complication of surgery and trauma and their intervention

1. COMPLICATIONS OF SURGERY
AND TRAUMA AND THEIR
PREVENTION
Supervised by : DR.MOSTAFA AHMED
LECTURER AT FACULTY OF PHYSICAL THERAPY

2. Introduction
Any operation, major trauma or other surgical admission may be attended by a
variety of complications. These not only cause additional pain and suffering to the
patient but may put the patient's life at risk.
◦ A large proportion of complications can be prevented or minimized by
appropriate prophylactic measures, careful attention to detail and by early
recognition and treatment of problems as they develop. Early diagnosis and
treatment are essential, as delay often leads to catastrophic, snowballing' multi-
organ failure. Once three or more body systems become involved, mortality is
extremely high, e.g. ARDS and renal failure, complicating an operation for
obstructive jaundice.

3. ◦ In respect of operative surgery, complications can be divided into the
general complications of any operation and the specific complications
of individual operations. Both groups of complications can be
subdivided into immediate (during operation or within the next 24
hours), early postoperative (during the first postoperative week or so),
late postoperative (up to 30 days after operation) and long-term.

4. The complications of surgery can be
divided into five broad categories.
◦ Principal categories of surgical complications:
◦ 1. Complications predisposed to by intercurrent 'medical" disorders,
whether symptomatic or occult, e.g. ischemic heart disease, chronic
respiratory disease or diabetes mellitus.
◦ 2. Complications of anesthesia.
◦ 3. General complications of operations, e.g. hemorrhage or wound
infection.
◦ 4. Complications of any surgical condition, e.g. pulmonary embolus,
chest or urinary tract infection.

5. Complications of
specific disorders
and operations:

6. Complications of anesthesia:
1. Local anesthesia:
◦ Injection site pain, hematoma, delayed recovery of sensation (direct
nerve trauma), infection ,ischemic necrosis (if used in digits or penis).
◦ Systemic effects of local anesthetic agent:
◦ Idiosyncratic or allergic reactions (very rare).
◦ Toxicity due to either excess dosage, or inadvertent intravenous
injection. Toxic effects include: dizziness, tinnitus, nausea and
vomiting, fits, CNS depression, bradycardia and asystole.
◦

7. 2. Spinal, epidural and caudal anesthesia:
* Failure of anesthetic - anatomical difficulties or technical failure.
* Headache - loss of CSF or minor intrathecal hemorrhage.
*Intrathecal bleeding (especially if the patient is on anticoagulants).
*Unintentionally wide field of anesthesia:
-In epidural anesthesia, injection of local anesthetic into the wrong
tissue plane may give a spinal anesthetic.
- In spinal anesthesia, if the anesthetic agent flows too far
proximally, respiratory paralysis may occur.

8. * Permanent nerve or spinal cord damage
injection of incorrect drug.
* Paraspinal infection - introduced by the
needle.
* Systemic complications hypotension.
severe hypotension or postural

9. 3. General anesthesia:
* Direct trauma to, mouth or pharynx, e.g.
teeth, artificial crowns and bridges.
* Inherited disorders:
-Malignant hyperpyrexia (any potent
inhalational anesthetic may be
responsible).
-Pseudocholinesterase deficiency
(prolonged apnea after succinylcholine).
* Idiosyncratic or allergic reactions to
anesthetic agents:

10. Minor effects, e.g. postoperative nausea and vomiting.
-Major effects: e.g. cardiovascular collapse, respiratory depression, halothane
jaundice.
* Slow recovery from anesthetic:
-Drug interactions.
-Inappropriate choice of drugs or dosage in relation to age or the requirements of
day-case surgery.
-Inadequate reversal.
*Awareness during anesthetic effective paralysis but ineffective anesthesia (very
expensive medicolegally).
*Disorders of fluid balance inadequate or excessive replacement of fluids.

11. ◦ *Hypothermia:
◦ -Long operations with extensive fluid loss.
◦ -Large volume transfusion of cold blood. (Note: neonates and small infants are
especially vulnerable to hypothermia)
◦ *Inadvertent trauma:
◦ -Initiation of pressure sores.
◦ -Pressure injury to nerves (especially ulnar and lateral popliteal).
◦ -Diathermy-pad bums.
◦ -Corneal abrasions.

12. ◦GENERAL COMPLICATIONS OF OPERATIONS
◦The main complications of any operation are
hemorrhage, infection, delayed wound healing, surgical
damage to related structures and inadvertent trauma to
the patient in theatre.

