Gynecology EXIMIUS

Postoperative Management of Complications PART 1 2021

Corazon W. Adviento, MD March 2020
POSTOPERATIVE PERIOD § Physical examination à lungs, wound, costovertebral
§ Time fromSept-2019
the end of the procedure in the operating room angle, superficial veins and deep veins in the legs
until a woman has resumed her normal routine and § Laboratory evaluation à CBC c PC, UA, CXR
lifestyle § Others : culture, GS, UTZ, CT
§ GOAL § Microatelectasis
§ Restore a woman’s physiologic and psychological § 90% of fevers in the 1st 48 hours of operation
health Drug- induced fever
§ eosinophilia
Risk factors for surgical patients § does not look as ill as the temp course
§ Underlying cardiac and pulmonary disease § Diagnosis of exclusion
§ Smoking § Ex: allopurinol, carbamazepine, lamotrigine, phenytoin,
§ Obesity sulfasalazine, vancomycin, minocycline, dapsone,
§ Prior or recurrent surgery sulfamethoxazole
§ Type of anesthesia § Elderly and HIV patients à inc risk
§ Age ??? Superficial thrombophlebitis
§ Enigmatic fever
POSTOP FEVER § Tenderness on IV site
§ Febrile morbidity § Removal of IV catheter
§ Temp of >38C 24 hours after surgery
§ Incidence: 14-16% à post hysterectomy FALLING HEMOGLOBIN
§ Most common morbidity § Dec urine output à earliest sign of dec in intravascular
§ Causes: volume
§ Atelectesis § Minimum UO à 0.5 mL/kg/hr
§ Pneumonia § Dec in orthostatic BP >10 mmHg à dec in 20% of blood
§ UTI volume
§ Nonseptic phlebitis § Determination of Hgb
§ Wound infection § Done 24 hours and 48-72 hours postop
§ Operative site infection § Normal physiologic response to stress of operation and
§ Operative time >2 hours tissue destruction
§ Necessity for intraop transfusion § Increase levels of aldosterone, cortisol and ADH
§ increase blood loss § Increase in sodium and water retention
§ 20% infectious (Aldostererone)
§ 80% noninfectious § Promote free water retention (ADH)
§ Treat or not to treat § <7g/dL à BT done
§ Broad spectrum antibiotics à for high risk patients or for § 7-8 g/dL à BT done if cardiovascular disease is present
those with fever >48 hours § 8-10 g/dL
§ Pathophysiology
§ Release of cytokines RESPIRATORY COMPLICATIONS
§ Atelectasis
§ Pneumonia

ATELECTASIS
§ Form two Greek words that mean “imperfect expansion”
§ Ranges from small group of bronchioles and alveoli to
complete lung collapse
§ Failure to maintain patency of small pulmonary airways
and alveoli
§ Most common cause of postop fever
§ Postop à dec in functional residual capacity and lung
WORK UP FOR FEVER compliance
§ 5 Ws
§ Wind à atelectasis
§ Water à UTI
§ Wound à infection or hematoma
§ Walk à superficial or deep vein phlebitis
§ Wonder drugs à drug – induced fever

