Wound Complications
Seroma
Collection of liquefied fat, serum, & lymphatic fluid under incision
Localized, well-circumscribed swelling, pressure discomfortNo erythema, tenderness
Evacuated and packed heal by secondary intention
Secondary infection open wound
Hematoma
Ecchymotic, localized wound swelling, drainage of dark red fluid
Open wound and pack if detected soon after surgery
Small hematoma 2wks after surgery may resorb
Wound Dehiscence
Separation of fascial layersEvisceration of bowel
Technical error, deep wound infection
Case 1
87yo s/p repair of perforated bowel with gross stool spillage
How do you close the fascia?Interrupted figure-eight good
strengthCan use absorbable mesh or retention
sutures to reduce tension
Case 2 Cont.
How do you close the subcutaneous tissue?
Leave it openif wound clean after 5d, then you can approximate edges
…later that night
Sudden drainage of large volume of clear, salmon-colored fluid…Examine patient & wound…
probe wound with sterile applicator
Examine wound & see bowel… cover bowel with sterile saline
moistened towel O.R. STAT
Wound infection
Erythema, tenderness, edema, occasional drainage
Rx: open wound, free loculations, irrigate, packCT scan if pus emanating deep to
fascia
Called for a temp of 102…
Examine patient & woundErythema, drainage of grayish
dishwater-colored fluid, what seems like necrotic fascia, mild crepitus… O.R. STAT-rapid & expeditious
debridement clostridiomyonecrosis
Prevention of SSI
Stop smoking 48h prior, encourage weight loss, bowel prep, taper/stop immunosuppresants
Prophylactic antibiotics Insert drain if gangrenous organ Delayed primary closure in
contaminated field
Complications of Thermal Regulation & Cardiac Complications
Sumit De, M.D
Complications of Thermal Regulation
• Hypothermia
• Malignant Hyperthermia
• Postoperative Fever
• Respiratory Complications
• Aspiration Pneumonitis
• Pulmonary Edema, Acute Lung Injury, ARDS
• Pulmonary Embolism
•Causes: cold environment, paralysis, rapid resuscitation, intra-op exposed areas, irrigation
•Body’s response: CO, HR, cardiac arrhythmias, coagulation, vasoconstriction
•Cardiac alterations, diuresis, hepatic & neurological dysfunction
•Keep patient WARMWARM
Hypothermia
•Exposure to inhalation agents or succinylcholine
•Mostly occurs in youth
•High fever, tachycardia, muscular rigidity, and cyanosis
•Metabolic acidosis, hyperkalemia, hypercalcemia
Malignant Hyperthermia
Management:
Stop inhalation agent
Cancel/conclude surgery
Dantrolene, 2.5 mg/kg
Cool body
Reverse met acidosisBox 14-3, Sabiston
Post-op Fever
Wind: Atelectasis – 24-48 hrs
Water (UTI) – after POD #3
Wound – after POD #3
Walking (DVT/PE/Thrombophlebitis) – POD #7-10
Wonder drugs - Anytime
•Most post-op patients who have respiratory complications can be managed with pulmonary toilet
•Two types of respiratory failure:
•Type I: hypoxic – abnormal gas exchange at alveolar level (e.g. pulmonary edema, sepsis)
•Type II: hypercapnia – excessive narcotic use, increased CO2, respiratory dynamic changes , ARDS
Respiratory Complications
PNEUMONIA & Aspiration Pneumonitis
Pulmonary Edema, Acute Lung Injury,and Adult Respiratory Distress Syndrome
