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Post operative complications

Post operative complications. อาจารย์ที่ปรึกษา อ.พญ.พิมประภา กัณฑะษา จัดทำโดย นสพ . กมลศักดิ์ อุ่นตา นสพ.รัฐศาสตร์ พุ่มรส นสพ.พิมลศักดิ์ ศรีธรรมา นสพ.ใหม่ จำปาศักดิ์ โรงพยาบาลพิจิตร. Content. Wound complication Thermal regulation complication Pulmonary complication

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Post operative complications

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  1. Post operative complications อาจารย์ที่ปรึกษา อ.พญ.พิมประภา กัณฑะษา จัดทำโดย นสพ. กมลศักดิ์ อุ่นตา นสพ.รัฐศาสตร์ พุ่มรส นสพ.พิมลศักดิ์ ศรีธรรมา นสพ.ใหม่ จำปาศักดิ์ โรงพยาบาลพิจิตร

  2. Content • Wound complication • Thermal regulation complication • Pulmonary complication • Endocrine complication • Cardiovascular complication • Neurological complication • Renal complication • GI complication • HEENT complication

  3. WOUND COMPLICATIONS

  4. Wound Complications 1. Wound infection 2. Woundhematoma 3. Wound seroma 4. Wound dehiscence

  5. Wound infection • Surgical and environment factor • Pre-op, Intra-op, Post-op • Microbial factor • Staphylococcus aureus • Enteric organism in the boweloperations • Host factor • U/D

  6. Classification of operative wounds and risk of infection

  7. Clinical presentation Inflammatory sign Pain Swollen and edematous redness and cellulitis warmth Fever , Heart rate increase Day 5th – 8th postoperative days

  8. Mangement Depends on the extent of destruction and the type of the wound infection Simple collection of purulent material in skin and subcutaneous. Opening the incision and drainage Debridement

  9. Wound hematoma Caused by inadequate hemostasis Pain and swelling Serosanguinous in drainage Wound opened and evacuated Closed suction (predisposing factor/ hemostasis) Correct hemostasis problem

  10. Wound seroma Lymph collection Large area of lymph-bearing tissues are transected Fertile ground for bact  wound infect Management  repeat aspiration/ closed suction drainage

  11. Wound dehiscence The seperation within the fascial layer Usually of the abdomen Generally caused by technical factor Incision in vertical  horizontal incision

  12. Wound dehiscence (Cont.) Factors Malnutrition Hypoproteinemia morbid obesity Malignancy w/ immunologic deficiency Uremia DM Coughing increase abd. Pressure Remote infection

  13. Wound dehiscence (Cont.) Local factors Midline vertical incision Hemorrhage Wound infection Poor technique

  14. Prevention • Correct factor : infection, nutrition, blood sugar • Midline incision  oblique, transverse incision • Mass closure suture • Suture material • Chromic catgut  dehiscence • Nylon, prolene, steel wire • Dexon, vicryl

  15. Thermal regulation complications

  16. Thermal regulation Fever Malignant Hyperthermia Hypothermia

  17. Post-operative fever

  18. Pathophysiology • Fever >38ºC is common after surgery • Usually inflammatory stimulus of surgery and resolves spontaneously • Fever = response to cytokine release • Fever-associated cytokines are released by tissue trauma and do not necessarily signal infection • Cytokines produced by monocyte, macrophages, endothelial cells • Fever-associated cytokines = IL-1, IL-6, TNF-alpha, IFN-gamma

  19. สาเหตุที่พบบ่อย ใช้ตัวย่อคือ “5 W” โดยเกิดเรียงลำดับหลังการผ่าตัดดังนี้ • Wind, POD1-2: the lungs, i.e. pneumonia, aspiration, and pulmonary embolism, but not atelectasis • Water, POD3-5: urinary tract infection • Walking (or VEINS, which then sounds like "Weins"), POD4-6: deep vein thrombosis or pulmonary embolism • Wound, POD5-7: surgical site infection, which in obstetrics or gynaecology, may refer to the Womb. • Wonder drugs or “What did we do?”, POD7+: drug fever, infections related to intravenous lines

  20. Causes of Postoperative Fever

  21. Malignant Hyperthermia After exposure to a triggering GA (anesthetic complications) Occurs rare in 1 in 30,000 to 50,000 adults.

  22. INCIDENCE • 1:12 000 - 1:40 000 • Male = Female • No racial difference

  23. Susceptibility to MH is inherited as an AD disease (mutation) Altered Ca2+ regulation in skeletal muscle Abnormal release of Ca2+ Prolonged activation of muscle filaments Excessive generation of heat. If untreated : myocyte death  rhabdomyolysis  hyperK & myoglobulinuria.

  24. Clinical presentation Rapid rise in body temp ,usually during the initiaton of a GA after admin. of succinylcl.or potent inhalation agent ,particularly halothane Metabolic acidosis & e’lyte imbalance (hyperCa2+) Hypotonicity of skeletal muscle (acidosis) >42 C  hypercapnia, cardiac arrhythmia

  25. FULMINANT CRISIS • Tachycardia • Metabolic acidosis,  O2 sat,  pCO2 • Muscle rigidity • Electrolyte disturbance • Arrhythmias • Myoglobinuria • Hyperthermia

  26. DIAGNOSIS, consider MH if • Masseter muscle spasm after sux • Unexplained, unexpected tachycardia • Unexplained, unexpected increase in end - tidal CO2

  27. EARLY MANAGEMENT 1 • STOP ALL ANAESTHETIC VAPOURS • CHANGE TO CLEAN ANAESTHETIC BREATHING SYSTEM • ABANDON SURGERY IF FEASABLE

  28. EARLY MANAGEMENT 2 • DANTROLENE • MEASURE ABGs, K+ AND CK • MEASURE CORE TEMP • COOL PATIENT

  29. Hypothermia Core temperature below 35° C 80% of elective operative procedures are associated with a drop in body temperature 50% of trauma patients are hypothermic on arrival in the operating suite.

  30. Risk Factors for Decreased Thermostability

  31. Cool ambient room temp. Rapid administration of IV fluids or blood. Prolonged surgical procedure Advanced age Opioid analgesia Propofol causes vasodilation and significant redistribution hypothermia

  32. Degrees of Hypothermia

  33. A core temperature < 35°C after surgery Hypertension (Sympathetic  NE  vasoconstriction  elevated arterial blood pressure) Shivering, uncomfortable cold sensation Clinical presentation

  34. Core To < 35°C Early postoperative ischemia Ventricular tachyarrhythmia. Coagulation defect  bleeding Impairs platelet function Reduces the activity of coagulation factors

  35. Poor healing and infection. Impaired macrophage function Reduced tissue oxygen tension Impaired collagen deposition Relative diuresis Compromised hepatic function Neurologic manifestations. Impaired acid-base balance In severe cases the patient Bradycardia low BP DecreaseRR Comatose

  36. Monitoring core temperature, Undergoing body cavity surgery Surgery lasting longer than 1 hour Children and the elderly General-epidural anesthesia Anesthetized and during skin preparation  significant evaporative cooling can take place  the patient is kept warm by increasing the ambient temperature and using heated humidifiers and warmed IV fluid. Prevention

  37. Treatment Warm blankets Forced-air warming devices Infusion of blood and IV fluids through a warming device    Heating and humidifying inhalational gases Peritoneal lavage with warmed fluids    In rare cases, cardiopulmonary bypass

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