   Pneumonia
·       Chest x-ray will show infiltrates. Do sputum cultures
o   UTI: day 3. Work up with urinalysis, urinary cultures. Treat with appropriate antibiotics.
o   DVT: D5, Doppler studies of deep leg and pelvic veins is the best diagnostic modality
o   Wound infxn: D7, do U/S to r/o abscess, then tx w/ Abx
o   Deep abscess: D10-15, ⨁ U/S or CT, tx: drainage (OR)!
Chest pain
·       MI
o   either intra-op, or D2-3 Post-op
o   d/t hypotension
o   HIGH MORTALITY (50-90%)
o   Dx: EKG –> Troponin (most reliable)
o   Tx: Cath lab
o   NEVER EVER NEVER USE tPA
·       PE
o   D7
o   Pain is pluiritic
o   ⤵️ CVP/JVP essentially r/o dx
o   Dx: CT Angio
o   Tx: Heparin / IVC filter (if you can’t anticoagulate)
o   PPx
·       Low risk: compression device
·       High risk: anticoagulation
·       RF: Age >40, prolonged immobilzation, Leg/pelvic fx, femoral venous catheter
Pulmonary complications
·       Aspiration
o   If full stomach, awake pt
o   can be lethal, or cause chemical injurt, or 2˚ pneumonia
o   Prevent by NPO + Antacid
o   Tx: Bronchoscopy and remove offending agent –> bronchodilators w/ resp support
·       Tension pneumothorax
o   traumatized lung + positive pressure breathing,
o   BP ⤵️ + CVP ⤴️
o   Tx: if open abdomen: quick decompression, if not: a needle can be inserted through the anterior chest wall into the pleural space
Postoperative pulmonary complications:
complications
·       Atelectasis, infection (e.g., pneumonia)
·       Bronchospasm, exacerbation of chronic lung disease
·       Prolonged mechanical ventilation
Risk factors
·       Age >50 years
·       Emergency surgery or surgery duration >3hours
·       Heat failure, chronic obstructive lung disease
·       Poor general health (American Society of Anesthesiologists class >2)
Pre-operative strategies
(to reduce risk)
·       Smoking cessation at least 8 weeks prior to surgery
·       Symptom control of chronic obstructive lung disease (e.g., preoperative glucocorticoids if not well controlled)
·       Treatment of any respiratory infections prior to surgery
·       Patient education for lung expansion maneuvers (e.g., chest physical therapy, coughing, deep breathing exercises, incentive, spirometry)
Post-operative strategies
·       Inactive spirometry
·       Deep breathing exercises
·       Epidural analgesia instead of parenteral opioids
·       Continuous positive airway pressure
Pulmonary contusion
Clx
·       Present <24 hours after blunt thoracic trauma
·       Tachypnea, tachycardia, hypoxia
Dx
·       Rales or decreased breath sounds
·       CT scan (most sensitive) or CXR with patchy, alveolar infiltrate not restricted by anatomical borders
Tx
·       Pain control
·       Pulmonary hygiene (e.g., nebulizer treatment, chest PT)
·       Supplemental oxygen and ventilatory support
Aspiration syndromes:
Pneumonia
Pneumonitis
Path
·       Lung parenchyma infection
·       Aspiration of upper airway or stomach microbes (anaerobes)
·       Lung parenchyma infection
·       Aspiration of gastric acid with direct tissue injury
Clx
·       Present days after aspiration event
·       Fever, cough, ↑sputum
·       CXR infiltrate in dependent lung segment (classically RLL)
·       Progress to abscess
·       Present hours after aspiration event
·       Range from no symptoms to nonproductive cough, ↓O2, respiratory distress.
·       CXR infiltrates (one or both lower lobes) resolve without antibiotics
Tx
Antibiotics: Clindamycin or beta-lactam and beta-lactamase inhibitor
Supportive (no antibiotics)
AMS
Abd Distension
·       Either: functional vs Mechanical / Severity: partial –> complete
·       S/S: Abd distension + pain (obvious). Also they have ø gas / stool (if complete). 
·       1˚ Dx step: ALWAYS KUB.
·       If pt is stable –> you can go for CT w/ contrast
·       If pt is allergic to contrast or u are in ER –> U/S can work
·       If you are suspecting perforation? Use CT w/ gastrofringen contrast as it’s water-solube
ileus
Obstruction
·       Path: Functional (pt got surgery, things take a while to move)
·       Post-OP day 1-2
·       Pt has ø Gas ø Stool
·       Absent bowel sounds
·       Dx: KUB
·       Findings: Everything is affected & dilated w/ air
·        
·       Tx: Make pt move, IVF + K+
·       Path: obstruction
·       Types: SMO vs. LBO
·       SBO: Vomits early, constipate later.
·       LBO: Vomits late, constipate early
·       Post-op day 5
·       Pt has ø Gas ø Stool
·       High-pitched bowel sounds
·       Dx: KUB
·       Findings: only 1 area affected (distal to it: ø / Proximal: dilated + filled w/ gas)
·       Tx:
·       Conservative:
§  If pt is stable & not detriorating
§  NPO + NG Tube
§  for 3 days. if no improvement ⤵️
·       Surgical:
§  If pt deteriorates (ischemia/necrosis, hypotensive, persistant obstruction 3-5 days)
§  If pt is peritoneal
§  Surgical decompression.
Acute Urinary Retention
The major risk factors for development of AUR include:
·       👨🏻 (rarely occurs in women)
·       Advanced age (~33% of men age will develop AUR)
·       History of neurologic disease (eg, mild cognitive impairment)
·       Surgery (especially abdominal surgery, pelvic surgery, and joint arthroplasty)
Dx: bladder ultrasound demonstrating 2300 mL of urine.
Tx: insertion of a Foley catheter, + UA to rule out UTI.
Foley catheter insertion can be both diagnostic and therapeutic.
 

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