Pulmonary edema associated with a increased wedge & right-sided heart pressures: hydrostatic pressure to high
ALI & ARDS: hypo-oxygenation due to pathophysiologic inflammatory response, PCWP <18 mmHg, and bilateral infiltrates
PaO2/FiO2 ratio in ALI <300 ARDS <200
Criteria for Ventilator Weaning:RR <25 B/min Vmin 8-9 L/min
PaO2 >70 mmHg (FiO2 <40%) VT 5-6 mL/kg
PaCO2 <45 mmHg Nif –25 cm H20
500,000 PEs occur annually, 100,000 fatal Iliofemoral venous system most common source
of PE; fat emboli s/p long bone fractures & air emboli s/p central lines are also well-known causes as well
Signs & Sx of PE are shared with MI, PTX, PNA, and atelectasis
ABG with PaO2 <70 mmHg, T-wave inversions, and non-specific ST segment changes
Severe PE: S1Q3T3, RBBB, right-axis deviation CT angiography, Treat with HEPARIN
Pulmonary Embolism
Cardiac Complications
Post-Op HTN
CVA & op site bleeding are biggest concerns, especially after CEA, AAA, head & neck procedures. -blockade
Perioperative Ischemia and Infarction
~30% OR patients have CAD, perioperative MI mortality rate is ~30% compared to 12% for thiose without a surgical procedure; 8-15% reinfarction rate for <3 mos post-MI OR patient, 3.5% reinfarction rate for 3-6 mos post-MI OR patient
Cardiogenic Shock
~50% or more LV mass damaged post-MI => hypoperfusion, ruptured papillary muscle, ventricular wall, aortic valvular insufficiency, mitral regurg, VSD
Arrhythmias & CHF
Intra-op occurrence of arrhythmias (30 sec abnl cardiac activity) is 60-80%. Electrolyte abnormalities, medications, stress, endocrine abnormalities, and cardiac disease are main causes
RENAL AND URINARY TRACT COMPLICATIONS
URINARY RETENTION
6-7 HOURS POST OP DISCOORDINATION OF TRIGONE
AND DETRUSOR MUSCLES STRAIGHT CATH
ACUTE RENAL FAILURE
10% PATIENTS IN PERIOP COURSE
OLIGURIC <480 ML/DAY NONOLIGURIC >2L/DAY
POSTOP RENAL FAILURE
PRERENAL RENAL POSTRENAL
HEMORRHAGE TOXINSURETERAL LIGATION
HYPOVOLEMIA DRUGSBLADDER
DYSFUNCTION
CARDIAC FAILURE
PIGMENT NEPHROPATHY
URETHETRAL OBSTRUCTION
DEHYDRATION
EVALUATION
BUN:CR FRACTIONAL EXCRETION OF
SODIUM PRERENAL FENA <1%
RENAL FENA >3%
CONTRAST NEPHROPATHY
HYPOVOLEMIC DIABETIC VASCULOPATH HEART FAILURE ACE-I, NSAID HYDRATION MUCOMYST/ N-ACETYLCYSTEINE
600MG PO BID X 48HRSTepel M, van der Giet M, Schwarzfeld C, Laufer U, Liermann D, Zidek W: Prevention of radiographic-contrast-agent-induced reductions in renal function by acetylcysteine. N Engl J Med 343: 180–184, 2000
RHABDOMYOLYSIS
CRUSH INJURY MYOGLOBINURIC RENAL INJURY HYPERKALEMIA AND ACIDOSIS HYDRATION DIURESIS ALKALINIZATION
INDICATIONS FOR HEMODIALYSIS
SERUM POTASSIUM >5.5 MEQ/L BUN >80-90 MG/DL PERSISTENT ACIDOSIS ACUTE FLUID OVERLOAD UREMIC SYMPTOMS REMOVAL OF TOXINS
METABOLIC COMPLICATIONS
ADRENAL INSUFFICIENY
PRIMARYADDISONSINFECTIOUS
SECONDARYPITUITARY OR HYPOTHALAMIC
DISEASECESSATION CHRONIC STEROIDS
DIAGNOSIS
BASELINE CORTISOL <15 UG/DL ACTH STIMULATION
BASELINE CORTISOL0.25 MG COSYNTROPIN IVGLUCOCORTICOIDMEASURE CORTISOL AT 30 MIN
SIADH
HIGH ADH DESPITE HYPONATREMIA
TRAUMA STROKE ADH PRODUCING TUMORS FLUID RESTRICTION ADMINISTRATION OF SALINE DIURETICS
Gastrointestinal and Hepatobiliary Complications
Harsh Jain, M.D.
