Post-op complications: When To worry

1. Post-op complications:When To worry Aaron Morgenstein, MD Resident Physician Dept of Orthopaedic Surgery Atlanta Medical Center

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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 patient’s with posterior hip precautions • Next: • Notify surgeon and get x-ray

17. Delirium Tremens (DT’s) • Risk factors for Post-op DT’s: • Alcoholics (age>30yo) • 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.

18. 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.

19. Post-op Fever • Causes of Post-op fever: (5 W’s) • Water = UTI • Wind = atelectasis or pneumonia • Walk = DVT • Wound = surgical wound infection • Weird Drugs = Drug induced fever

20. 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

21. Periprosthetic Fracture • Risk factors for periprosthetic fracture: • Osteopneia/osteoporesis • Inflammatory disease (eg: Rhuematoidarhtirits) • 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

22. 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

23. 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

24. 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 fx’s, open fractures) • Post-op Signs : • Swelling, ecchymosis, and tenderness • Remember: • Missed injuries are common, so look for them • Next: • Notify physician

25. 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