Post-Operative Complications: Classification and Management

1. بسم الله الرحمن الرحيم

2. POST-OPERATIVE COMPLICATIONS

3. Classification • AnaestheticSurgical • Local General • (Operation site) (Other systems) • respiratory • cardiovascular • urological

4. Surgical Immediate (within first 24 hs.) Early (2nd day- 3 weeks) Late (afterdischarge)

6. Other Post-op. Complications • Post.op. pancreatitis ( 10% of all cases of acute pancreatitis) Operations in vicinity of pancreas e.g. 1% after cholecystectomy and 8% after CBD exploration. • Post-op. Parotitis. • C.V.A. ( 1-3% after carotid endarterectomy) • Post-op. cholecystitis. • Complications of I.V. Therapy ( air embolism, phlebitis.)

7. Post-op. jaundice. • I. Pre-hepatic jaundice (bilirubin overload) • Haemolysis (drugs, Transfusion, sickle cell crisis) • Reabsorption of haematomas. • II. Hepatocellular insufficiency • Viral hepatitis. • Drug-induced (anesthesia, others) • Ischemia (shock, hypoxemia, low-output states) • Sepsis • Liver resection (loss of parenchyma) • III. Post-hepatic obstruction to bile flow • Retained stones • Injury to ducts • Tumour (unrecognized or untreated) • Cholecystitis • Pancreatitis

8. WoundInfection After After open surgery laparoscopic surgery 10% <2% ●large wound size ●small ●open to atmosphere ●not ●more manipulation ●less ●poor blood supply ●better

9. Aetiology Pre-operative Operative Post-operative (exist before surgery) (during operation) (after patient’s return to ward) ●perforated organ. ● inadequate sterilization ● cross ● compound of instruments, surgeon’s infection fracture hands or dressings between ● skin infection patients (boils) ● nasal carriers of ● contamination Staphylococci among during dressing nurses and surgeons. ● operations on alimentary, biliary or urinary tracts

10. Clinical Picture • Occurs a few days or even weeks after surgery. • Pain and swelling of site of operation. • General manifestations e.g. malaise, vomiting or anorexia. • Swinging temperature (hic tic). • Wound is also red and tender. • Pus may be expressed out on pressure.

11. Treatment Prophylactic Therapeutic ●good sterilization. ●drainage of pus ●scrupulous O.R. and ●antibiotics if dressing techniques. associated ●isolation of infected cases. with spreading ●elimination of carriers with cellulitis cold or septic lesions among nurses and surgical teams

12. Burst Abdomen Total (early) Partial (late) ●all layers gape●Skin is intact which leads to including skin, soweak scar leading to viscera comes out incisional hernia

13. Clinical Picture • Usually occurs on the 10th post-operative day. • Pinkish discharge (pink fluid sign). • Viscera may come out after a strain e.g. coughing or sneezing.

14. Treatment • Sedation to alleviate fear. • Cover contents with sterile saline packs • Re-suturing of wound using strong nylon through all layers of abdominal wall (tension sutures). • Usually heals rapidly and soundly.

15. Post-operative sinus or fistula Gastrointestinal Biliary Pancreatic

16. Causes • Poor surgical technique. • Poor blood supply at anastomotic site. • Sepsis leading to suture line break-down. • Poor patient’s condition e.g. uraemia, anaemia, protein deficiency or cachexia. • Distal obstruction e.g. missed CBD stone.

17. Clinical Picture • Usually obvious due to escape of bowel contents or bile. • Oral methylene blue test. • Testing fistula fluid for bile or pancreatic enzymes e.g. amylase. • Injection of contrast to delineate the tract. • Sinogram / Fistulogram

18. Management ●protect skin ●replace fluid and ●reduce sepsis by from ulceration electrolytes judicious ●vitamins and drainage of nutrients pus ●antibiotic therapy

19. Post-operative Pyrexia (high temperature for more than 48 hours) • Causes : • Wound haematoma. • Pelvic abscess. • D. V. T. • Chest infection (collapse, pneumonia, infarction or sub-phrenic abscess). • U. T. I. • Enterocolitis. • Possible drug sensitivity.

20. Pulmonary Collapse • It is a common post-operative complication after abdominal or thoracic surgery. • Due to mucous retention blocking fine bronchi. • Usually involves basal lung segments. • May become secondarily infected by inhaled organisms or blood born.

21. Aetiology Pre-operative Operative Post-operative ●pre-existing ● irritant ● pain acute or anaesthetic ● immobilization chronic lung agents infection. ● atropine which ● emphysema. Makes secretions viscid ● heavy Smoking

22. Clinical Picture • Occurs within first 48 hours post-operative • Dyspnea, tachycardia and fever. • May be cyanosis. • Fruity cough. • Impaired chest movement particularly on the affected side. • Basal dullness and crepitations with diminished air entry. • CxR opacity of involved segments.

23. Treatment Pre-operative Post-operative ●breathing ●breathing exercises exercises. ●encourage coughing. ●stop smoking. ●small doses of ●antibiotics for sedatives for pain infection. ●antibiotics if sputum is infected

24. Deep Vein Thrombosis • (D. V. T.) • Usually occurs at time of operation. • Manifest itself during the second post-operative week. • Involves the deep veins of lower limbs and pelvis. • Pain and swelling of the leg and calf muscles. • Skin temperature is increased with dilated superficial veins. • May be mild pyrexia. • Homan’s sign may be positive.

25. Investigations Venogram I125 labeled Doppler fibrinogen ultrasound ●very valuable ●very sensitive ●simple and sensitive. ●can be repeated at ●non-invasive ●can not be short intervals. ●can detect loss repeated frequently ●only useful for of doppler detection of veins effect on the below knee occluded (excreted in urine veins and held in bladder).

26. Treatment • Prophylactic • active and early mobilization • post-operatively. • elevation of legs. • elastic graded compression • stocking. • use of inflatable bags. • electrical stimulation of leg • muscles. • prophylactic S.C. doses of • heparin. • Therapeutic • heparinization. • oral anticoagulants. • ligation of I.V.C. • I.V.C. umbrella.

27. Pulmonary Embolism • Due to dislodgement of a clot from deep veins of lower limbs or pelvis. • A massive embolus can obstruct the right heart out put and causes death. • Less severe cases give rise to shock, breathlessness and cyanosis with severe retro-sternal pain and discomfort. • Mild cases present with pleural pain, dyspnea and haemoptesis in 50% of cases. • Might lead to lung infarction if patient has cardiac failure due to lung congestion.

28. Clinical Picture • Difficult to diagnose clinically. • Helpful signs are : • pleural rub • crepitations • diminished air entry • May be silent.

29. Investigations • CxR →normal in early stage, but shows patchy shadowing later-on. • E.C.G. → Changes of right heart strain. • Perfusion lung scan → uneven circulation through the lungs with multiple perfusion defects. • Ventilation scan → normal in absence of pre-existing pulmonary diseases. • Arteriogram (diagnostic) → shows filling defect due to embolus in pulmonary artery.

30. Treatment • Morphia for pain. • Oxygen. • Lysis of embolus with streptokinase if seen early. • Heparinization. • Embolectomy in critically ill patients using the cardio-pulmonary by-pass machine

31. يسعدني تهنئتكم بحلول شهر رمضان المبارك وكل عام وأنتم بخير

33. Thank you