Transcript Complications in Minor Procedures

Complications in Minor Procedures
Directed
by
Dr.M.A.Sahebi
• The decision to obtain central venous access
•
must be a thoughtful one, and the data
regarding the risk and cost of complications
must be underscored. Steps to decrease
complications include the following:
1. Ensure that the patient's condition indeed
warrants central venous access. Experienced
personnel should insert the line with proper
positioning and sterile technique. Controversy
exists as to whether or not placing the patient in
Trendelenburg position facilitates access.
Central Venous Access Lines
• 2. Antibiotic-coated catheters may decrease the
rate of central line sepsis, although they initially
are more
expensive
3.Routine central line changes should not be
performed, and the lines should be removed as
soon as adequate peripheral intravenous access
can be established for medications that do not
require central access.
• One of the most common complications of
central venous access is pneumothorax. It
is not just inexperienced clinicians that
create these iatrogenic injuries, but
pneumothorax rates appear to be higher
among the inexperienced. Pneumothorax
occurrence rates from both subclavian and
internal jugular vein approaches are on
the order of 1 to 6%.
`
• The first step in prevention is proper
positioning of the patient during the
procedure. Even if a pneumothorax is not
suspected to have occurred during the
procedure, a chest x-ray is still needed to
confirm the presence or absence of a
pneumothorax following the line insertion.
• The decision regarding the need for a
thoracostomy tube is similar to that
described for bronchoscopy; if the patient
is stable, then expectant observation may
be adequate, but if any concerns about
the patient's clinical condition exist, a
thoracostomy tube should be placed.
• Occasionally, a delayed presentation of
pneumothorax will manifest as late as 48
to 72 hours after central venous access
attempts. This usually creates significant
clinical compromise such that a tube
thoracostomy is required.
• Other complications that bear mentioning
for both central venous and pulmonary
artery catheters include transient
arrhythmias during catheter insertion,
arterial puncture with hematoma
formation or persistent bleeding, and
occasionally loss of a guidewire in the
vena cava.
Arrhythmias (the most common
complication) result from myocardial
irritability secondary to the guidewire
placement, and usually will resolve when
the catheter or guidewire is withdrawn
from the right heart.
• Arterial puncture with bleeding can be
troublesome, but the majority will resolve
with direct pressure on or near the arterial
injury site. It is only the rare case that will
require angiography, stent placement, or
surgery to repair the puncture site, but
these patients usually will do well
following the procedure, and have no
significant arterial abnormalities over the
long term
• A lost guidewire or catheter now can be
readily retrieved with interventional
angiography techniques, and no longer
represents an automatic need for surgical
exploration to retrieve the lost material.
• Another error with central access lines
involving either a venous line or a
pulmonary artery line is that of air
embolus. These are estimated to occur in
0.2 to 1% of patients. However, when an
air embolism does occur, the results often
can be dramatic and mortality can reach
50%. Treatment may prove futile if the
diagnosis is ignored, especially if the air
embolism bolus is larger than 50 mL.
• Clinical auscultation over the precordium
often is nonspecific, so a portable chest xray may be required if the patient will
tolerate the procedure. Nonetheless,
aspiration via a central venous line
accessing the heart may assist in
decreasing the volume of gas in the right
side of the heart, and minimize the
amount traversing into the pulmonary
circulation
• Maneuvers to entrap the air in the right
heart include placing the patient in the left
lateral decubitus position and in
Trendelenburg position, so the entrapped
air can then be aspirated or anatomically
stabilized within the right ventricle..
• The advantage of the operative approach
is that the resources needed to salvage
the patient are more readily available in
the operating suite, should there be an
acute deterioration in the patient's
condition.
• perhaps the most dreaded complication of
the pulmonary artery catheter is a
pulmonary artery rupture. There usually is
a sentinel bleed noted when a pulmonary
artery catheter balloon is inflated, and
then the patient begins to have
uncontrolled coughing with hemoptysis..
