post operative care surgical...
TRANSCRIPT
Dr. Apirak Chetpaophan
Department of Surgery, Faculty of Medicine.
Prince of Songkla University
Post Operative Care &
Surgical Complications
Pre operative management Post operative management
Intraoperative management
Surgery
Pre&Post Operative Care and Surgical Complications
Pre Operative evaluation :
History & Physical Examinations
Investigations and Radiologic diagnostic Tools
Routine lab, EKG, etc.
Effect of Hormonal response in relation to :
Post Operative Care
Post Operative Complications
Summary of Preoperative Summary of Preoperative
EvaluationEvaluation
1. Cardiovascular
History of stable/unstable angina, arrhythimias,
MI, CHF, cardiac surgery, rheumatic fever,valvular disease, endocarditis, stroke,claudication
Summary of Preoperative Summary of Preoperative
EvaluationEvaluation
2. Pulmonary
Recent pneumonia, exposure to pulmonary
irritants, dyspnea, productive/non-productive cough, wheezing, hemoptysis, history of pulmonary tuberculosis, asthma, bronchitis,fungal exposure, smoking history, cyanosis or aspiration, availability of previous chest film or CT scans.
Summary of Preoperative Summary of Preoperative
EvaluationEvaluation
3.Renal
Renal insufficiency( recent or in the past),
renal stone
Summary of Preoperative Summary of Preoperative
EvaluationEvaluation
4. Hematologic
History of blood transfusion, bleeding disorders,
easy bruising, use of NSAID, aspirin or antiplateletmedications , previous history of DVT or PE,information regarding blood donation and autologous blood program
Summary of Preoperative Summary of Preoperative
EvaluationEvaluation
5. Gastrointentinal
History of GI bleeding or previous operation for ulcers or carcinoma, GER disease
Summary of Preoperative Summary of Preoperative
EvaluationEvaluation
6. Endocrine
history of DM, thyroid disease, long-term steroid use, pituitary or adrenal insufficiency
Summary of Preoperative Summary of Preoperative
EvaluationEvaluation
7. Infection
History of bacterial or viral pneumonia,chronic bronchitis, pulmonary TB, fungal infection, hepatitis, CMV or HIV
Summary of Preoperative Summary of Preoperative
EvaluationEvaluation
8. Medication
Use of prescription and nonprescription drugs, previous radiation or chemotherapy.
Summary of Preoperative Summary of Preoperative
EvaluationEvaluation
9. Previous operation
Especially thoracic and abdominal operations
Summary of Preoperative Summary of Preoperative
EvaluationEvaluation
10. Nutrition
Note overall appearance of nutritional status, weight loss or gain, obesity and overall eating habit
Summary of Preoperative Summary of Preoperative
EvaluationEvaluation
11. Patient directives&Health Care
Organ donation, living will, next of kin,privacy request, points of contact perioperatively, logistical and social issues regarding costs, home care, rehabilitation,case cancellation protocols, preoperative counseling.
- Avoidable (Preventible, non Preventible)
- Physiological, Biochemical ; Anemia, Coagulopathy
- Related to timing
Classification of Post Operative Complications
Immediate 0-24 Hrs.
Intermediate 1-30 days [avr. 7 day] (LOS)
Late > 30 Days, after D/C.
Organ
Systems
Other Systems
Anesthesia
Pain
Bleeding
Shock, Renal failure
Related to timing
Surgical Complications
- Postoperative Fever and Infection
- Infective causes of postoperative fever
- Miscellaneous causes of postoperative fever
- Noninfective causes of postoperative fever
- Wound Complications
- Hematoma and seroma
- Wound infection
- Wound failure
Respiratory Complications
- Atelectasis and Pneumonia
- Pulmonary Aspiration
- Pulmonary Edema
- Immediate Postoperative Respiratory Depression
- Acute Respiratory Failure
* SHOCK
- Hypovolemic shock (Immediate phase)
- Cardiogenic shock
- Septic shock
- Subphrenic abscess
* RENAL FAILURE
Deep Vein Thrombosis and Pulmonary Embolism
- Prophylaxis
- Fat embolism
Fluid, Electrolyte, and pH Imbalance
- Potassium imbalance
- Acid-Base imbalance
Alimentary Tracy Dysfunction- Acute gastric dilatation
- Gastroduodenal mucosal hemorrhage
- Intestinal obstruction
- Postoperative fecal impaction
- Colitis
- Anastomotic leak
- Hepatobiliary complications and jaundice
* Complications of Minimal-Access Surgical Procedures
* Neurologic Complications
- Prolonged alteration of consciousness
- Convulsions
Common Post Operative Complication
;Post Operative Pain
;Bleeding : Hypovolemia
;Hypoxia : Hypoventilation
;Hemodynamic Unstable
;Fluid&Electrolyte imbalance
;Wound Complication :
Hematoma, infection
Dehiscent, Keloid
Hematoma, Seroma
Risk
Chemical
Pathological - Mechanical
CVS, arrhythmia, HypovolemiaContractility (MI)Post Op Pulmonary edema, CHF
;Post Operative infection : wound (Site of Operation)
;Post Operative Renal Failure
- Liver Failure
- Hematological disorder: Coagulopathy
;Post Operation Sepsis : ARDS
;Post Operative Respiratory Failure : Atelectasis, Pneumonia,MOF.
