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GS8 General Surgery and Thoracic Surgery
Pre- and Post-Operative Orders
ADDAVIDS
Admit to ward X under Dr. Y
Diagnosis
Diet
Activity
Vitals (q4h from ED and post-operative is standard)
IV, Investigations, Ins and Outs
Drugs, Dressings, Drains
Special procedures
5 Ws of Post-Operative Fever
Wind POD #1-2 (pulmonary – atelectasis, pneumonia)
Water POD #3-5 (urine – UTI)
Wound POD #5-8 (wound infection - if earlier think streptococcal or clostridial infection) Walk POD #8+ (thrombosis – DVT/PE) Wonder drugs POD #1+ (drug)
Drugs–7As
Analgesia
Anti-emetic
Anticoagulation
Antibiotics
Anxiolytics
Anticonstipation
All other patient meds (home meds, stress dose steroids, and β-blockers)
Approach to the Critically Ill Surgical/ Trauma Patient
ABC, I’M FINE
ABC
IV: 2 large bore IVs with NS, wide open Monitors: O2 sat, ECG, BP
Foley catheter to measure urine output Investigations: blood work
NGT if indicated
“Ex” rays (abdomen 3 views, CXR), other imaging – only when stable
Surgical Complications Toronto Notes 2019
■ POD#1-2(acute)
◆ atelectasis (most common cause of fever on POD #1)
◆ early wound infection (especially Clostridium, Group A Streptococcus – feel for crepitus and
look for “dishwater” drainage)
◆ aspiration pneumonitis
◆ other: Addisonian crisis, thyroid storm, and transfusion reaction
■ POD #3-7: likely infectious
◆ UTI, surgical site infection, IV site/line infection, septic thrombophlebitis, and leakage at bowel
anastomosis (tachycardia, hypotension, oliguria, and abdominal pain) ■ POD#8+
◆ intra-abdominal abscess, DVT/PE (can be anytime post-operative, most commonly POD #8- 10), and drug fever
◆ other: cholecystitis, peri-rectal abscess, URTI, infected seroma/biloma/hematoma, parotitis, C. difficile colitis, and endocarditis
Treatment
• treatprimarycause
• antipyrexia(e.g.acetaminophen)
Wound/Incisional Complications
WOUND CARE (see Plastic Surgery, PL8)
• canshowerPOD#2-3afterepithelializationofwound
• dressingscanberemovedPOD#2andleftuncoveredifdry
• examinewoundifwetdressing,signsofinfection(fever,tachycardia,andpain) • skinsuturesandstaplescanberemovedPOD#7-10
■ exceptions: incision crosses crease (groin), closed under tension, in extremities (hand) or patient factors (elderly, corticosteroid use, or immunosuppressed) removed POD #14, earlier if signs of infection
• negativepressuredressingsconsistoffoamandsuction,promotegranulation
■ ideal for large (grafted sites) or non-healing wounds (irradiated skin, or ulcer)
DRAINS
• drainsmaybeplacedselectivelyatthetimeofsurgerytopreventfluidaccumulation(blood,pus,serum, bile, and urine)
■ can be used to assess quantity of third space fluid accumulation post-operatively
• potentialrouteofinfection;todecreaseriskofwoundinfectionbringoutthroughseparateincision(vs.
operative wound) and remove as soon as possible • types of drains
■ open (e.g. Penrose), higher risk of infection
■ closed: 1) Gravity drainage (e.g. Foley catheter); 2) Underwater-seal drainage system (e.g. chest
tube); 3) Suction drainage (e.g. Jackson-Pratt) ■ sump (e.g. NGT)
• monitor drain outputs daily
• drains should be removed once drainage is minimal (usually <30-50 cc/24 h)
• drainsdonotguaranteethatthepatientwillnotformacollectionoffluid
• ridgeddrainscanerodethroughinternalstructures,andexcessivesuctioncancausenecrosis • evidencedoesnotsupportroutinepost-operativedrainageofabdominalcavity
SURGICAL SITE INFECTION Etiology
• S.aureus,E.coli,Enterococcus,Streptococcusspp.,Clostridiumspp. Risk Factors
Table 4. Procedures and Their Impact on Surgical Site Infection
Classification
Definition
Example
Infection Rate Wound Closure
Clean
Incision under sterile conditions; nontraumatic; no entrance of hollow organ
Hernia repair
<2%
Primary closure
Clean-Contaminated
Incision under sterile conditions; ENTRANCE of hollow viscus; no evidence of active infection; minimal contamination
Routine cholecystectomy; colon resection
3-4%
Primary closure
Contaminated
Incision under sterile conditions; MAJOR contamination of wound during procedure (i.e. gross spillage of stool, infection in biliary, respiratory, or GU systems)
Bowel obstruction with enterotomy and spillage of contents; necrotic bowel resection; fresh traumatic wounds
7-10%
Often secondary closure
Dirty/Infected
Established infection present before wound is made in skin
Appendiceal abscess; traumatic wound with contaminated devitalized tissue; perforated viscus
30-40% Secondary closure