POST – OPERATIVE COMPLICATIONS

1. POST – OPERATIVE COMPLICATIONS General Surgery rotation Y. Edden MD Department of General Surgery

2. When does it end ?

4. I would like to see the day when somebody would be appointed surgeon somewhere who had no hands, for the operative part is the least part of the work. -Harvey W. Cushing

5. Surgery Personal responsibility, Ego, Conservatism Y. Edden MD

6. Post-Op Fever 25-50% of patients Will have fever in 1st24hr post-op 1-2 days post-op: Atelectasis 3-4 days post-op: Phlebitis, Pneumonia 5 days post-op: Wound infection 7 days post-op: Anastomotic leak or disruption

7. Respiratory Complications 30-50% of surgical patients • Atelectasis & Pneumonia • Most common pulmonary complication • Collapse of alveolar segments causing shunts • Non cleared pulmonary secretions infected causing • pneumonia • 10-20% of ICU patients suffer from pneumonia

8. Respiratory Complications • Clinical Presentation • Low grade fever • Decreased breath sounds over lower lung fields • Crepitations • Secretions Pneumonia- Fever, WBC, CXR with infiltrates, infected thick secretions

9. Respiratory Complications • Prevention: • Cease smoking 2-4 weeks pre-op • Optimal analgesia • Aggressive pulmonary toilet • Early ambulation • Incentive spirometry

10. Respiratory Complications • Aspiration • Inhalation of gastric fluid – ‘Mendelson aspiration’ • Low pH of gastric content : pulmonary Edema, • Hemorrhage, atelectasis, alveoli necrosis • 50% will have bacterial contamination and severe • pneumonia • Contributing Factors • Altered mental status • Altered swallowing mechanism • NGT

11. Post-Op Fever 25-50% of patients will have fever in 1st24hr post-op 1-2 days post-op: Atelectasis 3-4 days post-op: Phlebitis, Pneumonia 5 days post-op: Wound infection 7 days post-op: Anastomotic leak or disruption

12. Phlebitis • Can happen any time • Large diameter > more infections • Change every 3 days • Usually poor technique

13. Post-Op Fever 25-50% of pts. Will have fever in 1st24hr post-op 1-2 days post-op: Atelectasis 3-4 days post-op: Phlebitis, Pneumonia 5 days post-op: Wound infection 7 days post-op: Anastomotic leak or disruption

14. Wound Complications Contributing Factors: • Inadequate surgical technique • Increased presuure/ tension on closure (bowel distention. Ascites, cough) • Inadequate wound healing: Age, DM, malnutrition, CRF, Steroids, CTx, Rad

15. Wound Complications • Surgical Site Infection • Most common infection in surgical patients (40%) • 2/3 involve superficial or deep incisional tissue • 1/3 involve organs/ space operated Source: Flora of skin/ mucous membranes and hollow viscera Pathogens: 20% Staph Aureus, 15% Coag. Neg. Staph, 12% Enterococcus, 8% E. Coli

16. Wound Complications Contributing Factors.. Patient:Operation: Age Duration of scrub (6min=2min) Malnutrition Duration of operation Diabetes Foreign material Co-existant infection Skin antisepsis Immune deficiency Surgical technique Presentation ‘Rubor’ ‘Calor’ ‘Dolor’ ‘Tumor’ Usually on 5th day Low grade fever Progression of cellulitis

17. Wound Complications Treatment Opening wound, culture, mechanical drainage ABx only if marked cellulitis or systemic signs Necrotizing Fasciitis- Early appearance ! Day 1 Step. A,Clostridium Perfringens (G+ rods) Prevention: Bowel prep (?) Peri-op IV Abx Control of Diabetes Treatment of coexistent infections 2-4 weeks non smoking

18. Wound Complications • Wound Hematoma • Inadequate hemostasis • Coagulopathy • Myeloproliferative Disorder • NSAIDs • Wound seroma • Collection of serum & lymph in SQ tissue • Usually not infected • Discomfort, swelling • Treatment: Aspiration (infecting) • Closed suction drain