13. HAEMORRHAGE

14. ◦Perioperative Hemorrhage:
◦Hemorrhage occurring during an operation (primary
hemorrhage) should be controlled by the surgeon before the
operation is completed.

15. Early Postoperative Hemorrhage:
◦Hemorrhage during the immediate postoperative period
usually indicates inadequate operative hemostasis or a
technical mishap such as a slipped ligature or unrecognized
trauma to a blood vessel. After major blood loss requiring
large volume transfusion of stored blood.

16. Later Postoperative Hemorrhage
◦ Hemorrhage occurring several days after operation is usually related
to infection which erodes vessels at operation site; this is known as
secondary hemorrhage. Treatment involves managing the infection,
but exploratory operation is often required to legate bleeding vessels.

17. INFECTION RELATED TO THE
OPERATION SITE:
`
◦ Minor Wound Infections:
◦ The most common operative infection is a superficial wound infection occurring
within the first postoperative week. This relatively trivial infection presents as
localized pain, redness and a slight discharge. The organisms are usually
staphylococci or streptococci derived from the skin. The infection usually settles
without treatment. The exception is the patient in whom a prosthesis has been
inserted, such as an arterial graft or artificial
◦ joint. For these patients, antibiotics must be given to prevent the devastating
consequences of infection around the prosthesis.

18. Wound Cellulitis and Abscess:
◦More severe wound infections occur most commonly after
bowel-related surgery, when faecal organisms are usually
incriminated. The majority present in the first postoperative
week but they may occur as late as the third postoperative
week, often after the patient has left hospital. These
infections commonly present first with a pyrexia;
examination of the wound reveals either a spreading cellulitis
or localized abscess formation. Cellulitis is treated with
appropriate antibiotics.

19. ◦LATE INFECTIVE COMPLICATIONS:
◦A late infective complication of surgery is a chronically
discharging wound sinus which emanates from a deep
chronic abscess. It usually relates to foreign material such as
a non- absorbable suture or mesh or sometimes necrotic
fascia or tendon. These sinuses commonly follow wound
infections where healing is delayed and incomplete.

20. IMPAIRED HEALING
◦ Factors Retarding Wound Healing:
◦Wound healing in general is retarded if blood supply is poor
(as in arterial insufficiency) or if the wound is under excess
suture tension. Other Factors which may retard wound
healing are long-term steroid therapy, immunosuppressive
therapy, previous radiotherapy, severe rheumatoid disease,
malnutrition and vitamin deficiency, especially of vitamin C.

21. Incisional Hernia:
◦ Incisional hernia is a late complication of abdominal surgery. These
hernias usually become apparent within the first postoperative year
but sometimes develop as long as 5 years later, the overall incidence is
about 10-15% of abdominal wounds. The hernia is caused by
breakdown of the repair to abdominal wall muscle and fascia.
Predisposing factors are abdominal obesity, distension and poor
muscle quality, poor choice of incision, inadequate closure technique,
post-operative wound infection and multiple operations through the
same incision.

22. ◦ An incisional hernia usually presents as a bulge in the
abdominal wall near previous wound. The condition is
usually asymptomatic but occasionally a narrow-necked
hernia presents with pain or strangulation. Once an incisional
hernia has appeared, it tends to enlarge progressively and
may become a nuisance cosmetically or for dressing. Repair is
indicated for strangulation, pain or inconvenience.

23. SURGICAL INJURY:
◦Unavoidable Tissue Damage:
◦Anatomical structures, particularly nerves, blood vessels and
lymphatics, may be unavoidably damaged during operation. This
is particularly true in cancer surgery, illustrated by facial nerve
damage during total parotidectomy.
◦Inadvertent Tissue Damage:
◦Structures may be inadvertently damaged during operation.
Examples include recurrent laryngeal nerve damage during
thyroidectomy and trauma.

24. INADVERTENT OPERATING THEATRE
TRAUMA:
◦Apart from surgical trauma, patients are at risk of
injury when being, transported in the operating theatre
and during anesthesia. Special precautions are taken by
all who work in operating theaters to minimize these
risks.

25. Surgery and Trauma and their Prevention:
The most common complications caused by trauma in the operating theatre are:
*Injuries resulting from falls from trolleys or operating table during, positioning.
*Injury to diseased bones and joints from manipulation or positioning. These include
dislocation of a rheumatoid Atlanta-axial joint and dislocation of a prosthetic hip joint.
*Ulnar and lateral popliteal nerve palsies.
*Electrical bums from wet or poorly contacting diathermy pads.
*Excess pressure on the calf causing deep venous thrombosis.
*Excess heel pressure causing pressure sores. Cardiac pacemaker disruption by diathermy
equipment.

