Surgical Complications

1. Surgical Complications Rajan Thakkar

2. Surgical Complications • Wound • Thermal Regulation • Postoperative Fever • Pulmonary • Cardiac • Renal • Gastrointestinal • Metabolic • Neurological

3. Surgical Complications • Primary disease • Operation • Unrelated factors • Complications leading to other complications • Prevention

4. Wound Complications • Dehiscence • Seroma • Hematoma • Infection • Incisional Hernia

5. Wound Dehiscence • Separation of facial layers • Serosanguinous drainage • Technical Complication • Risk Factors • Mortality approaches 30% • Evisceration

6. Evisceration

7. Incisional Hernia

8. Seroma • Collection of liquefied fat, serum and lymphatic fluid under the incision • Benign • No erythema or tenderness • Mastectomy, axillary and groin dissections • Treatment

9. Hematoma • Abnormal collection of blood • Discoloration of the wound edges (purple/blue) • Blood leaks through skin sutures • Imperfect hemostasis • Potential for secondary infection • Neck hematomas can be dangerous

10. Wound Infection • Major problem • Superficial • Deep • Organ space • Most commonly occur 4-6 days post-op • Erythema, tender, edema • 2.5% of abdominal incisions • Staphylococcus aureus

11. Wound Infection • Necrotizing fasciitis • Bacterial infection of underlying fascia • Classically Streptococcus, most often polymicrobial with anaerobes/GNR • Surgical debridement and IV antibiotics • Clostridial Myosistis • Clostridial muscle infection (myonecrosis and gas gangrene) • Clostridium perfringens • Surgical debridement and IV antibiotics

12. Necrotizing fasciitis

13. Necrotizing fasciitis

14. Necrotizing Fasciitis

15. Complications of Thermal Regulation • Hypothermia • Malignant Hyperthermia

16. Hypothermia • Drop in body temperature of 2 degrees C • Causes • Body’s Response • Temperature below 35 C • Coagulopathic • Platelet dysfunction • Mild - 32 – 35C = 90-95F • Mod – 28 – 32C = 82–90F • Severe – 25 – 28C = 77-82F • Extreme

17. Malignant Hyperthermia • Rare; autosomal dominant • Fever, tachycardia, rigidity, cyanosis • First sign is increased end tidal CO2 • Often within 30 minutes • Treatment: Dantrolene, correct electrolytes, cooling blanket

18. Postoperative Fever • The Six W’s • Wind: pneumonia • Wound: infections • Water: UTI • Walking: DVT (possible PE) • Waste: abscess • Wonder Drug: medication • Noninfectious • Within the first 48-72 hours • Infectious • Fevers POD 3-8 • Standard work up includes • Blood cultures • UA and Urine Cultures • CXR • Sputum cultures • Tylenol/Motrin

19. Pulmonary Complications • Atelectasis • Peripheral alveolar collapse due to shallow tidal breaths • Most common cause of fever within 48 hours of surgery • Incentive spirometry • Aspiration Pneumonitis • Reduced by pre-op fasting, protonix, cricoid pressure • Nosocomial Pneumonia • Pulmonary edema • CHF • ARDS • Pulmonary embolus • 500,000 per year • 1 in 5 are fatal • Prevention

20. Pulmonary Embolus

21. ARDS

22. Cardiac complications • Hypertension • Ischemia/Infarction • Leading cause of death in any surgical patient • Key to treatment: prevention • MONA • Arrhythmias • >30 seconds of abnormal cardiac activity • Key to treatment is to correct underlying medical condition

23. Renal Complications • Urinary retention • Inability to evacuate a urine-filled bladder • Commonly a reversible abnormality • Perianal and Hernia repairs • Acute Renal Failure • Pre-renal • Intrinsic • Post-renal

24. Gastrointestinal Complications • Postoperative ileus • GI Bleeding • Pseudomembranous colitis • Ischemic Colitis • Anastomotic Leak • Enterocutaneous fistula

25. Postoperative Ileus • Lack of function without definitive obstruction • Prolonged by extensive operative manipulation, SB injury, narcotic use, abscess and pancreatitis • Must be distinguished from SBO • Flat and Upright abdominal film • Ileus: dilated bowel throughout, air in colon and rectum • SBO: air fluid levels, no colonic or rectal air

26. ILEUS

27. SBO

28. Gastrointestinal Complications • GI Bleeding • From Any source (get a detailed history) • Gastric “stress” ulcers (Curling’s Ulcer) • Uncommon with invention of H2Blockers and PPIs • Pseudomembranous colitis • Superinfection with C difficile • Alteration of intestinal flora by perioperative antibiotics • Toxic colitis is a surgical emergency (mortality of 20-30%) • Ischemic Colitis • Bowel affected helps determine cause • Surgical devascularization, hypercoagulable states, hypovolemia and emboli • Anastomotic leak • Enterocutaneous fistula • The most complex and challenging surgical complication

29. C diff colitis

30. C diff colitis

31. Anastomotic leak in GBP

32. Metabolic Complications • Adrenal Insufficiency • Uncommon but potentially lethal • Sudden cardiovascular collapse • Hypotension, fever, confusion, abdominal pain • “Stim” test, administration of hydrocortisone • Baseline serum cortisol, 30 min, 60 min • Hyper/Hypothyroidism • SIADH • Continued ADH secretion despite hyponatremia • Neurosurgical procedures, trauma stroke, drugs (ACE-I, NSAIDs)

33. Neurologic Complications • Beware the drugs you will be prescribing • Delirium, Dementia and Psychosis • Seizure Disorders • Stroke and Transient Ischemic Attacks