01complications of surgery -.pdf

 Objectives of the lecture: By the end of this lecture the student should be able to: Recognize types of post-operative complications Identify pulmonary problems after surgery Identify circulatory problems postoperatively Differentiate between different types of hemorrhage post su...

 Objectives of the lecture: By the end of this lecture the student should be able to: Recognize types of post-operative complications Identify pulmonary problems after surgery Identify circulatory problems postoperatively Differentiate between different types of hemorrhage post surgery Realize how to avoid pressure sores  Classifications of complications 1-Acording to the time of occurrence Immediate Early Late long term (1st 24 hours) (1st week) (1st Month) ( after 1 month) 2- 2nd Classification General Specific For any surgery For Specific surgery  A range of drains may be used e.g. T-tube drains in gall bladder surgery; multiple drains in head and neck or breast surgery. Stoma care may be required after bowel surgery – Specifics color, size, surrounding skin and activity must be considered. of Orthopedic surgery may require Surgery extensive physiotherapy ttt. Cardiac surgery involves transfer to CCU for 24 hours. Body image may be affected especially in head and neck, breast, genito-urinary or bowel surgery.  I. Complications predisposed to medical disorders, e.g. ischemic heart disease. II. Complications of anesthesia. General surgical III. Wound site complications e.g. hemorrhage or complications. infection. IV. Complications of internal organs and systems, e.g. urinary tract, GIT, cardiovascular system. II-Complications secondary to Anesthesia 1-RESPIRATORY COMPLICATIONS -Lung tidal volume may be reduced by as much as 50%, depending on the incision site. -Lung expansion is reduced by the supine posture during and after operation, pain, abdominal distension, abdominal constriction by bandages and the effects of sedative drugs. -There is loss of normal periodic hyperinflation. -Airway defenses are compromised by loss of the cough reflex and diminished ciliary activity, which both lead to accumulation of secretions.  a-Atelectasis: Predisposing factors include shallow ventilation, loss of periodic hyperinflation, inhibition of coughing and pooling of mucus. Prevention and treatment of atelectasis: *This includes deep breathing *Nebulizer bronchodilators such exercises, regular adjustments of as salbutamol may assist the posture and vigorous coughing. patient-to cough up secretions. *Severe cases of diffuse atelectasis may require endotracheal incubation and positive pressure ventilation 2-Pneumonias: Bronchopneumonia is the usual form of chest infection seen in surgical patients. Infection is manifest by pyrexia, tachypnoea, tachycardia and sometimes cyanosis. The mucopurulent sputum is thick, copious and green. Antibiotics, usually amoxycillin may be given. 3-Adult Respiratory Distress Syndrome: This syndrome of acute respiratory failure is characterized by rapid, shallow breathing, severe hypoxaemia, stiff lungs. Chest X-ray Pulmonary Edema Pleural Effusion Pneumonia Cardiac Complications Ischemia/Infarction Leading cause of death in any surgical patient Hypertension Key to treatment = prevention Arrhythmias 30 seconds of abnormal cardiac activity Key to treatment = correct underlying medical condition, electrolyte replacement (Mg > 2, K > 4)  Complications according to types of anesthesia: 1.Local anaesthesia: Injection site - pain, haematoma, delayed recovery of sensation (direct nerve trauma). Systemic effects of local anaesthetic agent: - Allergic reactions (very rare). - Toxicity due to excess dosage, it includes: dizziness, tinnitus. nausea and vomiting, fits, CNS depression, bradycardia 2-Spinal, Epidural and Caudal Anaesthesia:  Technical failure.  Headache  Intrathecal bleeding  Permanent nerve or spinal cord damage  Injection of incorrect drug.  Paraspinal infection - introduced by the needle.  Systemic complications - severe hypotension or postural hypotension  3.General anaesthesia: Direct trauma to mouth or pharynx, e.g. teeth. allergic reactions. Minor effects, e.g. postoperative nausea and vomiting. Major effects: e.g. cardiovascular collapse. Slow recovery from anaesthesia. Drug interactions. Inappropriate choice of drugs or dosage in relation to age. Hypothermia.  3-GENERAL COMPLICATIONS OF OPERATIONS The main complications of any operation are: 1. hemorrhage 2. Infection 3. delayed wound healing 4. surgical damage to related structures 5. inadvertent trauma to the patient in theatre. 6. Thermal regulation 7. GIT 8. Pulmonary complications 10. Renal 11. Cardiovascular 12. Neurological 13. Circulatory 1.HEMORRHAGE A. Intraoperative Hemorrhage: Hemorrhage occurring during an operation (primary hemorrhage) should be controlled by the surgeon before the operation is completed. B. Early Postoperative Hemorrhage: Hemorrhage during the immediate postoperative period indicates inadequate operative hemostasis or unrecognized trauma to a blood vessel.  C)Late Postoperative Hemorrhage Hemorrhage occurring several days after operation ,is usually related to infection which erodes vessels at operation site; this is known as secondary hemorrhage. Treatment involves managing the infection, but exploratory operation is often required to legate bleeding vessels.  