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