Wound Complications

Seroma

Collection of liquefied fat, serum, & lymphatic fluid under incision

Localized, well-circumscribed swelling, pressure discomfortNo erythema, tenderness

Evacuated and packed heal by secondary intention

Secondary infection open wound

Hematoma

Ecchymotic, localized wound swelling, drainage of dark red fluid

Open wound and pack if detected soon after surgery

Small hematoma 2wks after surgery may resorb

Wound Dehiscence

Separation of fascial layersEvisceration of bowel

Technical error, deep wound infection

Case 1

87yo s/p repair of perforated bowel with gross stool spillage

How do you close the fascia?Interrupted figure-eight good

strengthCan use absorbable mesh or retention

sutures to reduce tension

Case 2 Cont.

How do you close the subcutaneous tissue?

Leave it openif wound clean after 5d, then you can approximate edges

…later that night

Sudden drainage of large volume of clear, salmon-colored fluid…Examine patient & wound…

probe wound with sterile applicator

Examine wound & see bowel… cover bowel with sterile saline

moistened towel O.R. STAT

Wound infection

Erythema, tenderness, edema, occasional drainage

Rx: open wound, free loculations, irrigate, packCT scan if pus emanating deep to

fascia

Called for a temp of 102…

Examine patient & woundErythema, drainage of grayish

dishwater-colored fluid, what seems like necrotic fascia, mild crepitus… O.R. STAT-rapid & expeditious

debridement clostridiomyonecrosis

Prevention of SSI

Stop smoking 48h prior, encourage weight loss, bowel prep, taper/stop immunosuppresants

Prophylactic antibiotics Insert drain if gangrenous organ Delayed primary closure in

contaminated field

Complications of Thermal Regulation & Cardiac Complications

Sumit De, M.D

Complications of Thermal Regulation

• Hypothermia

• Malignant Hyperthermia

• Postoperative Fever

• Respiratory Complications

• Aspiration Pneumonitis

• Pulmonary Edema, Acute Lung Injury, ARDS

• Pulmonary Embolism

•Causes: cold environment, paralysis, rapid resuscitation, intra-op exposed areas, irrigation

•Body’s response: CO, HR, cardiac arrhythmias, coagulation, vasoconstriction

•Cardiac alterations, diuresis, hepatic & neurological dysfunction

•Keep patient WARMWARM

Hypothermia

•Exposure to inhalation agents or succinylcholine

•Mostly occurs in youth

•High fever, tachycardia, muscular rigidity, and cyanosis

•Metabolic acidosis, hyperkalemia, hypercalcemia

Malignant Hyperthermia

Management:

Stop inhalation agent

Cancel/conclude surgery

Dantrolene, 2.5 mg/kg

Cool body

Reverse met acidosisBox 14-3, Sabiston

Post-op Fever

Wind: Atelectasis – 24-48 hrs

Water (UTI) – after POD #3

Wound – after POD #3

Walking (DVT/PE/Thrombophlebitis) – POD #7-10

Wonder drugs - Anytime

•Most post-op patients who have respiratory complications can be managed with pulmonary toilet

•Two types of respiratory failure:

•Type I: hypoxic – abnormal gas exchange at alveolar level (e.g. pulmonary edema, sepsis)

•Type II: hypercapnia – excessive narcotic use, increased CO2, respiratory dynamic changes , ARDS

Respiratory Complications

PNEUMONIA & Aspiration Pneumonitis

Pulmonary Edema, Acute Lung Injury,and Adult Respiratory Distress Syndrome

Pulmonary edema associated with a increased wedge & right-sided heart pressures: hydrostatic pressure to high

ALI & ARDS: hypo-oxygenation due to pathophysiologic inflammatory response, PCWP <18 mmHg, and bilateral infiltrates

PaO2/FiO2 ratio in ALI <300 ARDS <200

Criteria for Ventilator Weaning:RR <25 B/min Vmin 8-9 L/min

PaO2 >70 mmHg (FiO2 <40%) VT 5-6 mL/kg

PaCO2 <45 mmHg Nif –25 cm H20

500,000 PEs occur annually, 100,000 fatal Iliofemoral venous system most common source

of PE; fat emboli s/p long bone fractures & air emboli s/p central lines are also well-known causes as well

