Post-Surgical Red Flags

Post-SurgicalPost-Surgical Red Flags Red Flags

Heather Wyatt, PA-CHeather Wyatt, PA-C

Physician Assistant for Physician Assistant for Angelo J. Colosimo, M.D.Angelo J. Colosimo, M.D.

University Orthopaedic University Orthopaedic Consultants of CincinnatiConsultants of Cincinnati

Prevention of post-surgical Prevention of post-surgical problems is the key to a problems is the key to a successful operationsuccessful operation

Some of the possible post-operative complicationsSome of the possible post-operative complications

Post-Operative Nausea and VomitingPost-Operative Nausea and VomitingUrinary RetentionUrinary RetentionConstipationConstipationHypotensionHypotensionArrhythmiasArrhythmiasNeurovascular injuriesNeurovascular injuriesDVT (Deep Vein Thrombosis)DVT (Deep Vein Thrombosis)InfectionInfectionArthrofibrosisArthrofibrosis

Post-operative Nausea and VomitingPost-operative Nausea and Vomiting

Occurs in 20-30% of surgical casesOccurs in 20-30% of surgical casesPredisposing Factors:Predisposing Factors:

Duration of anesthesiaDuration of anesthesiaUse of reversal agentsUse of reversal agentsIntraoperative OpioidsIntraoperative OpioidsFemale genderFemale genderDiabeticDiabeticPremenstrualPremenstrual

Easily treated with Oral or Rectal medicationsEasily treated with Oral or Rectal medicationsCan have serious complications if left untreatedCan have serious complications if left untreated

ConstipationConstipation

All Narcotics pre-dispose patients to All Narcotics pre-dispose patients to getting constipatedgetting constipatedIf a patient asks you:If a patient asks you:

They can take Docusate OTC or Senna They can take Docusate OTC or Senna OTC for stool softenerOTC for stool softenerDrink 8 8oz glasses of water per dayDrink 8 8oz glasses of water per dayAmbulation helps bowel mobilityAmbulation helps bowel mobilityHave them call the officeHave them call the office

Urinary RetentionUrinary Retention

This is a side-effect of the anesthesiaThis is a side-effect of the anesthesiaIncreased incidence with spinals or Increased incidence with spinals or epiduralsepiduralsBladder cannot sense that it is fullBladder cannot sense that it is fullPatients need to relax to allow bladder to Patients need to relax to allow bladder to emptyemptyCall office immediatelyCall office immediatelyMay need to go to the ED for a May need to go to the ED for a catheterizationcatheterization

Sore Throat/HoarsenessSore Throat/Hoarseness

Often a very normal side effect of Often a very normal side effect of intubation during surgeryintubation during surgery

Occurs in 1/3 of all intubated Occurs in 1/3 of all intubated patientspatients

Resolves with in 2-3 weeksResolves with in 2-3 weeks

No treatment necessaryNo treatment necessary

Warm salt water gargles may helpWarm salt water gargles may help

Post-operative ConfusionPost-operative Confusion

Mild cases may occur – should Mild cases may occur – should resolve with in 48 hoursresolve with in 48 hours

Risk Factors:Risk Factors:High ageHigh age

Vitamin B deficiencyVitamin B deficiency

AlcoholicAlcoholic

Peripheral Nerve DamagePeripheral Nerve Damage

Also called neuropraxiasAlso called neuropraxiasArms,legs, shoulders and neck may be in Arms,legs, shoulders and neck may be in an atypical position for a long period of an atypical position for a long period of timetimeThis can cause pressure on an underlying This can cause pressure on an underlying nerve or nerve bundlenerve or nerve bundleHave patient report any numbness, Have patient report any numbness, radiating pain or tingling immediatelyradiating pain or tingling immediatelyEarly detection is key to treatmentEarly detection is key to treatment

Deep Vein Thrombosis (DVT)Deep Vein Thrombosis (DVT)

Thrombosis is a blood clotThrombosis is a blood clot

DVT is a blood clot in the deep DVT is a blood clot in the deep veins of the extremityveins of the extremity

Can form after any surgery but Can form after any surgery but are more common in lower are more common in lower extremity surgeriesextremity surgeries

DVTDVT

The body can resolve the The body can resolve the majority of lcots with in the 6 majority of lcots with in the 6 week post-operative periodweek post-operative period

Either dissolves clotEither dissolves clotOr creates new veins through the Or creates new veins through the clotclotMost DVTs are treated out-patientMost DVTs are treated out-patient

