post – operative complications complications general surgery rotation y. edden md department of...

POST – OPERATIVEPOST – OPERATIVE

COMPLICATIONS COMPLICATIONS

General Surgery rotationGeneral Surgery rotation

Y. Edden MD Department of General SurgeryY. Edden MD Department of General Surgery

When does it end ?When does it end ?

I would like to see the day when I would like to see the day when somebody would be appointed surgeon somebody would be appointed surgeon somewhere who had no hands, for the somewhere who had no hands, for the operative part is the least part of the work.operative part is the least part of the work.

--Harvey W. CushingHarvey W. Cushing

SurgerySurgery

Personal responsibility, Ego, Conservatism

Y. Edden MDY. Edden MD

Post-Op FeverPost-Op Fever

25-50% of patients Will have fever in 125-50% of patients Will have fever in 1stst 2424hr post-ophr post-op

1-2 days post-op: Atelectasis1-2 days post-op: Atelectasis

3-4 days post-op: Phlebitis, Pneumonia3-4 days post-op: Phlebitis, Pneumonia

5 days post-op: Wound infection5 days post-op: Wound infection

7 days post-op: Anastomotic leak or disruption7 days post-op: Anastomotic leak or disruption

Respiratory ComplicationsRespiratory Complications

30-50% of surgical patients30-50% of surgical patients

Atelectasis & PneumoniaAtelectasis & Pneumonia• Most common pulmonary complicationMost common pulmonary complication• Collapse of alveolar segments causing shuntsCollapse of alveolar segments causing shunts• Non cleared pulmonary secretions infected causing Non cleared pulmonary secretions infected causing pneumoniapneumonia• 10-20% of ICU patients suffer from pneumonia 10-20% of ICU patients suffer from pneumonia


Clinical PresentationClinical Presentation• Low grade feverLow grade fever• Decreased breath sounds over lower lung fieldsDecreased breath sounds over lower lung fields• CrepitationsCrepitations• SecretionsSecretions

Pneumonia- Pneumonia- Fever, WBCFever, WBC, CXR with infiltrates,, CXR with infiltrates, infected thick secretionsinfected thick secretions


Prevention:Prevention:

• Cease smoking 2-4 weeks pre-opCease smoking 2-4 weeks pre-op• Optimal analgesiaOptimal analgesia• Aggressive pulmonary toiletAggressive pulmonary toilet• Early ambulationEarly ambulation• Incentive spirometryIncentive spirometry


AspirationAspiration

• Inhalation of gastric fluid – ‘Mendelson aspiration’Inhalation of gastric fluid – ‘Mendelson aspiration’ Low pH of gastric content : pulmonary Edema, Low pH of gastric content : pulmonary Edema,

Hemorrhage, atelectasis, alveoli necrosisHemorrhage, atelectasis, alveoli necrosis

• 50% will have bacterial contamination and severe 50% will have bacterial contamination and severe pneumoniapneumonia

Contributing FactorsContributing Factors• Altered mental statusAltered mental status• Altered swallowing mechanismAltered swallowing mechanism• NGTNGT


25-50% of patients will have fever in 125-50% of patients will have fever in 1stst 2424hr post-ophr post-op





PhlebitisPhlebitis

• Can happen any timeCan happen any time

• Large diameter > more infectionsLarge diameter > more infections

• Change every 3 daysChange every 3 days

• Usually poor techniqueUsually poor technique


25-50% of pts. Will have fever in 125-50% of pts. Will have fever in 1stst 2424hr post-ophr post-op





Wound ComplicationsWound Complications

Contributing Factors:Contributing Factors:• Inadequate surgical techniqueInadequate surgical technique

• Increased presuure/ tension on closure (bowel Increased presuure/ tension on closure (bowel

distention. Ascites, cough)distention. Ascites, cough)

• Inadequate wound healing: Age, DM, Inadequate wound healing: Age, DM, malnutrition, CRF, Steroids, CTx, Radmalnutrition, CRF, Steroids, CTx, Rad


Surgical Site InfectionSurgical Site Infection• Most common infection in surgical patients (40%)Most common infection in surgical patients (40%)• 2/3 involve superficial or deep incisional tissue2/3 involve superficial or deep incisional tissue• 1/3 involve organs/ space operated1/3 involve organs/ space operated

SourceSource: Flora of skin/ mucous membranes : Flora of skin/ mucous membranes and hollow visceraand hollow viscera

PathogensPathogens: 20% : 20% Staph AureusStaph Aureus, 15% , 15% Coag. Neg. StaphCoag. Neg. Staph,, 12% 12% EnterococcusEnterococcus, 8% , 8% E. ColiE. Coli

Wound ComplicationsWound ComplicationsContributing Factors..Contributing Factors..

