POSTOPERATIVE SURGICAL COMPLICATIONS, Classification systems of surgical complications

1. By
Hassaan A. Gad
Assistant Lecturer of urology
Aswan University , Egypt
hassaan.ali@aswu.edu.eg
POSTOPRATIVE SURGICAL
COMPLICATIONS

2. Classification systems of surgical
complications
 Clavien-Dindo grading system.
 MSKCC = Memorial Sloan-Kettering Cancer
Centre classification - modification of the
original T92 Clavien classification
 NSQIP = National Surgical Quality
Improvement Programme
 NCT-CTC = National Cancer Institute
Common Toxicity Criteria
 Accordion :contracted/extended
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3. Clavien-Dindo grading system
 Grade I Any deviation from the normal postoperative course
without the need for pharmacological treatment or surgical,
endoscopic, and radiological interventions.
 Grade II Requiring pharmacological treatment with drug other
than such allowed for Grade I complications.
 Grade III Requiring surgical, endoscopic or radiological
intervention.
Grade IIIa Intervention not under general anaesthesia.
Grade IIIb Intervention under general anaesthesia.
 Grade IV Life-threatening complication.
Grade IVa Single organ dysfunction.
Grade IVb Multi organ dysfunction.
 Grade V Death of a patient.
 Suffix “d” If the patient suffers from a complication at the time of
discharge .
hassaan.ali@aswu.edu.eg

4. Classification
 Wound
 Thermal regulation
 Postoperative fever
 Pulmonary
 Cardiac
 Gastrointestinal
 Metabolic
 Neurological
Immediate/Early/Late
Systemic:
 Neurological
 Respiratory
 Cardiovascular
 Gastrointestinal
 Urological
 Endocrine
 Haematological
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5. POSTOPERATIVE FEVER
hassaan.ali@aswu.edu.eg

6. TYPES OF POSTOPERATIVE
FEVER
 INTERMITTENT
 Intermittent elevation of temp with regular return to
normal temp (infection within closed space-
abscess)
 REMITTENT/FLUCTUATING
Continuous type of fever drop in fever without
returning to normal
-brucellosis, blood stream infections, infected
arterial grafts, phlebitis.
 UNREMITTING/CONTINUOUS
Continuous high fever-CNS injury, pneumonias,
typhoid.hassaan.ali@aswu.edu.eg

7. CAUSES OF POST-OP FEVER
THE 5 ‘W’ OF POST-OP FEVER
 1.Wind Atelectasis, pneumonia

 2.Water UTI
 3.Wound Wound/Surgical site infection,
Abscess, Anastomotic leak, Lines (IVC, CVC,
drains, )
 4.Walking DVT / PE
 5.Wonder drugs
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8. FIRST DAY FEVER (24 – 48
HRS.)
 ATELACTASIS
 PNEUMONITIS
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9. ATELACTASIS
Anesthesia agents cause increase production
of secretions, as water evaporates, they
become viscous. with diminished cough reflex
& decrease ciliary activity - formation of
mucus plug- obstruct small airways.
When the gases distal to plug get absorbed
the airways collapse.
Febrile response is due to Low grade infection
distal to obstructing plug and absorption of
bacterial pyrogens
Temp elevation within 12 hrs of onset of plug
formation.max temp is characteristically 38.9
degree centigradehassaan.ali@aswu.edu.eg

10. PNEUMONITIS
High risk group - Cigarette smoking, chronic
bronchitis, COPD
Prevention:
 Assessment of patient,
 Avoid General Anaesthesia,
 Stop smoking,
 Spirometery ,
 Assess pulmonary mechanics,
 Chest physiotherapy,
 Early mobilization
hassaan.ali@aswu.edu.eg

11. THIRD DAYS URGICAL FEVER 48-
72HRS
CAUSES
Temp elevation to 40.6-41. 1°C
 PHLEBITIS
 IV catheter sepsis
 DVT and Pulmonary embolism
 Suppurative thrombophlebitis
hassaan.ali@aswu.edu.eg