DVTDVT

Most clots are formed during the Most clots are formed during the surgerysurgeryCan occur up to 3 months post-Can occur up to 3 months post-operativelyoperativelyMost are detected 3-5 days post Most are detected 3-5 days post surgerysurgeryAfter that the next highest period of After that the next highest period of risk is 10-14 days post surgeryrisk is 10-14 days post surgery

Risk Factors for DVT formationRisk Factors for DVT formation1.1. Longer Surgery Time >30 minutesLonger Surgery Time >30 minutes2.2. Pro-longed immobilityPro-longed immobility3.3. SmokerSmoker4.4. Hormone replacement/Birth control pillsHormone replacement/Birth control pills5.5. Age greater than 40Age greater than 406.6. TourniquetTourniquet7.7. ObesityObesity8.8. Varicose veinsVaricose veins9.9. History of prior DVTHistory of prior DVT10.10. Pelvis, hip or leg fracturePelvis, hip or leg fracture11.11. Concommittant diseasesConcommittant diseases12.12. Heart Disease or Stroke historyHeart Disease or Stroke history

Signs and Symptoms of DVTSigns and Symptoms of DVT

Up to 2/3 of DVTs remain SilentUp to 2/3 of DVTs remain SilentUsually one leg onlyUsually one leg onlySwelling of one calf greater than 1 cm Swelling of one calf greater than 1 cm differencedifference

If there is any concern regarding possible DVT call If there is any concern regarding possible DVT call the office and we will get a Venous Doppler the office and we will get a Venous Doppler (ultrasound) of the lower extremity(ultrasound) of the lower extremity

Muscles above the clot are painful to palpationMuscles above the clot are painful to palpation+ Homan’s sign - Passive stretching of the calf + Homan’s sign - Passive stretching of the calf muscles by pushing the foot cranially (towards muscles by pushing the foot cranially (towards head) provokes severe pain in calf muscleshead) provokes severe pain in calf muscles

Prevention of DVTPrevention of DVT

Early ROM of the LEEarly ROM of the LECalf exercises – pulling toes Calf exercises – pulling toes towards the nose with leg fully towards the nose with leg fully extendedextendedTED hoseTED hoseMedications to thin the blood if Medications to thin the blood if indicated for prophylaxisindicated for prophylaxis

Blood thinning medicationsBlood thinning medications

ASA (Aspirin) – 325mg QDASA (Aspirin) – 325mg QD

Ibuprofen – 800mg TIDIbuprofen – 800mg TID

Naproxen – 500mg BIDNaproxen – 500mg BID

Low Molecular Weight HeparinLow Molecular Weight HeparinFragmin, Lovenox and Innohep Fragmin, Lovenox and Innohep InjectablesInjectables

Warfarin – for long term controlWarfarin – for long term control

DVT leading to Pulmonary EmbolusDVT leading to Pulmonary Embolus

10% of DVTs progress to PEs10% of DVTs progress to PEs

SymptomsSymptomsDizzinessDizziness

Shortness of breathShortness of breath

Coughing episode – uncontrollableCoughing episode – uncontrollable

Chest painChest pain

InfectionInfection

All wounds are contaminated with bacteria All wounds are contaminated with bacteria – only a m inority become actual infections– only a m inority become actual infections

Amount of bacteria in woundAmount of bacteria in woundVirulence of the bacteriaVirulence of the bacteriaInnate and acquired host defensesInnate and acquired host defensesEffects of microenvironmentEffects of microenvironment1.1. Hgb can stimulate growth of bacteriaHgb can stimulate growth of bacteria2.2. Necrotic tissue acts as hostNecrotic tissue acts as host3.3. Braided suture materialBraided suture material4.4. Dead space within the surgical siteDead space within the surgical site

Signs and Symptoms of InfectionSigns and Symptoms of Infection

Elevated temperature (>101.5)Elevated temperature (>101.5)It is often normal to run a slightly elevated It is often normal to run a slightly elevated temperature for the first few days after surgerytemperature for the first few days after surgeryIt is only a concern if it is above 101.5°It is only a concern if it is above 101.5°

MUST be documented with a thermometerMUST be documented with a thermometer Severely decreased ROMSeverely decreased ROMPain and Swelling greater than expectedPain and Swelling greater than expectedRedness with HeatRedness with HeatPus From the woundPus From the wound

Risk Factors for InfectionRisk Factors for Infection

Wound StatusWound StatusCleanCleanClean-contaminatedClean-contaminatedContaminatedContaminatedDirtyDirty

