Post Operative Recovery Series - Part 5 Deep Venous Thrombosis
Deep venous thrombosis or DVT is a blood clot in the venous system. Most commonly, DVT's arise in the lower extremities.
Two million people suffer from DVT's per year. The danger with DVT's in the lower extremities is that a fragment of
the blood clot can come loose and travel via the veins into the lungs where it lodges in the pulmonary artery. This is called
a pulmonary embolism. A clot in the pulmonary artery prevents exchange of oxygen from the lung to the blood. Oxygen is
normally travels from the lungs to the blood to all the organs in the body including the heart and brain. Pulmonary embolism
kills 300,000 people a year, more than breast cancer and AIDS combined.
There are several predisposing factors
that can make one more susceptible to developing a blood clot. They include obesity, cancer, and a post-operative state. followed
by long periods of immobility or bedrest. Long periods of being sedentary such as a long airplane flight is also a risk factor
for the development of DVT. Pregnancy and use of birth control pills also increases the chance of developing a DVT.
DVT's in the lower extremity usually causes swelling and pain. In fact after surgery, the presence of one
swollen leg is very suspicious for DVT and you should call your physician immediately if this occurs. Shortness of breath
in the setting of a swollen leg is very suggestive of a pulmonary embolism and you should go directly to the emergency room
should you be experiencing these symptoms.
A DVT can be diagnosed with an ultrasound study. An ultrasound probe
is ran over your legs to visualize the veins. The study lasts approximately one hour and is not painful. To diagnose a pulmonary
embolism can be done via two studies. The most commonly performed study is a CT scan of the chest. Contrast dye is injected
through an intravenous line in your arm to visualize the pulmonary arteries. This test is completed in the time it takes to
hold your breath. This study can should be performed with caution in patients who have a history of kidney disease
as the contrast dye from the CT scan can be toxic to the kidneys. Also patients with an allergy to iodine or shellfish should
be premedicated with steroids and benadryl to prevent an allergic reaction to the contrast dye. An alternative study is the
ventilation-perfusion study which uses low-dose radioactive material to test if any areas of the lungs are not receiving
active blood flow which could be caused by blockage from a blood clot.
Once the diagnosis is made, treatment is
with blood thinners. Admission to the hospital is generally required since intravenous blood thinners are given first prior
to starting blood thinners by mouth. Heparin which is an IV blood thinner takes effect very rapidly while oral blood thinners
such as coumadin take a few days to produce an effect. The IV blood thinners are stopped once the oral blood thinners have
kicked in. An alternative to IV blood thinners is an injectable blood thinner that bridges the gap until the oral blood thinner
take effect. The injectable blood thinner, enoxaparin, is given under the skin twice a day and can be administered at home.
It is extraordinarily expensive and is not always covered by insurance.
Preventing DVT can be done by modifying
risk factors. Getting up, moving around, and staying active is the best thing you can do after surgery. In the hospital, stockings
will be placed on your feet or calves. The stockings inflate intermittently to improve the flow of blood in your veins to
prevent blood clots. These stockings have been shown to be effective in lowering the risk of DVT's, yet arecent multicenter
study found that only one-third of hospitalized patients had them in place and functioning. To protect yourself against DVT's
make sure the stockings are in place and on when you are in the hospital bed and make sure you start ambulating as early as
the day one after surgery.
Post-Operative Recovery Series - Part 4 Appetite and Diet
Many people after surgery complain that they do not have an appetite. Whether this is related to anesthesia or the general
healing process is unknown, but it is very common. For some it is not only just the lack of desire to eat, but disturbances
in the way food tastes. You should try to eat three square meals even if you do not feel like it. And most importantly continue
to drink to stay hydrated. A common cause of re-admission to the hospital after surgery is dehyrdation precisely for this
reason. A good option is a nutritional supplement such as Boosts or Ensure. These low-volume drinks are high in calories and
protein - essential for adequate healing. In addition, they ensure that you say hydrated.
