Post Operative Care Surgical...

Dr. Apirak Chetpaophan

Department of Surgery, Faculty of Medicine.

Prince of Songkla University

Post Operative Care &

Surgical Complications

Pre operative management Post operative management

Intraoperative management

Surgery

Pre&Post Operative Care and Surgical Complications

Pre Operative evaluation :

History & Physical Examinations

Investigations and Radiologic diagnostic Tools

Routine lab, EKG, etc.

Effect of Hormonal response in relation to :

Post Operative Care

Post Operative Complications

Summary of Preoperative Summary of Preoperative

EvaluationEvaluation

1. Cardiovascular

History of stable/unstable angina, arrhythimias,

MI, CHF, cardiac surgery, rheumatic fever,valvular disease, endocarditis, stroke,claudication



2. Pulmonary

Recent pneumonia, exposure to pulmonary

irritants, dyspnea, productive/non-productive cough, wheezing, hemoptysis, history of pulmonary tuberculosis, asthma, bronchitis,fungal exposure, smoking history, cyanosis or aspiration, availability of previous chest film or CT scans.



3.Renal

Renal insufficiency( recent or in the past),

renal stone



4. Hematologic

History of blood transfusion, bleeding disorders,

easy bruising, use of NSAID, aspirin or antiplateletmedications , previous history of DVT or PE,information regarding blood donation and autologous blood program



5. Gastrointentinal

History of GI bleeding or previous operation for ulcers or carcinoma, GER disease



6. Endocrine

history of DM, thyroid disease, long-term steroid use, pituitary or adrenal insufficiency



7. Infection

History of bacterial or viral pneumonia,chronic bronchitis, pulmonary TB, fungal infection, hepatitis, CMV or HIV



8. Medication

Use of prescription and nonprescription drugs, previous radiation or chemotherapy.



9. Previous operation

Especially thoracic and abdominal operations



10. Nutrition

Note overall appearance of nutritional status, weight loss or gain, obesity and overall eating habit



11. Patient directives&Health Care

Organ donation, living will, next of kin,privacy request, points of contact perioperatively, logistical and social issues regarding costs, home care, rehabilitation,case cancellation protocols, preoperative counseling.

- Avoidable (Preventible, non Preventible)

- Physiological, Biochemical ; Anemia, Coagulopathy

- Related to timing

Classification of Post Operative Complications

Immediate 0-24 Hrs.

Intermediate 1-30 days [avr. 7 day] (LOS)

Late > 30 Days, after D/C.

Organ

Systems

Other Systems

Anesthesia

Pain

Bleeding

Shock, Renal failure

Related to timing

Surgical Complications

- Postoperative Fever and Infection

- Infective causes of postoperative fever

- Miscellaneous causes of postoperative fever

- Noninfective causes of postoperative fever

- Wound Complications

- Hematoma and seroma

- Wound infection

- Wound failure

Respiratory Complications

- Atelectasis and Pneumonia

- Pulmonary Aspiration

- Pulmonary Edema

- Immediate Postoperative Respiratory Depression

- Acute Respiratory Failure

* SHOCK

- Hypovolemic shock (Immediate phase)

- Cardiogenic shock

- Septic shock

- Subphrenic abscess

* RENAL FAILURE

Deep Vein Thrombosis and Pulmonary Embolism

- Prophylaxis

- Fat embolism

Fluid, Electrolyte, and pH Imbalance

- Potassium imbalance

- Acid-Base imbalance

Alimentary Tracy Dysfunction- Acute gastric dilatation

- Gastroduodenal mucosal hemorrhage

- Intestinal obstruction

- Postoperative fecal impaction

- Colitis

- Anastomotic leak

- Hepatobiliary complications and jaundice

* Complications of Minimal-Access Surgical Procedures

* Neurologic Complications

- Prolonged alteration of consciousness

- Convulsions

Common Post Operative Complication

;Post Operative Pain

;Bleeding : Hypovolemia

;Hypoxia : Hypoventilation

;Hemodynamic Unstable

;Fluid&Electrolyte imbalance

;Wound Complication :

Hematoma, infection

Dehiscent, Keloid

Hematoma, Seroma

Risk

Chemical

Pathological - Mechanical

CVS, arrhythmia, HypovolemiaContractility (MI)Post Op Pulmonary edema, CHF

;Post Operative infection : wound (Site of Operation)

;Post Operative Renal Failure

- Liver Failure

- Hematological disorder: Coagulopathy

;Post Operation Sepsis : ARDS

;Post Operative Respiratory Failure : Atelectasis, Pneumonia,MOF.

