complication of surgery &trauma and .pptx

complication of surgery and trauma and their intervention

1. COMPLICATIONS OF SURGERY AND TRAUMA AND THEIR PREVENTION Supervised by : DR.MOSTAFA AHMED LECTURER AT FACULTY OF PHYSICAL THERAPY

2. Introduction Any operation, major trauma or other surgical admission may be attended by a variety of complications. These not only cause additional pain and suffering to the patient but may put the patient's life at risk. A large proportion of complications can be prevented or minimized by appropriate prophylactic measures, careful attention to detail and by early recognition and treatment of problems as they develop. Early diagnosis and treatment are essential, as delay often leads to catastrophic, snowballing' multi- organ failure. Once three or more body systems become involved, mortality is extremely high, e.g. ARDS and renal failure, complicating an operation for obstructive jaundice.

3. In respect of operative surgery, complications can be divided into the general complications of any operation and the specific complications of individual operations. Both groups of complications can be subdivided into immediate (during operation or within the next 24 hours), early postoperative (during the first postoperative week or so), late postoperative (up to 30 days after operation) and long-term.

4. The complications of surgery can be divided into five broad categories. Principal categories of surgical complications: 1. Complications predisposed to by intercurrent 'medical" disorders, whether symptomatic or occult, e.g. ischemic heart disease, chronic respiratory disease or diabetes mellitus. 2. Complications of anesthesia. 3. General complications of operations, e.g. hemorrhage or wound infection. 4. Complications of any surgical condition, e.g. pulmonary embolus, chest or urinary tract infection.

5. Complications of specific disorders and operations:

6. Complications of anesthesia: 1. Local anesthesia: Injection site pain, hematoma, delayed recovery of sensation (direct nerve trauma), infection ,ischemic necrosis (if used in digits or penis). Systemic effects of local anesthetic agent: Idiosyncratic or allergic reactions (very rare). Toxicity due to either excess dosage, or inadvertent intravenous injection. Toxic effects include: dizziness, tinnitus, nausea and vomiting, fits, CNS depression, bradycardia and asystole.  

7. 2. Spinal, epidural and caudal anesthesia: * Failure of anesthetic - anatomical difficulties or technical failure. * Headache - loss of CSF or minor intrathecal hemorrhage. *Intrathecal bleeding (especially if the patient is on anticoagulants). *Unintentionally wide field of anesthesia: -In epidural anesthesia, injection of local anesthetic into the wrong tissue plane may give a spinal anesthetic. - In spinal anesthesia, if the anesthetic agent flows too far proximally, respiratory paralysis may occur.

8. * Permanent nerve or spinal cord damage injection of incorrect drug. * Paraspinal infection - introduced by the needle. * Systemic complications hypotension. severe hypotension or postural

9. 3. General anesthesia: * Direct trauma to, mouth or pharynx, e.g. teeth, artificial crowns and bridges. * Inherited disorders: -Malignant hyperpyrexia (any potent inhalational anesthetic may be responsible). -Pseudocholinesterase deficiency (prolonged apnea after succinylcholine). * Idiosyncratic or allergic reactions to anesthetic agents:

10. Minor effects, e.g. postoperative nausea and vomiting. -Major effects: e.g. cardiovascular collapse, respiratory depression, halothane jaundice. * Slow recovery from anesthetic: -Drug interactions. -Inappropriate choice of drugs or dosage in relation to age or the requirements of day-case surgery. -Inadequate reversal. *Awareness during anesthetic effective paralysis but ineffective anesthesia (very expensive medicolegally). *Disorders of fluid balance inadequate or excessive replacement of fluids.

11. *Hypothermia: -Long operations with extensive fluid loss. -Large volume transfusion of cold blood. (Note: neonates and small infants are especially vulnerable to hypothermia) *Inadvertent trauma: -Initiation of pressure sores. -Pressure injury to nerves (especially ulnar and lateral popliteal). -Diathermy-pad bums. -Corneal abrasions.

12. GENERAL COMPLICATIONS OF OPERATIONS The main complications of any operation are hemorrhage, infection, delayed wound healing, surgical damage to related structures and inadvertent trauma to the patient in theatre.

