Transcript Post-operative complications

Postoperative care
&
gENeRAL Complications
OF SURGERY
M K ALAM
MS; FRCS
Professor of Surgery
ALMAAREFA COLLEGE
Intended learning objectives
• At the end of this presentation students will be able to:
 Recognize the importance of proper postoperative care.
 Describe immediate and delayed complications of surgery.
 Explain immediate postoperative care of pain, fluids,
drains, and wound.
• Describe prevention and management of postoperative
complication.
Introduction
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All surgeons expect speedy, uneventful recovery.
Always have recognized the risk of complications.
Affects result of surgery: poor scar, hernia.
Prolongs hospital stay and increased cost.
Increased morbidity/ mortality.
Raises medico-legal issues.
Reducing the risks of complications
• Good pre-operative evaluation.
• Optimizing the general condition of patients.
-Medical issues- diabetes, hypertension.
-Nutritional issues- malnutrition, obesity.
• Minimizing preoperative hospital stay.
• Good surgical technique.
• Early mobilization.
Phases of post-op. patient care
• Recovery room.
• Surgical ward.
• On discharge.
Complications developing in recovery room
• Airway obstruction.
• Acute pulmonary complications.
• Cardio-vascular complications.
• Fluid derangements.
• Reactive haemorrhage.
-Slipped ligature.
-Dislodgement of clot.
Immediate post-operative care
• Observation in recovery room until patient fully conscious.
• Frequent monitoring of ABC (vital signs).
• Surgical wound and drain- surgeon’s responsibility.
• Drain- nature & volume.
• Urine output.
• ECG, pulse oximetry, CVP.
• Supplemental O₂ after extubation.
Causes of postoperative airway
problems
• Obstruction by tongue fall back- depressed level of
consciousness, loss of muscle tone.
• Bleeding into oropharynx.
• Loose tooth / denture causing obstruction.
• Laryngeal spasm or oedema.
• Tracheal compression- bleeding after thyroid surgery.
• Bronchospasm- aspiration, drug reaction.
Management
• Defining and rectifying the cause.
• Chin lift or jaw thrust-protects tongue fall back.
• Suction of oropharynx.
• Oropharyngeal airway.
• Supplemental oxygen.
• Re-intubation if no improvement.
Haemorrhage
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Blood coming through drain.
Bleeding from suture line- rarely a problem
Hypovolaemic shock- if blood loss is large.
Reactionary haemorrhage.
 Slipped ligature.
 Dislodged clot.
• Management: Patient back to theatre.
Fluid resuscitation.
Post-op. care in ward
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Monitoring vital signs.
Intake (oral/IV)- output ( urine, NG tube, vomitus and drain) record.
Regular analgesia.
Chest expansion and coughing encouraged.
Early mobilization.
Legs checked regularly for DVT.
NG tube removed- ↓ drainage, bowel sound returned, passage of flatus.
Post-op. care in ward (contd.)
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IV fluid - adjusted daily until free oral intake.
Daily IV fluid in adults- NS 1 L+ D5 2L.
KCl- from 2nd day (60-80 mmols/ 24 Hrs).
Oral feeding started once bowel activity returns.
Surgical drains- removed once effluent diminishes.
FBC & electrolytes usually checked on 1st postoperative
day.
Blood transfusion- hemoglobin <8 Gm/dl.
Oral feeding delayed or cannot commence in 5 daysnutritional support by enteral or parenteral feeding.
DVT prophylaxis(heparin, anti-embolic stocking) until freely mobile.
Sutures- removed in 7-8 days.
Postoperative complications
• Local complications: Specific to the type of surgery.
Example: Hypocalcemia after thyroidectomy.
• General complications: may develop as a result of
any surgery.
Example: UTI, chest infection, DVT
General complications
• Nausea/ vomiting.
• Persistent hiccups -gastric distension
renal failure
• Headache - spinal anaesthesia.
• IV site- bruising, haematoma, phlebitis,
vein thrombosis, air embolism, infection.
Pulmonary complications
• Largest single cause of post-op. morbidity.
