Operative Complications & Anaphylaxis

Operative Complications

• Preoperative considerations should include medical comorbidities, medication/supplements, and patient behavior.
• Post-operative care, activity limits, pain control and medication management must be taken into account

Anaphylaxis

• Anaphylaxis is an acute, potentially life-threatening, systemic hypersensitivity reaction caused by the sudden release of mast cell mediators.
• Anaphylaxis to anesthetic is rare
• Doctors should always ask about the patient's allergies before any procedure so they can avoid common allergens like Betadine, latex, bacitracin, adhesives and PABA.
• Signs include skin and mucosal signs (up to 90%) like generalized hives, itching or flushing, swollen lips/tongue/uvula, periorbital edema.
• Respiratory signs (up to 85%) include rhinorrhea, congestion, sneezing, itching of the throat and ear canals, muffled voice, sensation of throat closure or choking, stridor, SOB, wheeze or cough.
• GI signs (up to 45%) include N/V, diarrhea and crampy abdominal pain.
• Cardiovascular signs (up to 45%) include syncope, dizziness, tachycardia and hypotension.

Vasovagal Reactions

• Vasovagal syncope is a transient loss of consciousness caused by a period of inadequate cerebral nutrient flow, often caused by an abrupt drop of systemic blood pressure.
• This is caused by a neural reflex that results in usually self-limited systemic hypotension characterized by bradycardia and/or peripheral vasodilation/venodilation.
• Signs include lightheadedness, feeling warm or cold, sweating, palpitations, nausea or non-specific abdominal discomfort, visual blurring, diminution of hearing and/or occurrence of unusual sounds ("whooshing"), pallor, and fatigue after recovery.

Anesthetic Toxicity

• Local anesthetic systemic toxicity (LAST) has a very low incidence.
• Risk factors include infants/young children, elderly patients, pregnant patients, renal insufficiency, cardiac disease, hepatic disease and injection into highly vascular sites that lead to direct IV injection and increased systemic absorption.
• Signs occur soon after the injection and progresses through CNS excitation, CNS inhibition, cardiovascular excitation and CV arrest in extreme cases.
• CNS effects include perioral numbness, metallic taste, mental status changes, anxiety, visual changes, muscle twitching and seizures.
• CV effects occurs after or along with CNS effects, initial sympathetic activation can cause tachycardia and hypertension, and can progress to arrhythmias and/or asystole.

Wound Dehiscence

• Wound dehiscence is defined as the separation of the epidermal and/or dermal edges of a wound.
• The most vulnerable period for dehiscence is just after suture removal.
• Anatomic location mostly closely associated with dehiscence is the chest.
• High wound tension, infection, necrosis, residual tumor, suture reaction, trauma to the wound or poor wound healing can cause dehiscence

Bleeding

• Intraoperative bleeding can be addressed by applying direct pressure over a bleeding vessel for 15-20 min.
• Topical hemostatic agents like physical hemostatic agents, chemical hemostatic agents, biologic scaffold agents, and biologically active agents can be applied
• Electrocautery or suture ligation can also be used.

Hemostasis

• Risk factors that increase intraoperative bleeding are medications, supplements and genetic diseases.
• Medications like Aspirin, Clopidogrel, Nonsteroidal anti-inflammatory drugs, Warfarin, Heparin Dabigatran, Argatroban, Bivalirudin, Lepirudin, Rivaroxaban, Apixaban, Edoxaban and Fondaparinux.
• Supplements like Ginseng, Gingko, Vitamin E, Fish oil, Garlic, Dong Quai (Angelica sinensis), Feverfew, Licorice, Bilberry, German chamomile, Red clover, Poplar, Meadowsweet, Willow bark, Tamarind, Danshen, Alfalfa, Goldenseal and Green tea
• Genetic Diseases like Von Willebrand disease and Hemophilia A/B (factor VIII and IX deficiency).
• Other patient factors like uremia, liver disease, hepatosplenomegaly, excessive alcohol use, myeloproliferative diseases/bone marrow failure, vitamin K deficiency and immune thrombocytopenia also contribute

Infection

• Surgical site infections can occur within 30 days of surgery, usually developing within 4-8 days.
• Signs include a purulent discharge from the incisional wound, organisms present on culture, pain, tenderness, localized swelling, redness or heat.
• Patient risk factors include infection at a remote coincident site, cigarette smoking, diabetes, systemic immunosuppression, obesity, extremes of age and poor nutritional status.

