This document discusses various post-operative complications organized into categories. It describes wound complications including seroma, hematoma, wound dehiscence, and surgical site infections. It also covers thermal regulation issues like hypothermia and malignant hyperthermia. Gastrointestinal complications involving ileus, bleeding, and leaks are outlined. Other complications discussed include DVT, pulmonary embolism, infections and fever, pulmonary issues, renal failure, cardiovascular events, neurological problems like stroke and delirium, and diabetic ketoacidosis. Prevention and management strategies are provided for each complication.
2. Complications
Complications related to:-
1) Wound
2) Thermal regulation
3) GI
4) DVT and Pulmonary Embolism
5) Infections and fever
6) Pulmonary
7) Renal
8) Cardiovascular
9) Neurological
10)Complications of Diabetes
3. 1) Wound Complications
a) Seroma
b) Haematoma
c) Wound Dehiscence
d) SSI (Surgical Site Infections)
e) Chronic wound
4. 1) Wound Complications
a) Seroma
- Collection of Liquified Fat, Serum and lymphatic fluid under the
incision
-yellow fluid
-Localised well circumscribed swelling
-Occasional drainage of clear fluid
-Place drain during surgery/ Aspiration/ Opening the wound and
packing
-Synthetic Mesh to be taken into consideration
5. 1) Wound Complications
b) Hematoma
-Abnormal collection of blood, usually in S/C or in a potential space in
abdominal cavity
- potential for secondary infection
-inadequate hemostasis, depletion of clotting factors, coagulopathy
-expanding unsightly swelling/ purple bluish swelling/ tender
-compromise airway in neck, ileus in abdomen, anemia, local bleeding
-Balance the risk, correct clotting abnormilities
-Small hematomas: expectant wait and watch for resorbtion
- Large hematomas: open the wound in OT
6. 1) Wound Complications
c) Wound dehiscence (burst abdomen)
-refers to the post-operative separation of the abdominal musculo-
aponeurotic layers
- mostly occurs in approx 7-10 days
-Factors Associated With Wound Dehiscence
➔ Technical error in fascial closure
➔ Emergency surgery
➔ Intra-abdominal infection
➔ Advanced age
➔ Wound infection, hematoma, and seroma
➔ Elevated intra-abdominal pressure
➔ Obesity
➔ Chronic corticosteroid use
➔ Previous wound dehiscence
➔ Malnutrition
➔ Radiation therapy and chemotherapy
7. 1) Wound Complications
c) Wound dehiscence (burst abdomen)
-Sudden drainage of a relatively large volume of a clear fluid
- Probing the wound with a sterile tipped applicatoror a gloved finger
- Prevention: Interrupted suturing
- Avoid tension suturing of the fascia
- once diagnosed shift the pt to OT, covering the wound with saline
soaked towels
- Exploration/ Removal of the septic foci
- Use Absorbable mesh to avoid tension
8. 1) Wound Complications
d) Surgical Site Infection (SSI)
- surgical wound encompasses the area of the body , both internally and
externally, that involves the entire operative site.
Types:
➔ Superficial, including the skin and SC tissue
➔ Deep, including the fascia and muscle
➔ Organ space, including the internal organs of the body if the operation
includes that area
11. 1) Wound Complications
d) Surgical Site Infection (SSI)
- Erythema, tenderness, oedema and occasional drainage
- Leukocytosis and fever
-Wound is considered infected if
➔ Grossly purulent material drains from the wound
➔ The wound spontaneously opens and drains purulent fluid
➔ The wound drains fluid that is culture positive or Gram stain positive
for bacteria
➔ The surgeon notes erythema or drainage and opens the wound after
deeming it to be infected
➔ (Joint Commission on Accreditation of Health Organisation)
12. 1) Wound Complications
d) Surgical Site Infection (SSI)
-Prevention: Select high risk pts
-Prophylactic antibiotics
- Intraoperative Precautions
- Mx:
-Remove sutures/staples
-Drainage of the pus and IV antibiotics
-Debridement
-Keep open/ healing by secondary intention
-Superfiucial infection (cellulitis)- IV antibiotics
- Deep infection: Open in OT
14. 2) Thermal Regulation
a)Hypothermia
- A drop of 2 Degree Celsius of body temperature
