-General Complications of ....Surgery.ppt

-General Complications of ....Surgery.ppt

1. General Complications of Surgery
Dr Awad Alqahtani Dr Awad Alqahtani
MD,MSc,FRCSC(Surgery)MD,MSc,FRCSC(Surgery)
FRCSC(Oncology),FICS FRCSC(Oncology),FICS
Laparoscopic Bariatric Laparoscopic Bariatric
Surgeon and Surgical Surgeon and Surgical
OncologistOncologist

2. Pre&Post Operative Care and Surgical
Complications
Pre Operative evaluation :
•History & Physical Examinations
•Investigations and Radiologic diagnostic Tools
•Routine lab, EKG, etc.

3. Pre-operative Preparation
•Testing
–Determines ability to sustain surgical insult
–Determines type of anesthesia delivery
–Blood Pressure, Diabetes, EKG, Liver function, CBC, Chest X-
ray, UA
•Medications
–Day before surgery, anti-inflammatory
–Day of surgery, antibiotics
–Post op pain meds
–Smoking cessation?

4. Patient/Procedure Confirmation
•Surgical Consent
•Pre-operative marking
•“Time Out” in the operating room

5. Types of Injuries
•Wrong site, wrong procedure
•Wrong medication
•Skin breakdown/decubiti
•Burns
•Nerve damage
•Ischemia
•Eyesight

6. Classification of Post Operative
Complications
•Avoidable (Preventible, non Preventible)
•- Physiological, Biochemical ; Anemia,
Coagulopathy
•- Related to timing

7. Related to timing
Immediate 0-24 Hrs.
•Anesthesia
•Pain
•Bleeding
•Shock, Renal failure
Intermediate 1-30 days [avr. 7 day] (LOS)
•Organ
•Systems
•Other Systems
Late > 30 Days, after D/C.

8. Surgical Complications
•Wound
•Thermal Regulation
•Postoperative Fever
•Pulmonary
•Cardiac
•Renal
•Gastrointestinal
•Metabolic
•Neurological

9. Surgical Complications
•Primary disease
•Operation
•Unrelated factors
•Complications leading to other complications
•Prevention

10. Wound Complications
•Dehiscence
•Seroma
•Hematoma
•Infection
•Incisional Hernia

11. Wound Dehiscence
•Separation of facial layers
•Serosanguinous drainage
•Technical Complication
•Risk Factors
•Mortality approaches 30%
•Evisceration

12. Evisceration

13. Incisional Hernia

14. Seroma
•Collection of liquefied fat, serum and lymphatic
fluid under the incision
•Benign
•No erythema or tenderness
•Mastectomy, axillary and groin dissections
•Treatment

15. 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

16. 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

17. 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

18. Necrotizing fasciitis

19. Complications of Thermal Regulation
•Hypothermia
•Malignant Hyperthermia

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. Gastrointestinal Complications
•Postoperative ileus
•GI Bleeding
•Pseudomembranous colitis
•Ischemic Colitis
•Anastomotic Leak
•Enterocutaneous fistula

27. 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

30. 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

31. 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)

32. Neurologic Complications
•Beware the drugs you will be prescribing
•Delirium, Dementia and Psychosis
•Seizure Disorders
•Stroke and Transient Ischemic Attacks