Post Operative Hemodynamic evaluation

Physical signs of shock ( Pulse pressure, BP, tachycardia, confusion syncope)

Physical signs of venous pressure (neck veins, chest auscultation)

High venous pressure Cardiac failure, PE,

Tamponade, pneumothorax

Low venous pressureHypovolemiaMetabolicParalysis, anaphylaxisSepsis Chest radiograph, EGG, CVP ICU, response to initial Rx

Not improved Improved

PA catheter Is Do2 adequate for Vo2 (Vsat>65)?

Is perfusion adequate?Yes No

Yes No Needs acute Rx

Ensure volume statusPCWP>10CVP>5No acute Rx needed Hypovolemic

CrystalloidPlasmaPRBC

Normovolemic

Inotropes until chemical balanceInotropes

Normal CO, Vsat

CO, Vsat

MechanicalIntrathoracic pressure

PETamponadeValve malfunctionTachycardia

ContractilityIschemiaMetabolicToxic

HypocalcemiaHypoglycemiaAddison diseaseSystemic hypertension

Peripheral dilation dueto sepsis, paralysis

Inotropes until RxReduce pressureTreat PE, valveTreat arrhythmia

Vasodilation

Treat infection with œ agonist:PhenylephinineEpinepherineNorepinephrineConsider vasodilation but do not treat SVR

Balloon pump or LVAD

Hemodynamic algorithm. (After Bartlett RH. University of Michigan critical care handbook. 1991)

Measure cardiac output and VsatCO, Vsat

Common Causes of Elevated Temperature in Surgical Patients Hyperthermia Hyperpyrexia

Environmental Sepsis

Malignant hyperthermia Infection

Neuroleptic malignant syndrome Drug reaction

Thyrotoxicosis Transfusion reaction

Pheochromocytoma Collagen disorders

Carcinoid syndrome Factitious syndrome

Iatrogenic Neoplastic disorders

Central/hypothalamic responses

Pulmonary embolism

Adrenal insufficiency

Common Causes of Postoperative Hypoxemia

Atelectasis

Alveolar infiltrates

Aspiration

Cardiac-associated pulmonary edema

Noncardiac-associated pulmonary edema

(e.g., capillary leak, neurogenic, negative pressure)

Pulmonary embolus

Pneumothorax

Bronchospasm

Mucus plugging

Pulmonary contusion/hemorrhage

Common Causes of Postoperative Hypercapnia

Residual volatile anesthetics

Residual neuromuscular blockade

Narcotic overdose

Sedative overdose

High regional block

Cerebrovascular event

Neuromuscular disorders

Hypothyroidism

Insufflated carbon dioxide (laparoscopic procedures)

Metabolic alkalosis

Malnutrition

Hypermetabolism

Sepsis

Increased physiologic dead space

Respiratory ParametersParameter Normal FailureRespiratory rate 12-18 > 35

Inspiratory force (cm H2 O) -75 to -125 < -25

Vital capacity (ml/kg) 65-75 < 15

FEV1 (ml/kg) 50-60 < 10

Compliance (ml/cm H2 O) > 100 < 30

Pao2 (mm Hg) 80-95 < 70

A-a DO2 (mm Hg) 25-65 > 450

Qs/Qt 5-8 > 15-20

PaCO2 (mm Hg) 35-45 > 55

VD/VT (%) 20-30 > 60

A-a DO2, Alveolar-arterial oxygen delivery; FEV1, forced expiratory rate in one second; Qs/Qt, ration of shunted cardiac output to total cardiac output; VD/VT, ration of dead space volume to tidal volume.

Post op. Respiratory Failure

Risk Factors for Postoperative Pulmonary Complications

Risk Factor Relative RiskAge > 70 7.46

Age 50-69 4.14

Major abdominal surgery 3.90

Emergency surgery 3.49

Chronic obstructive pulmonary disease 3.13

Age 30-49 2.29

General anesthesia > 180 minutes 1.52

Acute respiratory failure (tube, vent, Fi02 > 0.5)

(arterial catheter, oximeter PA catheter)Mechanical RX Ventilator RX Systemic RX

Treat pneumothorax,hydrothoraxLarge ET tubeTracheostomy?BronchoscopyBronchodilators?Rx ascitesconsider PE if PASystolic > 40

VentilationTV 5 mL/kgrate 10

TV, rate to Paco

240

Limit: PIP 40

OxygenationF10

20.5

PEEP 5PEEP to V

satmax

F102

to Vsat

max Limit: F10

20.6

PIP 40

Maximize O2

deliverySat

a> 95%

PRBC to Hct > 14CO to V sat > 70

Limit : PCWP 20

> Dry weight

DiureseFilterPRBC or albumin

Limit: CO

Paco2> 45

TV, rate(Limit: PIP 40)

Vco2

ParalysisCoolLipid feed

NutritionPositive balanceEnergyProtein

Decrease Vo2

Treat infectionSedationParalysisCool?

