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Postoperative Complications

Surgery

Assumptions

The student understands that prevention is the best form of management for postoperative complications; is knowledgeable about the normal physiology of the cardio-respiratory, gastrointestinal, renal, immunological, neurological, and circulatory systems; and understands the alterations in physiology which are produced by surgical stress.

Knowledge Objectives

Through their reading and patient care experiences, at the end of the rotation students should be able to:

Describe the differential diagnosis of a patient having postoperative fever and, for each entity, discuss the clinical manifestations, appropriate diagnostic work-up, and management:
Within 24 hours - response to surgical trauma; atelectasis; necrotizing wound infections.
Between 24 and 72 hours:
pulmonary disorders (atelectasis, pneumonia)
catheter related complications (IV-phlebitis, Foley-UTI)
After 72 hours:
infectious (UTI, pneumonia, wound infection, deep abscess, anastomotic leak, prosthetic infection, acalculous cholecystitis, parotitis)
noninfectious (deep vein thrombosis)
Intraoperative - malignant hyperthermia
Discuss the following wound complications in terms of predisposing risk factors (patient condition, type of operation, technique), as well as their recognition, treatment, and prevention:
hematoma and seroma
wound infection
dehiscence
incisional hernia
Discuss the various causes of respiratory distress and respiratory insufficiency that may occur in the postoperative patient. For each complication, describe the etiology, clinical presentation, management, and methods of prevention:
atelectasis
pneumonia
aspiration
pulmonary edema
ARDS
pulmonary embolism (including deep venous thrombosis)
fat embolism
Discuss the diagnostic work-up and treatment of oliguria in the postoperative period. Include pre-renal, renal, and post-renal causes (including urinary retention).
Discuss the possible causes of hypotension which may occur in the postoperative period. For each etiology describe its pathophysiology and treatment:
hypovolemia
sepsis
cardiogenic shock - including postoperative myocardial infarction, fluid overload, arrhythmias, pericardial tamponade
medication effects
Describe the management of postoperative chest pain and arrhythmias.
Describe factors which can lead to abnormal bleeding postoperatively, and discuss its prevention and management:
Surgical site - inherited and acquired factor deficiencies, DIC, transfusion reactions, operative technique
Gastroduodenal (i.e. stress ulcerations)
Discuss disorders of alimentary tract function following laparotomy which may produce nausea, vomiting, and/or abdominal distension:
paralytic ileus
acute gastric dilatation
intestinal obstruction
fecal impaction
Discuss precipitating factors and treatment of the following postoperative metabolic disorders:
hyperglycemia
adrenal insufficiency
thyroid storm
Discuss external gastrointestinal fistulas:
contributing factors
management
Describe the factors which can give rise to alterations in cognitive function postoperatively, as well as their evaluation and treatment:
hypoxia
perioperative stroke
medication effects
metabolic and electrolyte abnormalities
functional delirium
convulsions
Describe methods to prevent postoperative complications including:
Wound complications - meticulous surgical techniques, perioperative antibiotics for clean-contaminated wounds, delayed closure of dirty wounds.
Respiratory complications - avoid smoking in advance of elective surgery, encourage coughing and deep breathing, sufficient but not excessive analgesia, early postoperative ambulation.
Oliguria - adequate intravenous fluids, assure outflow.
Hypotension - avoid hypovolemia, monitor for arrhythmias, early recognition and treatment of infection, titrate medication doses carefully.
Bleeding
Surgical site: meticulous operative technique, screen for factor deficiencies, give platelets and fresh frozen plasma for massive blood loss, avoid DIC by preventing infections and treating them early.
Gastroduodenal: keep gastric pH neutral.
Alimentary tract dysfunction - use nasogastric tube, stool softeners, and cathartics when necessary.
Hyperglycemia - avoid too large infusions of glucose, monitor diabetics carefully and administer insulin appropriately.
Adrenal insufficiency - provide stress doses of corticosteroids when adrenals are chronically suppressed.
Thyroid storm - control hyperthyroidism prior to surgery.
Alterations in cognitive function - avoid hypoxia and electrolyte imbalances, titrate medications carefully.