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),By ancillary measure
3、s 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 for meckels
4、, 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 quickest to
5、return (almost immediately) Stomach with 48 hours Colon up to 5 days ANY LONGER is definitely an ileus,GI Comps,Causes of ileus ?Normal Electrolytes (Hypokalemia most common) Diabetes Intra-abdominal infection Existing intestinal problemNeed to differentiate from early SBO,GI Comps,Complications of
6、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 splenectomy (ITP) Pa
7、st 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) Ex
8、acerbation 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,Re
9、sp 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 pulmo
10、nary 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) In
11、tercostal 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 year
12、 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?,Cardiac complication,Perioperative
13、 MI Triggered most commonly by hypotension ECG shows ST depression & T wave flattening Typically within 2 to 3 post op day Chest pain only in 1/3 of cases Trop I is the best diagnostic test Tx Treatment of complication Clot busters cannot be used in perioperative settings,Case 4,Post umbelical herni
14、a POD 3 with pus from wound Red, tender, swallen, slight feverDx: infectionDDx? ,Wound infection,Factors to increase wound infectionPOD1 infectionPOD 4 infection,Surgical wound complication,Seroma Hematoma Wound dehiscence Wound infection,Seroma,Collection of liquified fat, serum & lymphatic fluid u
15、nder incision Developed when large skin flaps are developed during operation, eg : mastectomy, axillary dissection, groin dissection Prevented by placing suction drain/pressure dressing,Hematoma,Collection of blood in the SC layer of a recent incision or in a potential space in Abd cavity, eg spleni
16、c fossa hematoma after splenectomy Related to inadequate hemostasis,clotting factor deficiency,medication eg aspirin, sepsis Prevented by preoperative correction of clotting abnormality & D/C medication that alter coagulations, adequate hemostasis during surgery & close suction drainage,Wound dehisc
17、ence,Wound looks intact but large amount of pink, salmon color fluid discharge Usually on 5th postop day Wound has to be taped securely, the abd bound, mobilization & coughing done with great care Reoperation needed to avoid or to treat ventral hernia,Wound infection,Usually on 5th post op day Crite
18、ria Grossly purulent material drain from the wound Wound spontaneously open Fluid Gm stain & C/S positive Prevented by Cessation of smoking Reducing wt for obese Control of bl sugar Weaned of corticosteroid Preop abx prophylaxis,Prophylactic abx is indicated for clean contaminated wound Prophylaxis
19、is controversial for clean cases A preop dose within 30 min before the incision & two postop doses are given,Urinary output,What is the fluid balance of POD1 laparotomy?Why?What if urine output is 0 after rectal surgery?,Urinary complication,Post op urinary retention Common after lower abd,pelvis or
20、 perineal surgery In & out catheterization at 6 hrs post op if no spontaneous voiding Indwelling catheter at 2nd consequative catheterization Zero urinary output Mechanical rather than biological May be for plugged or kinked catheter,Low urinary output Urine output 40meq/l in RF ).,Fluid & electroly
21、te abnormalities,Hyponatremia Developed by infusion of Na free IV fluid in post op pt with high ADH C/F Confusion Convulsion , coma eventually death Correction by 3 to 5% NaCl solution Correction should not 0.5 mmol/hr OR 12 mmol/day,Hypernatremia Means pt has lost water or other hypotonic fluid C/F
22、 volume depletion Tx Rapid replacement of fluid deficit by D51/2 NS or D51/3 NS,Hypokalemia Developed when K is lossed from GIT or in Urine (loop diuretics) & it is not replaced Tx K replacement ( IV or oral ) Safe speed limit is 10 meq/hr,Hyperkalemia Occur in renal failure,aldosterone antagonist, crush injury, acidosis Tx 50 % dextrose & insulin Exchange resin IV Ca gluconate The ultimate therapy is hemodialysis,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,
