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Fwd: Post op complications

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From: UCD Graduate '09 None <;
Date: 2009/2/25
Subject: Post op complications

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Fwd: Post op complications

  1. 1. Postoperative Care and Management of Complications
  2. 2. Outline of Talk <ul><li>Common presentations of postoperative complications </li></ul><ul><ul><li>postoperative fever </li></ul></ul><ul><ul><li>wound problems </li></ul></ul><ul><ul><li>hypotension </li></ul></ul><ul><ul><li>low urinary output </li></ul></ul><ul><ul><li>obstruction </li></ul></ul><ul><ul><li>confusion </li></ul></ul><ul><li>Prevention and management </li></ul>
  3. 3. Fail to prepare Prepare to fail Keane R. Siapan 2002
  4. 4. Postoperative Complications <ul><li>General health of the patient </li></ul><ul><li>Preoperative care </li></ul><ul><li>Magnitude of the operation </li></ul><ul><li>Quality of postoperative care </li></ul>
  5. 5. Postoperative Complications <ul><li>Pre-op: </li></ul><ul><ul><li>Optimise the patients condition </li></ul></ul><ul><ul><li>Give prophylaxis </li></ul></ul><ul><ul><li>Select from of anaesthesia </li></ul></ul><ul><li>Intra-op : </li></ul><ul><ul><li>Attention to detail </li></ul></ul><ul><li>Post-op : </li></ul><ul><ul><li>Monitor to detect </li></ul></ul>
  6. 6. Postoperative fever <ul><li>Common problem </li></ul><ul><li>Physical exam is important in evaluating postoperative fever </li></ul><ul><li>Timing of fever </li></ul>
  7. 7. Early postoperative fever <ul><li>Respiratory </li></ul><ul><ul><li>atelectasis </li></ul></ul><ul><li>Systemic response to trauma of surgery </li></ul>
  8. 8. Postoperative fever (1-3 days) <ul><li>Urinary tract infection </li></ul><ul><li>IV sites </li></ul><ul><ul><li>Phlebitis </li></ul></ul><ul><ul><li>Infection </li></ul></ul>
  9. 9. Postoperative fever (after 5 days) <ul><li>Wound infection </li></ul><ul><li>Respiratory tract infection </li></ul><ul><li>Abscess </li></ul><ul><ul><li>Wound </li></ul></ul><ul><ul><li>Intra-abdominal </li></ul></ul><ul><li>Urinary tract infection </li></ul>
  10. 10. Postoperative fever <ul><li>Transfusion reaction </li></ul><ul><li>Hematoma </li></ul><ul><li>Deep venous thrombosis </li></ul><ul><li>Pulmonary embolus </li></ul><ul><li>Thyroid storm </li></ul><ul><li>Malignant hyperthermia </li></ul>
  11. 11. Wound complications <ul><li>Type of operation </li></ul><ul><ul><li>Clean </li></ul></ul><ul><ul><li>Clean contaminated </li></ul></ul><ul><ul><li>Contaminated </li></ul></ul><ul><ul><li>Infected </li></ul></ul><ul><li>Emergent versus elective </li></ul><ul><li>Patients general health </li></ul>
  12. 12. Specific wound complications <ul><li>Hematomas and seromas </li></ul><ul><li>Infections </li></ul><ul><li>Dehiscence </li></ul><ul><ul><li>partial </li></ul></ul><ul><ul><li>complete </li></ul></ul>
  13. 13. Hematomas and Seromas <ul><li>Inadequate hemostasis </li></ul><ul><li>Anticoagualants </li></ul><ul><li>Intraoperative anticoagulation </li></ul><ul><li>Lack of obliteration of dead space </li></ul>
  14. 14. Wound infections <ul><li>Measure of ‘good house keeping’ in clean wound </li></ul><ul><li>Erythema to pus collection </li></ul><ul><li>Primary or secondary </li></ul>
