Seroma Collection of liquified fat, serum and lymphatic fluid under an incision Fluid is clear, yellow and somewhat viscous Mastectomy, axillary dissection, groin dissection, large ventral hernias Presents as localized, well circumscribed swelling, presssure discomfort and sometimes clear drainage aspiration under sterile conditions If persist of becomes infected – open and allow to heal by secondary intention
Hematoma ► Abnormal collection of blood in subcutaneous layer of recent incision ► More worrisome than seromas – because of infection potential ► Reason: Inadequate hemostasis Rough handling of tissue Coagulopathy
Hematoma ► Presents as purplish/blue discoloration Localized wound swelling Drainage of dark red fluid In patients who have had neck dissection, a hematoma can develop postoperatively that is life threatening Compression of soft tissues surrounding the airway Immediate and emergent evacuation can be a lifesaving maneuver
Hematoma ► Prevention The most important principle is careful hemostasis Correct all clotting abnormalities Discontinue medications that can prolong bleeding time Wounds with large sking flaps should be drained
Wound Dehiscence ► Separation of fascial layers early in post operative course ► Great concern because of possibility of evisceration ( protrusion of intestines through the fascial layer)
Wound Dehiscence Scenario: You are called to see a patient post op day one with large amount of clear, salmon colored fluid from his laparotomy incision. WHAT DO YOU DO? Open a few staples Probe the wound with sterile cotton tipped swab Call the OR What do you do if pt eviscerates on the floor?
Wound Dehiscence ► Etiology Technical error ► Placing sutures too close to edge ► Too far apart ► Too much tension ► A multitude of other factors
Wound Dehiscence ► Technical error ► Intra abd infection ► Malnutrition ► Advanced age ► Chronic steroid use ► Wound complications ( hematoma, infection etc ) ► Underlying diseases ( DM, RF, CA, chemo, irradiation ) ► Increased intra-abd pressure ( ascites, coughing, etc ) Factors associated with Wound Dehiscence
Wound Dehiscence ► Approx 2% of patients undergoing abd surgery ► In healthy patients, no difference in dehiscence rate between continuous versus interrupted technique ► High risk patients – interrupted may occasionally be a wise choice
Wound Dehiscence Management Condition of the fascia ► If tech error and fascia is strong and intact, merely be closed ► If infected or weak – debride and close with retention sutures ► Look for evidence of anastomotic leak or other infection
Wound Dehiscence ► If significant amount of fascia needs to be debrided because of infection – do not close
Wound Infection Also referred to as SSI ( Surgical Site Infection) ► Superficial Incisional Skin and Subcutaneous tissue ► Deep Incisional Fascia and muscle ► Organ Space Internal organs
Superficial Incisional ► Infection less than thirty days after operation ► Involves skin and tissue only plus Purulent drainage Diagnosis of superficial SSI by surgeo Sx of erythema, pain, local edema
Deep Incisional ► Less than 30 days after op with no implant or soft tissue involvement ► Infection less than one year after op with implant and infection involves deep soft tissue ( fascia/muscle) plus Purulent drainage from the deep space but no extension into organ space Abscess found in the deep space on direct or radiologic exam or on re-op Dx of deep SSI by Surgeon Sx of fever, pain and tenderness lead to dehiscence of wound or opening by a surgeon.
Organ Space ► Less than 30 days after op with no implant or soft tissue involvement ► Infection less than one year after op with implant and infection involves any part of the op opened or manipulated plus Purulent drainage from a drain placed into the organ space Cx organisms from material aspirated from organ space Abscess found on direct or radiologic exam or during re-op Dx of organ space infection by surgeon
Risk factors for wound infection PatientOperation ► Advanced age ► In adequate preop prep ► Diabetes ► Duration of op ► Malnutrition ► No Abx when indicated ► Morbid Obesity ► Instrument contamination ► Immunosuppression ► Break in technique ► Coexisting remote infection ► Foreign body in wound ► Colonization with bacteria ► Ischemic tissue ► Prior radiation ► Devitalized tissue ► Smoking ► Amt of intraop contamination ( spillage)
Classification of Surgical Wounds CategoryCriteria Infection rate Clean No hollow viscus entered Primary wound closure No inflammation No breaks in aseptic tech Elective procedure 1 – 3% Clean contaminated Hollow viscus entered but controlled No inflammation Primary wound closure Minor breaks in aseptic tech Bowel prep preop 5-6% Contaminated Uncontrolled spillage from viscus Inflammation apparent Open,traumatic wound Major break in aseptic tech 20 – 25% Dirty Untreated, uncontrolled spillage Pus in op wound Open suppurative wound Severe inflammation 30 – 40%
► What is the most common pathogen associated with post operative wound infection? STAPHYLOCOCCUS AUREUS
Presentation and management ► Commonly occur 5-6 days post op may present sooner. ► % occur within thirty days after surgery ► Superficial wound infection Staples removed, allow efflux of purulent material, explored, irrigated debridement of non viable tissue if fascia is intact, no further concerns If fascia seperated – re xplore
Scenario #2 ► On POD #1, colostomy take down called to see pt with fever 102.5, HR 115, grayish dishwater colored fluid from wound. WHAT DO YOU DO? ► and crepitus along wound ► Typically what organisms?