26. COMPLICATIONS OF ANY SURGICAL
CONDITION
◦ RESPIRATORY COMPLICATIONS:
◦ Up to 15% of patients suffer from respiratory complications associated with
general anesthesia and major operations. The most common of these are
atelectasis, pneumonia, aspiration pneumonitis and aspiration pneumonia. Pre-
existing lung disease greatly increases the risk of complications. Severely ill
patients including those with acute pancreatitis, and bums or trauma victims are
susceptible to the development of adult respiratory distress syndrome.

27. Effects of Anesthesia and Surgery on
Respiratory Function:
Anesthesia and surgery predispose to post-operative complications by altering lung
function and compromising normal defense mechanisms as follows:
-Lung tidal volume may be reduced by as much as 50%, depending on the incision site.
Thoracic, upper abdominal and lower abdominal incisions (in decreasing order of effect)
particularly reduce lung volume.
-Lung expansion is reduced by the supine posture during and after operation, pain,
abdominal distension, abdominal constriction by bandages and the effects of sedative
drugs.
-Ventilation rate usually increases and there is loss of normal periodic hyperinflation.
-Diminished ventilation and pulmonary perfusion result in reduced gaseous exchange.
-Airway defences are compromised by loss of the cough reflex and diminished ciliary
activity, which both lead to accumulation of secretions.

28. Atelectasis:
◦ Pathophysiology and clinical features:
Atelectasis or alveolar collapse occurs
when airways become obstructed and air is
absorbed from the air spaces distal to the
obstruction. Bronchial secretions are the
main cause of this obstruction.
Predisposing factors include shallow
ventilation, loss of periodic hyperinflation,
inhibition of coughing and pooling of
mucus. All of these are particular problems
after thoracic and upper abdominal surgery.

29. Prevention and treatment of atelectasis:
◦ Atelectasis is best prevented by preoperative and postoperative
physiotherapy for patients undergoing major surgery. This includes
deep breathing exercises, regular adjustments of posture and vigorous
coughing. During physiotherapy, wounds should be supported by the
patient's hand. Effective analgesia facilitates physiotherapy and
mobility e.g., infiltration of the wound with local anesthetic or
epidural analgesia.

30. ◦. Nebulizer bronchodilators such
as salbutamol may assist the
patient to cough up secretions.
Severe cases of diffuse atelectasis
may require endotracheal
incubation and positive- pressure
ventilation. Lobar or whole lung
collapse requires intensive
physiotherapy and sometimes
flexible bronchoscopy to aspirate
occluding mucus plugs.

31. Pneumonias
Bronchopneumonia is the usual form of chest infection seen
in surgical patients. It occurs secondarily to chronic lung
disease or following atelectasis or aspiration of gastric
contents.

32. ◦ Infection is manifest by pyrexia, tachypnoea, tachycardia and
sometimes cyanosis. The mucopurulent sputum is thick, copious and
green. Antibiotics, usually amoxycillin or co-trimoxazole, are given on
a 'best-guess' basis until sputum culture and sensitivities are available.
Physiotherapy and encouragement to cough are equally important for
recovery.

33. Adult Respiratory Distress Syndrome:
◦ This syndrome of acute respiratory failure is
characterized by rapid, shallow breathing, severe
hypoxemia, stiff lungs and diffuse pulmonary
pacification of X-ray.

34. THROMBOEMBOLISM
Pathophysiology
◦ Venous thromboembolism is a major cause of complications and death after
surgery or trauma. Venous blood is normally prevented from clotting within the
veins by a complex of mechanisms which include local inhibition of the clotting
cascade, prompt lysis of small clots that do form, and continues flow of blood.
This subtle balance can be disturbed by several local and systemic factors, many
incompletely understood. Imbalance results in thrombus formation within the
venous sinuses of the calf muscles and sometimes primarily in the pelvic veins.