Patient:Patient: Operation:Operation:AgeAge Duration of scrub (6min=2min)Duration of scrub (6min=2min)MalnutritionMalnutrition Duration of operationDuration of operationDiabetesDiabetes Foreign materialForeign materialCo-existant infectionCo-existant infection Skin antisepsisSkin antisepsisImmune deficiencyImmune deficiency Surgical technique Surgical technique

PresentationPresentation‘‘Rubor’ ‘Calor’ ‘Dolor’ ‘Tumor’ Rubor’ ‘Calor’ ‘Dolor’ ‘Tumor’ Usually on 5Usually on 5thth day dayLow grade feverLow grade feverProgression of cellulitisProgression of cellulitis


TreatmentTreatment

Opening wound, culture, mechanical drainageOpening wound, culture, mechanical drainageABx only if marked cellulitis or systemic signsABx only if marked cellulitis or systemic signsNecrotizing Fasciitis- Early appearance ! Day 1Necrotizing Fasciitis- Early appearance ! Day 1 Step. A,Step. A, Clostridium PerfringensClostridium Perfringens (G+ rods) (G+ rods)

Prevention:Prevention:

Bowel prep (?)Bowel prep (?)Peri-op IV AbxPeri-op IV AbxControl of DiabetesControl of DiabetesTreatment of coexistent infectionsTreatment of coexistent infections2-4 weeks non smoking2-4 weeks non smoking


Wound HematomaWound Hematoma

• Inadequate hemostasisInadequate hemostasis• CoagulopathyCoagulopathy• Myeloproliferative DisorderMyeloproliferative Disorder• NSAIDsNSAIDs

Wound seromaWound seroma

• Collection of serum & lymph in SQ tissueCollection of serum & lymph in SQ tissue• Usually not infectedUsually not infected• Discomfort, swellingDiscomfort, swelling• Treatment: Aspiration (infecting)Treatment: Aspiration (infecting)• Closed suction drainClosed suction drain

WoundWound ComplicationsComplications

Wound DehiscenceWound Dehiscence

• 2% of Abdominal operations2% of Abdominal operations

• Dehiscence- separation of fascial layer in earlyDehiscence- separation of fascial layer in early post operativepost operative

• Evisceration- large dehiscence allowingEvisceration- large dehiscence allowing protrusion of visceraprotrusion of viscera

‘‘Salmon PinkSalmon Pink’’

Venous ThromboembolismVenous Thromboembolism

DVT & PEDVT & PE100,000 death per year from PE in the USA100,000 death per year from PE in the USASurgical patients are in increased risk for DVTSurgical patients are in increased risk for DVT

• 90% clot originates from ileofemoral vessels90% clot originates from ileofemoral vessels

• Clinical significance according to clot size and patient’s Clinical significance according to clot size and patient’s

statusstatus

• Other forms: Fat embolism, Amniotic fluid embolismOther forms: Fat embolism, Amniotic fluid embolism

Air embolism, Foreign body embolismAir embolism, Foreign body embolism


Risk FactorsRisk Factors

Age>40Age>40 Paralysis Paralysis Chronic heart diseaseChronic heart disease Prolonged immobilizationProlonged immobilizationMalignancyMalignancy Prolonged surgery Prolonged surgeryInherited Coag deficienciesInherited Coag deficiencies Multiple traumaMultiple traumaPrevious DVTPrevious DVT ObesityObesity

TreatmentTreatmentResuscitation (Oxygen, Intubation, Cardiac arrest)Resuscitation (Oxygen, Intubation, Cardiac arrest)Diagnosis- ABG, CXR, ECG, VDiagnosis- ABG, CXR, ECG, V//QQ scan, Angio, CT scanscan, Angio, CT scanAnticoagulation, IVC filterAnticoagulation, IVC filter


PreventionPrevention

• ProphylaxisProphylaxis

• Mechanical- pneumatic compressive devicesMechanical- pneumatic compressive devices

Elastic stockings Elastic stockings

MobilizationMobilization

• Pharmacological- Anticoagulants Pharmacological- Anticoagulants

(Heparin, Clexane, Warfarin)(Heparin, Clexane, Warfarin)

• IVC FilterIVC Filter

IVC FilterIVC Filter

! !הפסקההפסקה

GI Tract ComplicationsGI Tract ComplicationsPost-op IleusPost-op Ileus• Uncomplicated recovery from abdominal surgeryUncomplicated recovery from abdominal surgery• SB motility returns almost immediatelySB motility returns almost immediately• Gastric motility returns in 2-3 daysGastric motility returns in 2-3 days• Colonic motility returns in 3-5 daysColonic motility returns in 3-5 days

Contributing factors for prolonged ileusContributing factors for prolonged ileus• OpioidsOpioids• Upper GI surgeryUpper GI surgery• Pre-op obstructionPre-op obstruction• Diabetic neuropathyDiabetic neuropathy• Retroperitoneal hematomaRetroperitoneal hematoma• Excessive trauma to the bowelExcessive trauma to the bowel