Patient StatusPatient StatusImmune status (HIV, Chemotherapy)Immune status (HIV, Chemotherapy)ObesityObesityDiabetesDiabetesRheumatoid ArthritisRheumatoid ArthritisLifestyle (smoker, alcohol)Lifestyle (smoker, alcohol)

Anesthesia Pre-operative Scores >2Anesthesia Pre-operative Scores >2Length of Surgery – T scores >75%Length of Surgery – T scores >75%

Diagnosis of infectionDiagnosis of infection

Blood WorkBlood WorkX-raysX-raysBone scansBone scansAspiration and CultureAspiration and CultureIncise and Drain (I&D) with Incise and Drain (I&D) with Pathology specimensPathology specimensRevsion Surgery with Pathology Revsion Surgery with Pathology specimensspecimens

ArthrofibrosisArthrofibrosis

Abnormal proliferation of fibrous Abnormal proliferation of fibrous tissuetissue

Loss of extension greater than 10 Loss of extension greater than 10 degreesdegreesFlexion less than 125 degreesFlexion less than 125 degrees

Studies state that 4%-35% of knee Studies state that 4%-35% of knee surgeries get arthrfibrosissurgeries get arthrfibrosis

Occurs in 11% of ACL reconstructionsOccurs in 11% of ACL reconstructions

Harner et al


PathenogenesisPathenogenesisInsult or injury starts clotting Insult or injury starts clotting cascadecascade

Over productive clotting cascade Over productive clotting cascade does not turn off due to many does not turn off due to many possible variablespossible variables

Stiffness leads to loss of cartilageStiffness leads to loss of cartilage


Risk FactorsRisk FactorsExtent of insult due to surgeryExtent of insult due to surgeryTiming of surgeryTiming of surgeryROM before SurgeryROM before SurgeryGraft ChoiceGraft ChoiceTechnique ErrorsTechnique ErrorsStart of ROM after surgeryStart of ROM after surgeryHemarthrosis and large EffusionsHemarthrosis and large Effusions


PreventionPreventionEarly and aggressive ROMEarly and aggressive ROM

Early and aggressive PTEarly and aggressive PT

Anti-inflammatoriesAnti-inflammatories

CryotherapyCryotherapy

What is What is NOTNOT a Reason for concern a Reason for concern

Clear fluid from the woundClear fluid from the wound

Mild heat without redness is normal for Mild heat without redness is normal for inflammatory reaction after surgeryinflammatory reaction after surgery

Black tissue near or around woundBlack tissue near or around wound

Swelling with a bluish discoloration of Swelling with a bluish discoloration of skinskin

Positive cultures showing normal skin Positive cultures showing normal skin floraflora

What is What is NOTNOT a Reason for concern a Reason for concern

Redness and itching around the Redness and itching around the sutures – usually indicates near time sutures – usually indicates near time for suture removalfor suture removal

Redness, itching and blistering Redness, itching and blistering under steri-strips – OTC Benadryl, under steri-strips – OTC Benadryl, removal of steri-strips and benzoinremoval of steri-strips and benzoin

RED FLAGSRED FLAGS

Swelling and/or warmth around surgical Swelling and/or warmth around surgical site if associated with one of the following site if associated with one of the following or any of the following alone:or any of the following alone:

1. Redness1. Redness2. Pus from wound2. Pus from wound3. Lines radiating from wound3. Lines radiating from wound

Calf pain with increased calf Calf pain with increased calf measurementsmeasurementsPositive Homan’s SignPositive Homan’s Sign

RED FLAGSRED FLAGSTachycardiaTachycardiaChest PainsChest PainsExtreme shortness of breathExtreme shortness of breathFevers >101.5 documented with a thermometerFevers >101.5 documented with a thermometerConstipation greater than 3-4 daysConstipation greater than 3-4 daysNeurologic changesNeurologic changes

1. 1. Confusion - generalConfusion - general

2. Numbness in extremity2. Numbness in extremity3. Tingling in extremity3. Tingling in extremity4. Severe headaches4. Severe headaches

MiscellaneousMiscellaneous

Suture and Staple RemovalSuture and Staple RemovalSkin heals from bottom upSkin heals from bottom up

Suture removal 5-10 days after surgerySuture removal 5-10 days after surgery

Staple removal 10-14 days after Staple removal 10-14 days after surgerysurgery

PainCare RemovalPainCare RemovalJust pulls out – No magic!!Just pulls out – No magic!!

THANK YOU!!THANK YOU!!

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Post-Surgical Red Flags