Transcript Common Complications in Surgery 2012

Common Complications in
Surgery
Assoc. Prof Hamish Ewing
The Northern Hospital
October 2008
“The Ward Round”
Avoid complications by anticipating
them
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Vital signs
Chest
Operation site care
Fluid balance
Medications
VTE prophylaxis
Diet (ERAS/enteral/parenteral)
Pressure care
Psyche
Complications of Surgery
General & Local
GENERAL
• Respiratory
• Haemorrhage (primary/reactionary/secondary)
• Urinary
• Thrombosis
• Electrolyte imbalance
• Pressure sores
• Faecal impaction/Diarrhoea
LOCAL
• Wound infection
• Wound haematoma
• Wound dehiscence
• Intra-abdominal abscess
• Enteric fistula
• Drain tube issue
What to do?
“Simple” wound infection
• Recognition
• Management?
Management of wound infection
-open wound at point of discharge or fluctuance
-simply undertaken in ward/OOPD setting by:
removing some/all sutures
insert tips of artery forceps
open and allow pus to drain freely
analgesia not usually necessary
insert small gauze wick to keep skin edges apart
antibiotics only if toxic or marked spreading cellulitis
send pus M&C in case of ongoing issues
More “complex” infection
• What is the issue here?
Pulse 125
BP 90 systolic
Shallow breathing
Looks moribund
. What to do?
This is ‘gas gangrene’
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Resuscitate/ICU
(Gram positive spore forming rods)
Gram stain
High dose penicillin
Debride ALL dead tissue in theatre
Consider hyperbaric oxygen
Wound Dehiscence
• Superficial
• Deep
Superficial dehiscence
Healing by ‘second intention’
Deep wound dehiscence
• Deep layers give way
……”pink sign”may
precede
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Case 1
• Mr.W is a 73 yr. old under your care following an
anterior resection for cancer.
• Surgery Friday 23/11/07
• Managed in HDU over weekend, returns Unit D
Sunday evening, all stable and looks great.
Monday (day 3)commences free fluids
Tuesday (day 4) is off food and feels full.
Q. How to assess this?
Case 1 ……p.2
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TPR chart
Only change minor rise pulse to 98 from 80
Temp. 37.5 several days now
Abdomen a little distended and silent
No drain tube
………….what to do?
• Suspect intra-abdominal mischief, leak/abscess
Case 1…..p3
• Today Wed. (day 5) patient now looks unwell..
• Obs. P 110, sweaty, lower abdominal pain,
silent distended abdomen, T38.5
• Your approach?
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Case 1 ……….p4
• CT scan reveals a little free gas and large volume
intraperitoneal fluid.
• Laparotomy and Hartmann’s procedure
• Gets home after 3 weeks, but,…now has stoma
Case 1 ………summary
• Normal - management of feeds. Lot of
surgeon difference. Lot of evidence shows
improved results with early (Day 1) feeding.
• Normal management drains. Surgeons vary.
Common to leave until bowels open.
• Daily round review routine? Must check TPR,
chest, abdomen, I/V site and Fluid balance &
electrolytes
• Newspaper and glasses? Good sign if present,
worry if disappears!
Case 2
• 42 yr old woman admitted acute cholecystitis
Friday evening.
• Only issue is pain RUQ
• Kept fasted over weekend as hopeful of
emergency cholecystectomy
• In fact still nil by mouth (NBM) Tuesday round.
• Noted to have had temp 38.5 overnight.
• Your approach?
Case 2 …...p2
• TPR chart
• Full examination
- abdomen soft & non-tender
• Investigations
WCC 17.9
LFT bili 23
AST 230
ALP 140
GGT 80
Case 2 ……….p3
• Examination revealed peripheral line in left
forearm purulent & red
• Blood cultures MRSA
• Echo …..vegetations on aortic valve
Case Summary
• Don’t forget I/V lines. Need to be changed
every 48-72 hrs. May always be site for life
threatening sepsis.
CASE 3
• 81 yr. Old woman with diabetes admitted to ward
for routine observation after straightforward
balloon dilation of stenosis in left common iliac
artery.
• You are called by nurse as P 80, BP 100/60 & she
looked pale. How would you respond?
• Examination confirms obs. and she is peripherally
shut down.
• What else would you do?
• Review of left leg revealed no puncture site
swelling & weak posterior tibial pulse. Also some
mild discomfort in LIF.
• What now?
Review of left leg revealed no puncture site
swelling & weak posterior tibial pulse. Also some
mild discomfort in LIF.
What now?
Case 3 cont’d.
• Drug chart shows Beta-blocker & a pre-procedure BP
160/90.
• What now? Remember beta-blocker will prevent a
tachycardia.
• Non-sustained response to 500ml colloid. What
now?
• Must call Vascular Surgery Team, best to have done
this prior to this point.
• Laparotomy reveals large bleed from ruptured
common iliac artery.
• What is role for CT?... Only relevant if bleeding
not critical. If clearly haemorrhaging the
treatment is to stop the bleeding, ie. operate
• Learning point
- a Radiological intervention = an operation.
CASE 4
• 35 yr.old woman underwent uncomplicated lap.chole
8 hours ago.
• You are night intern called by nurse as patient
anxious and complaining of right shoulder tip pain.
The nurse is worried. How will you respond?
• Answer: “Go & see the patient”
• Obs. P 120. BP 90/50. RR 21. T 37.0 Redivac contains
40ml haemoserous fluid. What now?