§ Microatelectasis à atelectasis = 1st 72 hours postop

§ Dec in O2 saturation
§ Dec in Po2
§ Normal – low Pco2
§ History

TRANSCRIBERS GROUP 10: AKASH 1

 Gynecology EXIMIUS
Postoperative Management of Complications PART 1 2021
Corazon W. Adviento, MD March 2020
Pneumonia- treatment
Sept-2019 § No risk for MDR
§ Ceftriaxone 2g OD
§ Ampisul 3g q6
§ Levofloxacin 750mg OD
§ Moxifloxacin 400 mg OD
§ Ertapenem 1g OD
With risk of MDR
§ Antipseudomonal cephalosporin
§ Cefepime 2g q8
§ Ceftazidime 2g q8
§ Classic triad Antipseudomoanal carbapenem
§ Fever § Meropenem 1g q8
§ Tachypnea § Imipinem 500mg-1g q6
§ tachycardia § Piptazo 4.5g q 6
§ PE § For patients with severe allergies to penicillins
§ Tubular breathing § Aztreonam 2g q6-8 hour plus
§ Dec breath sounds § Antipseudomonal fluoroquinolone à
§ Moist inspiratory rales ciprofloxacin/ levofloxacin or
à Prominent on bases § Aminogylcoside à gentamycin, tobramycin,
§ Usually resolves spontaneously by 3rd or 5th postop day amikacin
§ Management: § MRSA coverage
§ Ambulation § Linezolid 600 mg q12hours
§ Deep breathing § Telavancin 10 mg/kg IV q 24 hours
§ Cough
§ Turn from side to side ASPIRATION PNEUMONIA
§ Remain semi erect § Occurs due to loss in protective airway reflexes
§ Use of Incentive spirometer during intubation and extubation or related to
postop N/V
PNEUMONIA § Pathogens:
§ Associated with atelectasis because bacterial infections § S. pneumoniae
usually begins at the collapsed lung. § H. influenza
§ Presdisposing factors: § S. aureus
Chronic pulmonary disease § G- rods
§ Heavy cigarette smoking § Treatment
§ Alcohol abuse § Clindamycin 600 mg IV q 8 hrs followed by 300
§ Obesity mg q6 hrs or 450 mg q 8 hrs
§ Advanced age or
§ NGT § Co amoxiclav 875 mg BID
§ Long operative procedures or
§ G(-) bacterial infections § Amoxicillin 500 mg TID plus Metronidazole 500
§ Postop peritonitis mg TID
§ Debilitating infections § Aspiration Pneumonitis
§ S/Sx § 1 in 3000 patients
§ Fever § Sec to aspiration of gastric fluid à severe
§ Cough chemical pneumonitis
§ Dyspnea § Aspiration and its complicationsà causes 30% of
§ Tachypnea anesthetic mortalities
§ Purulent sputum § Risk factors
§ Pain at the back § Older age
§ PE àCoarse rales § Obesity
§ Leukocytosis § Hiatal hernia
§ CXR: diffuse patchy infiltrates § Emergency surgery associated with full
§ GS : used to differentiate between bacterial colonization stomach
and infection
§ Management SLEEP APNEA
§ As atelectasis § Increased soft tissues of the head and neck can lead to
§ Parenteral antibiotics à based on type of airway compromise that leads to intermittent apnea and
pneumonia hypoventilation while a woman sleeps
§ Categories § Increased weight of adipose tissue on the neck, chest and
§ HAP à 48 hrs or more after admission abdominal wall leads to dec pulmonary compliance à
§ VAP à 48-72 hrs post intubation relative hypoxia à systemic as well as pulmonary
§ HCAP hypertension à hypercapnia
§ Morbidly obese patients

TRANSCRIBERS GROUP 10: AKASH 2

 Gynecology EXIMIUS
Postoperative Management of Complications PART 1 2021
Corazon W. Adviento, MD March 2020
§ When given higher levels of O2 and narcotics à § Development of shock from acute blood loss depends on
Sept-2019
inc risk for apnea rate of bleeding
§ Develop increased sensitivity to narcotics à § Slow blood loss form venous source à blood
shuts down respiratory drive loss but not shock
§ Postop à O2 sat = 94% § Rapid blood loss of 20% blood volume à mild
§ 96-99% à lose respiratory drive à shock
hypercarbic and acidotic § Rapid blood loss of 40% of blood volume à
Stop – bang questions severe shock
§ Do you Snore?
§ Feel Tired easily? § Massive blood loss
§ Has anyone Observed you to stop breathing during sleep? § Hemorrhage that results in the replacement if
§ Are you being treated for high blood Pressure? 50% of blood volume in 3 hours
§ Is your BMI >35 ?
§ Are you older than Age 50? Hypotension : DDx
§ Is your Neck size >16 inches for a woman? § Blood loss
§ Is your Gender – male? § Anesthesia
OBSTRUCTIVE SLEEP APNEA § Over sedation
§ 0 – 2 yes à low risk § Postop bleeding
§ 3-4 yes à intermediate risk § Less than ideal ligature/ hemorrhage
§ > 5 à high risk from a vessel that has retracted during
operation
§ Sec to clotting abnormality

