Surgical Complications

Reducing the risks of complication Good pre-operative evaluation Optimizing the general condition of patients Medical issues Nutritional issues (malnutrition, obesity) Minimizing preoperative hospital stay Good surgical technique Early mobilization

Complications What operation did the patient have? What are the most common complications of this operation? What is most life-threatening? What comorbidities does that particular patient have?

Overview Post op care has 3 phases Immediate post op care (Recovery phase) Care in the ward while discharging from the hospital Continued care after discharge from the hospital

Classification Wound Thermal regulation Postoperative fever Pulmonary Cardiac Gastrointestinal Metabolic Neurological

Wound Complications Dehiscence Evisceration Seroma Hematoma Infection Incisional Hernia Dehiscence – partial or total disruption of any or all layers of the operative wound, 2% of patients undergoing abd operation, separation of fascial layers with serosang drainage, technical complication Risk Factors – technical, infection, malnutrition, age, steroid use, inc intra-abdominal pressure, diabetes, poor wound healing Evisceration – rupture of all layers of the abdominal wall & extrusion of abd viscera Dehiscence may require an operation, but if it occurs at >POD 10, may be able to watch the wound, anticipate ventral hernia. Evisceration is a surgical emergency, cover the intestine with sterile saline moistened towel.

What do you do? Wrap in moist (with normal saline) dressing and call your chief.

Seroma Collection of liquefied fat, serum and lymphatic fluid under the incision Benign No erythema or tenderness Associated procedures: mastectomy, axillary and groin dissection Treatment: evacuation, pack, suction drains Persistent seromas may need OR exploration & ligation of lymphatic ducts. Clear, yellow fluid, viscous Groin seromas best left untouched (don’t want to introduce an infection). Treatment – evacuation, packed, suction drains

Hematoma Abnormal collection of blood Presentation: discoloration of the wound edges (purple/blue), blood leaking through sutures Etiology: imperfect hemostasis What is the biggest concern with retained hematoma in the wound? Can have pain, Small hematomas may resolve. Larger hematomas require evacuation. Prevention – careful hemostasis of the subcutaneous layer during closure. Treatment – depends on size and age, soon after surgery evacuate and pack, 2 wks post op will usually reabsorb.

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 40% of hospital acquired inf in surgery pt Surgical site infections – result from bacterial contamination during or after a surgical procedure Superficial – skin and subq Deep – fascia and muscle Organ – internal organs Where it comes from – intraluminal contents, skin, breaking sterile technique Operation risk vs patient risk Coagulase negative staphylococcus 22% Classification into clean, clean contaminated, contaminated, and dirty Necrotizing fasc – beta hemolytic strep (group A)

Necrotizing Fasciitis

Wound Infection Group A β-hemolytic streptococcal gangrene – following penetrating wounds Clostridial myonecrosis – postoperative abdominal wound Presentation: sudden onset of pain at the surgical site following abdominal surgery, crepitus  edema, tense skin, bullae = EMERGENCY Necrotizing fasciitis – associated with strep, Polymicrobial, associated with DM and PVD Management: aggressive early debridement, IV antibiotics

Complications of Thermal Regulation Hypothermia Malignant hyperthermia

Complications of Thermal Regulation Hypothermia Drop in temp by 2° C Temp below 35 ° C  coagulopathy, platelet dysfunction Risks: (1) 3x risk increase of cardiac events (2) 3x risk increase of SSI (3) increase risk of blood loss and transfusion requirement Normal – 37 degrees C Eg - trauma pt, paralytics (lose the shiver mechanism), rapid resuscitation with cool fluids, irrigation of body cavity Body response – decrease HR, Decrease CO, arrhythmias Make sure the patient is warm in the OR, Blankets, bear hugger, infusion of warmed IVF. Monitor with esophageal thermometer. Cardiac irritability seen with warming. Hypermetabolic state triggered by exposure to certain inhalational gases or succinylcholine. Often within 30 min but may see 24hrs later Causes intracellular Calcium to increase resulting in skeletal muscle contraction, arterial hypoxemia, metabolic respiratory acidosis, profound hyperthermia, hyperkalemia, hypercalcemia Elevated creatinine kinase Dantrolene 2.5mg/kg

Malignant hyperthermia Autosomal dominant, rare Presentation: fever, tachycardia, rigidity, cyanosis Treatment: Dantrolene 1 to 2 mg/kg 10 mg/kg total until symptoms subside