Post Operative Hemodynamic evaluation
Physical signs of shock ( Pulse pressure, BP, tachycardia, confusion syncope)
Physical signs of venous pressure (neck veins, chest auscultation)
High venous pressure Cardiac failure, PE,
Tamponade, pneumothorax
Low venous pressureHypovolemiaMetabolicParalysis, anaphylaxisSepsis Chest radiograph, EGG, CVP ICU, response to initial Rx
Not improved Improved
PA catheter Is Do2 adequate for Vo2 (Vsat>65)?
Is perfusion adequate?Yes No
Yes No Needs acute Rx
Ensure volume statusPCWP>10CVP>5No acute Rx needed Hypovolemic
CrystalloidPlasmaPRBC
Normovolemic
Inotropes until chemical balanceInotropes
Normal CO, Vsat
CO, Vsat
MechanicalIntrathoracic pressure
PETamponadeValve malfunctionTachycardia
ContractilityIschemiaMetabolicToxic
HypocalcemiaHypoglycemiaAddison diseaseSystemic hypertension
Peripheral dilation dueto sepsis, paralysis
Inotropes until RxReduce pressureTreat PE, valveTreat arrhythmia
Vasodilation
Treat infection with œ agonist:PhenylephinineEpinepherineNorepinephrineConsider vasodilation but do not treat SVR
Balloon pump or LVAD
Hemodynamic algorithm. (After Bartlett RH. University of Michigan critical care handbook. 1991)
Measure cardiac output and VsatCO, Vsat
Common Causes of Elevated Temperature in Surgical Patients Hyperthermia Hyperpyrexia
Environmental Sepsis
Malignant hyperthermia Infection
Neuroleptic malignant syndrome Drug reaction
Thyrotoxicosis Transfusion reaction
Pheochromocytoma Collagen disorders
Carcinoid syndrome Factitious syndrome
Iatrogenic Neoplastic disorders
Central/hypothalamic responses
Pulmonary embolism
Adrenal insufficiency
Common Causes of Postoperative Hypoxemia
Atelectasis
Alveolar infiltrates
Aspiration
Cardiac-associated pulmonary edema
Noncardiac-associated pulmonary edema
(e.g., capillary leak, neurogenic, negative pressure)
Pulmonary embolus
Pneumothorax
Bronchospasm
Mucus plugging
Pulmonary contusion/hemorrhage
Common Causes of Postoperative Hypercapnia
Residual volatile anesthetics
Residual neuromuscular blockade
Narcotic overdose
Sedative overdose
High regional block
Cerebrovascular event
Neuromuscular disorders
Hypothyroidism
Insufflated carbon dioxide (laparoscopic procedures)
Metabolic alkalosis
Malnutrition
Hypermetabolism
Sepsis
Increased physiologic dead space
Respiratory ParametersParameter Normal FailureRespiratory rate 12-18 > 35
Inspiratory force (cm H2 O) -75 to -125 < -25
Vital capacity (ml/kg) 65-75 < 15
FEV1 (ml/kg) 50-60 < 10
Compliance (ml/cm H2 O) > 100 < 30
Pao2 (mm Hg) 80-95 < 70
A-a DO2 (mm Hg) 25-65 > 450
Qs/Qt 5-8 > 15-20
PaCO2 (mm Hg) 35-45 > 55
VD/VT (%) 20-30 > 60
A-a DO2, Alveolar-arterial oxygen delivery; FEV1, forced expiratory rate in one second; Qs/Qt, ration of shunted cardiac output to total cardiac output; VD/VT, ration of dead space volume to tidal volume.
Post op. Respiratory Failure
Risk Factors for Postoperative Pulmonary Complications
Risk Factor Relative RiskAge > 70 7.46
Age 50-69 4.14
Major abdominal surgery 3.90
Emergency surgery 3.49
Chronic obstructive pulmonary disease 3.13
Age 30-49 2.29
General anesthesia > 180 minutes 1.52
Acute respiratory failure (tube, vent, Fi02 > 0.5)
(arterial catheter, oximeter PA catheter)Mechanical RX Ventilator RX Systemic RX
Treat pneumothorax,hydrothoraxLarge ET tubeTracheostomy?BronchoscopyBronchodilators?Rx ascitesconsider PE if PASystolic > 40
VentilationTV 5 mL/kgrate 10
TV, rate to Paco
240
Limit: PIP 40
OxygenationF10
20.5
PEEP 5PEEP to V
satmax
F102
to Vsat
max Limit: F10
20.6
PIP 40
Maximize O2
deliverySat
a> 95%
PRBC to Hct > 14CO to V sat > 70
Limit : PCWP 20
> Dry weight
DiureseFilterPRBC or albumin
Limit: CO
Paco2> 45
TV, rate(Limit: PIP 40)
Vco2
ParalysisCoolLipid feed
NutritionPositive balanceEnergyProtein
Decrease Vo2
Treat infectionSedationParalysisCool?