  15. 15. Wound dehiscence <ul><li>Type </li></ul><ul><ul><li>Partial </li></ul></ul><ul><ul><li>Complete </li></ul></ul><ul><li>Timing </li></ul><ul><ul><li>Early </li></ul></ul><ul><ul><li>Late </li></ul></ul>
  16. 16. Patient Factors Wound Dehiscence <ul><li>Malnutrition </li></ul><ul><li>Sepsis </li></ul><ul><li>Anemia </li></ul><ul><li>Steroid therapy </li></ul><ul><li>Uremia </li></ul><ul><li>Diabetes </li></ul><ul><li>Liver failure </li></ul>
  17. 17. Other Factors <ul><li>Surgical technique </li></ul><ul><li>Wound infection </li></ul><ul><li>Postoperative distension </li></ul><ul><li>Site of the incision </li></ul>
  18. 18. Wound failure <ul><li>Incisional hernia </li></ul>
  19. 19. Respiratory complications <ul><li>Atelectasis </li></ul><ul><li>Pneumonia </li></ul><ul><li>Aspiration </li></ul><ul><li>Pulmonary edema </li></ul><ul><li>Acute respiratory depression </li></ul><ul><li>Acute respiratory failure </li></ul>
  20. 25. Shock <ul><li>Acute circulatory failure - inability of the cardiovascular system to maintain adequate tissue perfusion </li></ul><ul><li>There are three types </li></ul><ul><ul><li>hypovolemic </li></ul></ul><ul><ul><li>cardiogenic </li></ul></ul><ul><ul><li>septic </li></ul></ul>
  21. 26. Hypovolemic <ul><li>Inadequate fluid replacement </li></ul><ul><li>Postoperative bleeding </li></ul><ul><li>Loss of approximately 40 percent may cause irreversible damage </li></ul>
  22. 27. Cardiogenic <ul><li>Myocardial ischemia with ventricular dysfunction (decreased cardiac output) </li></ul><ul><li>Excessive fluid resuscitation during </li></ul><ul><li>Accurate diagnosis is important because treatment is different </li></ul><ul><li>Increased CVP implies cardiac failure with fluid overload </li></ul>
  23. 28. Septic <ul><li>Increased bacterial counts in the blood causes rigors and fever </li></ul><ul><li>May be due to surgical complications (anastomotic leak) </li></ul><ul><li>Causes loss vasomotor tone, increased capillary permeability and myocardial depression </li></ul>
  24. 29. Renal dysfunction <ul><li>Postoperative reduction of urine output to < 0.5 ml / kg / hr </li></ul><ul><li>Early postoperative fluid and sodium retention </li></ul>
  25. 30. Prerenal <ul><li>Implies decreased renal blood flow which is usually due to: </li></ul><ul><ul><li>decreased blood volume </li></ul></ul><ul><ul><li>decreased cardiac output </li></ul></ul><ul><ul><li>medications </li></ul></ul>
  26. 31. Renal <ul><li>Usually occurs with prolonged or uncorrected pre-renal failure (acute tubular necrosis) </li></ul><ul><li>Can also be caused by: </li></ul><ul><ul><li>aminoglycosides </li></ul></ul><ul><ul><li>intravenous contrast dye </li></ul></ul><ul><ul><li>blood transfusions </li></ul></ul><ul><ul><li>NSAI’s </li></ul></ul>
  27. 32. Post renal <ul><li>Usually occurs after the urinary tract has been obstructed </li></ul><ul><li>Can be caused by: </li></ul><ul><ul><li>enlarged prostate </li></ul></ul><ul><ul><li>ligation of the ureter during surgery </li></ul></ul><ul><ul><li>Foley catheter blockage </li></ul></ul>
  28. 33. Alimentary tract dysfunction <ul><li>Ileus </li></ul><ul><li>Anorexia </li></ul><ul><li>Nausea and vomiting </li></ul><ul><li>Postoperative bowel obstruction </li></ul>
  29. 34. Paralytic ileus <ul><li>Intra-abdominal inflammation </li></ul><ul><li>Drugs </li></ul>
  30. 35. Paralytic ileus <ul><li>X-ray findings </li></ul>