Signs & Sx of PE are shared with MI, PTX, PNA, and atelectasis

ABG with PaO2 <70 mmHg, T-wave inversions, and non-specific ST segment changes

Severe PE: S1Q3T3, RBBB, right-axis deviation CT angiography, Treat with HEPARIN

Pulmonary Embolism

Cardiac Complications

Post-Op HTN

CVA & op site bleeding are biggest concerns, especially after CEA, AAA, head & neck procedures. -blockade

Perioperative Ischemia and Infarction

~30% OR patients have CAD, perioperative MI mortality rate is ~30% compared to 12% for thiose without a surgical procedure; 8-15% reinfarction rate for <3 mos post-MI OR patient, 3.5% reinfarction rate for 3-6 mos post-MI OR patient

Cardiogenic Shock

~50% or more LV mass damaged post-MI => hypoperfusion, ruptured papillary muscle, ventricular wall, aortic valvular insufficiency, mitral regurg, VSD

Arrhythmias & CHF

Intra-op occurrence of arrhythmias (30 sec abnl cardiac activity) is 60-80%. Electrolyte abnormalities, medications, stress, endocrine abnormalities, and cardiac disease are main causes

RENAL AND URINARY TRACT COMPLICATIONS

URINARY RETENTION

6-7 HOURS POST OP DISCOORDINATION OF TRIGONE

AND DETRUSOR MUSCLES STRAIGHT CATH

ACUTE RENAL FAILURE

10% PATIENTS IN PERIOP COURSE

OLIGURIC <480 ML/DAY NONOLIGURIC >2L/DAY

POSTOP RENAL FAILURE

PRERENAL RENAL POSTRENAL

HEMORRHAGE TOXINSURETERAL LIGATION

HYPOVOLEMIA DRUGSBLADDER

DYSFUNCTION

CARDIAC FAILURE

PIGMENT NEPHROPATHY

URETHETRAL OBSTRUCTION

DEHYDRATION

EVALUATION

BUN:CR FRACTIONAL EXCRETION OF

SODIUM PRERENAL FENA <1%

RENAL FENA >3%

CONTRAST NEPHROPATHY

HYPOVOLEMIC DIABETIC VASCULOPATH HEART FAILURE ACE-I, NSAID HYDRATION MUCOMYST/ N-ACETYLCYSTEINE

600MG PO BID X 48HRSTepel M, van der Giet M, Schwarzfeld C, Laufer U, Liermann D, Zidek W: Prevention of radiographic-contrast-agent-induced reductions in renal function by acetylcysteine. N Engl J Med 343: 180–184, 2000  

RHABDOMYOLYSIS

CRUSH INJURY MYOGLOBINURIC RENAL INJURY HYPERKALEMIA AND ACIDOSIS HYDRATION DIURESIS ALKALINIZATION

INDICATIONS FOR HEMODIALYSIS

SERUM POTASSIUM >5.5 MEQ/L BUN >80-90 MG/DL PERSISTENT ACIDOSIS ACUTE FLUID OVERLOAD UREMIC SYMPTOMS REMOVAL OF TOXINS

METABOLIC COMPLICATIONS

ADRENAL INSUFFICIENY

PRIMARYADDISONSINFECTIOUS

SECONDARYPITUITARY OR HYPOTHALAMIC

DISEASECESSATION CHRONIC STEROIDS

DIAGNOSIS

BASELINE CORTISOL <15 UG/DL ACTH STIMULATION

BASELINE CORTISOL0.25 MG COSYNTROPIN IVGLUCOCORTICOIDMEASURE CORTISOL AT 30 MIN

SIADH

HIGH ADH DESPITE HYPONATREMIA

TRAUMA STROKE ADH PRODUCING TUMORS FLUID RESTRICTION ADMINISTRATION OF SALINE DIURETICS

Gastrointestinal and Hepatobiliary Complications

Harsh Jain, M.D.