Gastrointestinal complications
IleusIntestine that ceases contrancting for
brief period of time (3-5 days)Operative manipulation, major small
bowel injury, heavy narcotic use, intra-abdominal infection, and pancreatitis can prolong the ileus
Past 7 days – prolonged ileus vs SBO
Ileus vs SBO
Ileus Distention Diffuse discomfort Hypoactive BS AXR
• Air into colon and rectum
Treat underlying cause
SBO Distention Often intermittent,
colicky pain Nausea, vomiting Obstipation AXR
• No air into colon and rectum
May require operative therapy
SBO
Causes Adhesions Malignancy Hernias
Diagnosis Flat plate and
upright abdominal films
CT Scan
Management Hydration Correct electrolyte
imbalances NGT Operative therapy
if conservative management fails
Abdominal Compartment Syndrome
Etiology Massive abdominal
trauma Operation for massive
abdominal infection Prolonged operation Pressures >25cmH2O
Presentation Distended, tense Hypoxia Elevated airway
pressure Oliguria
Diagnosis Measure intra-
abdominal pressures through foley cathether
Treatment Surgical emergency Open fascial closure
and re-do with temporary closure
Post op GI Bleeding
Etiology Stomach
• PUD, Stress erosions, M-W tear, varices
Small intestines• AV malformations,
anastomotic bleeding Large intestines
• anastomotic bleeding, diverticulosis, AV malformations, varices
Management Large bore IV’s Fluids Labs NGT Correct coagulopathy Endoscopy/
Colonoscopy Rarely surgery
Stomal Complications
Prolapse Rarely surgical
problem Necrosis
Ischemia to skin level usually resolves
Stenosis Peristomal hernia High output Bleeding
Stoma placement Avoid skin folds Mobilize adequate
length Through the rectus Below the anterior
superior iliac crest
Pseudomembranous Colitis
1 % of patients who receive antibiotics in peri-op period
Superinfection with C.Diff
Secretion of exotoxin Pseudomembranes
Whitish membrane consisting of fibrin, WBC, mucus
Diarrhea, cramping and dehydration
Diagnosis by stool sample for exotoxin
Treat with oral metronidazole or vanocmycin, IV metronidazole
Sometimes disease progresses despite treatment
If febrile, shock and tender __> colectomy
Anastomotic Leak
Caused by Ischemia Tension Mismatch of the lumens Rough handling of tissues
Presentation Fever Abdominal pain Malaise Paralytic ileus Fullness of the area Wound dehiscence Fistula
CT Scan Large fluid collection Air fluid levels in
abscess cavity Free air
Small leak with controlled fistula, conservative management with gut rest, TPN and antibiotics
Larger leaks, or uncontrolled infection, no drainage usually require reoperation
Fistulas
Abnormal communication between one hollow epithelialized organ and another epithelialized surface.
Entero-cutaneous fistula Initial erythema,
abscess, and the subsequent efflux of GI contents
Entero-vesical fistula Pneumaturia or fecaluria
Initial treatment includes fluids, antibiotics, protection of skin
NPO, TPN Low output (<200ml/day),
consider enteral feedings Watch lytes with high
output (1-2 L/day) H2 blockers, octreotide Foreign body, radiation,
infection at fistula site, epithelialization of the fistula tract, neoplasm or, distal obstruction
Bile Duct Injuries
Increased incidence after lap chole became generally accepted
Presentation Fever, RUQ Pain,
malaise and occasionally jaundice
Immediate CT Scan If fluid collection,
precutaneous drainage with the drain left in
ERCP
Small leak and open common bile duct – stent
Cystic duct injury or small leak – stent and drain
Major injury or obstruction of bile duct – stenting is only supplementary to surgery
Surgery If adequate control of
leak, wait 5-7 days Debride nonviable CBD Roux-en-Y limb to CBD Multiple drains
Neurological and ENT Complications
Muhammad Irfan Saeed MD
Neurological Complications
Delirium, Dementia, Psychosis Seizure Disorder Stroke and Transient Ischemic attack
Delirium
High Risk Patients
Elderly
Prior history of Substance abuse
Prior history of Psychiatric disorder
Children
Causes of Acute Delirium Drug Intoxication (Alcohol, Antihistamines, Sedatives) Drug Withdrawal (Alcohol, Narcotics, Anxiolytics) Acute Cerebral Disorder (Edema, TIA, Stroke, Neoplasm) Metabolic Disturbance (Electrolyte disturbance,
Hypoglycemia) Hemodynamic disturbances (Hypovolemia, MI, CHF) Infections (septicemia, UTI, Pneumonia) Respiratory Disorder (Respiratory failure, PE) Trauma (Head Injury, Burns)
Symptoms
Impaired memory Altered perception Altered sleep patterns Hallucinations Combativeness Confusion
Management
History and Physical examination
(Neurological examination) Check Medication List Vitals with Pulse oximetry EKG, ABG, UA, CXR CT scan MRI
Treatment
Appropriate Sedation Treatment of the underlying cause Careful Observation (one to one nursing, transfer the
patient to a naturally lighted room)
Delirium Tremens
Onset usually 72 to 96 hours after alcohol cessation.
