Fwd: Post op complications

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From: UCD Graduate '09 None <ucdgrad09@gmail.com&gt;
Date: 2009/2/25
Subject: Post op complications
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  • 1. Postoperative Care and Management of Complications
  • 2. Outline of Talk
    • Common presentations of postoperative complications
      • postoperative fever
      • wound problems
      • hypotension
      • low urinary output
      • obstruction
      • confusion
    • Prevention and management
  • 3. Fail to prepare Prepare to fail Keane R. Siapan 2002
  • 4. Postoperative Complications
    • General health of the patient
    • Preoperative care
    • Magnitude of the operation
    • Quality of postoperative care
  • 5. Postoperative Complications
    • Pre-op:
      • Optimise the patients condition
      • Give prophylaxis
      • Select from of anaesthesia
    • Intra-op :
      • Attention to detail
    • Post-op :
      • Monitor to detect
  • 6. Postoperative fever
    • Common problem
    • Physical exam is important in evaluating postoperative fever
    • Timing of fever
  • 7. Early postoperative fever
    • Respiratory
      • atelectasis
    • Systemic response to trauma of surgery
  • 8. Postoperative fever (1-3 days)
    • Urinary tract infection
    • IV sites
      • Phlebitis
      • Infection
  • 9. Postoperative fever (after 5 days)
    • Wound infection
    • Respiratory tract infection
    • Abscess
      • Wound
      • Intra-abdominal
    • Urinary tract infection
  • 10. Postoperative fever
    • Transfusion reaction
    • Hematoma
    • Deep venous thrombosis
    • Pulmonary embolus
    • Thyroid storm
    • Malignant hyperthermia
  • 11. Wound complications
    • Type of operation
      • Clean
      • Clean contaminated
      • Contaminated
      • Infected
    • Emergent versus elective
    • Patients general health
  • 12. Specific wound complications
    • Hematomas and seromas
    • Infections
    • Dehiscence
      • partial
      • complete
  • 13. Hematomas and Seromas
    • Inadequate hemostasis
    • Anticoagualants
    • Intraoperative anticoagulation
    • Lack of obliteration of dead space
  • 14. Wound infections
    • Measure of ‘good house keeping’ in clean wound
    • Erythema to pus collection
    • Primary or secondary
  • 15. Wound dehiscence
    • Type
      • Partial
      • Complete
    • Timing
      • Early
      • Late
  • 16. Patient Factors Wound Dehiscence
    • Malnutrition
    • Sepsis
    • Anemia
    • Steroid therapy
    • Uremia
    • Diabetes
    • Liver failure
  • 17. Other Factors
    • Surgical technique
    • Wound infection
    • Postoperative distension
    • Site of the incision
  • 18. Wound failure
    • Incisional hernia
  • 19. Respiratory complications
    • Atelectasis
    • Pneumonia
    • Aspiration
    • Pulmonary edema
    • Acute respiratory depression
    • Acute respiratory failure
  • 20.  
  • 21.  
  • 22.  
  • 23.  
  • 24.  
  • 25. Shock
    • Acute circulatory failure - inability of the cardiovascular system to maintain adequate tissue perfusion
    • There are three types
      • hypovolemic
      • cardiogenic
      • septic
  • 26. Hypovolemic
    • Inadequate fluid replacement
    • Postoperative bleeding
    • Loss of approximately 40 percent may cause irreversible damage
  • 27. Cardiogenic
    • Myocardial ischemia with ventricular dysfunction (decreased cardiac output)
    • Excessive fluid resuscitation during
    • Accurate diagnosis is important because treatment is different
    • Increased CVP implies cardiac failure with fluid overload
  • 28. Septic
    • Increased bacterial counts in the blood causes rigors and fever
    • May be due to surgical complications (anastomotic leak)
    • Causes loss vasomotor tone, increased capillary permeability and myocardial depression
  • 29. Renal dysfunction
    • Postoperative reduction of urine output to < 0.5 ml / kg / hr
    • Early postoperative fluid and sodium retention
  • 30. Prerenal
    • Implies decreased renal blood flow which is usually due to:
      • decreased blood volume
      • decreased cardiac output
      • medications
  • 31. Renal
    • Usually occurs with prolonged or uncorrected pre-renal failure (acute tubular necrosis)
    • Can also be caused by:
      • aminoglycosides
      • intravenous contrast dye
      • blood transfusions
      • NSAI’s
  • 32. Post renal
    • Usually occurs after the urinary tract has been obstructed
    • Can be caused by:
      • enlarged prostate
      • ligation of the ureter during surgery
      • Foley catheter blockage
  • 33. Alimentary tract dysfunction
    • Ileus
    • Anorexia
    • Nausea and vomiting
    • Postoperative bowel obstruction
  • 34. Paralytic ileus
    • Intra-abdominal inflammation
    • Drugs
  • 35. Paralytic ileus
    • X-ray findings
  • 36.  
  • 37.  
  • 38. Postoperative bowel obstruction
    • Early obstruction
      • Paralytic ileus
      • mechanical obstruction
    • Bowel obstruction should be considered in patients if the bowel function does not return to normal after about four days
  • 39. Postoperative bowel obstruction
    • Commonly caused by postoperative adhesions
    • Patients usually exhibit normal bowel function for a short while then shows signs of obstruction
    • Diagnosis
      • abdominal x-rays
      • CT scanning
  • 40.  
  • 41. Deep venous thrombosis
    • Is important cause of morbidity in the surgical patient
    • Can lead to pulmonary embolism
    • Its prevalence is up to 40 percent
    • It can occur in the calf, femoral and iliac veins
  • 42. Deep venous thrombosis
    • Assessing risk
    • Prevention
      • Mechanical
      • Pharmacological
  • 43. Predisposing factors for DVT
    • Smoking
    • Type of surgery
    • Obesity
    • Venous stasis
    • Cancer
    • Hypercoaguable states
    • Inactivity after surgery
    • Oral contraceptive use
  • 44. Clinical features of DVT
    • Calf tenderness and swelling
    • Positive Homan’s sign
    • Fever
  • 45. Diagnosis of DVT
    • History and physical examination
    • D-dimers
    • Ultrasound
  • 46. Treatment of DVT
    • Anticoagulation
    • Bed rest early
  • 47. Pulmoary embolism
    • A very serious complication of DVT
    • 10% die within the first hour
    • 90% live longer than one hour-of these patients 70 percent go undiagnosed and of these 30 % die
  • 48. Diagnosis of PE
    • Clinical
      • dyspnea
      • chest pain
      • Hypotension
    • D-dimers
    • Imaging
      • CT
      • Ventilation perfusion scan
  • 49.  
  • 50. Treatment of PE
    • Medical management
      • supportive care
      • anticogualtion
      • thrombolysis
    • Surgical management
  • 51. Mental status
    • Mental changes can include somnolence, coma, confusion, disorientation, agitation and convulsions
    • Elderly
    • This could be due to hypoxia, low blood sugar, uremia, ammonia or anesthetic agents
    • Failure to awaken issue usually due to anesthesia
  • 52. Mental status
    • Consider postoperative stroke in patients with carotid bruits
    • If the patient is a heavy drinker considered delirium tremens
    • Disorientation at night
  • 53. Other considerations
    • Each surgical procedure has its own set of inherent complications
    • Surgeon treating the patient usually has the best idea as to what is happening
  • 54.