Gastrointestinal complications

IleusIntestine that ceases contrancting for

brief period of time (3-5 days)Operative manipulation, major small

bowel injury, heavy narcotic use, intra-abdominal infection, and pancreatitis can prolong the ileus

Past 7 days – prolonged ileus vs SBO

Ileus vs SBO

Ileus Distention Diffuse discomfort Hypoactive BS AXR

• Air into colon and rectum

Treat underlying cause

SBO Distention Often intermittent,

colicky pain Nausea, vomiting Obstipation AXR

• No air into colon and rectum

May require operative therapy

SBO

Causes Adhesions Malignancy Hernias

Diagnosis Flat plate and

upright abdominal films

CT Scan

Management Hydration Correct electrolyte

imbalances NGT Operative therapy

if conservative management fails

Abdominal Compartment Syndrome

Etiology Massive abdominal

trauma Operation for massive

abdominal infection Prolonged operation Pressures >25cmH2O

Presentation Distended, tense Hypoxia Elevated airway

pressure Oliguria

Diagnosis Measure intra-

abdominal pressures through foley cathether

Treatment Surgical emergency Open fascial closure

and re-do with temporary closure

Post op GI Bleeding

Etiology Stomach

• PUD, Stress erosions, M-W tear, varices

Small intestines• AV malformations,

anastomotic bleeding Large intestines

• anastomotic bleeding, diverticulosis, AV malformations, varices

Management Large bore IV’s Fluids Labs NGT Correct coagulopathy Endoscopy/

Colonoscopy Rarely surgery

Stomal Complications

Prolapse Rarely surgical

problem Necrosis

Ischemia to skin level usually resolves

Stenosis Peristomal hernia High output Bleeding

Stoma placement Avoid skin folds Mobilize adequate

length Through the rectus Below the anterior

superior iliac crest

Pseudomembranous Colitis

1 % of patients who receive antibiotics in peri-op period

Superinfection with C.Diff

Secretion of exotoxin Pseudomembranes

Whitish membrane consisting of fibrin, WBC, mucus

Diarrhea, cramping and dehydration

Diagnosis by stool sample for exotoxin

Treat with oral metronidazole or vanocmycin, IV metronidazole

Sometimes disease progresses despite treatment

If febrile, shock and tender __> colectomy

Anastomotic Leak

Caused by Ischemia Tension Mismatch of the lumens Rough handling of tissues

Presentation Fever Abdominal pain Malaise Paralytic ileus Fullness of the area Wound dehiscence Fistula

CT Scan Large fluid collection Air fluid levels in

abscess cavity Free air

Small leak with controlled fistula, conservative management with gut rest, TPN and antibiotics

Larger leaks, or uncontrolled infection, no drainage usually require reoperation

Fistulas

Abnormal communication between one hollow epithelialized organ and another epithelialized surface.

Entero-cutaneous fistula Initial erythema,

abscess, and the subsequent efflux of GI contents

Entero-vesical fistula Pneumaturia or fecaluria

Initial treatment includes fluids, antibiotics, protection of skin

NPO, TPN Low output (<200ml/day),

consider enteral feedings Watch lytes with high

output (1-2 L/day) H2 blockers, octreotide Foreign body, radiation,

infection at fistula site, epithelialization of the fistula tract, neoplasm or, distal obstruction

Bile Duct Injuries

Increased incidence after lap chole became generally accepted

Presentation Fever, RUQ Pain,

malaise and occasionally jaundice

Immediate CT Scan If fluid collection,

precutaneous drainage with the drain left in

ERCP

Small leak and open common bile duct – stent

Cystic duct injury or small leak – stent and drain

Major injury or obstruction of bile duct – stenting is only supplementary to surgery

Surgery If adequate control of

leak, wait 5-7 days Debride nonviable CBD Roux-en-Y limb to CBD Multiple drains

Neurological and ENT Complications

Muhammad Irfan Saeed MD

Neurological Complications

Delirium, Dementia, Psychosis Seizure Disorder Stroke and Transient Ischemic attack

Delirium

High Risk Patients

Elderly

Prior history of Substance abuse

Prior history of Psychiatric disorder

Children

Causes of Acute Delirium Drug Intoxication (Alcohol, Antihistamines, Sedatives) Drug Withdrawal (Alcohol, Narcotics, Anxiolytics) Acute Cerebral Disorder (Edema, TIA, Stroke, Neoplasm) Metabolic Disturbance (Electrolyte disturbance,

Hypoglycemia) Hemodynamic disturbances (Hypovolemia, MI, CHF) Infections (septicemia, UTI, Pneumonia) Respiratory Disorder (Respiratory failure, PE) Trauma (Head Injury, Burns)

Symptoms

Impaired memory Altered perception Altered sleep patterns Hallucinations Combativeness Confusion

Management

History and Physical examination

(Neurological examination) Check Medication List Vitals with Pulse oximetry EKG, ABG, UA, CXR CT scan MRI

Treatment

Appropriate Sedation Treatment of the underlying cause Careful Observation (one to one nursing, transfer the

patient to a naturally lighted room)

Delirium Tremens

Onset usually 72 to 96 hours after alcohol cessation.