• Reinflation of the catheter balloon is the
initial step in management, followed by
immediate airway intubation with
mechanical ventilation, an urgent portable
chest x-ray, and notification of the
operating room that an emergent
thoracotomy may be required.
• If there is no further bleeding after the
balloon is reinflated, and the x-ray shows
no significant consolidation of lung fields
from ongoing bleeding and the patient is
easily ventilated, then a conservative
nonoperative approach may be considered
• This approach might include observation
alone if the patient has no signs of
bleeding or hemodynamic compromise;
however, more typically today a pulmonary
angiogram with angioembolization or
vascular stenting is the next step in
treatment.
• For hemodynamically unstable patients
after pulmonary artery rupture, unless the
patient is already in the operating room
having thoracic surgery, attempts at
salvaging these catastrophic situations
often is unsuccessful because of the time
needed to perform the thoracotomy and
identify the branch of the pulmonary
artery that has ruptured.
• Another complication that may well be
underreported is central venous line
infections. 1–4 The Centers for Disease
Control and Prevention (CDC) reports
mortality rates of 12 to 25% when a
central venous line infection becomes
systemic, and this carries a cost of
approximately $25,000 per episode.
• The CDC does not recommend routine
central line changes, but when the clinical
suspicion is high, the site of venous access
must be changed. Additionally, nearly 15%
of hospitalized patients will acquire central
venous line sepsis (defined as >15 colonyforming units [CFU] on an agar roll plate,
or >103 CFU on sonication).
•
In many instances, once an infection is
recognized as central line sepsis, removing
the line is adequate. Staphylococcus
aureus infections, however, present a
unique problem because of the potential
for metastatic seeding of bacterial emboli.
The treatment for this situation is 4 to 6
weeks of tailored antibiotic therapy
Arterial Lines
• Arterial lines are placed to facilitate
arterial blood gas draws and to optimize
hemodynamic monitoring. They often are
not removed when central venous access
is not in place so ongoing phlebotomy can
easily be performed, a practice that may
lead to higher complication rates.
• Arterial access is preferably obtained via a
sterile Seldinger technique, and a variety
of arteries are utilized, such as the radial,
femoral, brachial, axillary, dorsal pedis,
and superficial temporal arteries
• complications generally occur less than
1% of the time, when present they can be
catastrophic. Complications include arterial
spasm, bacteremia, thrombosis (the most
common complication), bleeding (second
most common), hematoma, pulselessness,
and infection (0 to 10%). .
•
One could argue that should thrombosis
or distal embolization occur, a hand is
more precious than a foot, yet the
literature suggests that the risk is nearly
the same for both femoral and radial
cannulation. This also is true for infection
rates between the two sites as well.
• For complications related to thrombosis,
bleeding, and infected catheters with
bacteremia, the catheters should all be
removed and direct pressure placed for 5
to 10 minutes following removal.
• Thrombosis with distal tissue ischemia
often can be treated with anticoagulation,
but occasionally a surgical intervention is
required to reestablish adequate inflow.
The occurrence of pseudo-aneurysms and
arteriovenous fistulae is remarkably low
for these catheters.
Endoscopy and Bronchoscopy
• For gastrointestinal endoscopy, the most
dreaded risk is perforation. Perforation
may occur for 1:10,000 patients with
endoscopy alone, but carries a higher
incidence rate when performed with
biopsy (0 to 30%).
• This increased risk often occurs due to
complications of intubating a
gastrointestinal diverticulum (either
esophageal or colonic), and also from the
presence of weakened tissue in the wall of
the intestine related to an inflammatory
response secondary to infection (e.g.,
diverticulitis) or glucocorticoid use (e.g.,
inflammatory bowel disease).
• Recognition that a perforation has
occurred often is straightforward, but on
occasion may be difficult. Patients will
usually complain of diffuse abdominal pain
shortly after the procedure, and then will
quickly progress with worsening
abdominal discomfort on examination.
