Surgical Complications: Prevention and Post-Op Care

• Surgical complications are addressed
• Risk reduction includes pre-operative evaluation.
• Optimizing a patient's general condition helps reduce the chance of complications
• Early mobilization and good surgical technique can lower risks

Post-Op Care

• Post-op has 3 phases: immediate, care in the ward before discharge and continued care after discharge

Types of Complications

• Surgical complications are classified in the following categories
• Wound
• Thermo-regulation
• Post-operative fever
• Pulmonary
• Cardiac
• Gastrointestinal
• Metabolic
• Neurological

Wound Complications

• Problem in the closure of the fascia can cause wound complications
• Types of wound complications include:
• Dehiscence
• Evisceration
• Seroma
• Hematoma
• Infection
• Incisional hernia
• Proper closure of the fascia and muscle layers can prevent wound complications

Seroma

• Seroma is a collection of liquefied fat, serum, and lymphatic fluid under the incision
• Seromas are benign and without erythema or tenderness
• Seromas are associated with:
• Mastectomy
• Axillary and groin dissection
• Evacuating the seroma, packing, and using suction drains are all effective treatments

Hematoma

• Hematoma is an abnormal collection of blood
• Symptoms of a hematoma is discoloration of the wound edges (purple/blue) and blood leaking through sutures
• Hematomas are caused by imperfect hemostasis

Necrotizing Fasciitis

• Necrotizing fasciitis is a severe, rapidly progressive infection of the fascia, subcutaneous fat, and skin
• It is a specific type of surgical infection that requires major surgery
• Large, dark, boil-like blisters are diagnostic of this disease
• Necrotizing fasciitis does not involve deep fascia

Wound Infection

• Wound infections can be caused by several factors
• Group A hemolytic streptococcal gangrene from penetrating wounds
• Clostridial myonecrosis from postoperative abdominal wounds
• Other signs of infection include:
• Sudden onset of pain at the surgical site following abdominal surgey
• Crepitus
• Edema
• Tense skin
• Bullae
• These are a medical emergency
• Necrotizing fasciitis as associated with strep, is polymicrobial and presents in immunocompromised patients
• Aggressive early debridement and IV antibiotics are key in management

Thermal Regulation Complications

• Hypothermia is a complication of thermal regulation, especially intraoperatively
• A drop in temperature of 2 degrees Celcius constitutes hypothermia
• A temp below 35 °C can cause coagulopathy and result in platelet dysfunction
• Risks are 3x increase in cardiac events and SSI (surgical site infection)
• There is also an increased risk of blood loss and the need for transfusion

Malignant Hyperthermia

• Autosomal dominant, rare
• Symptoms include: fever, tachycardia, rigidity, and cyanosis
• It can be treated with Dantrolene 1 to 2 mg/kg

Postoperative Fever

• The number one cause of fever post-op day #1 (POD#1) is atelectasis within 24 hours
• Management includes incentive spirometry and early ambulation to inflate alveoli and improve ventilation
• Consider further work-up beyond 48 hours after surgery
• Other considerations:
• H&P
• Blood, Urine, and Sputum cultures
• Chest X-ray (CXR)
• Treat the fever
• Whenever surgery is close to the thoracic cavity, there is a high possibility for atelectasis to occur

The 6 W's

• Common causes of post-operative fever can be distilled to the 6 "W's"
• Wind: Pneumonia, atelectasis
• Wound: Infection
• Water: UTI (urinary tract infection)
• Walking: DVT (deep vein thrombosis), possible PE (pulmonary embolism)
• Waste: Abscess
• Wonder: Medications

Pulmonary Complications

• Atelectasis is a pulmonary complication with the peripheral aveolar collapsing due to shallow tidal breaths
• It is the most common cause of fever within 48 hours post-op
• Aspiration pneumonitis requires only 0.3 ml per kilogram of body weight (20 to 25 ml in adults)
• Other pulmonary complications include:
• Nosocomial pneumonia
• Pulmonary edema (CHF, ARDS)
• Pulmonary embolus (1/5 are fatal)

Cardiac Complications

• Surgical cardiac complications are hypertension, arrhythmia, and ischemia/infarction
• Ischemia/infarction is the leading cause of death in any surgical patient
• Key to treatment for both of these events is prevention
• An arrhythmia is 30 seconds of abnormal cardiac activity
• Key to treatment for arrhythmias is to correct the underlying medical condition and conduct electrolyte replacement
• Magnesium > 2
• Potassium > 4

Renal Complications

• Renal complications include urinary retention, acute renal failure, and oliguria
• Inability to evacuate a urine-filled bladder after 6 hours can be a sign of a problem
• Catheterization becomes necessary with 250-300mL of urine
• Foley replacement is triggered with >500mL
• Oliguria is defined as < 0.5 cc/kg/hr
• Also consider:
• Pre-renal (FeNa < 1)
• Intrinsic (FeNa > 1)
• Post-renal (FeNa > 1)
• Preventing dehydration is key, especially in patients with some form of pre-existing renal impariment

Gastrointestinal Complications

• Postoperative ileus
• GI Bleeding
• Pseudomembranous colitis
• Ischemic colitis
• Anastomotic leak
• Enterocutaneous fistula

Postoperative Ileus

• Lack of function without evidence of obstruction

Small Bowel Obstruction

• Small bowel obstruction can occur, main cause is likely adhesions

GI Bleeding

• Find the source for GI Bleeding, get a detailed history, and place an NG tube if bleeding has occured
• Could be Cushing's ulcer
• Pseudomembranous colitis can also occur
• Superinfection with C difficile can occur, this is likely due to alteration or normal flora
• Toxic colitis requires surgical intervention and may lead to mortality betwen 20-30%

Gastrointestinal Complications Continued

• Ischemic colitis can result from atherosclerosis/thromboembolism
• Knowing which part of the bowel the patient has will help determine cause
• Surgical devascularization is another cause of hypercoagulable states, hypovolemia, and emboli which can cause further complications
• Anastomotic leak depends on the tension of the blood supply
• Enterocutaneous fistula is a very complex an challenging complication

Metabolic Complications

• Adrenal insufficiency is uncommon by potentially lethal
• This involves sudden cardiovascular collapse
• Presentation:
• Hypotension
• Fever
• Confusion
• Abdominal pain
• Hyper/Hypothyroidism
• Patients should be in euthyroid status before undergoing surgery
• SIADH
• Continue secretion despite hyponatremia
• Neurosurgical procedures and trauma

Neurologic Complications

• Beware the drugs that you will be prescribing
• Neurologic Complications:
• Delirium
• Dementia
• Psychosis
• Other concerns include infection, hypoxia, and electrolyte imbalance
• Seizure disorders
• Stroke and TIA

Haemorrhage

• Immediate Haemorrhage: inadequate haemostasis, unrecognized damage to blood vessels
• Early postoperative Haemorrhage: defective vascular anastomosis, clotting factor deficiency, intraoperative anticoagulants. Requires surgical re-exploring in most cases
• Secondary hemorrhage: from infection which erodes blood vessel. Treat cause