Paco2

> 45ECMO adapt toacidosis

F102

0.6 1.0Prone positionTolerate hypoxemia?ECMO

WeanF10

2to 0.4

PEEP to 5PIP to 25

Sata< 90

Satv

< 70Sat

a> 90

Satv

> 70

Dry weight

Paco2

40

Stable

Paco2

40

Respiratory failure algorithm. (After Bartlett RH. University of Michigan critical care handbook. 1991)

Fluid Status

Acute renal failure in

surgical patients

Setting Frequency of ARF (%)

General surgery 3-5

Elective abdominal surgery 1-5

Open heart surgery 3-15

Cardiac surgery performed with 8-30

cardiopulmonary bypass

Severe burns 20-60

Intensive care unit 10-25

Sepsis 20-50

Radiocontrast exposure 10-30

Rhabdomyolysis 10-30

Conditions Associated with Acute Renal Failure (ARF)

Metabolic: hyperkalemia, acidemia, hyponatremia,

hypocalcemia

Cardiovascular: pulmonary edema, arrhythmias,

myocardial infarction, pericardial disease

including cardiac tamponade

Gastrointestinal: nausea, vomiting

Neurologic: mental status change, seizure, asterixis

Hematologic: anemia, bleeding

Infectious: pulmonary, urinary, peritoneal cavity,

sepsis

Common Complications of Acute Renal Failure

OliguriaRule out urinary obstruction Bladder catheter

Ultrasound Ensure good renal blood flow

Blood volumeCardiac outputDopamine?

Confirm by urineelectrolytesand clearance

Dx: renal parenchymal disease

Furosemide, 100-500 mg Diuretic trial

Polyuria Oliguria

Dx: some nephrons functional Dx: no nephrons functional

- Continue diuretics- Expect azotemia- Full nutrition- Intermittent hemodialysis asneeded for solute clearance

Isolated renal failure- Full nutrition- Intermittent hemodialysisor PD as needed for volume and solute control

Multiple-organ failure- Full nutrition- CAVH for volume- CAVHD for solute control

Dx: some or all nephrons recovered

Dx: no nephrons recovered Renal recovery

Chronic renal failure

Acute renal failure management algorithm. (After Mault JR, Bartlett RH. Acute renal failure, In:

Greenfield LJ, ed. Complications in surgery and trauma, ed 2. Philadelphia, JB Lippincott,

1989:149-162

Chronic dialysis

Post OperativeSurgical Infection

Risk Factors for Development of Surgical Site Infections Patient factors

Older age

Immunosuppression

Obesity

Diabetes mellitus

Chronic inflammatory process

Malnutrition

Peripheral vascular disease

Anemia

Radiation

Chronic skin disease

Carrier state (e.g., chronic Staphylococcus carriage)

Recent operation

Local factorsPoor skin preparationContamination of instrumentsInadequate antibiotic prophylaxisProlonged procedureLocal tissue necrosisHypoxia, hypothermia

Microbial factorsProlonged hospitalization (leading to nosocomial organisms)Toxin secretionResistance to clearance (e.g., capsule formation)

Wound Class, Representative Procedures,and Expected Infection Rates

Wound Class Examples of Cases Expected Infection RatesClean (class I) Hernia repair, breast 1.0 - 5.4%

Biopsy

Clean/contaminated Cholecystectomy, 2.1 - 9.5%

(class II) Elective GI surgery

Contaminated Penetrating abdominal 3.4 - 13.2%

(class III) trauma, large tissue

injury, enterotomy

during bowel

obstruction

Dirty (class IV) Perforated diverticulitis, 3.1 - 12.8%

necrotizing soft tissue

infections

Causes of Abdominal wound dehiscence

Imperfect technical closure

Increased intra-abdominal pressure from bowel distention,

ascites, coughing, vomiting, or straining

Hematoma with or without infection

Infection

Metabolic diseases such as diabetes mellitus, uremia, CushingK s

Tissues inadequate for strong closure

Inclusion Criteria for the Acute Respiratory Distress Syndrome (ARDS)

Acute onset

Predisposing condition

Pao2: F102 ratio < 200 (regardless of positive end-expiratory pressure)

Bilateral infiltrated

Pulmonary artery occlusion pressure <18 mm Hg

No clinical evidence of right heart failure

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References

; .Schwartz�s . Principle of surgery . 8th ed. McGraw Hill. 2005

; .Sabiston DC ed. Textbook of Surgery. 16th ed. WB Saunders 2001

; .Greenfield LJ. Surgery: Scientific principles and practice. 3rd ed. Lippincott William&Wilkins. 2001

; .Bailey&Love�s. Short practice of Surgery. 23rd ed. Arnold. 2000

The End

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