• For patients that are difficult to evaluate, a
change in clinical status may take several
hours, and occasionally as long as 24 to
48 hours, to become manifest. When
concern for a perforation exists, the
patient should immediately have radiologic
studies to assess for free intraperitoneal
air, retroperitoneal air, or a pneumothorax.
• A delay in diagnosis of an endoscopic
perforation creates the potential for
ongoing gastrointestinal contamination
and systemic sepsis
• Recognition that a perforation has
occurred often is straightforward, but on
occasion may be difficult. Patients will
usually complain of diffuse abdominal pain
shortly after the procedure, and then will
quickly progress with worsening
abdominal discomfort on examination.
• Treatment for a gastrointestinal endoscopy
perforation is usually surgical exploration
to locate the perforation, decontaminate
the surrounding tissues, and then to
surgically close the perforation site. The
exact type of surgery depends on the site
of perforation and the degree of
contamination or sepsis that is found at
surgery.
There are some patients in whom surgical
exploration is not required; however, these
are the exception rather than the rule. The
patient who may be a candidate for
nonoperative management usually is one
for whom suspicions for perforation arise
during an elective, bowel-prepped,
endoscopy, and yet the patient does not
have significant pain or clinical signs of
perforation.
• With the concern for perforation, an x-ray
is usually performed that then shows free
air. If the patient remains without
significant pain and with a benign
abdominal exam, then this type of patient
may be observed in a monitored setting,
kept on strict dietary restriction, placed on
broad-spectrum antibiotics, and closely
observed for 48 to 72 hours to detect any
deterioration in clinical status.
If the patient remains with an uneventful
course, a diet is gradually increased and
the antibiotics discontinued after 3 to 7
days. If the patient clinically deteriorates
at any time, immediate surgery is
required.
• Bronchoscope, however, has several
indications but relatively less-severe
complications compared with perforation.
Indications for bronchoscopy include
removal of foreign bodies, biopsy for
cancer, difficult intubations, diagnosis for
pneumonia, and delivery of medications.
• The contraindications are relatively few
and include a partial arterial pressure of
oxygen (PO2) less than 60 mm Hg on
100% supplemental oxygen, an evolving
myocardial infarction, and therapeutic
anticoagulation.
• The complications of bronchoscopy include
bronchial plugging (the most common
complication), hypoxemia, pneumothorax,
lobar collapse, and bleeding. When each
of these is diagnosed appropriately and in
a timely fashion, they are rarely lifethreatening
• bleeding is usually quick to resolve and rarely
requires surgery, but occasionally may require
repeat endoscopy for thermocoagulation or
fibrin glue application. The presence of a
pneumothorax necessitates placement of a
thoracostomy tube only when significant
oxygenation deterioration occurs or the
pulmonary mechanics are significantly
compromised;
• otherwise expectant observation is
adequate. The presence of a lobar
collapse or mucous plugging usually will
respond to aggressive pulmonary toilet,
but occasionally requires repeat
bronchoscopy.
Tracheostomy
• One of the oldest operations performed is that
of the tracheostomy, and when performed
correctly, it leads to decreased ventilator days,
decreased length of intensive care unit (ICU) or
hospital stay, and improved pulmonary toilet.
Tracheostomies are now performed open,
percutaneously, with or without bronchoscopy,
and with or without Doppler guidance, and yet
complications still arise.