GI Tract ComplicationsGI Tract Complications

GI BleedingGI BleedingStress gastritis common in critically illStress gastritis common in critically ill patients patients(Burn, Trauma, Major Abd surgery, CNS inj, Sepsis, AMI)(Burn, Trauma, Major Abd surgery, CNS inj, Sepsis, AMI)

TreatmentTreatmentResuscitation (IV fluids, Blood, correct anticoag, treat sepsis)Resuscitation (IV fluids, Blood, correct anticoag, treat sepsis)Upper endoscopy- diagnosis and treatmentUpper endoscopy- diagnosis and treatment

PreventionPreventionReducing intragastric acid production- Antacids, H2 blockersReducing intragastric acid production- Antacids, H2 blockersHealing of gastric mucosa- Sucralfate (PGE2Healing of gastric mucosa- Sucralfate (PGE2↑↑, mucous, mucous↑↑))

Cardiac ComplicationsCardiac Complications

Perioperative Ischemia & InfarctionPerioperative Ischemia & InfarctionLeading cause of death in elderly patients after non cardiac Leading cause of death in elderly patients after non cardiac surgerysurgery

Previous AMI- Major risk factorPrevious AMI- Major risk factor

AMIAMI Re-infarction rateRe-infarction rate3mo3mo 30%30%3-6mo3-6mo 10%10%>6mo>6mo 5-8% (general risk)5-8% (general risk)

Cardiac ComplicationsCardiac Complications

PreventionPrevention

• Identification of high risk patientsIdentification of high risk patients

• Optimization of cardiac function peri-opOptimization of cardiac function peri-op

• High index of suspicionHigh index of suspicion

Cardiac ComplicationsCardiac ComplicationsArrhythmiasArrhythmias

• Intrinsic cardiac diseaseIntrinsic cardiac disease

• Thoracic or mediastinal surgeriesThoracic or mediastinal surgeries

• Electrolyte abnormalitiesElectrolyte abnormalities

• Cardiac medicationsCardiac medications

• Catecholamine stress responseCatecholamine stress response

• Endocrine abnormalitiesEndocrine abnormalitiesTreatmentTreatment

According to ACLSAccording to ACLS

Renal & Urinary Tract ComplicationsRenal & Urinary Tract Complications

Urinary RetentionUrinary RetentionInability to empty urine filled bladderInability to empty urine filled bladderEspecially after Inguinal Hernias, anorectal proceduresEspecially after Inguinal Hernias, anorectal procedures

Causing Factors:Causing Factors:Post-op painPost-op painEpidural analgesia prevent Epidural analgesia prevent adrenergic inhibition adrenergic inhibitionOverly vigorous IV fluidsOverly vigorous IV fluids

PresentationPresentation• UrgencyUrgency• DiscomfortDiscomfort• PainPain• Enlarged palpable bladder ‘Globe vesicle’Enlarged palpable bladder ‘Globe vesicle’


TreatmentTreatmentCatheterizationCatheterization

PreventionPreventionVoid before surgeryVoid before surgery BlockersBlockersMin fluids peri-opMin fluids peri-op

Acute Renal FailureAcute Renal FailureCommon complication (5-10% of surgical patients)Common complication (5-10% of surgical patients)Mostly in CABG, vascular, transplant, urologic Mostly in CABG, vascular, transplant, urologic surgeriessurgeries

Pre-renalPre-renal• HypotensionHypotension• HypovolemiaHypovolemia• Cardiac failureCardiac failure• Arterial stenosis or occlusionArterial stenosis or occlusion


Intra-renalIntra-renal• Toxins (Rad contrast, endotoxins)Toxins (Rad contrast, endotoxins)• Pigment (myoglobin)Pigment (myoglobin)

Post-renalPost-renal• Ureteral obstruction (stone, trauma, surgical injury)Ureteral obstruction (stone, trauma, surgical injury)• Bladder distention (nerve injury, drugs)Bladder distention (nerve injury, drugs)• Uretheral obstruction (Trauma, BPH, malignancy)Uretheral obstruction (Trauma, BPH, malignancy)


Neurological ComplicationsNeurological Complications

CVA & TIACVA & TIA

Non hemorrhagic stroke:Non hemorrhagic stroke:Cardiac or extra-cranial vascular lesion Cardiac or extra-cranial vascular lesion (AF, Carotid stenosis)(AF, Carotid stenosis)

Hemorrhagic stroke:Hemorrhagic stroke:Uncontrolled HTNUncontrolled HTNUncontrolled anticoagulationUncontrolled anticoagulation

If you can’t stand the heat stay If you can’t stand the heat stay out of the kitchen…out of the kitchen…

Harry S. Truman 33Harry S. Truman 33rdrd US president US president 1945-19531945-1953

post – operative complications complications general surgery rotation y. edden md department of...

Documents