Characterized by disorientation, hallucinations, autonomic lability (tachycardia, fever, HTN, diaphoresis)

Treatment

Benzodiazepines Clonidine IVF Thiamine Magnesium sulphate Folate Restraints

Seizure Disorder

Caused by paroxysmal electrical discharges from the cerebral cortex.

Cause

Primary

Secondary

Causes

Primary Intracranial Tumor Hemorrhage Trauma Idiopathic

Secondary Metabolic Sepsis Systemic disease

(epilepsy) Pharmacological

agents (antidepressants, hypoglycemic agents, Lidocaine)

Symptoms and Signs

Convulsions Rhythmic myoclonic activity Loss of consciousness Change in mental status (lack of

neurological responsiveness) Fecal and urinary incontinence Post event amnesia

Diagnostic Workup

Rapid blood glucose determination Oxygen saturation CBC Chem-7 Serum calcium / magnesium Serum levels of anticonvulsants CT scan

Treatment

Patient safety (airway, restraints) IV Benzodiazepines Phenytoin Carbamezapine Valproic acid Gabapentin Treat the underlying cause

Stroke and TIA One of the most devastating complication Most common causes include Advanced atherosclerotic disease of Internal

carotid artery. Atrial fibrillation VSD Acute hepatic failure Excessive anticoagulation

Symptoms and Signs

Unilateral weakness or clumsiness Sensory loss Speech disorder Diplopia Vertigo Alteration in mental status

Diagnostic Workup Finger stick glucose Pulse oximetry CBC Chem-7 Coagulation studies CT scan of head Echocardiography Carotid ultrasound

Management Depends upon type of stroke (hemorrhagic

vs. Non-hemorrhagic) Supplemental oxygen and IVF Pharmacological BP reduction (Mannitol and

Dexamethasone) Aspirin 325 mg orally Thrombolytic therapy in close consultation

with neurologist

ENT Complications Epistaxis Most frequent postoperative causes NG tube placement Endotracheal tube placement Temperature probe Pressure application for 3-5 minutes Nasal packing for 10-15 minutes Nasal packing for 1-3 days Treatment of underlying cause

Sinusitis Often missed in postoperative period due to

analgesics, antipyretics and NG tube Malaise, dull aching pain in maxillary or frontal sinus

area and low grade fever CT scan of head Treatment

Removal of NG tube

Antibiotics

Decongestants

Drainage Procedure

Questions???

Question #1

Which of the following statements about tracheoinominate artery fistulas after tracheostomy is not true?A Occur within 2-3 weeksB Caused by excessive inflation of

cuffC Mortality of 50%D Hyperinflation of cuff may control

bleeding temporarily

Answer!!!

C Mortality is 80%Can be life threateningPresents as exsanguinating

hemoptysis (small herald bleed may be noted)

Avoid placing trach below 4th tracheal ring

Can place finger along trach and compress artery

Question#2

Which of the following insufflation gases for laparoscopic pneumoperitoneum can cause hypercarbia and acidosis?A Carbon dioxideB Nitrous oxideC HeliumD Argon

Answer!!!

A Carbon dioxideAlso associated with increases in

arterial pressure, pulmonary vascular resistance, pulmonary arterial pressure. Decreases in cardiac contractility.

Question#3

A postop patient has a serum Na of 125 meq/L and blood glucose of 500 mg/dl (nl 100). What would Na level be if glucose level normal?A 120 meq/LB 122 meq/LC 137 meq/L

Answer!!!

C 137 meq/LEach 100 mg/dl rise in blood glucose

above normal is equivalent to a 1.6-3.0 meq/L fall in the apparent Na concentration.