Some gastrointestinal
surgeries will place limitations on what you can eat post-operatively. You should consult with your surgeon prior to your
discharge on what you can and can not eat. As a general overview, after surgery on the stomach, you are generally restricted
to a liquid or soft mushy food diet for a period of a few weeks. After gall bladder surgery, some surgeons advise staying
away from fatty foods as this can exacerbate post-cholecystectomy diarrhea. Lastly, for those who have had intestinal surgery,
some surgeons advise against eating foods with a lot of bulk or fiber to allow the connection between the two pieces of bowel
to heal.
Low grade fevers are common after surgery. There are a number of contributing factors. A fever can come from the lungs. Laying
flat on an operating room table for several hours can cause collapse of some of the air sacs, also known as alveoli, at
the base of your lungs. Collapse of these air sacs can cause fever which is why you will be encouraged right after
surgery to sit upright, walk, and take deep breaths. Breakdown of blood products in the surgical field can also result
in low-grade fevers. All this is normal and no cause for concern. A temperature greater than 101.5 is abnormal however and
can signal a wound infection, urinary tract infection, pneumonia, or infection elsewhere. If you develop a fever >101.5,
call your doctor for further instructions.
Post Operative Recovery Series - Part 2 Pain Control
In most cases, you will have some pain after surgery requiring medication. Incisional pain always gets better over time, however,
you will find that you will have some good days and some bad days. The bad days may be followed by a day of unusually higher
activity, a long walk or hours of housework. If you develop pain beyond the control of your pain medications, you
should call your surgeon. This may be the early sign of a complication.
Another important point is that pain medications,
particularly narcotics, slow down the gastrointestinal system leading to severe constipation. Taking a stool softener as
soon as you start taking pain medication helps as well as increasing the amount of water your drink. If you do find that
you are constipated, a number of over the counter medications are available to help. If you have had intestinal surgery, ask
your surgeon which laxatives are safe for you to take.
Post Operative Recovery Series - Part 1 Wound Care
While you should discuss with your surgeon prior to your discharge, the specifics on taking care of your wound, there are
some general guidelines to follow.
If your wound was closed with stitches or staples, avoid immersing it in water
for several weeks after surgery. Immersion in water causes maceration of the skin edges and possible separation of the
wound. Do keep the wound clean however by running soapy water over top of it and then rinsing it with straight water. This
can be done when you are in the shower. Most wounds do not need to be covered. If your doctor advises it then after your shower,
place a dry gauze over top of it daily.
Things to watch out for are redness around the wound, increased warmth,
and increased pain around the incision. This can all signal an infection and these findings should be reported to your surgeon
right away. If you should develop drainage of fluid or blood from your wound, this also needs to be reported to your surgeon.
The drainage could be from bleeding from the operative bed. Drainage could also be arise after the development of a seroma.
A seroma is a collection of fluid that builds up from disruption of lymphatic channels or from your body's attempt to
seal a cavity. Seromas generally occur after hernia surgery or other types of soft tissue surgery. A classic example is that
of a patient with a benign soft tissue tumor such as a lipoma in their arm. Once the lipoma is removed, the space where the
lipoma was contained remains. During the operation, your surgeon will close the hole in multiple layers to thwart the body's
natural response to that now vacant cavity which is to fill it with fluid. If a seroma does form, the fluid generally becomes
absorbed over time. If it does not, then serial drainage of the seroma with a needle and syringe through the skin can often
resolve it. The seroma can sometimes put tension on the incision causing it to open which results in a persistent
drainage from the wound. Drainage from the wound does not also mean infection, but the tract from which the drainage
is coming from can lead to the entry of bacteria into the wound. Drainage of the wound generally requires opening of the wound,
packing it with gauze to maintain a passageway for the fluid to drain completely. The opened portion of the wound contracts
and gets smaller and smaller over time until it seals completely.
Questions to ask your surgeon: How should
I keep my wound clean? Should I leave it open or covered? When can I shower or bathe? Do any of the stitches
need to be removed and if so when?
