Pre Postoperative care complications Fuad Ammari

1. Pre & Postoperative care & complicationsFuad Ammari May result from primary dis., the operation, or others. e.g MI after Bleeding The usual clinical signs of disease are blurred in the post operative period Early detection of postop. Comp. Requires repeated evaluation of the patient by the operating team.

2. Prevention of complications - Pre-op care: Stop smoking, loss of weight, control of chronic disease, prophylactic antibiotics, respiratory exercise, correction of any bleeding tendency and good surgical tech. post-op care: Early mobilization, respy. Care and fluids and electrolytes needs

3. Routine preop. Evaluation History: Resp. dis., smoking, CVS disease including DVT, Bleeding diathesis, Hypertension, diabetes, Previous gen. anesthesia, drugs and alcohol intake.

4. Goldman cardiac risk factors in non cardiac surgical operations Listed in descending order Signs of cong. heart failure----------------- 11 Myocardial. Infarction in the last 6 months--10 Premature ventricular beats 5or more----------7 Arrhythmias---------------------------------------7 Age-70y or more--------------------------------- 5 Emergency surgery-------------------------------4 Thoracic, up. Abdo.surg, vasc., ao.stenosis---3

5. Clinical Predictors of Increased Risk for Perioperative Cardiac Complications MAJOR�� Recent myocardial infarction (within 30 days)�� Unstable or severe angina�� Decompensated congestive heart failure�� Significant arrhythmias (high-grade atrioventricular block, symptomatic ventricular arrhythmias with underlying heart disease, supraventricular arrhythmias with uncontrolled rate)� �Severe valvular disease

6. Clinical Predictors INTERMEDIATE�� Mild angina�� Prior myocardial infarction by history or electrocardiogram�� Compensated or prior congestive heart failure�� Diabetes mellitus��Renal insufficiency

7. Clinical Predictors MINOR�� Advanced age� �Abnormal electrocardiogram��Rhythm other than sinus (e.g., atrial fibrillation)� �Poor functional capacity� �History of stroke�� Uncontrolled hypertension (e.g., diastolic blood pressure >10 mm Hg)

8. prevention O/E: � Nutrition, mental status. Dentures, abnormalities of jaw and neck. Resp. & CVS disease. Investigations: Hb, Blood group, urinalysis. CXR & ECG Pt. Above 50y, smokers, CVS, & Resp. dis. Urea and electrolytes.

9. Physical status scale: American Society of Anesthesiologists ASA class Physical state 1 A normally healthy individual 2 Pt.with mild to moderate disturbances controlled DM or Hypertension 3 severe systemic disease not incapacitating � Heart dis.with limited exercise tolerence, � Uncontrolled hypertension or DM

10. Physical status scale 4. Incapacitating systemic dis. That is a constant threat to life with or without surgery eg. CCF & severe angina. .5 A moribund patient who is not expected to live and where surgery is performed as a last resort e.g. ruptured aortic aneurysm .6 A pt. Who requires an emergency surgery

11. High risk group Eldery patients, resp.dis., smokers. CV dis., Obese pt., DM., Jaundice. Chronic drug medication Bleeding tendency Oral contraceptive pills.

12. Elderly patient Due to limited mobility Intercurrent illness Diminished cardiac, respiratory and renal reserve Higher postoperative wound infection Longer hospital care DVT and delirium.

13. Respiratory dis. & smoking Obstructive airway disease increase the risk of post-op pulmonary complications and require careful pre-op evaluation. Blood gas analysis Spirometry Exercise tolerance test Sputum cultureActive

14. Resp. & Smoking Breathing exercise. Physiotherapy Salbutamol nebulizer Cessation of smoking: Due to Viscid secretions and impaired clearance of mucus Pulmonary collapse & infection results

15. Obese patients Increased risk of Resp. complications DVT Wound Infections & Dehiscence Limited mobility & hypertension Difficult operation Encourage weight reduction

16. Postoperative care Immediately after surgery Patient care of assurance, mobilization, oral fluids and prevention of complication Pain control and analgesia Bleeding, breathing and urinary output. Initial and post op. tests e.g. Hb, CXR, KFT �..etc.

