POST OPERATIVE COMPLICATIONS

-Dr. Minhajuddin Khurram

Al-Ameen Medical College Hospital, Bijapur, IndIA

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

1) Wound Complications

a) Seroma

b) Haematoma

c) Wound Dehiscence

d) SSI (Surgical Site Infections)

e) Chronic wound

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

1) Wound Complicationsb) 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

1) Wound Complicationsc) 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➔ Systemic disease (uremia, diabetes mellitus)

1) Wound Complicationsc) 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

1) Wound Complicationsd) 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

1) Wound Complicationsd) Surgical Site Infection (SSI)

Risk Factors:

1) Wound Complicationsd) Surgical Site Infection (SSI)

Classification of surgical wound:

1) Wound Complicationsd) 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)

1) Wound Complicationsd) 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

2) Thermal Regulation

a) Hypothermia

b) Malignant Hyperthermia

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)

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

2) Thermal Regulation

b) Malignant Hyperthermia

- Gene mediated (Autosomal Dominant)

- Cyanosis

- Raised body temperature

- Arrhythmias

- CHF

- tachypnea,

- hypercapnia

- hypotension

- electrolyte abnormalities

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

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

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

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

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

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

- Embolectomy

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

5) Infections and Feverb) 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

More than 72 hrs: Broad differential diagnosis

5) Infections and Feverb) Post operative fever causes

5) Infections and Feverb) 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

5) Infections and Feverb) 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

6) Pulmonary Complications

a) Atelactesis

b) Pneumonia

c) Aspiration Pneumonitis

d) Pulmonary Edema, Acute Lung Injury and ARDS

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

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

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

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

- Emergency surgeries, trauma pts

- Diabetics

- NG tube

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

6) Pulmonary Complications

c) Aspiration PneumonitisMx:

-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

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

7) Renal Complications

a) Urinary Retention

b) Acute Renal Failure

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

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.

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

7) Renal Complications

a) Acute Renal Failure

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

8) Cardiovascular Complications

a) Myocardial ischaemia and infarction

b) Congestive heart failure

c) Hypertension

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

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

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

9) Neuroligal Complications

a) Perioperative Stroke

b) Seizures

c) Delerium

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.

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

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

9) Neurological Complications

c)Delirium

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

10) Complication of Diabetes

Diabetic Keto Acidosis

- Medical Emergency

- Lab Inv: Blood glucose

-CBC

- S. Electrolytes

- S. Osmolarity

- ABG

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%)