1. Surgical Complications

2. 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

3. 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?

4. 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

5. Classification Wound Thermal regulation Postoperative fever Pulmonary
Cardiac
Gastrointestinal
Metabolic
Neurological

6. 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.

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

8. 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

9. 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.

10. 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)

11. Necrotizing Fasciitis

12. 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

13. Complications of Thermal Regulation
Hypothermia
Malignant hyperthermia

14. 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

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

16. 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

17. 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

18. 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

19. Chest X-ray
Pulmonary Edema
Pleural Effusion
Pneumonia

20. 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.

21. Renal Complications Urinary retention
Inability to evacuate urine-filled bladder after 6 hours
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

22. 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.

23. 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

24. Small bowel obstruction

25. 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%)

26. C Diff Colitis

27. 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.

28. 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)

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

30. 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

31. 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)