• Some of the complications tend to be
minor and include changes in levels of
partial pressure of arterial carbon dioxide
(PCO2), radiographic changes in the
postprocedure x-rays, and minor
fluctuation in the pulse oximetry
saturation levels
• The indications for tracheostomy are
important when deciding how and when
to commit to a surgical airway. Historically,
those patients on a moderate to high level
of positive end-expiratory pressure (PEEP)
have been considered not to be the best
candidates for early tracheostomy for
various reason
• Hypercarbia is known to contribute to
intracranial hypertension for traumatic brain
injury patients. Using fiberoptic bronchoscopy
(FOB) in percutaneous tracheostomy will
contribute to hypercapnia if the endotracheal
tube (ET) is small (<7.5 mm), or if the minute
ventilation is such that adequate ventilation is
not administered during the procedure
• A recent study examined PEEP and
hypoxemia at 1 and 24 hours
postprocedure. The study concluded that
it was safe to perform percutaneous
dilatational tracheostomy on patients with
high PEEP settings because the patients
did not have adverse oxygenation at 1 and
24 hours status postprocedure. 5
• . Croce and colleagues examined FOB
performed on patients with closed head
injury when evaluating for pneumonia,
and were able to confirm that intracranial
pressure (ICP) did rise with a concomitant
decrease in the cerebral perfusion
pressure (CPP). 6
• Recent studies evaluating the incidence of
pneumothorax and the need for routine
posttracheostomy chest x-ray do not support
their routine use after either percutaneous or
open tracheostomy. 7,8 However, one reason for
continuing to perform routine chest x-ray after a
tracheostomy is for identifying and resolving
significant lobar collapse that occurs from
copious tracheal secretions or mechanical
obstruction from any number of etiologies.
• The most dramatic complication involving the
tracheostomy is a tracheoinnominate artery
fistula (TIAF). 9,10 These fistulas rarely occur (
0.3%), but when present, carry a 50 to 80%
mortality rate. TIAFs can occur as quickly as 2
days after tracheostomy, but also as late as 2
months postprocedure. The prototypical patient
at risk for a TIAF is a thin woman with a long,
gracile neck.
• The patient may have a sentinel bleed,
which occurs in 50% of TIAF cases,
followed by a most spectacular bleed.
Should a sentinel bleed be suspected, the
patient should be transported immediately
to the operating room for fiberoptic
evaluation
1. Although survival to this level is rare, for patients who are initially
surviving, the conduct of the team identifying a TIAF during
exsanguination is as follows (Figs. 11-1 and 11-2):
• 1. Inflate the tracheostomy balloon cuff to high pressure in order
to attempt compression of the innominate
artery.
2.Reintubate the patient with an endotracheal tube via the
orotracheal or nasotracheal
route.
3. If needed, remove the tracheostomy, and place a finger through
the tracheostomy site in order to apply direct pressure anteriorly for
compression of the innominate artery.
• 4. Sterile preparation of the patient for a
median sternotomy should include the
assistant's hand in the operative
field.
5. Once exposed, surgically ligate the
innominate artery proximally and distally to the
injury.
6. Mobilize a soft tissue flap to protect the
injured tracheal site from recurrent fistula
Percutaneous Endogastrostomy
• Technical errors usually are to blame for
endoscopically-misplaced feeding tubes.
Although it is not absolutely imperative to
transilluminate the abdomen, doing so
may decrease the margin for error and
prevent inadvertent colotomies.
• While an unplanned colotomy is potentially
catastrophic, other frustrating common errors
include the overzealous retrograde pulling of the
wire lasso through the abdominal wall and out
the oropharynx, the antegrade pulling of the
percutaneous endogastrostomy (PEG) tube disc
out of the anterior gastric wall during placement,
and progressive erosion of the PEG tube through
the anterior abdominal wall over the first few
weeks following PEG placement
• A misplaced PEG that is still being utilized for
administration of tube feeds may create intraabdominal sepsis with peritonitis and/or an
abdominal wall abscess with necrotizing fasciitis.
As in other minor procedures, the initial
placement techniques must be fastidious in
order to avoid these complications.