Postoperative Fever Infections – pod 5 UTI – pod 3 DVT, PE – pod 7-10 What is the number #1 culprit of fever POD #1? Atelectasis Management: IS (incentive spirometry), early ambulation Work-up > 48h: H&P Blood cultures UA/urine culture CXR Sputum culture …then Treat the Fever Infections – pod 5 UTI – pod 3 DVT, PE – pod 7-10 Abscess – pod 5-7 Drug - anytime

The 6 W’s WIND– pneumonia, atelectasis Wound – infection Water – UTI Walking – DVT, possible PE Waste – Abscess What day do we expect abscesses? Wonder – medications

Pulmonary complications Atelectasis – peripheral alveolar collapse due to shallow tidal breaths, MC cause of fever within 48h Aspiration pneumonitis – only requires 0.3 ml per kilogram of body weight (20 to 25 ml in adults) Nosocomial pneumonia Pulmonary edema – CHF, ARDS Pulmonary embolus – 1/5 are fatal greatest management = prevention After an operation you have loss of FRC Functional Residual Capacity due to abdominal distention, pain, obesity Smoking, COPD, Changes in pulmonary fxn include 1. decreased vital capacity, 2. decreased functional residual capacity and 3. pulmonary edema ICU pneumonia – staph aureus, #2 pseudomonas Prevention – teds, scds, subq heparin, ambulation

Chest X-ray Pulmonary Edema Pleural Effusion Pneumonia

Cardiac Complications Hypertension Ischemia/Infarction Leading cause of death in any surgical patient Key to treatment = prevention Arrhythmias 30 seconds of abnormal cardiac activity Key to treatment = correct underlying medical condition, electrolyte replacement (Mg > 2, K > 4) Post op HTN due to inadequate pain control, fluid overload, failure to give anti-HTN meds. Hypertension can cause aneurysm rupture, CVA, MI Arrhythmias can occur from electrolyte abnormalities, meds, stress, endocrine abnormalities, and underlying cardiac disease Atrial fibrillation is the most common arrhythmia and occurs between postoperative days 3 to 5 in high-risk patients. This is typically when patients begin to mobilize their interstitial fluid into the vascular fluid space. Contemporary evidence suggests that rate control is more important than rhythm control for atrial fibrillation.

Renal Complications Urinary retention Inability to evacuate urine-filled bladder after 6 hours 250-300 mL urine  catheterization >500 mL trigger foley replacement Acute renal failure Oliguria < 0.5 cc/kg/hr Pre-renal (FeNa < 1) Intrinsic (FeNa > 1) Post-renal (FeNa > 1) Mostly from dyscordination between the trigone and detrusor muscles as a result of post operative pain. Also may occur after spinal or epidural anesthesia, also medication use Bladder scan/straight catheterization Pre-renal – from impaired renal perfusion usually hypovolemia Intrinsic – actual injury to the nephrons, glomeruli, or tubules, think toxins Post – renal – obstruction, eg ligation of ureter Pre-renal dx, bun/cr ratio, FeNA

Gastrointestinal Complications Postoperative ileus GI bleeding Pseudomembranous colitis Ischemic colitis Anastomotic leak Enterocutaneous fistula Ischemic colitis 1-2 days following AAA with bloody bowel movement and/or earlier than expected return of bowel function. Fistulae are the abnormal communication of one structure to an adjacent structure or compartment, and are associated with extensive morbidity and mortality. Common causes for fistula formation are summarized in the pneumonic FRIENDS (Foreign body, Radiation, Ischemia/Inflammation/Infection, Epithelialization of a tract, Neoplasia, Distal obstruction, and Steroid use). The cause of the fistula must be recognized early, and treatment may include non-operative management with observation and nutritional support, or a delayed operative management strategy that also includes nutritional support and wound care. Postoperative ileus is related to dysfunction of the neural reflex axis of the intestine. Excessive narcotic use may delay return of bowel function. Epidural anesthesia results in better pain control, and there is an earlier return of bowel function, and a shorter length of hospital stay. The limited use of nasogastric tubes and the initiation of early postoperative feeding are associated with an earlier return of bowel function. SBO-When it does occur, adhesions are usually the cause. Internal and external hernias, technical errors, and infections or abscesses are also causative     Gastrointestinal bleeding can occur perioperatively (Table 11-3). Technical errors such as a poorly tied suture, a nonhemostatic staple line, or a missed injury can all lead to postoperative intestinal bleeding. The source of bleeding is in the upper gastrointestinal tract about 85 percent of the time, and is usually detected and treated endoscopically. Surgical control of intestinal bleeding is required in up to 40 percent of patients. Postsurgical intraabdominal abscesses can present with vague complaints of intermittent abdominal pain, fever, leukocytosis, and a change in bowel habits. Depending on the type and timing of the original procedure, the clinical assessment of these complaints is sometimes difficult, and a CT scan is usually required. When a fluid collection within the peritoneal cavity is found on CT scan, antibiotics and percutaneous drainage of the collection is the treatment of choice. There should still be a determination regarding what the cause of the infection was, so tailored antibiotic therapy can be initiated. Initial antibiotic treatment is usually with broad-spectrum antibiotics such as piperacillin-tazobactam or imipenem. Should the patient exhibit signs of peritonitis and/or have free air on radiograph or CT scan, then reexploration should be considered.