Characterized by disorientation, hallucinations, autonomic lability (tachycardia, fever, HTN, diaphoresis)
Treatment
Benzodiazepines Clonidine IVF Thiamine Magnesium sulphate Folate Restraints
Seizure Disorder
Caused by paroxysmal electrical discharges from the cerebral cortex.
Cause
Primary
Secondary
Causes
Primary Intracranial Tumor Hemorrhage Trauma Idiopathic
Secondary Metabolic Sepsis Systemic disease
(epilepsy) Pharmacological
agents (antidepressants, hypoglycemic agents, Lidocaine)
Symptoms and Signs
Convulsions Rhythmic myoclonic activity Loss of consciousness Change in mental status (lack of
neurological responsiveness) Fecal and urinary incontinence Post event amnesia
Diagnostic Workup
Rapid blood glucose determination Oxygen saturation CBC Chem-7 Serum calcium / magnesium Serum levels of anticonvulsants CT scan
Treatment
Patient safety (airway, restraints) IV Benzodiazepines Phenytoin Carbamezapine Valproic acid Gabapentin Treat the underlying cause
Stroke and TIA One of the most devastating complication Most common causes include Advanced atherosclerotic disease of Internal
carotid artery. Atrial fibrillation VSD Acute hepatic failure Excessive anticoagulation
Symptoms and Signs
Unilateral weakness or clumsiness Sensory loss Speech disorder Diplopia Vertigo Alteration in mental status
Diagnostic Workup Finger stick glucose Pulse oximetry CBC Chem-7 Coagulation studies CT scan of head Echocardiography Carotid ultrasound
Management Depends upon type of stroke (hemorrhagic
vs. Non-hemorrhagic) Supplemental oxygen and IVF Pharmacological BP reduction (Mannitol and
Dexamethasone) Aspirin 325 mg orally Thrombolytic therapy in close consultation
with neurologist
ENT Complications Epistaxis Most frequent postoperative causes NG tube placement Endotracheal tube placement Temperature probe Pressure application for 3-5 minutes Nasal packing for 10-15 minutes Nasal packing for 1-3 days Treatment of underlying cause
Sinusitis Often missed in postoperative period due to
analgesics, antipyretics and NG tube Malaise, dull aching pain in maxillary or frontal sinus
area and low grade fever CT scan of head Treatment
Removal of NG tube
Antibiotics
Decongestants
Drainage Procedure
Questions???
Question #1
Which of the following statements about tracheoinominate artery fistulas after tracheostomy is not true?A Occur within 2-3 weeksB Caused by excessive inflation of
cuffC Mortality of 50%D Hyperinflation of cuff may control
bleeding temporarily
Answer!!!
C Mortality is 80%Can be life threateningPresents as exsanguinating
hemoptysis (small herald bleed may be noted)
Avoid placing trach below 4th tracheal ring
Can place finger along trach and compress artery
Question#2
Which of the following insufflation gases for laparoscopic pneumoperitoneum can cause hypercarbia and acidosis?A Carbon dioxideB Nitrous oxideC HeliumD Argon
Answer!!!
A Carbon dioxideAlso associated with increases in
arterial pressure, pulmonary vascular resistance, pulmonary arterial pressure. Decreases in cardiac contractility.
Question#3
A postop patient has a serum Na of 125 meq/L and blood glucose of 500 mg/dl (nl 100). What would Na level be if glucose level normal?A 120 meq/LB 122 meq/LC 137 meq/L
Answer!!!
C 137 meq/LEach 100 mg/dl rise in blood glucose
above normal is equivalent to a 1.6-3.0 meq/L fall in the apparent Na concentration.