fwd: post op complications
DESCRIPTION
---------- Forwarded message ---------- From: UCD Graduate '09 None Date: 2009/2/25 Subject: Post op complications To: [email protected]TRANSCRIPT
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Postoperative Careand Management of
Complications
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Outline of Talk
Common presentations of postoperative complications
postoperative fever wound problems hypotension low urinary output obstruction confusion
Prevention and management
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Fail to prepare Prepare to fail
Keane R. Siapan 2002
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Postoperative Complications
General health of the patient
Preoperative care
Magnitude of the operation
Quality of postoperative care
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Postoperative Complications Pre-op:
Optimise the patients condition Give prophylaxis Select from of anaesthesia
Intra-op : Attention to detail
Post-op : Monitor to detect
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Postoperative fever
Common problem
Physical exam is important in evaluating postoperative fever
Timing of fever
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Early postoperative fever
Respiratory atelectasis
Systemic response to trauma of surgery
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Postoperative fever (1-3 days) Urinary tract infection
IV sites Phlebitis Infection
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Postoperative fever (after 5 days) Wound infection
Respiratory tract infection
Abscess Wound Intra-abdominal
Urinary tract infection
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Postoperative fever
Transfusion reaction Hematoma Deep venous thrombosis Pulmonary embolus Thyroid storm Malignant hyperthermia
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Wound complications Type of operation
Clean Clean contaminated Contaminated Infected
Emergent versus elective
Patients general health
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Specific wound complications
Hematomas and seromas
Infections
Dehiscence partial complete
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Hematomas and Seromas
Inadequate hemostasis
Anticoagualants
Intraoperative anticoagulation
Lack of obliteration of dead space
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Wound infections
Measure of ‘good house keeping’ in clean wound
Erythema to pus collection
Primary or secondary
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Wound dehiscence
Type Partial Complete
Timing Early Late
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Patient Factors Wound Dehiscence
Malnutrition Sepsis Anemia Steroid therapy
Uremia Diabetes Liver failure
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Other Factors
Surgical technique
Wound infection
Postoperative distension
Site of the incision
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Wound failure
Incisional hernia
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Respiratory complications
Atelectasis Pneumonia Aspiration Pulmonary edema Acute respiratory depression Acute respiratory failure
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Shock
Acute circulatory failure - inability of the cardiovascular system to maintain adequate tissue perfusion
There are three types hypovolemic cardiogenic septic
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Hypovolemic
Inadequate fluid replacement
Postoperative bleeding
Loss of approximately 40 percent may cause irreversible damage
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Cardiogenic Myocardial ischemia with ventricular
dysfunction (decreased cardiac output)
Excessive fluid resuscitation during Accurate diagnosis is important because
treatment is different
Increased CVP implies cardiac failure with fluid overload
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Septic Increased bacterial counts in the
blood causes rigors and fever
May be due to surgical complications (anastomotic leak)
Causes loss vasomotor tone, increased capillary permeability and myocardial depression
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Renal dysfunction
Postoperative reduction of urine output to < 0.5 ml / kg / hr
Early postoperative fluid and sodium retention
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Prerenal
Implies decreased renal blood flow which is usually due to:
decreased blood volume decreased cardiac output medications
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Renal Usually occurs with prolonged or
uncorrected pre-renal failure (acute tubular necrosis)
Can also be caused by: aminoglycosides intravenous contrast dye blood transfusions NSAI’s
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Post renal
Usually occurs after the urinary tract has been obstructed
Can be caused by: enlarged prostate ligation of the ureter during surgery Foley catheter blockage
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Alimentary tract dysfunction
Ileus
Anorexia
Nausea and vomiting
Postoperative bowel obstruction
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Paralytic ileus
Intra-abdominal inflammation
Drugs
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Paralytic ileus
X-ray findings
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Postoperative bowel obstruction
Early obstruction Paralytic ileus mechanical obstruction
Bowel obstruction should be considered in patients if the bowel function does not return to normal after about four days
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Postoperative bowel obstruction Commonly caused by postoperative
adhesions
Patients usually exhibit normal bowel function for a short while then shows signs of obstruction
Diagnosis abdominal x-rays CT scanning
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Deep venous thrombosis Is important cause of morbidity in the
surgical patient
Can lead to pulmonary embolism
Its prevalence is up to 40 percent
It can occur in the calf, femoral and iliac veins
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Deep venous thrombosis
Assessing risk
Prevention Mechanical Pharmacological
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Predisposing factors for DVT Smoking Type of surgery Obesity Venous stasis Cancer Hypercoaguable states Inactivity after surgery Oral contraceptive use
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Clinical features of DVT
Calf tenderness and swelling
Positive Homan’s sign
Fever
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Diagnosis of DVT
History and physical examination
D-dimers
Ultrasound
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Treatment of DVT
Anticoagulation
Bed rest early
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Pulmoary embolism
A very serious complication of DVT
10% die within the first hour
90% live longer than one hour-of these patients 70 percent go undiagnosed and of these 30 % die
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Diagnosis of PE Clinical
dyspnea chest pain Hypotension
D-dimers
Imaging CT Ventilation perfusion scan
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Treatment of PE
Medical management supportive care anticogualtion thrombolysis
Surgical management
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Mental status Mental changes can include somnolence,
coma, confusion, disorientation, agitation and convulsions
Elderly
This could be due to hypoxia, low blood sugar, uremia, ammonia or anesthetic agents
Failure to awaken issue usually due to anesthesia
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Mental status
Consider postoperative stroke in patients with carotid bruits
If the patient is a heavy drinker considered delirium tremens
Disorientation at night
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Other considerations
Each surgical procedure has its own set of inherent complications
Surgeon treating the patient usually has the best idea as to what is happening
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