1、Post operative complications,Ghiath Al Saied,How common are post operative complications,Pick post operative complications Incisional Pain conversion from laparoscopic to open Prolonged surgery/prolonged hospitalization Vomiting 3 hours after hernia surgery Wound opening at day 7 Asthma exacerbation
2、 Cancer recurring after 4 months?,Monitoring,Clinical CNS (pain, LOC, GCS) Resp (auscultate, RR, distress, cough, sats) CVS (BP, HR, skin, urine output, Hg) Renal (urine output, Cr, BUN, hematuria) GI (BM/flatus, N/V, distension, pain, NG output, drains) Heme (fever, skin color),Monitoring,By ancill
3、ary measures CNS (ICP monitor) Resp (CXR, O2 sats, ABGs) CVS (JVP/CVP, swan) Renal (Cr, BUN, sodium excretion ratio) GI (Abdo xray/CT) Heme/ID(WBC, Hg, Plt, coagulopathy, bloodfilm, cultures),Case 1,26 year old surgery resident post operative day 2 small bowel resection No past medical hx Resection
4、for meckels, acute Midline laparotomyVomited 3 times,Case 1 Hx,Vomiting Green, large, relieved abdominal distension 1.5 L No other vitals changed No fever, no abdo pain, but some crampsDx?,GI Comps,Nausea and vomiting Early is due to anesthesia and medications Late is due to post operative ILEUSSB q
5、uickest to return (almost immediately) Stomach with 48 hours Colon up to 5 days ANY LONGER is definitely an ileus,Causes of ileus ?Normal Electrolytes (Hypokalemia most common) Diabetes Intra-abdominal infection Existing intestinal problemNeed to differentiate from early SBO,GI Comps,Complications o
6、f ileus Aspiration Malnutrition Abdominal distention wound stress Respiratory function decline poor cough infc Prolonged hospital stay Prevention/Rx Treat cause (fix Dm, fix lytes, drain abscesses) Gentle tissue handling Time/nutrition (Ambulation),Case 2,57 yo post laparotomy for spleenectomy (ITP)
7、 Past Hx smoker, diabetic Good respiratory function preop Normal ECG Post operative day 1 Tachypnea (32) fever (38.0), tachycardia 110, and need for O2 (4 L) Differential (give me 10),Resp complications,Major clinically significant complications: Atelectasis Infection (incl pneumonia and bronchitis)
8、 Exacerbation of underlying chronic lung disease Hypoxia - Respiratory failure - Difficulties weaning Bronchospasm,Resp complications,also: Upper airway obstruction Pleural effusions Chemical (aspiration) pneumonitis Non-cardiogenic pulmonary edema/ARDS Tracheal laceration/rupture Pulmonary Embolism
9、,Resp complications,Very common Pain is a major factor Immobility Ciliary dysfunction Smoking: Increased risk of pulmonary complications, even in absence of chronic lung disease 3- to 4-fold reduction in complication rate if smoking cessation 8 weeks,Resp complications,Prevention of postoperative pu
10、lmonary complications:,Post-operative measures which are benificial: Deep breathing exercises incentive spirometry in high risk patients Epidural analgesia in lieu of parenteral opioids Epidural analgesics reduce the incidence of pulmonary complications compared to parenteral opioids (HR 0.51- 0.58)
11、 Intercostal nerve block (?superior to traditional parenteral analgesics?) CPAP: may decrease the incidence hypoxia and need for intubation in patients who develop PaO2/FiO2 300 following abdominal surgery Early patient mobilization and ambulation,Case 3,Post operative Day 1 perforated appendix 14 y
12、ear old Fever 38.4 RR 38 HR 145 BP 80/40 Differential,CVS complications,Differential?,CVS,Bleeding Pale, cool extremities, pale conjunctiva,Hypotension and tachycardiaSeptic shock Flushed, warm extremities, hyperactive circulation HypoBP and tachy,CVS,JVP will be ?Rx?,Case 4,Post umbelical hernia PO
13、D 3 with pus from wound Red, tender, swallen, slight feverDx: infectionDDx? ,Wound infection,Factors to increase wound infectionPOD1 infectionPOD 4 infection,Urinary output,What is the fluid balance of POD1 laparotomy?Why?What if urine output is 0 after rectal surgery?,Summary,CNS: GCS 15, pain score65, JVP? Resp: RR 12-20, sats92% on R/A GU: 0.5cc/kg/hour minimum Heme/ID: Temp 36-37.8,