DDX FOR POSTOP HEMORRHAGIC SHOCK

§ Pneumothorax
§ Pulmonary embolism
§ Massive pulmonary aspiration
§ MI
§ Acute gastric dilatation
DDX FOR INEFFECTIVE COAGULATION DEFECT
§ Sepsis
§ Fibrinolysis
§ Diffuse Intravascular Coagulopathy
§ Previously unrecognized coagulation defect à von
CARDIOVASCULAR PROBLEMS Willebrand disease
HEMORRHAGIC SHOCK § Coagulopathies can also develop form massive blood
§ Shock à a condition in which circulatory transfusion
insufficiency prevents adequate § Hypofibrinogenemia à 1st to develop
vascular perfusion and reduced capillary filling § Thrombocytopenia à last to be detected
§ If neglected, leads to § Adrenergic response to hemorrhage
§ Oliguria § Perspiration
§ Progressive metabolic acidosis § Tachycradia
§ Multiple organ failure § Peripheral vasoconstriction
§ Produced by: § Early signs of hypovolemia sec to internal bleeding
§ Hemorrhage § Tachycardia
§ Cardiac failure § Dec urine output à due to dec perfusion of the
§ Sepsis kidneys
§ Anaphylactic reaction § With further blood loss
§ Agitation
§ Hypovolemic shock § Weakness
§ Most common cause of circulatory failure in § Pallor
gyne pxs § Cold and clammy extremities
§ Cardiogenic and septic shock à less common § Systolic BP <80 mmHg
§ Seen several hours postop MANAGEMENT GOALS OF POSTOP SHOCK
§ Restore circulating blood volume
§ Tachycardia à classic cardiovascular physiologic response § Maintain oxygenation
to hypotension § Correct coagulopathy
§ Progressive hypovolemia à dec urine output § Maintain body temp
§ Perioperative cause of shock à inadequate hemostasis § Correct biochemical abnormalities
§ Prevent pulmonary and other organ dysfunction
§ Treat underlying cause pf hemorrhage
§ Adequate ventilation
§ Rapid fluid replacement = 3:1 rule!!!
§ Crystalloids vs. colloids

TRANSCRIBERS GROUP 10: AKASH 3

 Gynecology EXIMIUS
Postoperative Management of Complications PART 1 2021
Corazon W. Adviento, MD March 2020
§ Classic Sxs
Sept-2019 § Inflammation of the subcutaneous tissue
§ Fever
§ Painful and erythematous induration

Management
§ Removal of IV catheter
§ Mild à rest, elevation and hot compress
§ Moderate – severe à NSAID
§ With proximal progression à IV heparin and antibiotics

HEMATOMA
§ Wound or pelvic hematoma postop
§ Size depends on the potential size to which the hematoma
occurs
§ Increased risk
§ Patients on heparin and aspirin treatment prior
to surgery
§ S/Sx
§ Hgb is unexpectedly low at 3rd postop day
§ Tenderness on the affected area
§ Diagnosis:
§ PE
§ Imaging studies
Management:
§ Conservative à <5 cm
§ Percutaneous drainage : UTZ or CT- guided
§ Large hematomas becomes infected if untreated
even with antibiotics

RETAINED FOREIGN BODY

§ Incidence : 1 in 1200-1500 laparotomies
§ Sponge, ab pack, needles

THROMBOPHLEBITIS AND PULMONARY EMBOLUS

§ Surgery à Hypercoagulable state due to stress response
§ Superficial thrombophlebitis
§ Deep vein thrombosis
§ Pulmonary embolism

SUPERFICIAL THROMBOPHLEBITIS
§ one of the most common complicaitons
§ IV catheter
§ Benign but associated with deep vein thrombophlebitis in
5%

TRANSCRIBERS GROUP 10: AKASH 4