- Cool IV fluids
- Wash with Cool fluids
- Low ambient temperature
- Exposure of extra-operative surface
- Advancing age
- Anasthesia (Opoids)
15. 2) Thermal Regulation
a)Hypothermia
- Mx:
➔ Immediate placement of warm blankets
➔ Covering patient's head
➔ Infusion of blood and IV fluids through a warming device
➔ Heating and humidifying inhalational gases
➔ Peritoneal lavage with warmed fluids
➔ Rewarming infusion devices with an arteriovenous system
16. 2) Thermal Regulation
b) Malignant Hyperthermia
- Gene mediated (Autosomal Dominant)
- Cyanosis
- Raised body temperature
- Arrhythmias
- CHF
- tachypnea,
- hypercapnia
- hypotension
17. 2) Thermal Regulation
b) Malignant Hyperthermia
- Mx
- Discontinue the triggering anesthetic
- Hyperventilate the patient with 100% oxygen
- Terminate surgery
- Give dantrolene, 2.5 mg/kg as a bolus and repeat every 5 minutes
- Shift to ICU
18. 3) GI Complications
a) Post Operative ileus
b) Others specific to surgeries:
➔ Post Operative GI Bleeding
➔ Abdominal Compartment syndrome
➔ Anastomotic leak
➔ Complications related to stoma
19. 3) GI Complications
a) Post operative ileus
-within 30 days
Ileus Can be
i>Primary or Functional or Post op ileus
ii>Secondary
- No definite cause known
- Should be differentiated from Mechanical Obstruction
20. 3) GI Complications
a) Post operative ileus
-Prevention: Less handling
- Minimize injury
- Avoid dessication in air
- Mx: Correct electrolyte post op
- Three step approach
i> Resuscitate
ii> Investigate
iii> Surgery
21. 4) DVT and Pulmonary Embolism
-DVT: Post operative imobilisation/ prolonged bed rest
- Usually occurs within 6 days post op
- Oedema, Erythema, warmth, Dull aching calf pain, low grade fever
-Homan's test
- Moses test
Inv: Doppler
Mx: Bed rest, elevation of the limbs
- Antocoagulants
- Surgery
22. 4) DVT and Pulmonary Embolism
-Pulmonary Embolism:
- No specific signs and symptoms
-Dyspnoea, chest pain, hemoptysis, syncope, CVS collapse
- Should be considered in any unexplained hypoxia, tachycardia, or
dysarrhythmia
- Inv: Oxygen saturation, CXR, ECG, CT Chest
- V/Q scan (scan for exclusion)
- Pulmonary Angiography
- Mx: Supplemental O2
- Maintain vitals
- Anticoagulants
23. 5) Infections and Fever
a) Intra-operative fever:
- Secondary to malignant hyperthermia
- Secondary to transfusion reaction
- Pre-existing infections
b) Post Operative fever:
- Fever may be due to
i> Non infectious causes
ii> Infectious causes
A> Related to Surgey (Wound Complications)
B> Not related to Surgery
24. 5) Infections and Fever
b) Post operative fever
- First 24 hrs :
-Streptococcal or Clostridial infection
-Aspiration pneumonitis
-Pre-existing infection
- First 36 hrs :
-Atelactesis
-Intra-peritoneal leakage
-Soft tissue infection beginning in the wound by beta-
haemolytic streptococci
26. 5) Infections and Fever
b) Post operative fever
i. RTI
ii. GI infections
iii.Intra-abdominal infections
iv.UTI
v. Prosthesis Related
vi.Catheter Related
vii.Fascial or muscle Related
viii.Viral
ix.Fungal
27. 5) Infections and Fever
b) Post operative fever
-Inv:
– CBC
– Urinalysis
– CXR
– Culture and Sensitivity
- Mx:
– History
– Removal of foci if possible
– Emperical Antibiotics
– Definitive antibiotics as per C/S report
28. 6) Pulmonary Complications
a) Atelactesis
b) Pneumonia
c) Aspiration Pneumonitis
d) Pulmonary Edema, Acute Lung Injury and ARDS
29. 6) Pulmonary Complications
- Suspect as a differential diagnosis of dyspnoea
(atelactesis, lobar collapse, pneumonia, CHF, COPD, asthma
exacerbation, pneumothorax, PE and aspiration)
- Importance of history
-Inv: CXR
- Pulse oximetry
-ECG (Age > 30)
- CBC
- V/Q scan
30. 6) Pulmonary Complications
a) Atelactesis:
- Commonest cause of post operative fever (within 48 hrs)
- Post opeartive pain- the most important cause
- Low grade fever, malaise, NO OVERT RESP SYMPTOMS
- Decreased breath sounds in the lower lung fields
Mx: manage post op pain (analgesia)
- encourage to cough and take deep breaths
- counter presuure on abdominal insicion
- chest physiotherapy
31. 6) Pulmonary Complications
b) Pneumonia:
- Develops usually after 2 – 5 days post op.