  31. 38. Postoperative bowel obstruction <ul><li>Early obstruction </li></ul><ul><ul><li>Paralytic ileus </li></ul></ul><ul><ul><li>mechanical obstruction </li></ul></ul><ul><li>Bowel obstruction should be considered in patients if the bowel function does not return to normal after about four days </li></ul>
  32. 39. Postoperative bowel obstruction <ul><li>Commonly caused by postoperative adhesions </li></ul><ul><li>Patients usually exhibit normal bowel function for a short while then shows signs of obstruction </li></ul><ul><li>Diagnosis </li></ul><ul><ul><li>abdominal x-rays </li></ul></ul><ul><ul><li>CT scanning </li></ul></ul>
  33. 41. Deep venous thrombosis <ul><li>Is important cause of morbidity in the surgical patient </li></ul><ul><li>Can lead to pulmonary embolism </li></ul><ul><li>Its prevalence is up to 40 percent </li></ul><ul><li>It can occur in the calf, femoral and iliac veins </li></ul>
  34. 42. Deep venous thrombosis <ul><li>Assessing risk </li></ul><ul><li>Prevention </li></ul><ul><ul><li>Mechanical </li></ul></ul><ul><ul><li>Pharmacological </li></ul></ul>
  35. 43. Predisposing factors for DVT <ul><li>Smoking </li></ul><ul><li>Type of surgery </li></ul><ul><li>Obesity </li></ul><ul><li>Venous stasis </li></ul><ul><li>Cancer </li></ul><ul><li>Hypercoaguable states </li></ul><ul><li>Inactivity after surgery </li></ul><ul><li>Oral contraceptive use </li></ul>
  36. 44. Clinical features of DVT <ul><li>Calf tenderness and swelling </li></ul><ul><li>Positive Homan’s sign </li></ul><ul><li>Fever </li></ul>
  37. 45. Diagnosis of DVT <ul><li>History and physical examination </li></ul><ul><li>D-dimers </li></ul><ul><li>Ultrasound </li></ul>
  38. 46. Treatment of DVT <ul><li>Anticoagulation </li></ul><ul><li>Bed rest early </li></ul>
  39. 47. Pulmoary embolism <ul><li>A very serious complication of DVT </li></ul><ul><li>10% die within the first hour </li></ul><ul><li>90% live longer than one hour-of these patients 70 percent go undiagnosed and of these 30 % die </li></ul>
  40. 48. Diagnosis of PE <ul><li>Clinical </li></ul><ul><ul><li>dyspnea </li></ul></ul><ul><ul><li>chest pain </li></ul></ul><ul><ul><li>Hypotension </li></ul></ul><ul><li>D-dimers </li></ul><ul><li>Imaging </li></ul><ul><ul><li>CT </li></ul></ul><ul><ul><li>Ventilation perfusion scan </li></ul></ul>
  41. 50. Treatment of PE <ul><li>Medical management </li></ul><ul><ul><li>supportive care </li></ul></ul><ul><ul><li>anticogualtion </li></ul></ul><ul><ul><li>thrombolysis </li></ul></ul><ul><li>Surgical management </li></ul>
  42. 51. Mental status <ul><li>Mental changes can include somnolence, coma, confusion, disorientation, agitation and convulsions </li></ul><ul><li>Elderly </li></ul><ul><li>This could be due to hypoxia, low blood sugar, uremia, ammonia or anesthetic agents </li></ul><ul><li>Failure to awaken issue usually due to anesthesia </li></ul>
  43. 52. Mental status <ul><li>Consider postoperative stroke in patients with carotid bruits </li></ul><ul><li>If the patient is a heavy drinker considered delirium tremens </li></ul><ul><li>Disorientation at night </li></ul>
  44. 53. Other considerations <ul><li>Each surgical procedure has its own set of inherent complications </li></ul><ul><li>Surgeon treating the patient usually has the best idea as to what is happening </li></ul>