13. HAEMORRHAGE

14. Perioperative Hemorrhage: Hemorrhage occurring during an operation (primary hemorrhage) should be controlled by the surgeon before the operation is completed.

15. Early Postoperative Hemorrhage: Hemorrhage during the immediate postoperative period usually indicates inadequate operative hemostasis or a technical mishap such as a slipped ligature or unrecognized trauma to a blood vessel. After major blood loss requiring large volume transfusion of stored blood.

16. Later Postoperative Hemorrhage Hemorrhage occurring several days after operation is usually related to infection which erodes vessels at operation site; this is known as secondary hemorrhage. Treatment involves managing the infection, but exploratory operation is often required to legate bleeding vessels.

17. INFECTION RELATED TO THE OPERATION SITE: ` Minor Wound Infections: The most common operative infection is a superficial wound infection occurring within the first postoperative week. This relatively trivial infection presents as localized pain, redness and a slight discharge. The organisms are usually staphylococci or streptococci derived from the skin. The infection usually settles without treatment. The exception is the patient in whom a prosthesis has been inserted, such as an arterial graft or artificial joint. For these patients, antibiotics must be given to prevent the devastating consequences of infection around the prosthesis.

18. Wound Cellulitis and Abscess: More severe wound infections occur most commonly after bowel-related surgery, when faecal organisms are usually incriminated. The majority present in the first postoperative week but they may occur as late as the third postoperative week, often after the patient has left hospital. These infections commonly present first with a pyrexia; examination of the wound reveals either a spreading cellulitis or localized abscess formation. Cellulitis is treated with appropriate antibiotics.

19. LATE INFECTIVE COMPLICATIONS: A late infective complication of surgery is a chronically discharging wound sinus which emanates from a deep chronic abscess. It usually relates to foreign material such as a non- absorbable suture or mesh or sometimes necrotic fascia or tendon. These sinuses commonly follow wound infections where healing is delayed and incomplete.

20. IMPAIRED HEALING Factors Retarding Wound Healing: Wound healing in general is retarded if blood supply is poor (as in arterial insufficiency) or if the wound is under excess suture tension. Other Factors which may retard wound healing are long-term steroid therapy, immunosuppressive therapy, previous radiotherapy, severe rheumatoid disease, malnutrition and vitamin deficiency, especially of vitamin C.

21. Incisional Hernia: Incisional hernia is a late complication of abdominal surgery. These hernias usually become apparent within the first postoperative year but sometimes develop as long as 5 years later, the overall incidence is about 10-15% of abdominal wounds. The hernia is caused by breakdown of the repair to abdominal wall muscle and fascia. Predisposing factors are abdominal obesity, distension and poor muscle quality, poor choice of incision, inadequate closure technique, post-operative wound infection and multiple operations through the same incision.

22. An incisional hernia usually presents as a bulge in the abdominal wall near previous wound. The condition is usually asymptomatic but occasionally a narrow-necked hernia presents with pain or strangulation. Once an incisional hernia has appeared, it tends to enlarge progressively and may become a nuisance cosmetically or for dressing. Repair is indicated for strangulation, pain or inconvenience.

23. SURGICAL INJURY: Unavoidable Tissue Damage: Anatomical structures, particularly nerves, blood vessels and lymphatics, may be unavoidably damaged during operation. This is particularly true in cancer surgery, illustrated by facial nerve damage during total parotidectomy. Inadvertent Tissue Damage: Structures may be inadvertently damaged during operation. Examples include recurrent laryngeal nerve damage during thyroidectomy and trauma.

24. INADVERTENT OPERATING THEATRE TRAUMA: Apart from surgical trauma, patients are at risk of injury when being, transported in the operating theatre and during anesthesia. Special precautions are taken by all who work in operating theaters to minimize these risks.

25. Surgery and Trauma and their Prevention: The most common complications caused by trauma in the operating theatre are: *Injuries resulting from falls from trolleys or operating table during, positioning. *Injury to diseased bones and joints from manipulation or positioning. These include dislocation of a rheumatoid Atlanta-axial joint and dislocation of a prosthetic hip joint. *Ulnar and lateral popliteal nerve palsies. *Electrical bums from wet or poorly contacting diathermy pads. *Excess pressure on the calf causing deep venous thrombosis. *Excess heel pressure causing pressure sores. Cardiac pacemaker disruption by diathermy equipment.

