Preventing Surgical Complications of Modified Radical Mastectomy
Surgical Complications
description
Transcript of Surgical Complications
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Surgical Complications
John Cosgrove, MD FACSChairman and Residency Program DirectorBronx Lebanon Hospital Center
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Primum no nocere
Think before you act.
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Complications can be deadly…
Logarithmic increase in bile duct injuries after the introduction of laparoscopic cholecystectomy.
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SCIP
Antibiotics Normothermia VTE Prophylaxis
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Morbidity and Mortality Conference
Mainstay quality program of general surgery residency programs.
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Mortalities
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Morbidities
Cardiorespiratory Wound Urinary tract
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Wound
Seroma Hematoma Dehiscence Evisceration
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Wound
Superficial Deep Organ space
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Pathogens
Staphylococcus(coagulase neg) 25% Enterococcus(D) 11.5% Staph aureus 8.7% E. coli 6.5%
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Wound classification
Clean Clean contaminated Contaminated Dirty
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Temperature regulation
Issues of hypothermia
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Malignant hyperthermia
1 in 30,000 cases Mortality less than 10% Autosomal dominant with variable
penetrance Altered calcium metabolism Halothane, isoflurane, succinylcholine Cause rise myoplasmic calcium
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MH
Tachycardia Arrhythmia Raised temperature Acidosis Muscle rigidity Tachypnea Flushing (inability to open mouth)
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Treatment
Discontinue triggering anesthetic Hyperventilate with 100% oxygen Terminate surgery Dantrolene 2.5mg/kg as bolus and repeat every 5
minutes Monitoring Sodium bicarbonate Beta blockers Lidocaine Lasix
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Pulmonary complications
Atelectasis Pneumonia Pulmonary embolism Aspiration Pulmonary edema ARDS
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Weaning criteria
RR <25 breaths/min Pa02 >70mmHg(Fi02 of 40%) PaC02<45 mm Hg MV 8-9L/m TV 5-6mL/kg NIF -25cm H20
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Cardiac
Greatest risk in first 48 hours Non-Q wave, non ST segment elevation
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Prevention
Major predictors of risk Unstable chest pain, CHF, sympotomatic
arrhythmias, severe valvular disease
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Management
Cardiology consult Tachyarrhythmia Unstable-cardioversion SVT-Beta blocker, esmolol, amiodarone PSVT-vagal stimulation, adenosine, amiodarone MAT-B blocker or amiodarone VTach-lidocaine or amiodarone Brady-atropine Heart block-high grade second or third degree-
insertion of permanent pacemaker
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Amiodarone
Phosphodiesterase inhibitor Inhibits breakdown of camp Increase cardiac output and decreases
preload and after load without increasing myocardial oxygen demand
May cause vasodilitation and GI problems and thrombocytopenia
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Adrenal
Chronic use of steroids causes suppression of the HPA axis
Potentially life threatening Give 250ug cosyntropin intravenousl
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Hemodialysis indications
Serum potassium >5.5 BUN>80-90 Persistent metabolic acidosis Acute fluid overload Uremic symptoms(pericarditis, encephalopathy,
anorexia) Removal of toxins Platelet dysfunction Hyperphosphatemia with hypercalcemia
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SIADH
Common cause of chronic normovolemic hyponatremia
Serum sodium<135 Treat underlying disease process Fluid restriction Rapid correction may result in seizures
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Gastrointestinal
Ileus Early SBO Compartment syndrome GI bleeding Stomal complications C. difficile colitis
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Anastomotic leak
Strategies for prevention Low anterior resection
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Enterocutaneous fistula
Low output <200 cc/24h Moderate 200-500 cc/24 h High >500 cc/24 h
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“The Checklist”
Provonost Gawande
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Airline Industry
Crew resource management Communication No hierarchy Checklist, checklist, checklist Debriefing
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Universal Protocol
Preprocedure Verification Presurgical “timeout” Post procedure “debriefing”
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Prospective Case Conference
Dr. Judson Randolph 1988-Childrens Hospital Center, Washington,
DC A priori discussion of all upcoming pediatric
surgery cases involving multiple disciplines
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Interdisciplinary teamwork
GI/bleeds/biliary Radiology/bleeds/abscess Medicine/evaluation/cardiac Anesthesia/PST/surgical readiness
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“Never events”
CMS