17. Routine daily checks in postoperative care �SOAP� Subjective: Greet the patient, ask him how he is doing, assess consciousness and morale Pain Nausea Passed flatus and urine Complaint of abnormal neurovascular status

18. SOAP Objective: Gen. look, cyanosis, pain, shock. breathing, cough, sputum and pyrexia. � Pulse, BP, temp, RR. � Skin turgor, moist tongue, urinary output. Fluid balance, �

19. SOAP objective � drains and bowel sounds � Wound discharge, blood or sero-sanguinous � Pressure areas � Results of requested lab. or radiol. tests. � Check previous illnesses

20. SOAP Active problems and assessment Analysis of key problems arising from the subjective and objective findings. e.g. shortness of breath, low urinary output, or acute abdominal or chest pain Plan: the action to be taken according to analysis of findings

21. Wound complications Hematoma:- Due to Imperfect hemostasis during operation, bleeding tendencies, aspirin, heparin and warfarin. Vigorous cough or straining may initiate bleeding Clinically; swelling, discoloration of the wnd. edges, discomfort, blood ooze from skin edges

22. Hema-cont Neck hematomas expand rapidly, deviate & compress the trachea. It needs immediate evacuation Small hematomas may be absorbed but it predisposes to wnd infection Evacuatn under GA may be necessary with ligation of bleeding and closure

23. Seroma Collection of fluid �serum� Delays healing Increases the risk of wnd infection Often follow elevation of skin flaps that leeds to lymphatic damage Can be prevented by pressure dressing Aspiration or incision and evacuation Antibiotics cover.

24. Wound Dehiscence Partial or total disruption, it occurs between 5th-8th.post op days, serosanguinous fluid or evisceration It is due to: Systemic causes: Elderly, diabetics, jaundice, cancer, immunocompromised, hypoproteinemia, obesity, corticosteroids

25. Wnd. dehiscence- cont. Local causes: 1-In the wound:- Improper closure of anatomic layers.- Devitalized tissues due to rough handling -Suture material, - Dead space, - FBs and - drains 2- Increased intra-abdominal pressure; ileus, obesity , ascitis, and COPD 3-Infection: hematoma, seroma and FBs

26. Wnd. Deh. cont Management: Prevention by proper preop. Preparation Cover with moist sterile towels Antibiotics Closure under GA If neglected it will led to incisional hernia

27. Chronic pain Due to: Stitch abscess, Granuloma, Hernia, Neuroma

28. Respiratory complications Most common single cause of morbidity Second most common cause of death in patients older than 60 y It occurs more frequently in: Upper abdo. & chest surg., emergency, elderly, ch. Bronch. And asthma, smoking & obesity

29. Atelectasis It is the most common pulm. Complications It occurs within the first 48 h of surg. In about 25% of pts. With abdo. Surg. & responsible for over 90% of febrile episodes during that peroid Pathogenesis:1- Obstruction: by secretions, blood clots & malpositioning of endotracheal tube. 2- Non obstructive: closure of the bronchioles due to shallow breathing

30. Atelect. Cont. Clinically manifested by fever, tachypnoea, tachycardia. O/E Scattered rales, decreased air entry & elevation of the diaphragm on that side. . Prevenetd by preop. proper treatment of resp. disease, stop smoking (6w), early mobilization,and encourage deep breathe & cough in the postop period . Managed by chest percussions and breathing exercises, Nasotrach. Aspiration, broncho-dilators and mucolytics. Usually recover uneventful

31. Pulmonary Aspiration Normally prevented by GO & Pharyngo-oesoph sphincters Predisposed by NG & endotrach tubes, depression of the CNS by drugs, trauma, GO. Reflux, intestinal obstruction, pregnancy & pt. Positioning. Minor degrees of aspn. Can be found in 15% of abdo. Surg. & may occur during sleep and are well tolerated

32. pul. Aspn. cont  The magnitude of injury depends on: pH, frequency & volume of aspirate. Pathogen; chemical pneumonitis- oedema- inflammation-infection. Obst. Of bronci or bronchioles by large food particles� atelect. Prevention by preop. fasting ,proper positioning & careful intubation Treatment: Bronchoscopy, intubation, & suction fluid resuscitation, hydrocortisone, antibiotics & chest physioth.

33. Post-op. pneumonia The main cause of death after surg. Predesposed by Atelect.,aspiration, or copious secretions associated with infections & prolonged intubation Causative bacteria: staph, pseudomonas, klebsiela & G-ve bacilli. Clinically; fever, tachycardia, tachypnoea, & features of consolidation- CXR Treated by breathing exercise & cough, antibiot., mucolytics & bronchdilators

34. Deep vein thrombosis It is associated with a high mortality rate esp in the elderly. The cause is usually multi factorial Virchow�s triad; 1- Stasis can occur with venous insufficiency, severe heart failure, prolonged bed rest or immobility & surgery or fractures of the pelvis or hip joint

35. DVT Cont. 2-Endothelial vascular damage by cannulation or irritation by chemicals 3- Hypercoagulable state either; a-acquired e.g; In cancers of the lung, pancreas, prostate, breast & ovaries

36. DVT b-inherited e.g; � Deficiency of antithrombin III. � Protein C & S � As a result of nephrotic synd., liver failure, & DIC. 4- Advanced age, obesity, CCP, multiparity, Infly bowel dis.