• Common cause of death in over 60 age.
• Higher risk: chronic pulmonary disease (COPD).
Pulmonary collapse (atelectasis)
• Inability to breath deeply/ cough up secretions.
• Paralysis of cilia, impaired diaphragmatic
movement, abdominal distension, pain.
• Bronchus/bronchiole obstructed by secretions.
• Distal alveolar space close (atelectasis), solidify.
• Usually occurs within 24 hours.
• Tachypnoea, tachycardia, mild fever, ↓ breath
sound, ↓PaO2.
• Chest X-ray- areas of opacification.
Pulmonary collapse (atelectasis)
• Untreated: Infection- lobar or bronchopneumonia.
• Prophylaxis: stop smoking, physiotherapy for COPD.
• Delay surgery if chest infection.
• Treatment: encourage deep breathing/cough,
mobilization, analgesia, chest physiotherapy.
• Severe hypoxia- intubation, suction, bronchoscopy.
Pulmonary infection
• Follows atelectasis, gastric aspiration.
• Strep. pneumo.,H influenzae or gram negatives.
• Pyrexia, tachypnoea, greenish sputum.
• ↓ breath sounds, coarse crepit., bronchial breath.
• Chest X-ray: patchy fluffy opacities.
• Treatment: antibiotics, encourage to cough.
• Severe cases: O2, bronchoscopy, ventilation.
Respiratory failure
• Definition: Inability to maintain normal PaO2 & PaCO2.
• Normal PaO2= 11.6 -13 kPa.
• Resp. failure PaO2 < 6.7 kPa.
• Central cyanosis.
• ABG- key to early recognition.
• Treatment: Intubation and ventilation.
Acute respiratory distress syndrome (ARDS)
• Impaired oxygenation, diffuse lung opacification and lung
stiffness (↓ compliance).
• Aetiology: Systemic or lung sepsis, massive BT, aspiration.
• Endotoxin activated leucocyte→ oxygen-derived free
radicals, cytokines & chemical ↑capillary permeability
→interstitial & alveolar oedema.
• Tachypnoea, ↑ventilatory effort, confusion, hypoxia.
• CXR- bilateral diffuse fluffy opacities.
• Lung-increasing stiffness, difficult to ventilate.
• Treat: ventilation PEEP, sepsis, hypovolaemia.
• Mortality: 50%
PLEURAL EFFUSION
• Pulmonary pathology: collapse, consolidation,
infarction, tumour deposit.
• Abdominal pathology: sub-phrenic abscess.
• Small effusions left to reabsorb.
• Large effusions aspirated for culture/ cytology.
PNEUMOTHORAX
• Insertion of central venous line.
• Positive pressure ventilation- rupture of
pre-existing bullae.
• CXR after insertion central venous line is
necessary.
• Drained by underwater seal.
CARDIAC COMPLICATIONS
• Risk of anaesthesia/surgery high in patients
with cardiovascular disease
• Whenever possible, treat these before surgery
• Aortic stenosis impairs heart response to
increased post-operative demand
• Severe aortic/mitral valve dis.- carefully
monitor iv fluid administration
Myocardial Infarction
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Usually history of preceding cardiac disease
Gripping chest pain, hypotension
ECG changes
Cardiac enzymes
Cardiologist consultation
1/3rd postoperative MI fatal
Arrhythmias
• Sinus tachycardia: hypovolaemia,
hypotension, pain, fever, restlessness
• Sinus bradycardia:
pharyngeal suction
anaesthic agents,
• Atrial fibrillation may need medications
Post-operative shock
• Hypovolaemic: Inadequate fluid replacement, bleeding
• Cardiogenic: acute MI, arrhythmias
• ↑pulse, ↓BP, sweating, pallor, vasoconstriction,↓ urine
• Septic: early-hyperdynamic circulation, bounding pulse,
fever, rigor and warm extremity.
