Post-op complications: When To worry

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Post-op complicationsWhen To worry
Aaron Morgenstein, MD Resident Physician Dept of
Orthopaedic Surgery Atlanta Medical Center
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Mycardial Infarction (MI)

• Risk factors for post-op MI
• Elderly
• History of MI (within 1 year)
• Family history of MI at less than 50yo
• Large blood loss (low H/H)
• Post-op Signs of MI
• New onset tachycardia
• Changes on ECG
• Hypertension/Hypotension
• Chest pain
• Shortness of breath
• Remember
• Initial Cardiac Enzymes can be negative
• Women present with atypical symptoms

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Mycardial Infarction (MI) Continued

• Next Step
• Notify primary physician and consult Cardiology
• Get labs, ECG, CXR, Cardiac enzymes
• Initial Treatment (MONA)
• Morphine
• Oxygen
• Nitroglycerin
• Aspirin (162-325mg non-enteric coated)
• Beta Blocker

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Stroke

• Risk factors for Post-op stroke
• Elderly
• History of stroke or MI
• Acute renal failure or those on dialysis
• Hypertension or peripheral vascular disease
• COPD
• Post-op Signs
• Altered Mental Status
• Hemiplegia
• Remember
• Beach Chair Position has increased risk for
  stroke
• Next
• Notify Neuro/stroke team

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Compartment Syndrome

• Risk factors for Compartment Syndrome
• High energy fracture (x-ray segmental and
  comminuted fx)
• Most commonly tibial shaft/plateau fractures and
  both bone forearm fractures
• Post-op Signs
• Pain out of proportion
• Parastheisas
• Pain with passive stretch
• Firm compartments

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Compartment Syndrome

• Remember
• Can be seen in open fractures
• Can easily be missed in intubated patients
• Compartment syndrome can be seen without
  fracture
• Examples Crush Injuries, GSW, burns, vascular
  injuries constrictive dressings
• Pulseless limb Dead limb
• Next
• Notify orthopaedics or vascular surgery
• Loosen splint/dressings

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Pulmonary Embolism (PE)

• Risk factors for Post-op PE
• Surgery within 3 months
• Lower extremity surgery or injury
• Immobilization (eg splint/cast)
• History of DVT
• Chronic heart disease
• Cancer
• Obesity
• Heavy smokers

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Pulmonary Embolism Continued

• Post-op Signs
• Shortness of breath
• Chest pain or pain with breathing
• Wheezing
• Tachycardia
• Remember
• Hemodynamically unstable patient bad sign
• Next
• Notify primary physician
• STAT CT scan or VQ scan

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Hypotensive Crisis

• Causes of Post-op Hypotension
• Inadequate resuscitation
• MI, heart failure or arrythmia
• Medication induced (eg pain meds, muscle
  relaxants, restarting home meds)
• Post-op Signs
• Altered Mental Status
• Fatigue
• Chest pain
• Remember
• Watch for high wound vac or hemovac output
• Anesthesia and op notes may not be accurate
• Next
• Notify Primary physician, likely transfer to ICU
• Start bolus NS and determine etiology

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Deep Venous Thrombosis

• Risk factors for Post-op stroke
• Immobilization (bed rest and splints)
• Polytrauma
• Contraceptives/Pregnancy
• Thrombophilia, Cancer, Heart Disease, Renal
  Failure
• Post-op Signs
• Worsening swelling and pain in operative leg
• Remember
• All surgical patients have increased risk of DVT
• Sickle cell patients have greater risk for DVT
• Patients with knee immobilizer are at greater
  risk for DVT
• Next
• Notify primary physician and get Duplex

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Wound Drainage

• Risk factors for post-op wound drainage
• Obesity, smokers and diabetes
• Malnutrition
• Immunosuppressed/irradiated patients
• Vascular, renal, cardiac and liver disease
• anticoagulants
• Post-op Signs
• Draining incision seen on initial dressing change
• Remember
• Continuous wound drainage can be early sign of
  infection
• Next
• Notify surgeon, stop range of motion exercises,
  hold anticoagulants

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Post-op Anemia

• Risk factors for Post-op Anemia
• Low pre-op H/H
• High intra-op blood loss
• Elderly
• Fracture repair and long bone fracture
• Arthroplasty
• Post-op Signs
• Tachycardia, hypotension, fatigue, new onset
  arrthymia
• Remember
• Vitals, age and PMH dictate the need for
  transfusion
• Next
• Notify physician, H/H threshold for transfusion
  is debatable

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Post-op Hematoma

• Risk factors for Post-op Hematoma
• Poor hemostasis during surgery
• Removing surgical drain too early
• Arthroplasty
• Long or difficult surgery
• Post-op Signs
• Worsening swelling, stiffness, and erythema
• Changes in neurologic function
• Remember
• Significant post-op hematoma can lead to early
  infection or paralysis
• Next
• Notify surgeon, possible surgical evacuation

