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Post operative complications
- 1. POST OPERATIVE COMPLICATIONS -Dr. Minhajuddin Khurram Al-Ameen Medical College Hospital, Bijapur, IndIA
- 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
- 9. 1) Wound Complications d) Surgical Site Infection (SSI) Risk Factors:
- 10. 1) Wound Complications d) Surgical Site Infection (SSI) Classification of surgical wound:
- 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
- 13. 2) Thermal Regulation a) Hypothermia b) Malignant Hyperthermia
- 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
- 25. 5) Infections and Fever b) Post operative fever causes
- 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
- 36. 7) Renal Complications a) Urinary Retention b) Acute Renal Failure
- 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
- 40. 7) Renal Complications a) Acute Renal Failure
- 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
- 42. 8) Cardiovascular Complications a) Myocardial ischaemia and infarction b) Congestive heart failure c) Hypertension
- 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
- 46. 9) Neuroligal Complications a) Perioperative Stroke b) Seizures c) Delerium
- 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%)