Surgical Complications Rajan Thakkar. Surgical Complications Wound Thermal Regulation Postoperative...
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Transcript of Surgical Complications Rajan Thakkar. Surgical Complications Wound Thermal Regulation Postoperative...
Surgical Complications
Rajan Thakkar
Surgical Complications• Wound• Thermal Regulation• Postoperative Fever• Pulmonary• Cardiac• Renal• Gastrointestinal• Metabolic• Neurological
Surgical Complications
• Primary disease• Operation• Unrelated factors• Complications leading to other complications• Prevention
Wound Complications
• Dehiscence• Seroma• Hematoma• Infection• Incisional Hernia
Wound Dehiscence• Separation of facial layers• Serosanguinous drainage• Technical Complication• Risk Factors• Mortality approaches 30%• Evisceration
Evisceration
Incisional Hernia
Seroma
• Collection of liquefied fat, serum and lymphatic fluid under the incision
• Benign • No erythema or tenderness• Mastectomy, axillary and groin dissections• Treatment
Hematoma
• Abnormal collection of blood– Discoloration of the wound edges (purple/blue)– Blood leaks through skin sutures
• Imperfect hemostasis• Potential for secondary infection• Neck hematomas can be dangerous
Wound Infection• Major problem• Superficial• Deep• Organ space• Most commonly occur 4-6 days post-op• Erythema, tender, edema• 2.5% of abdominal incisions• Staphylococcus aureus
Wound Infection• Necrotizing fasciitis
– Bacterial infection of underlying fascia– Classically Streptococcus, most often polymicrobial with anaerobes/GNR– Surgical debridement and IV antibiotics
• Clostridial Myosistis– Clostridial muscle infection (myonecrosis and gas gangrene)– Clostridium perfringens– Surgical debridement and IV antibiotics
Necrotizing fasciitis
Necrotizing fasciitis
Necrotizing Fasciitis
Complications of Thermal Regulation
• Hypothermia• Malignant Hyperthermia
Hypothermia• Drop in body temperature of 2 degrees C• Causes• Body’s Response• Temperature below 35 C
– Coagulopathic– Platelet dysfunction
• Mild - 32 – 35C = 90-95F• Mod – 28 – 32C = 82–90F• Severe – 25 – 28C = 77-82F• Extreme
Malignant Hyperthermia
• Rare; autosomal dominant• Fever, tachycardia, rigidity, cyanosis• First sign is increased end tidal CO2• Often within 30 minutes• Treatment: Dantrolene, correct electrolytes,
cooling blanket
Postoperative Fever• The Six W’s
– Wind: pneumonia– Wound: infections – Water: UTI – Walking: DVT (possible PE) – Waste: abscess– Wonder Drug: medication
• Noninfectious– Within the first 48-72 hours
• Infectious– Fevers POD 3-8– Standard work up includes
• Blood cultures• UA and Urine Cultures• CXR• Sputum cultures• Tylenol/Motrin
Pulmonary Complications• Atelectasis
– Peripheral alveolar collapse due to shallow tidal breaths– Most common cause of fever within 48 hours of surgery– Incentive spirometry
• Aspiration Pneumonitis– Reduced by pre-op fasting, protonix, cricoid pressure
• Nosocomial Pneumonia
• Pulmonary edema– CHF– ARDS
• Pulmonary embolus– 500,000 per year– 1 in 5 are fatal– Prevention
Pulmonary Embolus
ARDS
Cardiac complications
• Hypertension• Ischemia/Infarction– Leading cause of death in any surgical patient– Key to treatment: prevention– MONA
• Arrhythmias– >30 seconds of abnormal cardiac activity– Key to treatment is to correct underlying medical
condition
Renal Complications
• Urinary retention– Inability to evacuate a urine-filled bladder– Commonly a reversible abnormality– Perianal and Hernia repairs
• Acute Renal Failure– Pre-renal– Intrinsic– Post-renal
Gastrointestinal Complications
• Postoperative ileus• GI Bleeding• Pseudomembranous colitis• Ischemic Colitis• Anastomotic Leak• Enterocutaneous fistula
Postoperative Ileus
• Lack of function without definitive obstruction• Prolonged by extensive operative
manipulation, SB injury, narcotic use, abscess and pancreatitis
• Must be distinguished from SBO• Flat and Upright abdominal film– Ileus: dilated bowel throughout, air in colon and
rectum– SBO: air fluid levels, no colonic or rectal air
ILEUS
SBO
Gastrointestinal Complications• GI Bleeding
– From Any source (get a detailed history)– Gastric “stress” ulcers (Curling’s Ulcer)
• Uncommon with invention of H2Blockers and PPIs • Pseudomembranous colitis
– Superinfection with C difficile– Alteration of intestinal flora by perioperative antibiotics– Toxic colitis is a surgical emergency (mortality of 20-30%)
• Ischemic Colitis– Bowel affected helps determine cause– Surgical devascularization, hypercoagulable states, hypovolemia and emboli
• Anastomotic leak• Enterocutaneous fistula
– The most complex and challenging surgical complication
C diff colitis
C diff colitis
Anastomotic leak in GBP
Metabolic Complications• Adrenal Insufficiency– Uncommon but potentially lethal– Sudden cardiovascular collapse
• Hypotension, fever, confusion, abdominal pain– “Stim” test, administration of hydrocortisone
• Baseline serum cortisol, 30 min, 60 min• Hyper/Hypothyroidism• SIADH– Continued ADH secretion despite hyponatremia– Neurosurgical procedures, trauma stroke, drugs (ACE-
I, NSAIDs)
Neurologic Complications
• Beware the drugs you will be prescribing• Delirium, Dementia and Psychosis• Seizure Disorders• Stroke and Transient Ischemic Attacks