► C.perfringens and group A Betalytic Strep ► Necrotizing fascitis/clostridiomyonecrosis ► OR – wound opened and aggressive debridement ► Cx wound Group A streptococcal infection Recent studies suggest that clindamycin is superior to penicillin in the treatment of experimental necrotizing fasciitis/myonecrosis. recommend the administration of penicillin G (4 million units intravenously every four hours in adults >60 kg in weight and with normal renal function) in combination with clindamycin (600 to 900 mg intravenously every eight hours)
Chronic Wounds ► Wounds that that have not healed within 30 – 90 days ► Corticosteroids, chemo, malnourihed, obese ► Management great deal of patience ► Debride as needed ► Skin graft ► Skin flaps ► Wound Vacs
Fifteen minutes into doing a mastectomy, the nurse anesthesist tells you that the patient has a temperature of deg,HR of 132 and high ETCO2. What is your most likely diagnosis and management of this patient ?
End tidal CO2 Tachycardia Fever 2°C per hour Cyanosis Mottling of skin Tachypnoea Arrhythmias Rigidity Sweating Hypercarbia Labile blood pressure Intense masseter spasm Ice packs Cooling blankets Fans Cold intravenous fluids Intragastric, intracystic cooling Peritoneal dialysis using cold diasylate Extracorporeal cooling if equipment is available Core temperature Arterial line and CVP line Urinary catheter ECG Pulse oximetry & capnography Blood gases Serum glucose Serum potassium Blood for CPK Urine for myoglobin Signs and Symptoms Active Cooling Monitoring Malignant Hyperthermia Terminate anaesthesia and surgery as soon as possible Hyperventilate with 100% oxygen Give Dantrolene Transfer to ICU as soon as possible
Malignant Hyperthermia DANTROLENE 2.5 mg/kg IV Repeat as required at 5.10 min intervals to a maximum cumulative dose of 10 mg/kg. Favorable response indicated by: (a) fall in heart rate (b) abolition of arrhythmia (c) decline in body temperature (d) reduced muscle tone ARRHYTHMIAS If these persist despite Dantrolene give: PROCAINAMIDE 1 mg/kg/ml IV Maximum dose: 15 mg/kg ACIDOSIS Correction with SODIUIM BICARBONATE mmol/kg/dose IV Repeated as necessary HYPERKALAEMIA Control if necessary using glucose and INSULIN 0.1 units/kg in 2 ml/kg 50% dextrose IV URINE OUTPUT MANNITOL g/kg ( ml/kg of 20% solution) and/or FUROSEMIDE 1 mg/kg IV to maintain urine output (> 1 ml/kg/hr)
Where is temperature modulation managed? ANTERIOR HYPOTHALAMUS
Postoperative Fever - Host of infectious and noninfectious agents may cause postoperative fever.
FIVE W’s of post op fever ► Wind ( lungs) Atelectasis, pneumonia ► Wound ► Water ( Urinary tract ) ► Waste ( lower GI tract ) ► Wonder drug
Atelectasis and Pneumonia Atelectasis is the most common cause of post op fever in first 48 hrs. Result of: Anesthesia Abdominal incision Post op narcotics Peripheral alveoli collapse and shunt may occur, also build up of secretion --- pneumonia
Atelectasis and Pneumonia ► Use of Incentive spirometry Deep Breathing Coughing Will resolve most of the time ► If aggressive toilet is not instituted, pneumonia may develop.
Atelectasis and Pneumonia ► Pt with pneumonia will have Fever Change in secretion Leukocytosis CXR – infiltrates ► Sent sputum Cx ► Broad spectrum, antibiotics ► Aggressive pulm toilet
You are called to see a pt few hours post-op in the ICU, this is the tracing on the monitor. Case 1. BP 70, HR160 Case 2.BP125/67, HR86 No prior history of this.