Postoperative Ileus Lack of function without evidence of obstruction Prolonged by extensive operation/manipulation, SB injury, narcotic use, abscess and pancreatitis Must be distinguished from SBO

Small bowel obstruction

Gastrointestinal complications GI Bleeding From any source  get detailed history, place NG tube Etiology: Cushing’s ulcer (less common with PPI use) Pseudomembranous colitis Superinfection with C difficile due to alteration in normal flora Toxic colitis is a surgical EMERGENCY (mortality 20-30%)

C Diff Colitis

Gastrointestinal complications Ischemic colitis Bowel affected helps determine cause Surgical devascularization, hypercoagulable states, hypovolemia, emboli Anastomotic leak POD# ? Enterocutaneous fistula The most complex and challenging complication Fistulae are the abnormal communication of one structure to an adjacent structure or compartment, and are associated with extensive morbidity and mortality. Common causes for fistula formation are summarized in the pneumonic FRIENDS (Foreign body, Radiation, Ischemia/Inflammation/Infection, Epithelialization of a tract, Neoplasia, Distal obstruction, and Steroid use). The cause of the fistula must be recognized early, and treatment may include non-operative management with observation and nutritional support, or a delayed operative management strategy that also includes nutritional support and wound care. Postoperative ileus is related to dysfunction of the neural reflex axis of the intestine. Excessive narcotic use may delay return of bowel function. Epidural anesthesia results in better pain control, and there is an earlier return of bowel function, and a shorter length of hospital stay. The limited use of nasogastric tubes and the initiation of early postoperative feeding are associated with an earlier return of bowel function. SBO-When it does occur, adhesions are usually the cause. Internal and external hernias, technical errors, and infections or abscesses are also causative     Gastrointestinal bleeding can occur perioperatively (Table 11-3). Technical errors such as a poorly tied suture, a nonhemostatic staple line, or a missed injury can all lead to postoperative intestinal bleeding. The source of bleeding is in the upper gastrointestinal tract about 85 percent of the time, and is usually detected and treated endoscopically. Surgical control of intestinal bleeding is required in up to 40 percent of patients. Postsurgical intraabdominal abscesses can present with vague complaints of intermittent abdominal pain, fever, leukocytosis, and a change in bowel habits. Depending on the type and timing of the original procedure, the clinical assessment of these complaints is sometimes difficult, and a CT scan is usually required. When a fluid collection within the peritoneal cavity is found on CT scan, antibiotics and percutaneous drainage of the collection is the treatment of choice. There should still be a determination regarding what the cause of the infection was, so tailored antibiotic therapy can be initiated. Initial antibiotic treatment is usually with broad-spectrum antibiotics such as piperacillin-tazobactam or imipenem. Should the patient exhibit signs of peritonitis and/or have free air on radiograph or CT scan, then reexploration should be considered.

Metabolic complications Adrenal insufficiency Uncommon but potentially lethal Sudden cardiovascular collapse Presentation: hypotension, fever, confusion, abdominal pain Work-up: Stim test with administration of hydrocortisone (baseline cortisol at 30 minutes and 60 minutes) Hyper/Hypothyroidism SIADH Continue ADH secretion despite hyponatremia Neurosurgical procedures, trauma stroke, drugs (ACEI, NSAIDs)

Neurologic Complications Beware the drugs that you will be subscribing Delirium, dementia, psychosis Seizure disorders Stroke and TIA

Haemorrhage Immediate: Inadequate haemostasis , unrecognized damage to blood vessels Early postoperative: defective vascular anastomosis , clotting factor deficiency , intraoperative anticoagulats surgical re-exploring is usually required Secondary hemorrhage: Related to infection which erodes blood vessel Several days postoperative treatment of infection

Scenario You are called by the nurse about a patient who has just undergone a thyroidectomy with report of the patient having difficulty breathing and desaturations? What do you do? What are you concerned about? Run to the bedside with a suture removal kit (one at bedside at all times)