26. COMPLICATIONS OF ANY SURGICAL CONDITION RESPIRATORY COMPLICATIONS: Up to 15% of patients suffer from respiratory complications associated with general anesthesia and major operations. The most common of these are atelectasis, pneumonia, aspiration pneumonitis and aspiration pneumonia. Pre-existing lung disease greatly increases the risk of complications. Severely ill patients including those with acute pancreatitis, and bums or trauma victims are susceptible to the development of adult respiratory distress syndrome.

27. Effects of Anesthesia and Surgery on Respiratory Function: Anesthesia and surgery predispose to post-operative complications by altering lung function and compromising normal defense mechanisms as follows: -Lung tidal volume may be reduced by as much as 50%, depending on the incision site. Thoracic, upper abdominal and lower abdominal incisions (in decreasing order of effect) particularly reduce lung volume. -Lung expansion is reduced by the supine posture during and after operation, pain, abdominal distension, abdominal constriction by bandages and the effects of sedative drugs. -Ventilation rate usually increases and there is loss of normal periodic hyperinflation. -Diminished ventilation and pulmonary perfusion result in reduced gaseous exchange. -Airway defences are compromised by loss of the cough reflex and diminished ciliary activity, which both lead to accumulation of secretions.

28. Atelectasis: Pathophysiology and clinical features: Atelectasis or alveolar collapse occurs when airways become obstructed and air is absorbed from the air spaces distal to the obstruction. Bronchial secretions are the main cause of this obstruction. Predisposing factors include shallow ventilation, loss of periodic hyperinflation, inhibition of coughing and pooling of mucus. All of these are particular problems after thoracic and upper abdominal surgery.

29. Prevention and treatment of atelectasis: Atelectasis is best prevented by preoperative and postoperative physiotherapy for patients undergoing major surgery. This includes deep breathing exercises, regular adjustments of posture and vigorous coughing. During physiotherapy, wounds should be supported by the patient's hand. Effective analgesia facilitates physiotherapy and mobility e.g., infiltration of the wound with local anesthetic or epidural analgesia.

30. . Nebulizer bronchodilators such as salbutamol may assist the patient to cough up secretions. Severe cases of diffuse atelectasis may require endotracheal incubation and positive- pressure ventilation. Lobar or whole lung collapse requires intensive physiotherapy and sometimes flexible bronchoscopy to aspirate occluding mucus plugs.

31. Pneumonias Bronchopneumonia is the usual form of chest infection seen in surgical patients. It occurs secondarily to chronic lung disease or following atelectasis or aspiration of gastric contents.

32. Infection is manifest by pyrexia, tachypnoea, tachycardia and sometimes cyanosis. The mucopurulent sputum is thick, copious and green. Antibiotics, usually amoxycillin or co-trimoxazole, are given on a 'best-guess' basis until sputum culture and sensitivities are available. Physiotherapy and encouragement to cough are equally important for recovery.

33. Adult Respiratory Distress Syndrome: This syndrome of acute respiratory failure is characterized by rapid, shallow breathing, severe hypoxemia, stiff lungs and diffuse pulmonary pacification of X-ray.

34. THROMBOEMBOLISM Pathophysiology Venous thromboembolism is a major cause of complications and death after surgery or trauma. Venous blood is normally prevented from clotting within the veins by a complex of mechanisms which include local inhibition of the clotting cascade, prompt lysis of small clots that do form, and continues flow of blood. This subtle balance can be disturbed by several local and systemic factors, many incompletely understood. Imbalance results in thrombus formation within the venous sinuses of the calf muscles and sometimes primarily in the pelvic veins.

