Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Primum no nocere Think before you act.

Complications can be deadly… Logarithmic increase in bile duct injuries after the introduction of laparoscopic cholecystectomy.

SCIP Antibiotics Normothermia VTE Prophylaxis

Morbidity and Mortality Conference Mainstay quality program of general surgery residency programs.

Mortalities

Morbidities Cardiorespiratory Wound Urinary tract

Wound Seroma Hematoma Dehiscence Evisceration

Wound Superficial Deep Organ space

Pathogens Staphylococcus(coagulase neg) 25% Enterococcus(D) 11.5% Staph aureus 8.7% E. coli 6.5%

Wound classification Clean Clean contaminated Contaminated Dirty

Temperature regulation Issues of hypothermia

Malignant hyperthermia 1 in 30,000 cases Mortality less than 10% Autosomal dominant with variable penetrance Altered calcium metabolism Halothane, isoflurane, succinylcholine Cause rise myoplasmic calcium

MH Tachycardia Arrhythmia Raised temperature Acidosis Muscle rigidity Tachypnea Flushing (inability to open mouth)

Treatment Discontinue triggering anesthetic Hyperventilate with 100% oxygen Terminate surgery Dantrolene 2.5mg/kg as bolus and repeat every 5 minutes Monitoring Sodium bicarbonate Beta blockers Lidocaine Lasix

Pulmonary complications Atelectasis Pneumonia Pulmonary embolism Aspiration Pulmonary edema ARDS

Weaning criteria RR <25 breaths/min Pa02 >70mmHg(Fi02 of 40%) PaC02<45 mm Hg MV 8-9L/m TV 5-6mL/kg NIF -25cm H20

Cardiac Greatest risk in first 48 hours Non-Q wave, non ST segment elevation

Prevention Major predictors of risk Unstable chest pain, CHF, sympotomatic arrhythmias, severe valvular disease

Management Cardiology consult Tachyarrhythmia Unstable-cardioversion SVT-Beta blocker, esmolol, amiodarone PSVT-vagal stimulation, adenosine, amiodarone MAT-B blocker or amiodarone VTach-lidocaine or amiodarone Brady-atropine Heart block-high grade second or third degree- insertion of permanent pacemaker

Amiodarone Phosphodiesterase inhibitor Inhibits breakdown of camp Increase cardiac output and decreases preload and after load without increasing myocardial oxygen demand May cause vasodilitation and GI problems and thrombocytopenia

Adrenal Chronic use of steroids causes suppression of the HPA axis Potentially life threatening Give 250ug cosyntropin intravenousl

Hemodialysis indications Serum potassium >5.5 BUN>80-90 Persistent metabolic acidosis Acute fluid overload Uremic symptoms(pericarditis, encephalopathy, anorexia) Removal of toxins Platelet dysfunction Hyperphosphatemia with hypercalcemia

SIADH Common cause of chronic normovolemic hyponatremia Serum sodium<135 Treat underlying disease process Fluid restriction Rapid correction may result in seizures

Gastrointestinal Ileus Early SBO Compartment syndrome GI bleeding Stomal complications C. difficile colitis

Anastomotic leak Strategies for prevention Low anterior resection

Enterocutaneous fistula Low output <200 cc/24h Moderate cc/24 h High >500 cc/24 h

“The Checklist” Provonost Gawande

Airline Industry Crew resource management Communication No hierarchy Checklist, checklist, checklist Debriefing

Universal Protocol Preprocedure Verification Presurgical “timeout” Post procedure “debriefing”

Prospective Case Conference Dr. Judson Randolph 1988-Childrens Hospital Center, Washington, DC A priori discussion of all upcoming pediatric surgery cases involving multiple disciplines

Interdisciplinary teamwork GI/bleeds/biliary Radiology/bleeds/abscess Medicine/evaluation/cardiac Anesthesia/PST/surgical readiness

“Never events” CMS