WOUND INFECTION Superficial Site Infection (SSI) Superficial Deep (involving the fascia/muscle Presentation: erythema, tenderness, drainage Organ Space Occurring 4-6 days postop Presentation: SIRS symptoms  WOUND INFECTION 1. Group A β-hemolytic streptococcal gangrene – following penetrating wounds 2. Clostridial myonecrosis – postoperative abdominal wound Presentation: sudden onset of pain at the surgical site following abdominal surgery, crepitus  edema, tense skin, bullae = EMERGENCY 3. Necrotizing fasciitis – associated with strep, Polymicrobial, associated with DM and PVD Management: aggressive early debridement, IV antibiotics  B)Wound Cellulitis and Abscess: These infections commonly present first with a pyrexia; examination of the wound reveals either a spreading cellulitis or localized abscess formation. Cellulitis is treated with appropriate anti-inflammatory C)Late infective complications: A late infective complication of surgery is a chronically discharging wound sinus. It usually relates to foreign material such as a non-absorbable suture or mesh or sometimes necrotic fascia or tendon. 3- IMPAIRED HEALING: A) Factors Retarding Wound Healing:  Arterial insufficiency  The wound is under excess suture tension  long-term steroid therapy  Immunosuppressive therapy  previous radiotherapy  Severe rheumatoid disease  Malnutrition  Vitamin deficiency especially of vitamin C.  B) Incisional Hernia: Incisional hernia is a late complication of abdominal surgery. - Predisposing factors are Abdominal obesity Distension Poor muscle quality Poor choice of incision Inadequate closure technique Post-operative wound infection Multiple operations through the same incision. 4-Surgical injury to related structures: *Unavoidable Tissue Damage: e.g. facial nerve damage during total parotidectomy. *Inadvertent Tissue Damage: e.g. recurrent laryngeal nerve damage during thyroidectomy *Inadvertent operating theatre trauma -Injuries resulting from falls from trolleys or operating table during positioning. -Injury to diseased bones and joints from manipulation. -Ulnar and lateral popliteal nerve palsies. 3- Predisposing factors for deep vein thrombosis and pulmonary embolism Thromboem bolism Direct trauma to the pelvis and lower limbs. Previous venous thromboembolism. Pre-existing lower limb venous disorder causing stasis. Venous stasis during general or regional anaesthesia. Malignant disease. Immobility. e.g. bed bound patients after operation. Pregnancy. Pelvic masses. Obesity. Dehydration. 4-Deep The classic clinical features Venous found include swelling of the leg, Thrombosis tenderness of the calf muscles, increased warmth of the leg, and calf pain on passive dorsiflexion of the foot (Homan’s sign). Occlusion of the ilio-femoral veins tends to produce diffuse and sometimes massive swelling of the whole lower limb. In addition, there is tenderness over the femoral vein in the groin. In severe cases, the leg becomes painful and white boggy with edema.  5-PULMONARY EMBOLISM The classic picture of pulmonary embolism (PE) is sudden dyspnoea and cardiovascular collapse, followed by pleuritic chest pain, development of a pleural rub and haemoptysis. ECG may show evidence of right heart strain. Prevention of Venous Thromboembolism These include early postoperative mobilization, adequate hydration and avoiding calf pressure. For patients at higher risk, specific prophylactic measures should be taken to reduce the risk of deep venous thrombosis (and consequent pulmonary embolism). Prophylactic measures for prevent Venous Thromboembolism include the following: Low-dose subcutaneous heparin. Calf compression devices. Several pneumatic and electrical devices are available for intraoperative. Compression to simulate normal muscle pump activity. Graded-compression “anti-embolism’ stockings Compression stocking General wound healing principles Optimize the host Evaluate for internal /external barriers to healing Promote perfusion and oxygenation Focus on glycemic control (hgb A1C) Infection control – prevent cross contamination Focus on nutritional needs‐ calories‐‐‐oral/dental health Manage pain and psychological factors Smoking cessation  Components of Wound Assessment Wound location Wound type Wound measurement Wound tissue color and percentage Wound drainage, amount and type Odor Surrounding skin / wound edge Dressing(s) used and frequency Pain level Etiology ?????????? 6-Pressure Sores Prevention and management of pressure sores: Relieving pressure on the heels. Use of ankle rests while on the operating table. use of heel pads. Special bed surfaces to spread the load. Regular change of posture - for most patients. Regular checking of pressure areas and local massage. Management of incontinence. 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) Hypothermia 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 KEEP THE PATIENT WARM Use warmer(Bair Hugger) blankets Use warm lights  GIT a) Post Operative ileus b) Others specific to surgeries: Complications ➔ Post Operative GI Bleeding ➔ Abdominal Compartment syndrome ➔ Anastomotic leak ➔ Complications related to stoma Renal Complications a) Urinary Retention b) Acute Renal Failure  a) Myocardial ischemia and infarction Cardiovascular b) Congestive heart Complications failure c) Hypertension Neuroligal Complications a) Perioperative Stroke b) Seizures c) Delerium Shock Position Keep the patient in shock position, flat on back, legs elevated at 20 degree + knee kept straight.  Psychological Issues ► Inability to ► Memory dysfunction concentrate e.g. unable reading a book or e.g. reduced ability to ► Easily tired said or done. to concentrate newspaper. remember things effectively whilst recently ► Behavioural ► Highly confused e.g. ► Reduced ability to problems- more hallucinations due to management. after surgery. perform arithmetic aggression due to medication on for pain increased confusion ► Self-esteem issues ► Body image issues ► Depression