• Usually the colotomies, intraperitoneal leakage
of tube feeds with peritonitis, and abdominal
wall abscesses manifest slowly over time, but
once present require surgery to correct the
complications and to replace the PEG with an
alternate feeding tube, usually a jejunostomy
• Other issues are more related to direct patient
management, such as wrist restraints for the
confused and combative, sedation and/or
anxiolysis, or unexplained removal. There should
be timely replacement of the tube with an
alternative tube within 6 to 8 hours of
dislodgment, because the gastrostomy site
closes rapidly.
• Once replaced, the new tube should not
be utilized until a simple contrast x-ray has
been performed to confirm the new tube's
intragastric position.
Tube Thoracostomy
• Tube thoracostomy is performed for
pneumothorax, hemothorax, and pleural
effusions or empyemas. The
aforementioned diagnoses are commonly
found on chest x-ray, but also can be seen
on ultrasound and computed tomographic
(CT) scans. A chest tube can be easily
placed with a combination of local
analgesia and light conscious sedation
• Common complications include inadequate
analgesia or sedation, incomplete penetration of
the pleura with formation of a subcutaneous
track for the tube, lacerations to the lung or
diaphragm, intraperitoneal placement of the
tube through the diaphragm, and bleeding
related to these various lacerations or injury to
pleural adhesions.
• Additional problems are related to
maintenance of the tubes, with slippage of
the tubes out of position, or mechanical
problems related to the drainage system.
• All of these complications can be avoided with
proper initial insertion techniques, plus a daily
review of the drainage system and follow-up
radiographs. Occasionally these tubes will need
replacement due to malfunctions or clogging of
the tubes, but the replacement techniques are
the same as for the original insertion.
• Removal of these tubes occasionally will
create a residual pneumothorax if the
patient does not maintain positive
intrapleural pressure during tube removal
and initial dressing application.
• Replacement of a tube in this setting depends
on the clinical status of the patient, but
expectant observation of the residual
pneumothorax is acceptable. The development
of an empyema related specifically to the
presence of the thoracostomy tube itself is a
debatable topic, but some centers now are
moving to a protocol of antibiotics for the
duration of the chest tube placement as an
attempt to decrease empyema rates.
Diagnostic Peritoneal Lavage
Diagnostic peritoneal lavage (DPL) is less
commonly performed in the emergent
trauma setting, but the indications are
chiefly for the hemodynamically-unstable
patient who arrives in the emergency
department with neurologic impairment
and an uncertain etiology for blood loss.
Should such a patient have life-threatening
hemodynamic lability and an obvious
source is yet to be found after initial
resuscitation measures, then an emergent
DPL is performed—especially when an
abdominal trauma ultrasound is not
available or is not reliable in a particular
institution
• It is imperative that the stomach and
bladder be decompressed via nasogastric
tube and bladder catheterization prior to
DPL, as both of these organs can be
lacerated during the procedure (Fig. 11-3).
It also has been recognized that the small
or large bowel and the major vessels of
the retroperitoneum can be punctured
inadvertently.
• While the renal system is not usually
involved, the occasional horseshoe or
pelvic kidney may become lacerated. All of
these injuries usually will require surgical
exploration and repair, because of the
difficulty of making an accurate diagnosis,
as well as the potential for confounding a
trauma resuscitation with untreated
iatrogenic injuries.
Complications with Angiography
• As vascular stent strategies evolve and the
use of angiography by surgeons increases
beyond intraoperative studies or for
trauma cases, the complications related to
angiography are becoming more readily
recognized.
• Dissection of a cannulated artery can lead to a
variety of vascular malperfusion findings that
include (but are not limited to) ischemic stroke
from a carotid artery dissection or occlusion,
mesenteric ischemia from dissection of the
superior mesenteric artery, or a more innocuous
finding of "blue toe syndrome" from a dissected
artery in a peripheral limb with thromboembolic
disease
• The important initial step is for recognition of
the ischemic tissue bed, and confirmation of the
diagnosis with clinical findings and/or a
combination of invasive or noninvasive imaging
studies. The severity of the ischemia and the
extent of the dissection will then determine if full
anticoagulation and aspirin would be adequate
therapy, or whether the patient shall require
urgent surgical exploration to repair the
dissection.