37. DVT. Cont. It occurs most frequently in the calf veins & spread to the proximal veins (25%) that can led to venous insufficiency or fatal pul. Embolism Clinically: 1-Pain in the thigh or calf, sometimes with oedema. 50% are asymptomatic 2- Hx of recent surgery,trauma, cancer, CCP, or immobilization.

38. DVT. Cont. 3- Homan�s sign positive in 50% of cases 4-Venous duplex U/S is diagnostic. Prevention by elastic stocking with sequential compression & low dose unfractionated heparin or LMWH Treatment: The primary treatment is by systemic anticoagulation, initially with heparin then continue with warfarin

39. Fat embolism It is relatively common but only rarely causes symptoms. Fat particles are present in the pulmonary bed in 90% of long bone fractures. Exogenous sources are; Bld. transfusion, IV. Lipid in parenteral nut., or bone marrow transplantn.

40. Fat emb. Fat emb. Syndrome: It occurs 12- 72 h after injury. Neurologic dysfunctn., Respiratory insufficiency. Petechiae of axilla, chest & arms The findings of fat droplets in sputum & urine. Treated by positive pressure ventn. & diuretics until symptoms disappear

41. Cardiac complications To avoid compln. Preexisted card. Dis. Should be properly evaluated by a cardiologist. Evaluatn. Of Lt. Vent. Ejection- fraction to identify pts. at high risk. ECG-monitoring Ao. Stenosis limits the ability of the heart to respond to increased demand. Bleeding & hypo-proteinemia--- compn.

42. Card. Compl. Dysrhythemias; appear during the operation & within 3/7 after surgery eg. Chest surg. Supra vent. Dysrhythemia Ventricular premature beats Heart block.

43. Postop. MI. Precipitated by hypoxia & hypotension Asymptomatic in 50% of cases Chest pain & hypotension are the main features Monitor in CCU, ECG changes Anticoagulants & O2 inhalation

44. Card. Failure Fluid overload in pts. With limited card. Reserve Postop. MI, sepsis, multiple injuries. Progressive dyspnoea & hypoxia Normal PCO2 & decreased PaO2. Diffuse congestion in CXR. Treat in CCU; Dopamine is the best drug for inotropic support, Diuretics, fluid restriction, digoxin & respiratory support �ventilation�

45. Peritoneal comp. Hemoperitoneum: Bleeding is a common cause of shock within 24h after surg. Mainly due to tech. Problems. Coagulopathy may play a role Clinicaly; hypovolemia & shock Increasing abdo. Girth If persisted--- Re-operate; evacuate clots & ligate bleeding vessels. .

46. Periton. Comp. Complications of drains Infection Erosion of viscera May cause leakage from anastomosis Prevention by closed suction drains with soft selastic tubes

47. GI. complications Gastric dilatation; massive distention of the stomach by gas & fluid predisposed by gastric outlet obstruction, drinking with paralytic ileus, splenectomy & Anorexia nervosa. Distention--- increased pressure--- congested veins--- bleeding� ischemia� necrosis.

48. Gastric dilatation Clinically -ill, hiccups, -hypoK., alkalosis, -collapse of the lower lobe of the Lt lung may occur Treated by: -NPO, NG tube, -fluid and electrolytes replacement.

49. GI.comp. Bowel obstruction Paralytic ileus Mech. Obstn. Adhesions or hernias. Treated by NG. Suction, fluid &electrolytes corrections for few days. If no response--- Surgery.

50. Urinary complications Urinary retention Over distention of urinary bladder inhibit contraction Interference with the neural mechanism Treated by: catheterization if operation is taking 3h or more.& to empty the bladder after retention. Look for features of BPH.

51. Urinary tract infection Instrumentation, retention & catheterization. Clinically; dysuria, fever, flank & supra-pubic tenderness Diagnosis; urine analysis & culture. Treatment; Hydration, antibiotics & catheterization

52. CNS comp. CVA Convulsions; in ulcerative colitis, & crohn�s for unknown reasons Psychosis � post-op�, mood disturbances, delirium � d. tremens in alcoholics� Sexual dysfunction, confusion, fear & disorientation.

53. Post- operative fever It occurs in about 40% after major surgery,it resolves without specific treatment in most patients. Within 48h--- atelectasis After 2 days--- Wound infection, anastomatic breakdown,& intra-abdo. Abscesses After 1 w--- Allergy to drugs, transfusion reactions & pelvic and abdo. Abscesses. Temp. >38.5`C, CT abdo. & pelvis