Paco2
> 45ECMO adapt toacidosis
F102
0.6 1.0Prone positionTolerate hypoxemia?ECMO
WeanF10
2to 0.4
PEEP to 5PIP to 25
Sata< 90
Satv
< 70Sat
a> 90
Satv
> 70
Dry weight
Paco2
40
Stable
Paco2
40
Respiratory failure algorithm. (After Bartlett RH. University of Michigan critical care handbook. 1991)
Fluid Status
Acute renal failure in
surgical patients
Setting Frequency of ARF (%)
General surgery 3-5
Elective abdominal surgery 1-5
Open heart surgery 3-15
Cardiac surgery performed with 8-30
cardiopulmonary bypass
Severe burns 20-60
Intensive care unit 10-25
Sepsis 20-50
Radiocontrast exposure 10-30
Rhabdomyolysis 10-30
Conditions Associated with Acute Renal Failure (ARF)
Metabolic: hyperkalemia, acidemia, hyponatremia,
hypocalcemia
Cardiovascular: pulmonary edema, arrhythmias,
myocardial infarction, pericardial disease
including cardiac tamponade
Gastrointestinal: nausea, vomiting
Neurologic: mental status change, seizure, asterixis
Hematologic: anemia, bleeding
Infectious: pulmonary, urinary, peritoneal cavity,
sepsis
Common Complications of Acute Renal Failure
OliguriaRule out urinary obstruction Bladder catheter
Ultrasound Ensure good renal blood flow
Blood volumeCardiac outputDopamine?
Confirm by urineelectrolytesand clearance
Dx: renal parenchymal disease
Furosemide, 100-500 mg Diuretic trial
Polyuria Oliguria
Dx: some nephrons functional Dx: no nephrons functional
- Continue diuretics- Expect azotemia- Full nutrition- Intermittent hemodialysis asneeded for solute clearance
Isolated renal failure- Full nutrition- Intermittent hemodialysisor PD as needed for volume and solute control
Multiple-organ failure- Full nutrition- CAVH for volume- CAVHD for solute control
Dx: some or all nephrons recovered
Dx: no nephrons recovered Renal recovery
Chronic renal failure
Acute renal failure management algorithm. (After Mault JR, Bartlett RH. Acute renal failure, In:
Greenfield LJ, ed. Complications in surgery and trauma, ed 2. Philadelphia, JB Lippincott,
1989:149-162
Chronic dialysis
Post OperativeSurgical Infection
Risk Factors for Development of Surgical Site Infections Patient factors
Older age
Immunosuppression
Obesity
Diabetes mellitus
Chronic inflammatory process
Malnutrition
Peripheral vascular disease
Anemia
Radiation
Chronic skin disease
Carrier state (e.g., chronic Staphylococcus carriage)
Recent operation
Local factorsPoor skin preparationContamination of instrumentsInadequate antibiotic prophylaxisProlonged procedureLocal tissue necrosisHypoxia, hypothermia
Microbial factorsProlonged hospitalization (leading to nosocomial organisms)Toxin secretionResistance to clearance (e.g., capsule formation)
Wound Class, Representative Procedures,and Expected Infection Rates
Wound Class Examples of Cases Expected Infection RatesClean (class I) Hernia repair, breast 1.0 - 5.4%
Biopsy
Clean/contaminated Cholecystectomy, 2.1 - 9.5%
(class II) Elective GI surgery
Contaminated Penetrating abdominal 3.4 - 13.2%
(class III) trauma, large tissue
injury, enterotomy
during bowel
obstruction
Dirty (class IV) Perforated diverticulitis, 3.1 - 12.8%
necrotizing soft tissue
infections
Causes of Abdominal wound dehiscence
Imperfect technical closure
Increased intra-abdominal pressure from bowel distention,
ascites, coughing, vomiting, or straining
Hematoma with or without infection
Infection
Metabolic diseases such as diabetes mellitus, uremia, CushingK s
Tissues inadequate for strong closure
Inclusion Criteria for the Acute Respiratory Distress Syndrome (ARDS)
Acute onset
Predisposing condition
Pao2: F102 ratio < 200 (regardless of positive end-expiratory pressure)
Bilateral infiltrated
Pulmonary artery occlusion pressure <18 mm Hg
No clinical evidence of right heart failure
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References
; .Schwartz�s . Principle of surgery . 8th ed. McGraw Hill. 2005
; .Sabiston DC ed. Textbook of Surgery. 16th ed. WB Saunders 2001
; .Greenfield LJ. Surgery: Scientific principles and practice. 3rd ed. Lippincott William&Wilkins. 2001
; .Bailey&Love�s. Short practice of Surgery. 23rd ed. Arnold. 2000
The End