surgical complications
DESCRIPTION
Surgical Complications. John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center. Primum no nocere. Think before you act. Complications can be deadly…. Logarithmic increase in bile duct injuries after the introduction of laparoscopic cholecystectomy. - PowerPoint PPT PresentationTRANSCRIPT
Surgical Complications
John Cosgrove, MD FACSChairman and Residency Program DirectorBronx Lebanon Hospital Center
Primum no nocere
Think before you act.
Complications can be deadly…
Logarithmic increase in bile duct injuries after the introduction of laparoscopic cholecystectomy.
SCIP
Antibiotics Normothermia VTE Prophylaxis
Morbidity and Mortality Conference
Mainstay quality program of general surgery residency programs.
Mortalities
Morbidities
Cardiorespiratory Wound Urinary tract
Wound
Seroma Hematoma Dehiscence Evisceration
Wound
Superficial Deep Organ space
Pathogens
Staphylococcus(coagulase neg) 25% Enterococcus(D) 11.5% Staph aureus 8.7% E. coli 6.5%
Wound classification
Clean Clean contaminated Contaminated Dirty
Temperature regulation
Issues of hypothermia
Malignant hyperthermia
1 in 30,000 cases Mortality less than 10% Autosomal dominant with variable
penetrance Altered calcium metabolism Halothane, isoflurane, succinylcholine Cause rise myoplasmic calcium
MH
Tachycardia Arrhythmia Raised temperature Acidosis Muscle rigidity Tachypnea Flushing (inability to open mouth)
Treatment
Discontinue triggering anesthetic Hyperventilate with 100% oxygen Terminate surgery Dantrolene 2.5mg/kg as bolus and repeat every 5
minutes Monitoring Sodium bicarbonate Beta blockers Lidocaine Lasix
Pulmonary complications
Atelectasis Pneumonia Pulmonary embolism Aspiration Pulmonary edema ARDS
Weaning criteria
RR <25 breaths/min Pa02 >70mmHg(Fi02 of 40%) PaC02<45 mm Hg MV 8-9L/m TV 5-6mL/kg NIF -25cm H20
Cardiac
Greatest risk in first 48 hours Non-Q wave, non ST segment elevation
Prevention
Major predictors of risk Unstable chest pain, CHF, sympotomatic
arrhythmias, severe valvular disease
Management
Cardiology consult Tachyarrhythmia Unstable-cardioversion SVT-Beta blocker, esmolol, amiodarone PSVT-vagal stimulation, adenosine, amiodarone MAT-B blocker or amiodarone VTach-lidocaine or amiodarone Brady-atropine Heart block-high grade second or third degree-
insertion of permanent pacemaker
Amiodarone
Phosphodiesterase inhibitor Inhibits breakdown of camp Increase cardiac output and decreases
preload and after load without increasing myocardial oxygen demand
May cause vasodilitation and GI problems and thrombocytopenia
Adrenal
Chronic use of steroids causes suppression of the HPA axis
Potentially life threatening Give 250ug cosyntropin intravenousl
Hemodialysis indications
Serum potassium >5.5 BUN>80-90 Persistent metabolic acidosis Acute fluid overload Uremic symptoms(pericarditis, encephalopathy,
anorexia) Removal of toxins Platelet dysfunction Hyperphosphatemia with hypercalcemia
SIADH
Common cause of chronic normovolemic hyponatremia
Serum sodium<135 Treat underlying disease process Fluid restriction Rapid correction may result in seizures
Gastrointestinal
Ileus Early SBO Compartment syndrome GI bleeding Stomal complications C. difficile colitis
Anastomotic leak
Strategies for prevention Low anterior resection
Enterocutaneous fistula
Low output <200 cc/24h Moderate 200-500 cc/24 h High >500 cc/24 h
“The Checklist”
Provonost Gawande
Airline Industry
Crew resource management Communication No hierarchy Checklist, checklist, checklist Debriefing
Universal Protocol
Preprocedure Verification Presurgical “timeout” Post procedure “debriefing”
Prospective Case Conference
Dr. Judson Randolph 1988-Childrens Hospital Center, Washington,
DC A priori discussion of all upcoming pediatric
surgery cases involving multiple disciplines
Interdisciplinary teamwork
GI/bleeds/biliary Radiology/bleeds/abscess Medicine/evaluation/cardiac Anesthesia/PST/surgical readiness
“Never events”
CMS