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Post-op Ileus

• Risk factors for Post-op ileus
• Prolonged surgical and anesthesia time
• Pelvic surgery
• Lack of bowel movements prior to surgery
• Post-op Signs
• Abdominal pain/fullness
• Remember
• It normal to go 48-72hrs post-op without BM
• Best prognosis flatus
• Bad prognosis Nausea/Vomiting
• Encourage caffeine intake
• Next
• Notify Physician. Hold narcotics. Get labs and
  KUB. Possible NG-tube

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Hardware Infection

• Risk factors for Hardware infection
• Obese, smokers, diabetics and advanced age
• Prolonged surgical time
• Chronic wound drainage
• Complex fracture repair
• Post-op Signs
• Drainage from incision site and/or erythema
• Fevers/chills
• New onset or worsening of pain
• Remember
• Infected hardware can be difficult to detect.
• It is unusual to have an acute infection in the
  hospital setting
• Next
• Notify surgeon. Get imaging studies, ESR/CRP, CBC

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THA Dislocation

• Risk factors for THA Dislocation
• Elderly females
• Trauma to hip
• Dementia or poor neurologic status
• Post-op Signs
• Most common Posterior dislocation
• Leg is adducted and internally rotated
• Leg length differences
• Remember
• Maintain abduction pillow for patients with
  posterior hip precautions
• Next
• Notify surgeon and get x-ray

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Delirium Tremens (DTs)

• Risk factors for Post-op DTs
• Alcoholics (agegt30yo)
• Post-op Signs
• Symptoms appear 48-96hrs after last drink
• Hallucinations, disorientation, tachycardia, HTN,
  fever, agitation, diaphoresis
• Remember
• Give a man a beer if you have any doubt.
• Next
• Notify physician. Benzodiazepines, IVF and ICU
  transfer.

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Hemovac Complication

• Remember
• Pulling out a surgical drain is not a benign
  process.
• Next
• Notify Surgeon
• Hold pressure with hand or compressive dressings
• Emergent surgery if bleeding does not stop.

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Post-op Fever

• Causes of Post-op fever (5 Ws)
• Water UTI
• Wind atelectasis or pneumonia
• Walk DVT
• Wound surgical wound infection
• Weird Drugs Drug induced fever

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Post-op Fever Continued

• Remember
• Fever w/in 48hrs surgery Atelectasis
• Prevention
• UTI d/c foley early
• Atelectasis early ambulation and incentive
  spirometry
• DVT early ambulation, medical prophylaxis
• Infection 24hr post-op antibiotics
• Open fractures must be started on antibiotics
  prior to surgery
• Next
• Notify surgeon

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Periprosthetic Fracture

• Risk factors for periprosthetic fracture
• Osteopneia/osteoporesis
• Inflammatory disease (eg Rhuematoid arhtirits)
• Patients with fall risk
• Post-op Signs
• New onset of pain/swelling
• Unable to bear weight
• Does not tolerate transfers
• Remember
• Look for fracture and prosthesis loosening on
  xray
• Next
• Get early xray

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Vascular Injury

• Post-op Signs
• Similar signs to compartment syndrome
• New onset of pain and paresthesias
• Compartments may be soft
• Remember
• Surgery around the knee can cause vascular injury
• Intraoperative vascular injuries are rare, but
  commonly have a delayed diagnosis
• Misleading a pulse may be present with vascular
  injury
• Next
• Notify Surgeon

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Patella Tendon Rupture

• Risk factors for Post-op patella tendon rupture
• Revision or more involved knee surgery
• Patient with Fall risk
• Pre-operative lack of flexion
• Inflammatory diseases or chronic tendinitis
• Post-op Signs
• Patient hears a loud pop
• Unable to extend leg
• Remember
• Extensor mechanism (patella or quad tendon)
  rupture is a poor prognosis for the patient with
  a knee replacement
• Next
• Notify surgeon and get xray

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Missed Injury

• Risk factors for Missed injury
• Patients with lower Glasgow Coma Scale and
  greater Injury severity scores
• Incomplete initial workup in ED. Trauma bay, etc
• Inadequate follow up physical exams
• Distracting injuries (eg spine fxs, open
  fractures)
• Post-op Signs
• Swelling, ecchymosis, and tenderness
• Remember
• Missed injuries are common, so look for them
• Next
• Notify physician

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Fat Embolism

• Risk factors for Fat Embolism
• Young male
• Long bone fractures
• Polytrauma patient with pelvic fractures
• Post-op Signs
• Classic Triad respiratory, neurological,
  petechiae
• Neuro/respiratory symptoms are more common than
  skin
• Requiring more oxygen with tachycardia
• Remember
• Symptoms occur w/in 24-72hrs after injury or
  surgery
• Next
• Notify physician, bolus IVF, supplemental oxygen