Later- hypotension and peripheral vasoconstriction
Cardiac failure
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Ischaemic or valvular diseases, arrythmia
Fluid overload
Progressive dyspnoea, hypoxaemia
CXR- diffuse congestion
Treatment: avoid fluid overload, CVP
monitoring
• Diuretics, cardiac inotropes
• Cardiologist consultation
Urinary complications
Post-op. urinary retention
• Groin, pelvic, perineal surgery, operations
under spinal/epidural anaesthesia
• Pain, effect of anaesthetic drugs, lying/sitting
position, BPH
• Males > females
• Palpable distended bladder,
• Catheterization
Urinary tract infection
• Most common nosocomial infection
• Pre-existing UTI, urinary retention, catheterization
• Frequency, dysuria, fever, flank tenderness
• Urine culture
• Adequate hydration, urinary drainage, antibiotics
Renal failure
• ARF: protracted inadequate renal perfusion
• Hypovolaemia, sepsis, nephrotoxic drugs
• Susceptible- pre-existing renal disease, jaundice
• Prevention: adequate IV fluid, urine >0.5ml/ hr
Renal failure
• Treatment: replace fluid loss+ 500ml
dietary protein to <20Gm/day
u/e monitoring, haemodialysis
• Polyuric phase: monitor of fluid intake and u/e
• Recovery 2-4 weeks
• Mortality up to 50%
Neurological complications
• Cerebrovascular accidents (CVA): sudden ↓ in BP
during/ post surgery, hypertensive patients.
Carotid endarterectomy, cardiac surgery
• Psychiatric disturbance: elderly, dementia due to
cerebral atrophy, use of sedatives/ hypnotics
• Acute toxic confusion: sepsis, hypoxia, uraemia,
electrolytes imbalance
• Sleep deprivation particularly in ICU
• Delirium tremens: agitation, tremors, hallucinations
Deep venous thrombosis (DVT)
• Virchow’s triad: stasis, ↑coagulability, vessel wall injury
• Risk factors: old age, obesity, prolonged surgery, pelvic/ hip surg.
malignancy, past DVT, varicose veins, pregnancy,
use of oral contraceptive pills
• Presentation: painful swollen tender calf & fever.
• Diagnosis: Duplex ultrasonography
• Prevention: Compression stockings, mechanical compressions of
calf during surgery, subcutaneous heparin
• Treatment: iv bolus/ infusion heparin, LMWH,
Warfarin for 3-6 months (INR 2-3 times normal)
Pulmonary embolism
• Massive PE: severe chest pain, pallor & shock
• CP resuscitation, heparinization, CT angiography,
streptokinase/ urokinase (if >6 days post surgery).
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Small PE: chest pain, tachypnoea, haemoptysis.
CXR, ECG , V/Q scan, CT
Haparinization
Warfarin for 3-6 months
Wound infection
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The most common complication.
Incidence: 1% (clean) to 30% (dirty).
Haematoma formation common before infection.
Manifests within 7 days of surgery.
Fever, tachycardia, increased pain at operation site.
Red, tender, swollen, discharging wound.
Remove few sutures to drain the wound.
Antibiotics- if septicaemic.
Malignant hyperthermia
• Trigger by GA in susceptible patients.
• Halogenated anaesthetics, succinylcholine,
suxamethionine.
• Abnormal release of Ca⁺.
• Prolonged muscle activation and heat generation.
• Patients develop high fever.
• Dantrolene + cooling of patient.
Postoperative fever
• 2/3rd postoperative patients.
• 48-72 hours after surgery.
Lung atelectasis- commonest cause.
Streptococcal or clostridial infection- uncommon.
• 4-5 days postoperative.
Chest infection.
Urinary tract infection.
Wound infection.
DVT.
Wound dehiscence
• Involves abdominal wall, Incidence <1%.
• Partial (deep layer), Complete (deep+ skin).
• Serosanguinous discharge, evisceration.
• Manifests within 2 weeks.
• Risk factors: Obesity, resp. disease, infection,
malnourishment, renal failure, malignancy, diabetes, steroid
use,& poor surgical technique.
• Resuture under GA. Develops hernia later.
Recommended book
Principle & Practice of Surgery
5th edition
Garden, Bradbury, Forsyth & Parks
THANK YOU!