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