Tissue Necrosis

• Decreased vascular perfusion that does not allow for adequate perfusion leads to tissue necrosis.
• Presentation is black, densely adherent eschar.
• Necrosis is a rare complication that can result from patient risk factors, anatomic risk factors, poor closure design (e.g., excessive tension), post-operative bleeding, or wound infection.
• Patient risk factors include anti-coagulant use, hepatic or renal insufficiency, excessive alcohol consumption and smoking.
• Heavy smokers develop necrosis three times more frequently than non-smokers.
• It is recommended that patients decrease their smoking to less than 1 pack per day for 2 days prior to surgery and for 1 week postoperatively to minimize complications

Hematoma

• Hematoma formations occur if bleeding continues within a closed wound.
• It can provide a substrate for bacterial growth, prevent wound healing and increase wound tension.
• The risk is greatest within the first 24 hours, most frequent within the first 6

Charting

• Any surgeries or procedures performed in-office have to be included in charting.
• Charts usually include a "Procedures" section that follows the "Plan.”
• Each chart note should have a "Plan" that includes everything done for the patient, for example, the “X procedure performed as documented in the "Procedures" section."
• Creating templates for procedures makes charting easier.
• Consent forms are required, so documenting informed consent is important:
• Informed consent is defined as "the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention; The patient must be competent to make a voluntary decision about whether to undergo the procedure or intervention."
• What to include in charting:
• Consent: “The risks, benefits and alternatives of this procedure were discussed in detail with the patient. Written consent was obtained"
• Indication/Pre-Operative diagnosis: give the reasoning behind the procedure by stating, for example that the patient wants it removed because it was explained that this lesion is pre-cancerous, verruca vulgaris, inflamed cyst, lipoma vs cyst, etc.
• Size/location: measure everything (mm, cm) and give the best anatomical location description
• Description of the procedure: you will need to describe everything you did including the position of the patient (ie, prone, seated, reclined, supine, etc), the anesthesia, the suture type and size, and the operational procedure.
• How was hemostasis obtained (electrocautery, pressure, silver nitrate, etc), the amount of blood lost and the dressing type can all be recorded.

Charting for Various Procedures

• Lipoma excision: mark the periphery and make an incision line over the lesion, inject the planned incision mark and lesion with 3cc of 1% lidocaine with 1:100,000 epinephrine, cleanse with Betadine scrub and cover with a fenestrated sterile drape.
• Follow the marked incision line using a #15 blade and bluntly dissect the lesion from surrounding tissue to the previously marked lateral margins of the lesion
• Compress the site and remove the lipoma and close the depth with 4-0 Vicryl sutures to eliminate dead space and reduce the risk of hematoma formation.
• Close the skin with 4-0 nylon simple interrsutures, measure the final suture line, redress the site with sterile gauze and Tegaderm under a pressure dressing designed to compress any possible dead space.
• Abscess incision and drainage involves marking the periphery and incision line of the lesion with a surgical pen, cleansing with chlorhexidine (or Betadine), perform a field block with cc lidocaine 1% with epinephrine and use an #11 blade to incise the skin over the area of the abscess with most fluctuance, express purulent discharge using direct compression.
• Break loculations within the abscess cavity using curved hemostats, irrigate the cavity with 100cc sterile water, use direct pressure to obtain hemostasis leave the cavity open to heal by secondary intention and place dressing of sterile gauze and surgical tape on the wound.
• Cyst excision involves marking the periphery and incision line of the lesion with a surgical pen, cleanse the area with isopropyl alcohol 70%, perform a field block using cc of lidocaine 1% with epinephrine and using a #15 blade to incise the skin over the lesion along the marked incision line.
• Rupture the cyst capsule and express the contents of the cyst, bluntly dissect the cyst capsule away from the surrounding tissue, irrigate the cavity with sterile water, use direct pressure to obtain hemostasis, close the superficial skin using 4-0 nylon simple interrupted sutures and redress the site with sterile gauze and Tegaderm under a pressure dressing designed to compress any possible dead space.
• Full nail avulsion without nail matrixectomy requires placing the patient supine on the exam table, cleansing the digit thoroughly with isopropyl alcohol 70%, performing a digital block with 4cc of plain lidocaine 1%.
• After administering anesthesia, prepare the area with Betadine and tourniquet, apply to the digit and remove the nail plate from the nailbed.
• Ligate and cauterize all bleeding vessels, place Adaptic gauze on the exposed nailbed and top with Bacitracin and redress the site with a dry sterile dressing.
• Matrixectomy procedure: Phenol 80% was applied to the nail matrix to prevent re-growth.
• Cyrotherapy required Liquid nitrogen to treat the lesion(s) with a one (or two) second freeze-thaw cycle.
• The patient was instructed to apply petroleum jelly or Aquaphor to the treatment areas 3x/day until crusting resolves.
• The patient was instructed to return for follow-up within 1 month if the lesion fails to resolve or immediately if there is enlarging of the lesion or any sign of infection in the area.
• Post-operative instructions should instruct patients on how to care for the wound/treated site, when to return for suture removal, signs of infection to look out for and what to do if they have questions/concerns.

Procedure Costs

• When determining costs, consider factors like time/expertise, supply costs and competitive rates.
• "No Surprises Act” requires providers to provide self-pay patients with an estimate of the cost before they receive care.
• A patient can dispute a medical bill if final charges are at least $400 higher than the estimate and they file a dispute within 120 days of the bill's date

Legal Considerations

• Current debates exist in Arizona regarding the scope of practice for naturopaths related to the definition of minor surgery and cancerous lesions.