12. PHLEBITIS
 Tachycardia, Hypotension, Oliguria,, Leukocytosis,
 septic shock develop 52%.
 Mortality rate 40% in above age 40yrs, and 80% in
above age 80yrs.
 Tenderness and erythema around catheter.
 Precipitating causes:
 Hyperosmolar infusate,
 Antibiotics ,
 size of vein in which catheter.
 This can be decreased by adding one unit of heparin.
 IV septic technique
 Cathater sepsis reduced from 23% to 4% if IV
catheter placed for max 12 hrs.
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13. IV catheter sepsis
 Lack of aseptic technique
 Use of hypertonic solutions
 Multiple infusions through same line
 Change of site after 72 hrs.
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14. Third and Fourth DAY fever
DVT
 PUL. EMBOLISM
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15. DVT
Diagnosis
 3 -4 days Temp elevation, calf Tenderness
(Homan’s sign)
 Doppler ultrasound, has replaces contrast
venograms
Treatment is PREVENTION
 Identify High risk group from pre-op stage.
 Start prophylactic heparin sub cut peri-operative
 Mechanical means
hassaan.ali@aswu.edu.eg

16. PULMONARY EMBOLISM
Sequelae of DVT
Fever does not appear until pul thrombo
embolisation-pain chest, dyspnoea,
Treatment is prevention
Therapeutic dose of heparin
need hdu
hassaan.ali@aswu.edu.eg

17. SUPPURATIVE THROMBO
PHLEBITIS
 Presence of suppurative infection in vein is often
lethal-need ligation of vein
 high fever , remittent type
 common sites are; basilic,cephalic, neck veins
 occasionally seen in pelvic veins after septic
abortion,
hassaan.ali@aswu.edu.eg

18. URINARY TRACT INFECTIONS
 Most common nosocomial infection (40%)
 75% patients have some form of urine tract
manipulation
 Bacteria found in urine in 1-5% of patients
undergoing short term catheterization, 90% pts in
whom Foley is left for 48hrs or more
 Post op UTI; temp 39.4-40°C, rigors/chills
Management –
 prevention, Catheter insertion only when must,
 Aseptic technique , closed drainage system.
 Discard drainage system if accidentally
disconnected and change when obstruction or
contamination occurs.hassaan.ali@aswu.edu.eg

19. DAY 5-8 FEVER Surgical wound
infection
Wound infection‘ present as abscess-cellulites
 Signs of erythema, foul discharge, indurations,
soakage
Treatment is adequate drainage &/antibiotic
coverage
 Factors responsible-patient related , disease
related, procedure related, environment related.
 Lack of preventive measures.
hassaan.ali@aswu.edu.eg

20. BENIGN POST OPERATIVE
FEVER
 During Operation Thermo regulatory mechanism
Hypothalamus becomes inhibited by Anesthetic
agents –fall in body temp,
 Once anesthesia effect is gone- recovery of this
mechanism but intracranial core temp still decreased-
thermosenstive receptors in hypothalamus sense
decreased temp and attempt to raise body temp to
hypothalic set point, often there is over compensation
with a mild febrile episode in post op period
 This is diagnosed by exclusion
hassaan.ali@aswu.edu.eg

21. OTHER CAUSES
HYPER METABOLISM -increased BMR in
response to surgery –burn pt, returns to normal
with wound healing
DRUG induced fever
DEHYDRATION-decreased sensitivity to
sweating mechanism
MALIGNANT HYPERTHERMIA
THYROID STORM
FEVER OF CNS ORIGIN
hassaan.ali@aswu.edu.eg

22. DRUGS THAT CAUSE FEVER
due to effects of pharmacological activity;
Antibiotics, Cytotoxic agents
Drugs causing fever due altered
thermoregulation
 Atropine, Catacholamines, (Decrease sweating)
 Increased BMR- thyroxine derivatives
Drugs causing fever due to contaminants;
IV solutions
Drugs causing fever due to hypersensitivity-
sulphas, penicillins,
hassaan.ali@aswu.edu.eg

23. Malignant hyperthermia
 Autosomal dominant, rare
 Presentation: fever, tachycardia, rigidity,
cyanosis
 Treatment: Dantrolene 1 to 2 mg/kg 10 mg/kg
total until symptoms subside
hassaan.ali@aswu.edu.eg