Post-Operative Complications Presentation

8/12/2019 Post-Operative Complications Presentation

1/37

POST-OPERATIVECOMPLICATIONS

Chris Neophytou CT1 General Surgery

Ali Qureishi CT1 ENT

Lincoln County

Hospital

ULH Trust

12/01/2012


2/37

Introduction

This was not my patient . . .

I was not present for this case . . .

I never saw this patient . . .

If you do enough operations you are bound to have this

happen

It was an act of God . . .

I did a perfect operation . . . the ungrateful patient died .

. .


3/37

Introduction

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 thework

Harvey Cushing

You are a true surgeon from the moment you are able to

deal with your complications

Owen H. Wangensteen


4/37

Introduction

Classification

General vs. Specific

Time after surgery

By system affected


5/37

General post-operative

complications

Immediate:

Pain

Primary haemorrhage

Shock: haemorrhagic - cardiogenic - septic

Low urine output

Basal atelectasis


6/37


complications

Early:Acute confusion

N+V

Fever

Secondary haemorrhage (infection vessel erosion) Infections: Wound - Urinary - Respiratory

Wound / anastomosis dehiscence

Deep vein thrombosis

Acute urinary retention Bowel obstruction (fibrinous adhesions)

Paralytic ileus (if prolonged sepsis)


7/37


complications

Late:

Bowel obstruction (fibrous adhesions)

Incisional hernia

Persistent sinus

Recurrence of reason for surgery


8/37

Post-operative pain


9/37

Post-operative pain


10/37

Post-operative pain

2007 League table of number needed to treat (NNT) for at least50% pain relief over 4-6 hours in patients with moderate to

severe pain


11/37

Post-operative fever


12/37


Pathophysiology of fever:

Fever is manifestation of cytokine release in responseto stressful stimuli

Cytokines released include interleukin-1, TNF-, IFN-

Fever-associated cytokines released by tissue traumaand do not necessarily signal infection

Fever < 38 is common in first few days after majorsurgery

Most early post-op fever caused by inflammatorystimulus of surgery

resolves spontaneously


13/37


Immediate questions

Common causes: 5 Ws

Fever pattern

Spiking fever: closed spaces

Continuous fever: systemic disease

Chills / rigors

Fever before procedure

Associated complaints

Immunocompromised patient


14/37


15/37

Post-operative fever - DDx

Atelectasis: 12 - 48h post-op

Anaesthesia - pain - anaelgesia - obese/smokers

alveoli collapse (secretions / non-expansion)

secondary infection

O/E: Low-grade fever - malaise - diminished lung

sounds - tachycardia / tachypnoea(severe cases)

Diagnosis: Clinicalfurther work-up in severe

cases

Management: Chest physio - nebs - anaelgesia - ?


16/37


Since 1988, the Centers for Disease Control and

Prevention (CDC) has published 2 articles in whichnosocomial infection and criteria for specific types of

nosocomial infection for surveillance purposes for use in

acute care settings have been defined


17/37


Symptomatic urinary tract infection:

Patient has at least 1 of the following signs or

symptoms with no other recognized cause:

Fever

LUTs: urgency, frequency, dysuria, or suprapubic

tenderness

And Positive urine culture (105 microorganisms per

cc)


18/37



19/37


P

N

E

U

M

O

NI

A


20/37


Surgical site infection (SSI):

Infection occurs within 30 days after the operativeprocedure

And

involves only skin and subcutaneous tissue of theincision

And

Patient has at least 1 of the following:

Purulent drainage from the superficial incision Organisms isolated from an aseptically obtained culture of

fluid

At least 1 of the signs or symptoms of infection: pain ortenderness, localized swelling, redness, or heat

Diagnosis of superficial incisional SSI by the surgeon


21/37

Management of wound

infections

Release pus, remove any retaining sutures, and

ensure adequate drainage

Debride necrotic non-viable tissue

Antibiotic empirical therapy (or based onmicrobiological analyses)

Topical antimicrobials (iodine or chlorhexidine)

