5. Discuss the development and treatment of postoperative pneumonia (nosocomial)

Question

5. Discuss the development and treatment of postoperative pneumonia (nosocomial). 6. What is the most common type of cancer to affect the colon? 7. Discuss the manner in which colorectal cancer can metastasize. 8. What is the significance of staging cancer and how does this correlate with prognosis 9. Identify appropriate discharge teaching/planning needs for a patient recovering from this major surgery. 10. Discuss the psychosocial and emotional issues following an AP resection and a colostomy.

Explanation / Answer

5. Pneumonia is defined as a lower respiratory tract infection with accompanying consolidation visible on chest x-ray. There are four main types of pneumonia:

In the post-operative setting, hospital-acquired pneumonia is the predominating type. HAP is a pneumonia that has onset >48hrs since hospital admission and was not present on admission.

Surgical patients are predisposed to developing lower respiratory tract infections due to a combination of:

Reduced mobility in bedridden patients results in an inability to fully ventilate their lungs, leading to accumulation of fluid secretions which subsequently become infected

The hospital environment microflora will vary compared to what the patient may normally be exposed to, nor have immunity to Common pathogens for HAP include E. coli, S. aureus (including MRSA), S. pneumoniae, and Pseudomonas.

Many patients undergoing surgery arelikely to be sick or have several co morbidities, compromising their immune systems and predisposing to pulmonary infections

Patients undergoing major surgery may need a stay in ICU and require intubation and ventilation, a major risk factor for a HAP

Risk factors for developing hospital-acquired pneumonia include: Age, Smoking (current or previous), Known respiratory disease or recent viral illness, Poor mobility (either baseline or post-operatively), Mechanical ventilation, Immunosuppression, Underlying co-morbidities, such as diabetes mellitus or cardiac disease.

Treatment:

All patients should receive appropriate O2 therapy as indicated, targeting 94% saturation (or 88-92% in those at risk of hypercapnic respiratory failure). Any evidence of sepsis or septic shock should be managed and treated accordingly.
Confirmed pneumonia should be treated with empirical antibiotics, pending sensitivities. Antibiotic choice should be guided by local policy; an example regimen is:

Mild: Co-amoxiclav 625mg oral TDS
Moderate: Co-amoxiclav 625mg oral TDS
Severe: Tazocin 4.5g TDS IV

Any post-operative patients with prolonged bedrest or reduced mobility are at risk of developing HAP (secondary to fluid stasis in the pulmonary tissue). The best practice is for post-operative patients to have chest physiotherapy to increase lung ventilation and reduce fluid stasis.

6. Colon cancer happens when tumorous growths develop in the large intestine. The colon, or large intestine, is where the body extracts water and salt from solid wastes. The waste then moves through the rectum and exits the body through the anus.Colon cancer and rectal cancer may occur together. This is called colorectal cancer.

Adenocarcinomas make up 95 percent of all colorectal cancer cases. In the gastrointestinal tract, adenocarcinomas develop in the cells of the lining inside the colon and/or the rectum. They typically start as a growth of tissue called a polyp. A particular type of polyp called an adenoma may develop into cancer.

7. Cancer cells may break away from a tumor in the colon or rectum and spread to other parts of the body through the bloodstream or lymphatic system. These cells may settle and form new tumors on a different organ. Even though the cancer has spread to a new organ, it is still named after the part of the body where it originally started. So colorectal cancer that spreads to the lungs, liver or any other organ is called metastatic colorectal cancer.

The most common site of metastases for colon or rectal cancer is the liver. Colorectal cancer cells may also spread to the lungs, bones, brain or spinal cord.

8. Cancer staging is the process of determining how much cancer is in the body and where it is located.

Staging describes the severity of an individual's cancer based on the magnitude of the original (primary) tumor as well as on the extent cancer has spread in the body.

Understanding the stage of the cancer helps doctors to develop a prognosis and design a treatment plan for individual patients.

Staging provides a common language for doctors to effectively communicate about a patient’s cancer and collaborate on the best courses of treatment.

Understanding the cancer’s stage is also critical to identifying clinical trials that may be appropriate for particular patients.

There are four different types of staging:

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