35. Predisposing factors for deep vein
thrombosis and pulmonary embolism
1.Trauma and surgery (complex systemic effects)
2.Direct trauma to the pelvis and lower limbs, especially fractures
3.Previous venous thromboembolism
4.Pre-existing lower limb venous disorder causing stasis
5.Venous stasis during general or regional anesthesia (loss of calf
muscle pump and postural pressure on the calves)
6.Malignant disease

36. 7.Immobility, e.g. bedbound patients after operation or stroke
8.Cardiac failure
9.High-oestrogen oral contraceptive piles, estrogen treatment
10.Pregnancy
11.Pelvic masses
12.Obesity
13.Dehydration
14.Blood disorders, e.g. polycythemia, thrombocythemia and prothrombotic
disorders

37. DEEP VEIN THROMBOSIS
◦Deep vein thrombosis in the lower limbs (DVT) is often
silent with the classic clinical features found in only half the
cases. These include swelling of the leg, tenderness of the
calf muscles, increased warmth of the leg, and calf pain on
passive dorsiflexion of the foot (Homan's sign).
◦ The presence of these features indicates that venous
occlusion has extended at least as far as the popliteal veins.

38. PULMONARY EMBOLISM
The classic picture of pulmonary embolism (PE) is sudden dyspnea and cardiovascular
collapse, followed by chest pain, development of a pleural rub (sound made by walking on
fresh snow) and hemoptysis. ECG may show evidence of right heart strain.
Prevention of Venous Thromboembolism:
The importance of general measures in preventing, venous thrombosis cannot be
overemphasized. These include early postoperative mobilization, adequate hydration and
avoiding calf pressure. For patients at higher risk, specific prophylactic measures should be
taken to reduce the risk of deep venous thrombosis (and consequent pulmonary
embolism). Prophylactic measures include the following:

39. Low-dose subcutaneous heparin.
▲ Calf compression devices - several pneumatic and electrical devices are
available for intraoperative calf compression to simulate normal muscle pump activity.
These have the advantage of being non-invasive and easily applied to all patients, even
those at low risk, but their efficacy is less than low dose heparin
◦ Graded-compression "anti-embolism' stockings - the use of these
stockings is simple and widely practiced. Provided the stockings are
correctly fitted, graded-compression stockings offer a suitable level of
prophylaxis for patients at low or moderate risk. The stockings must be
worn during operation as well as during the early postoperative period.

40. ◦Graded-compression "anti-embolism' stockings - the
use of these stockings is simple and widely practiced.
Provided the stockings are correctly fitted, graded-
compression stockings offer a suitable level of prophylaxis
for patients at low or moderate risk. The stockings must be
worn during operation as well as during the early
postoperative period.

41. PRESSURE SORES:
Pathophysiology:
◦ Elderly, debilitated and other bed-bound patients are extremely susceptible
to pressure sores (bed sores), particularly over bony prominences such as
the sacrum and heels. Pressure sores occur because the frequent
spontaneous adjustment of position that normally occurs is lost through

42. obtunded sensation and immobility. Diminished
protective pain response plays an important part.
Tissue necrosis and subsequent failure to heal result
from a combination of factors including recurrent
pressure ischemia, poor tissue perfusion (from cardiac
or peripheral vascular disease) and malnutrition.

43. Prevention and management of
pressure sores:
◦ Once established, pressure sores are difficult to eradicate and prevention must be
given high priority in patients at risk Relatively hard surfaces such as accident and
emergency department trolleys and operation" tables may initiate pressure sores in
susceptible patients in less than 1 hour. Likewise, pressure sores can develop in a
remarkably short time in a hospital bed, particularly if the patient is incontinent of
urine or feces. Prevention of pressure sores on the ward is mainly a nursing
responsibility;

44. ◦indeed, the incidence of pressure sores is a good indicator of
the quality of nursing care. Prevention of pressure sores
involves the following, procedures:

45. ◦ Relieving pressure on the heels use of ankle rests while on the operating table, use
of heel pads, sheepskin rugs and 'bean-bags' on return to the ward.
◦ Special bed surfaces to spread the load these include simple sheepskin mattress
covers, padded over-mattresses and electric ripple mattresses, water beds,
sophisticated vibrating mattresses and suspended net beds.
◦ Regular change of posture for most patients, this involves encouragement to get
out of bed, at least into a bedside chair, and to mobilize beyond this as much as
possible. A bed- bound patient requires regular turning so that the same skin area
is not subjected to constant pressure
◦ Regular checking of pressure areas and local massage.
◦ Management of incontinence.

46. ◦ Treatment of established pressure sores is unsatisfactory unless the
causative factors, can be eliminated. This is often impossible in the
permanently disabled patient. Avoiding pressure is the mainstay of
treatment, supplemented by local cleansing and dressings designed to
remove necrotic tissue and control secondary infection. For a deep
sacral sore. Major plastic surgery involving a rotational buttock flap is
occasionally justified.