POSTOPERATIVE COMPLICATIONS

Samaad Malik, MD, MSc, FRCSCSamaad Malik, MD, MSc, FRCSCClinical Fellow, CMASClinical Fellow, CMASMcMaster UniversityMcMaster UniversityAugust 20, 2008August 20, 2008

Objectives

Case BasedClinical ApproachExamination Preparation

POS Question sample

1. What enzyme facilitates access of snake venom into the human lymphatics?HyaluronidasePeroxidaseAcethycholinesteraseCrotalase

We shall not cease from exploration And the end of all our exploring Will be to arrive where we started And know the place for the first time.

T.S. Eliot

Surgical Complications

Surgical Wound Complications Complications of Thermal Regulation Pulmonary Complications Cardiac Complications Renal and Urinary Tract Complications Endocrine Complications Gastrointestinal Complications Hepatobiliary Complications Neurologic Complications Ear, Nose, and Throat Complications

Approach

PageElevator thoughtsQuick Bedside LookABCSelective H+PManagement

Case

85 yo elderly malePOD #3 Laparoscopic Colectomy Painful R cheek while eating

What are your thoughts?Diagnosis

How do you want to proceed??Treatment

Parotitis

Decrease in the secretory activity of the gland with inspissation of parotid secretions that become infected by staphylococci or gram-negative bacteria from the oral cavity

Parotitis

Potentially seriousElderlyPoor oral hygienePoor nutritional stateDehydration

Post operative Parotitis

Results in inflammation, accumulation of cells that obstruct large and medium-sized ducts, and, eventually, formation of multiple small abscesses

These lobular abscesses, separated by fibrous bands, may dissect through the capsule and spread to the periglandular tissues to involve the auditory canal, the superficial skin, and the neck

If the disease is not treated at this stage, it may produce acute respiratory failure from tracheal obstruction

ORAL HYGIENE?

Diagnosis

ClinicalPain or tenderness at the angle of the jawSwelling and redness in the parotid areaHigh fever and leukocytosis develop

InvestigationsUltrasound

Treatment

Clindamycin/Vancomycin should be started while the results of cultures are awaited

Warm moist packs and mouth irrigations may be helpful

Rehydrate

Case

68 yo malePOD #1 Lap APRDesaturated to 85%

What are your thoughts?

Case

ApproachABCHx and Px Investigations

BloodworkCEA

Consultation

Thromboembolisms

Mechanisms:Alterations in normal blood flow Injuries to vascular endotheliumAlterations in the constitution of blood

Symptoms and Signs of Pulmonary Embolism

Pleuritic chest pain[]   Sudden Dyspnea[]   Tachypnea   Hemoptysis[]  Tachycardia[]   Leg swelling[*]  Pain on palpation of the leg[*]  Acute right ventricular dysfunction  Hypoxia   Fourth heart sound[*]  Loud second pulmonary sound[*] Inspiratory crackles[*]

Investigations

CXR, ECG, ABGD-dimerCT scanV/Q scanDuplex U/SPulmonary AngiogramEcho

Treatment

Depends on hemodynamic stabilityUnstable

Get helpThrombolytics?

StableAnticoagulate intrinsic fibrinolysis restores pulmonary

blood flow

Heparin

ComplicationsBLEEDINGosteoporosisHIT

No increased risk of bleed INCREASED risk of Thrombosis

BOTH ARTERIAL AND VENOUS Increased for a period of 1 month

Heparin

Prevents formation of new thrombi and stops propagation of thrombi

Enhances antithrombotic activity of antithrombin III

ContraindicationsConsider IVC filterOvert bleeding

HIT

can occur with LMWH as wellUsually after 5-10 days

HIT

TreatmentGet help – HematologyDiscontinue HeparinOther anticouagulants

ArgatrobanDanaparoid

IVC Filter placement

IndicationsRecurrent PE despite adequate

anticoagulationContraindications to anticoagulation

DVT

Investigationspresentationsmanagementmedical

Cardiac

Mortality no h/o MI 1-1.2% 6 or more months 6% 3 months 16-37% age more than 70 AS medical conditions emergency operations

Intraoperative hypotension

Preoperative CHF Preoperative

Hypotension Angina

Cardiac Pearls

Inpatient HR 101

Intravascular volume depletion till proven otherwise

PainFever

Case

67 yo femalePOD #3, Ivor Lewis EsophagectomyHR= 168

BP= 80/60

What to do next?

ApproachABCACLS protocolCall for help!!

Catch!

Cardiac ArrythmiasUnderlying cause

Extracardiac – sepsisAnastomotic leak

Pulmonary

Smoking Obesity Age Home oxygen Unable to walk 1 flight of stairs w/o respiratory

compromise Major lung resection

Screen with PFTs, CXR

PFT’s

Studies demonstrate that any patient with an FEV1 greater than 2 L will probably not have serious pulmonary problems

Conversely, patients with an FEV1 less than 50% of the predicted value will probably have exertional dyspnea.

Ventilator

Criteria for Weaning From the VentilatorRespiratory rate<25 breaths/minPao2 >70 mm Hg (Fio2 of 40%)PaCo2 <45 mm HgMinute ventilation 8-9 L/minTidal volume 5-6 mL/kgNegative inspiratory force- 25 cm H2O

Case

POD #4, Whipple’sTemp, feverCXR shows collapse consolidation of

RLL consistent with pneumonia

Treat?

Community-acquired pneumonia (CAP) infection that begins outside of the hospital is diagnosed within 48 h after admission to

the hospital in a patient who has not resided in a long-term facility for 14 days or more before the onset of symptoms

Hospital-acquired pneumonia (HAP) infection of lung parenchyma occurring

more than 48 h after admission to a hospital

Empiric Therapy

HAPCefotaxime+ gentamycinTazocin

CAPFluoroquinolones

LevofloxacinMacrolides

azithromax

Postop Fever

Courtesy of DiagnosaurusWind: pneumonia, atelectasis Water: urinary tract infection Wound: wound infection

Superficial vs deepWalking: deep vein thrombosis (DVT) from

immobilization Wonderdrugs: drug feverWanes: CVL, peripheral lines

Postop Fever

Tubes: N/Gsinusitis

Surgery: anastomosisSpinal: epidural abscessCardiac – EndocarditisColorectal: perianal abscessHPB – acalalculous cholecystitis

Acute Renal Failure

Defined as urine output <25cc/hr, increasing Cr, increasing BUN

Associated mortality, >50%Differential dx

PrerenalRenalPost renal

Thyroid Storm

Thyrotoxic crisisAcute life threatening exacerbation of

thyrotoxicosisUsually in patient with discontinued

antithyroid medication or more commonly undiagnosed hyperthyroidism

Thyroid Storm

ClinicalAcute onset hyperpyrexia (temp>40 ‘C)DiaphoreticMarked tachycardia (Afib)Nausea, vomitingAgitationDeliriumTremulousness

Thyroid Storm

Precipitants:SurgeryDKASepsisMITraumaDrugs Iodinated contrast

Thyroid Storm

DiagnosisSerum T4, T3, free T4, free T3 elevatedTSH suppressed

Thyroid Storm

TreatmentABCGet help – Endocrinology/Medicine, ICUTreat the underlying causeSpecific

PropanalolPropylthiouracilMethimazoleKISteroids?

Take Home Messages

Clinical:Have a good approach to common

clinical scenariosAcknowledge your limitationsDo not hesitate to access

multidisciplinary approach

Take Home Messages

ExaminationDO NOT READ SCHWARTZ from

beginning to endOld exams

QUESTIONS?