Surgical Complications

Surgical Complications Rajan Thakkar

Surgical Complications • • • • • • • • •

Wound Thermal Regulation Postoperative Fever Pulmonary Cardiac Renal Gastrointestinal Metabolic Neurological

Surgical Complications • • • • •

Primary disease Operation Unrelated factors Complications leading to other complications Prevention

Wound Complications • • • • •

Dehiscence Seroma Hematoma Infection Incisional Hernia

Wound Dehiscence • • • • • •

Separation of facial layers Serosanguinous drainage Technical Complication Risk Factors Mortality approaches 30% Evisceration

Evisceration

Incisional Hernia

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

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

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

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

Necrotizing fasciitis

Necrotizing fasciitis

Necrotizing Fasciitis

Complications of Thermal Regulation • Hypothermia • Malignant Hyperthermia

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

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

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

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

Pulmonary Embolus

ARDS

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

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

Gastrointestinal Complications • • • • • •

Postoperative ileus GI Bleeding Pseudomembranous colitis Ischemic Colitis Anastomotic Leak Enterocutaneous fistula

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

ILEUS

SBO

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

C diff colitis

C diff colitis

Anastomotic leak in GBP

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 (ACEI, NSAIDs)

Neurologic Complications • • • •

Beware the drugs you will be prescribing Delirium, Dementia and Psychosis Seizure Disorders Stroke and Transient Ischemic Attacks