• Bleeding secondary to angiography usually
is related to bleeding at the vascular
access site, but also may be related to a
ruptured vessel at the distal portion of the
angiography catheter. Local access site
bleeding usually is readily detected, but
may not be visible when the blood loss is
tracking into the retroperitoneal tissue
planes.
• These patients can present with
hemorrhagic shock of an undetermined
etiology, and so the angiography site
needs to be closely inspected, and an
abdominopelvic CT scan done to delineate
the extent of bleeding into the
retroperitoneum. The initial management
is direct compression at the access site
and clinical observation with resuscitation
as indicated.
• For those patients that do not respond to
resuscitation measures and continue to
have decreasing hematocrit levels with
evidence of hemodynamic compromise,
there should be plans for urgent surgical
exploration to control the bleeding site..
• Patients with a similar clinical picture that
likely have bleeding at the more distal
portions of the original angiography study
path should have repeat angiography in
order to define the bleeding source so that
angioembolization techniques can be
utilized to control the bleeding. However,
surgery is needed for those cases where
angio-embolization is unsuccessful.
• Renal-related complications of angiography
occur in approximately 1 to 2% of patients.
Contrast nephropathy often is a temporary and
possibly a preventable complication of radiologic
work-ups utilizing contrast dye for CT,
angiography, and/or venography. The research
results have been mixed regarding the
prevention of acute tubular necrosis from
intravenous contrast with administration of nacetylcysteine.
• There are some studies that suggest an overall
improvement of renal function with nacetylcysteine use, and other studies that report
that its use has no overall benefit. If nacetylcysteine is to provide benefit, twice-daily
dosing 24 hours before and on the day of the
radiographic study is suggested. It also is
suggested that the greatest benefit with nacetylcysteine is derived from improved
intravenous hydration before and after the
procedure.
• Nonionic contrast also may be of benefit in
higher-risk patients. The contemporary
literature does not support the use of
other adjuncts such as administration of
furosemide or mannitol prior to
angiography, and these practices may add
to overall morbidity rather than salvage
renal function.
• As a current minimum, improved
intravenous hydration before and after the
procedure is still likely the simplest and
most efficient method for providing renal
protection from dye contrast.
Complications with Biopsies
• Biopsies are performed for multiple
reasons, including cosmesis, pathologic
diagnosis, and prognostic evaluation.
Lymph node biopsies have direct and
indirect complications. Direct
complications include bleeding, infection,
lymph leakage, and seromas.
• Measures to prevent direct complications include
proper surgical hemostasis, proper wound
preparation with chlorhexidine,
gluconate/isopropyl alcohol, or a similar
preparation, and possibly a single preoperative
dose of antibiotic to cover skin flora 30 to 60
minutes before incision. Bleeding at a biopsy site
usually will manifest shortly after the procedure,
but often can be controlled with direct pressure.
• Infection at a biopsy site will generally not
manifest for 5 to 10 days postoperatively,
and will usually require opening of the
wound to drain the necrotic infected tissue
in order to facilitate wound healing.
Seromas or lymphatic leaks may be
difficult to manage at times.
• Depending on the volume and duration of
leakage, control of a leak may take up to a
few weeks to resolve with aspiration of
seromas and the application of pressure
dressings.
• If a seroma or leak does not resolve, it
may be necessary to take the patient back
to the operating room in order to place
some form of closed suction drain into the
wound. This usually is not necessary, and
conservative management prevails
• Some surgeons prefer to place a closed suction
drain in the vicinity of the dissection at the time
of biopsy. At the time of drain placement and for
the duration of the indwelling drain, antibiotics
may be given, depending on the location of the
drain, patient allergies, or the available
formulary. Should a patient suffer an adverse
event related to the antibiotics, this would
exemplify an indirect complication.