“..a terrible mistake made at
the bedside will be better
received than most expert
management rendered from
the resident’s TV room”
Case 4 cont’d
• Patient is clearly bleeding internally.
• Needs resuscitation and surgery to stop the
bleeding……”contact the surgeon”
Case 6
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84 yr. old elective right hemicolectomy.
Previously fit & lives independently
No medications
Post-op course fantastic, all delighted…glasses
on &reading the Herald-Sun
• Day 6 called as in rapid AF
• Your approach?
Case 6 ………p2
• o/e
P 150 AF
BP 95/60
• What now?
• Timing would suggest, again, intrabdominal
complication first and a medical complication
second. “Think surgery”
Case 6 ……..p3
• Overnight deteriorated tranferred ICU with
hypotension.
• Laparotomy revealed leaking anastamosis.
Medical complications
• Always consider a surgical cause for
a medical complication first when
dealing with a surgical patient
Drain tube caveats
A drain tube is no guarantee to prevent fluid accumulation
A drain is no substitute for good surgical haemostasis
Drain tubes do get colonized, so bacteria can migrate inwards from skin
Too much suction can cause damage
Drain tubes can ‘fall-in’ as well as ‘fall-out’
Part of a drain can be left behind in body!
A drain in the peritoneal cavity will not drain the whole peritoneum
Beware the drain that stops draining dramatically
ISBAR
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I - Identify
S - Situation
B - Background
A - Assessment
R - Request
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I - Identify
• Identify yourself - name, position, location
• Identify the person you are talking to if not already
done
• Identify the patient and unique ID number
“Hello. My name is Jasmine Sass, I’m a Division 1 RN working
on Ward 2 at …. Hospital. Are you the medical registrar on for
ward referrals today? … I didn’t catch your name?…I’m calling
about a patient - Terry Jones - a 56 year old man in our
surgical ward at ….. Hospital”
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S - Situation
• Explanation of WHY you are calling
“I am calling you about a patient, Mr Jones*. He is a 56
year old man, 2 days post hernia repair who has
developed new atrial fibrillation with a blood pressure of
105/66. He looks pale and feels unwell. I would like you to
come and assess this patient please”
• If urgent, make this clear at the start
“Mr Jones is a 56 year old man who is 2 days post hernia
repair. He has gone into atrial fibrillation. He is stable at
present with a blood pressure of 105/66 but he is
normally hypertensive. He looks pale and feels unwell. I
am concerned about him and would appreciate it if you
could come and help us to stabilise him”
*No need to repeat patient’s name age and sex if already included in IDENTIFY
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B - Background
• Tell the story
“I’ll tell you the story…”
“I’ll give you the background information…”
• Provide RELEVANT information only. Deciding what
is relevant is a skill that comes with experience
• Don’t forget ‘less is often more’
– you may get the message across better with less
information
• Include aspects of history, examination,
investigations and management where relevant
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A - Assessment
• State what you think is going on. Give your
interpretation of the situation
• Don’t leave the receiver to guess what you are
thinking - tell them
• Stating the obvious is helpful here
• Include your degree of certainty
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R - Request
• State what you want from them
“We would be grateful for your opinion regarding the need for
surgery”
“I need help urgently, are you able to come now? … If not,
who should I call?”
• Ask questions
“What would be the most appropriate antibiotic in this
situation?”
“What are the priority tasks for me while you are on your
way?”
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ISBAR can be done briefly - 1
• I - “Hi, I’m Joe, an intern in ED”
• S - “I would like to refer a 66 year old man with
pneumonia”
• B - “He has been on oral antibiotics for 1 week with
no improvement. He is stable and we have
commenced IV antibiotics”
• A - “His presentation of pneumonia is
classic”
• R - “Are you able to see him with a view to
admission?”
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Case 5
• A 69 yr.old man undewent TURP three hours ago. He
has just returned to the ward. Nurse rings you as she
is “not happy” with the way he looks as he is shaking
uncontrollably. You are scrubbed in Theatre when
she pages. How would you respond?
• A: “ Go & see the patient”
• Obs. P 110 BP 95/60 T 39.0. Returned fluid in urine
bag is pink and no clots seen.
• What now?
• What is differential diagnosis?
• How to proceed?
Case 5 cont’d
• Resuscitate with fluids.
• Most likely diagnosis is Gram negative
sepsis….hypotension, vasodilated and febrile.
Other possibility is relative underfillling from
spinal, but, is febrile with rigors.
• Needs blood and urine cultures plus
antibiotics
Case 7
Case 7 cont’d
“Go and see the patient”
Case 7 cont’d
• This is the serious complication of postthyroidectomy bleeding.
• Can present in several ways:
Neck swelling and pain
Blood per drains
Stridor and difficulty breathing
Hypoxia with agitation,confusion or somnolence
• Needs urgent removal of all layers os neck sutures,
ideally in theatre but ,in extremis, on the ward, ie.
YOU
Case 8
Case 8
• Low grade fever one day after abdominal
surgery = ATELECTASIS, until proven
otherwise.
• Treatment of this condition is…..?
Case 9
Case 9
• Low grade fever over a week after surgery,
especially if resting bed with surgery to the
lower limb….think of DVT
Case 10
Case 10
• Swinging (spiking) temp. 5-7 days after surgery
= pus somewhere.
• Inspect wound, consider intra abdominal
(pelvic/subphrenic/perisurgery) and CT scan.