35. Predisposing factors for deep vein thrombosis and pulmonary embolism 1.Trauma and surgery (complex systemic effects) 2.Direct trauma to the pelvis and lower limbs, especially fractures 3.Previous venous thromboembolism 4.Pre-existing lower limb venous disorder causing stasis 5.Venous stasis during general or regional anesthesia (loss of calf muscle pump and postural pressure on the calves) 6.Malignant disease

36. 7.Immobility, e.g. bedbound patients after operation or stroke 8.Cardiac failure 9.High-oestrogen oral contraceptive piles, estrogen treatment 10.Pregnancy 11.Pelvic masses 12.Obesity 13.Dehydration 14.Blood disorders, e.g. polycythemia, thrombocythemia and prothrombotic disorders

37. DEEP VEIN THROMBOSIS Deep vein thrombosis in the lower limbs (DVT) is often silent with the classic clinical features found in only half the cases. These include swelling of the leg, tenderness of the calf muscles, increased warmth of the leg, and calf pain on passive dorsiflexion of the foot (Homan's sign). The presence of these features indicates that venous occlusion has extended at least as far as the popliteal veins.

38. PULMONARY EMBOLISM The classic picture of pulmonary embolism (PE) is sudden dyspnea and cardiovascular collapse, followed by chest pain, development of a pleural rub (sound made by walking on fresh snow) and hemoptysis. ECG may show evidence of right heart strain. Prevention of Venous Thromboembolism: The importance of general measures in preventing, venous thrombosis cannot be overemphasized. These include early postoperative mobilization, adequate hydration and avoiding calf pressure. For patients at higher risk, specific prophylactic measures should be taken to reduce the risk of deep venous thrombosis (and consequent pulmonary embolism). Prophylactic measures include the following:

39. Low-dose subcutaneous heparin. ▲ Calf compression devices - several pneumatic and electrical devices are available for intraoperative calf compression to simulate normal muscle pump activity. These have the advantage of being non-invasive and easily applied to all patients, even those at low risk, but their efficacy is less than low dose heparin Graded-compression "anti-embolism' stockings - the use of these stockings is simple and widely practiced. Provided the stockings are correctly fitted, graded-compression stockings offer a suitable level of prophylaxis for patients at low or moderate risk. The stockings must be worn during operation as well as during the early postoperative period.

40. Graded-compression "anti-embolism' stockings - the use of these stockings is simple and widely practiced. Provided the stockings are correctly fitted, graded-compression stockings offer a suitable level of prophylaxis for patients at low or moderate risk. The stockings must be worn during operation as well as during the early postoperative period .

41. PRESSURE SORES: Pathophysiology: Elderly, debilitated and other bed-bound patients are extremely susceptible to pressure sores (bed sores), particularly over bony prominences such as the sacrum and heels. Pressure sores occur because the frequent spontaneous adjustment of position that normally occurs is lost through

42. obtunded sensation and immobility. Diminished protective pain response plays an important part. Tissue necrosis and subsequent failure to heal result from a combination of factors including recurrent pressure ischemia, poor tissue perfusion (from cardiac or peripheral vascular disease) and malnutrition.

43. Prevention and management of pressure sores: Once established, pressure sores are difficult to eradicate and prevention must be given high priority in patients at risk Relatively hard surfaces such as accident and emergency department trolleys and operation" tables may initiate pressure sores in susceptible patients in less than 1 hour. Likewise, pressure sores can develop in a remarkably short time in a hospital bed, particularly if the patient is incontinent of urine or feces. Prevention of pressure sores on the ward is mainly a nursing responsibility;

44. indeed, the incidence of pressure sores is a good indicator of the quality of nursing care. Prevention of pressure sores involves the following, procedures:

45. Relieving pressure on the heels use of ankle rests while on the operating table, use of heel pads, sheepskin rugs and 'bean-bags' on return to the ward. Special bed surfaces to spread the load these include simple sheepskin mattress covers, padded over-mattresses and electric ripple mattresses, water beds, sophisticated vibrating mattresses and suspended net beds. Regular change of posture for most patients, this involves encouragement to get out of bed, at least into a bedside chair, and to mobilize beyond this as much as possible. A bed- bound patient requires regular turning so that the same skin area is not subjected to constant pressure Regular checking of pressure areas and local massage. Management of incontinence.

46. Treatment of established pressure sores is unsatisfactory unless the causative factors, can be eliminated. This is often impossible in the permanently disabled patient. Avoiding pressure is the mainstay of treatment, supplemented by local cleansing and dressings designed to remove necrotic tissue and control secondary infection. For a deep sacral sore. Major plastic surgery involving a rotational buttock flap is occasionally justified.