Keep wound moist with appropriate surgicaldressings

In the presence of clean granulations consider

grafting or secondary suture


22/37


23/37

Paralytic ileus

Ileus: disruption of the normal propulsive ability of the GI

tract

Paralytic ileus: ileus that persists for more than 3 daysfollowing surgery

After surgery there is a delay in return to normal bowel

function. Gastric stasis for


24/37

Paralytic ileus

Traditionally patients had oral intake withheld until

passage of flatus

little evidence to support this practice

Patients are increasingly encouraged to E+D (enhanced

recovery programmes)

A small proportion of patients do not tolerate early

feeding and develop paralytic ileus


25/37

Paralytic ileus

Clinical features

Absence of abdominal pain

No passage of flatus Abdominal distension

Vomiting often effortless

Respiratory compromise if

abdomen is tympanic

Bowel sounds are usually

absent

Management?


26/37

Anastomotic leak

Clinical features

Failure to progress, lethargy, anorexia

Cardiac dysfunctionAF, dysrhythmia, hypotension circulatory collapse

Respiratory signsdyspnoea or tachypnoea

Fever

Prolonged ileus, abdominal distension, or hiccups

High WCC and CRP

Metabolic acidosis


27/37

Anastomotic leak

Risk factors

Poor blood supply to the anastomosis

Tension at the anastomosis Distal obstruction

Surgical technique

Poor nutrition Steroids

Local infection or haematoma


28/37


29/37

Colorectal leak

Management

Unstable patient with peritonitis Resuscitation

Reoperation Anastomosis is taken down

Peritoneal lavage

Proximal stoma formation

Low grade sepsis and localized peritonitis CT scan/contrast enema

Percutaneous drainage of a perianastomotic abscess ? Reoperation if intraperitoneal free leak

Subclinical leaks Conservative management

Broad spectrum antibiotics for abscesses


30/37

Bile duct injury

0.20.5% incidence (open cholecystectomy:0.06%)

Types of injury to bile duct complete transection

complete transection with missing segment

partial transection

clip occlusion

diathermy injury

sectoral or accessory duct leak


31/37

Bile duct injury

Presentation

Intra-operative recognition

Bile in the drain

Clinical presentation

Abdominal pain

Nausea and vomiting

Fever Jaundice

Sepsis


32/37

Bile duct injury

Management

Investigation: LFTs, WCC, USS abdomen

Broad spectrum antibiotics

ERCP + stent (there is a cystic duct or lateral

duct leak) or PTC drain

Specialized hepatobiliary unit: Roux-en-Y

hepaticojejunostomy


33/37

Enterocutaneous fistula

Drainage of intestinal contents for >48hrs through

a wound or drain

More common than fistulas arising from diseased

bowel

Causes

Unrecognized intestinal injury

Breakdown of enterotomy repair

Breakdown of anastomosis

Breakdown of exposed bowel in a laparostomy

wound


34/37


Management

Resuscitation Patients often unwell due to sepsis and fluid depletion

IVI: 0.9% saline with added potassium

Nutrition Dietician input

Replace vitaminsmineraltrace element deficiencies

Consider TPN for high output fistulas

Contrast studies (once the patient is stable) Define the anatomy of the fistula

Check the condition of the proximal and distal gut Define an associated abscess cavity

Exclude distal obstruction


35/37


Spontaneous closure of a post-operative fistula

is likely if:

no distal obstruction

no diseased bowel no abscess or foreign body

no muco-cutaneous continuity

Surgical reconstruction


36/37

Adhesions

Inevitable consequence of abdominal surgery

Responsible for 75% of cases of small bowelobstruction

5% five year readmission rate after surgery

Chronic abdominal and pelvic pain

Causes

congenital (band adhesion) surgical trauma-denuded peritoneal membrane

foreign body reactionstarch on gloves, sutures

peritoneal blood


37/37

Adhesions

Conservative management usually (up to 80% resolution) Resuscitation, intravenous rehydration, electrolyte correction

Naso-gastric tube with free drainage and 4-hourly aspiration

Indications for surgery Tachycardia

Raised inflammatory markers

Abdominal tenderness

Failure of conservative management (48 hours is the usual

allowed time).

Chronic pain due to adhesions

Radiological investigation to exclude underlying pathology

Laparoscopic division of adhesions

Post-Operative Complications Presentation

Documents

Transcript of Post-Operative Complications Presentation