19. WoundComplications • Wound Dehiscence • 2% of Abdominal operations • Dehiscence- separation of fascial layer in early • post operative • Evisceration- large dehiscence allowing • protrusion of viscera

20. ‘Salmon Pink’

21. Venous Thromboembolism DVT & PE 100,000 death per year from PE in the USA Surgical patients are in increased risk for DVT • 90% clot originates from ileofemoral vessels • Clinical significance according to clot size and patient’s • status • Other forms: Fat embolism, Amniotic fluid embolism • Air embolism, Foreign body embolism

22. Venous Thromboembolism Risk Factors Age>40 Paralysis Chronic heart disease Prolonged immobilization Malignancy Prolonged surgery Inherited Coag deficiencies Multiple trauma Previous DVTObesity Treatment Resuscitation (Oxygen, Intubation, Cardiac arrest) Diagnosis- ABG, CXR, ECG, V/Qscan, Angio, CT scan Anticoagulation, IVC filter

23. Venous Thromboembolism • Prevention • Prophylaxis • Mechanical- pneumatic compressive devices • Elastic stockings • Mobilization • Pharmacological- Anticoagulants • (Heparin, Clexane, Warfarin) • IVC Filter

24. IVC Filter

25. הפסקה !

26. GI Tract Complications • Post-op Ileus • Uncomplicated recovery from abdominal surgery • SB motility returns almost immediately • Gastric motility returns in 2-3 days • Colonic motility returns in 3-5 days • Contributing factors for prolonged ileus • Opioids • Upper GI surgery • Pre-op obstruction • Diabetic neuropathy • Retroperitoneal hematoma • Excessive trauma to the bowel

27. GI Tract Complications GI Bleeding Stress gastritis common in critically ill patients (Burn, Trauma, Major Abd surgery, CNS inj, Sepsis, AMI) Treatment Resuscitation (IV fluids, Blood, correct anticoag, treat sepsis) Upper endoscopy- diagnosis and treatment Prevention Reducing intragastric acid production- Antacids, H2 blockers Healing of gastric mucosa- Sucralfate (PGE2↑, mucous↑)

28. Cardiac Complications Perioperative Ischemia & Infarction Leading cause of death in elderly patients after non cardiac surgery Previous AMI- Major risk factor AMIRe-infarction rate 3mo 30% 3-6mo 10% >6mo 5-8% (general risk)

29. Cardiac Complications • Prevention • Identification of high risk patients • Optimization of cardiac function peri-op • High index of suspicion

30. Cardiac Complications • Arrhythmias • Intrinsic cardiac disease • Thoracic or mediastinal surgeries • Electrolyte abnormalities • Cardiac medications • Catecholamine stress response • Endocrine abnormalities Treatment According to ACLS

31. Renal & Urinary Tract Complications Urinary Retention Inability to empty urine filled bladder Especially after Inguinal Hernias, anorectal procedures Causing Factors: Post-op pain Epidural analgesia prevent  adrenergic inhibition Overly vigorous IV fluids • Presentation • Urgency • Discomfort • Pain • Enlarged palpable bladder ‘Globe vesicle’

32. Renal & Urinary Tract Complications Treatment Catheterization • Prevention • Void before surgery • Blockers Min fluids peri-op

33. Renal & Urinary Tract Complications Acute Renal Failure Common complication (5-10% of surgical patients) Mostly in CABG, vascular, transplant, urologic surgeries • Pre-renal • Hypotension • Hypovolemia • Cardiac failure • Arterial stenosis or occlusion

34. Renal & Urinary Tract Complications • Intra-renal • Toxins (Rad contrast, endotoxins) • Pigment (myoglobin) • Post-renal • Ureteral obstruction (stone, trauma, surgical injury) • Bladder distention (nerve injury, drugs) • Uretheral obstruction (Trauma, BPH, malignancy)

35. Neurological Complications CVA & TIA Non hemorrhagic stroke: Cardiac or extra-cranial vascular lesion (AF, Carotid stenosis) Hemorrhagic stroke: Uncontrolled HTN Uncontrolled anticoagulation

36. If you can’t stand the heat stay out of the kitchen… Harry S. Truman 33rd US president 1945-1953