- Health care related problem
- High grade fever
- Thick sputum
Mx: IV antibiotics
- Encourage to cough, take deep breaths, Chest physiotherepy
32. 6) Pulmonary Complications
c) Aspiration Pneumonitis
- Aspiration pneumonitis is described as an acute lung
injury that results from the inhalation of regurgitated
gastric contents
- Critically ill pts
- General anasthesia
- GERD
- Altered level of consciousness
- Old age pts
- Bowel obstruction
33. 6) Pulmonary Complications
c) Aspiration Pneumonitis
- Dyspnoea Post op
- Progressive Wheezing
- Infiltrate on CXR
- May be silent
Prevention:
- Reduce gastric contents
- Minimize regurgitation
-Ambulate the pt post op
-Less of sedation
34. 6) Pulmonary Complications
c) Aspiration Pneumonitis
Mx:
-Place the pt on Oxygen (face mask)
- Confirm diagnosis by CXR (diffuse interstitial infiltrates)
- Enquire about previous resp problems
- If SpO2 is not maintained and RR is increases then intubate the pt and do suctioning
- Give IV antibiotics directed against Gram negative organisms
35. 6) Pulmonary Complications
d) Pulmonary Edema, Acute Lung Injury and ARDS
- Pulmonary Odema: Collection of fluid in the alveoli
- ALI and ARDS
Acute onset of respiratory symptoms
• Chest radiograph with bilateral infiltrates
• Pulmonary artery wedge pressure (PAWP) of less than 18 mmHg
(indicating no evidence of left heart failure)
• ALI: PaO2/FIO2 ratio < 300 mmHg
• ARDS: PaO2/FIO2 ratio < 200 mmHg
37. 7) Renal Complications
a) Urinary Retention
- Inability to empty a filled bladder
Causes: After Spinal Procedures
- Perianal Surgeries
- Rectal surgeries
- Hernia repair surgeries
- BPH, Stricture being the other causes
Presentation: Dull aching pain in the hypogastrium
- Fullness on palpaption
38. 7) Renal Complications
a) Urinary Retention
Mx:
- Management of post op pain
- Judicious use of IV fluids
- Encourage the patient to pass urine
- Straight catherization followed by Foley's
- No pt should be allowed to go home without passing urine for more
than 7 hrs.
39. 7) Renal Complications
a) Acute Renal Failure
- Acute renal failure (ARF) is characterized by a sudden reduction in
renal output that results in the systemic accumulation of nitrogenous
wastes
-ARF (Diagnostic Criteria):
i> Increase in Serum Creatinine level
ii> Urine output <500ml/day (20ml/hr)
Causes:
- Pre renal
- Renal
- Post renal
41. 7) Renal Complications
a) Acute Renal Failure
Mx: Otherwise healthy patient: consider post renal cause
-Ascertain cause of ARF
- Maintain Input/Output and BP chart
- Prerenal: Hypovolemia or CHF (Imp to differentiate)
- Correct Hypotension and hypovolemia
- Treat the cause
- Stop nephrotoxic drugs
- Hyperkalemia and Fluid overload
- Haemodialysis
43. 8) Cardiovascular Complications
a) Myocardial Ischaemia and infarction
- Mostly silent presentation
- D/D of post operative chest pain, dyspnoea and hypotension
- Check BP,HR
- Auscultation- Heart and Lungs
-Inv: ECG
- Troponin-I
- CXR
- ECHO
-Mx: Nitrates, Beta blockers, Calcium antagonist, Anti platelet therepy
44. 8) Cardiovascular Complications
b) Congestive Heart failure
-D/D of dyspnoea, hypoxia in the post-operative period
- Excessive Iv fluids intraoperatively
- MI leading to CHF
Inv: Pulse oximetry
- ECG
- CXR
- ECHO
- Troponin I
Mx: Oxygen supplementation, Diuretics, ACE inhibitors, Nitrates,
Inotropics
45. 8) Cardiovascular Complications
b) Hypertension
- Should be determined by the pre-op BP
- Target is reduce the BP to within 10% of pre-op BP
Mx: Treat the possible underlying cause
- Antihypertensive drugs
47. 9) Neurological Complications
a) Peri-operative Stroke:
- Focal loss of neurological function
- Altered mental status
- Mostly cardiovuscular cause
- May be Ischaemic or Hypotensive
- Ischaemic due to overzealous control of Hypertension
or from cardio-emboli (atrial fibrillation)
or from bacterial endocarditis
- Haemorrhagic due to thrombophilila or anticoagulant therepy
Mx: General supportive measures, Aspirin, Thrombolysis, correction of
hypotension.
48. 9) Neurological Complications
b) Seizures
- Mostly due to metabolic derangements, electrolyte abnormalities
- Take history
- Airway, oxygenation and hemodynamics
- Sequele of seizures
- Serum levels of anticonvulsant
- No cause identified: Go for CT
Mx: Treat the underlying cause
- Anticonvulsants
49. 9) Neurological Complications
c)Delirium
- Commonly elderly: stress of surgery
- Underlying cause: mostly medication or infection
Presentation: Impaired memory
-altered perception
- paranoia
- sundowning
- Disorientation and comabitiveness
51. 9) Neurological Complications
c)Delirium
Mx:
- Begins with eliminating the possible causes
- Monitor vitals
- Rule out infection
- CBC, Electrolytes,ECG, ABG, Urinalysis, CXR
- Transfer pt to naturally lighted room
- History of alcohol intake to be elicited
-Remove the medication
- Haloperidol can be prescribed
52. 10) Complication of Diabetes
Diabetic Keto Acidosis
- Medical Emergency
- Lab Inv: Blood glucose
-CBC
- S. Electrolytes
- S. Osmolarity
- ABG
53. 10) Complication of Diabetes
Diabetic Keto Acidosis
- Medical Emergency
- Lab Inv: Blood glucose
-CBC
- S. Electrolytes
- S. Osmolarity
- ABG
Mx: Fluid resuscitation
Insulin infusion with Dextrose (Blood Glucose <250mg%)