Atrial Fibrillation Irregular P waves > 300/min, irregular ventricular rhythm Associated Conditions: MI.HTN,hypoxia,Hyperthyroidism,electrolyte imbalance, pulmonary embolus If Unstable ( Case 1) Cardioversion – 200 – 360 J Initial Therapy Diltiazem 0.25mg/kg, then 10-15mg/hr Digoxin 0.5mg, then 0.25mg Q2hrs Esmolol, procainamide, amiodarone Subsequent therapy Procainamide, Digoxin, anticoagulation
Following laparotomy - return of function MATCH THE FOLLOWING Small bowel Stomach Colon 48hrs 3-5days 24hrs
Causes of Adynamic Ileus ► Inflammation e.g. appendicitis, pancreatitis ► Retroperitoneal disorders e.g. ureter, spine, blood ► Thoracic conditions e.g. pneumonia ► Systemic disorders e.g. sepsis, hyponatremia, hypokalemia, hypomagnesemia ► Drugs e.g opiates, Ca-channel blockers, psychotropics
PartialvsComplete ► Flatus ► Residual colonic gas above peritoneal reflection /p 6-12h ► Adhesions ► 60-80% resolve with non- operative Mx ► Must show objective improvement, if none by 48h consider OR ► Complete obstipation ► No residual colonic gas on AXR ► SBFT may differentiate early complete from high-grade partial ► Almost all should be operated on within 24h
Is there strangulation? ► 4 Cardinal Signs × fever, tachycardia, localized abdominal tenderness, leukocytosis 0/40% strangulated bowel 1/47%““ 2-3/4 24%““ 4/467%““ ► process accelerated with closed-loop obstr.
55 year old POD#5, from thoracotomy with severe foul smelling diarrhea, WBC 40,000, 15 bands. General surgery consult, colonscopy shown below.
Pseudomembranous Colitis - - Pseudomembranes compromised of fibrin, mucus and necrotic epithelial cells - - Mostly in rectosigmoid - - Accessible to sig-scope - - C.diff toxin is agent responsible - - found in % of pts with Pseudomembranous colitis - - Mortality 20% - if untreated - - Progression – perforation, toxic megacolon TREATMENT: Flagyl – 250mg PO Q 6 hrs – 7 – 10days If unsuccessful Vancomycin – 125 mg Q6 hrs
Abdominal Compartment Syndrome TNICU – PTD #2, Ex-lap, GradeII liver injury & splenectomy. You are called at 0100 to see pt. Increase peak airway pressures Low urine output Abdominal distention WHAT DO YOU DO DOC? A Foley catheter attached to a manometer accurately reflects intra-abdominal pressure in the supine patient.
Thyroid Storm ► ► a decompensated state of thyroid hormone– induced, severe hypermetabolism involving multiple systems. ► ► Thyroid storm is the most extreme state of thyrotoxicosis.
Thyroid Storm ► MANIFESTATIONS Tachycardia: r Tachycardia: rates that can exceed 140 beats/min Hyperpyrexia: to 104 to 106º F is common CNS signs: CNS signs: Agitation, delirium, psychosis, stupor, or coma are common TRIGGERED BY Palpation of gland during surgery Emotional stress Iodine/iodide administration (without prior PTU)
Thyroid Storm The therapeutic regimen ► ► A beta-blocker to control the symptoms induced by increased adrenergic tone. ► ► A thionamide, such as methimazole, to block new hormone synthesis. ► ► An iodinated radiocontrast agent to inhibit the peripheral conversion of T4 to T3. ► ► An iodine solution to block the release of thyroid hormone. ► ► Glucocorticoids to reduce T4-to-T3 conversion and possibly treat the autoimmune process in Graves' disease.
A 56 year old wm, s/p AAA repair, in the ICU on the vent,with the following persistent hypotension despite fluids and pressors PCWP - 20 CVP15 hyponatremia hypoglycemia
► Causes of postoperative primary adrenal insufficiency include Autoimmune disease, TB, fungal disease, malignancy, AIDS, and drug suppression. Hemmorhage is a common cause in the ICU ► Secondary causes (decreased ACTH) include: suppresion by glucocorticoid therapy, ACTH secreting tumors, pituitary operation, irradiation, head trauma. ► Clinical findings– anorexia, malaise, hypoglycemia, hypotension: Low CO and high SVRI or High CO and low SVRI ► Dx is by measuring free cortisol and cosyntropin stim.test ► Tx is with fluids and steriods (dexamethasone followed by hydrocortisone) Causes of adrenal insufficiency in surgical setting, as well as clinical and laboratory findings
Adrenal Insufficiency ► Random cortisol level of less than 20µg/dl is suggestive ► Cosyntropin test µg of cosyntropin ► Check cortisol level at 30 and 60 minutes ► Failure to increase greater than 20 µg is diagnostic or by 9 over baseline ► Administer Dexamethasone - it does not affect cosyntropin test
Syndrome of Inappropriate ADH Release ► ► The diagnosis of SIADH is made when hyponatremia coexists with serum hypo- osmolality (<280 mOsm per kg H 2 O) and a urine osmolality of more than 100 mOsm per kg H 2 O.
Disorders Associated With SIADH ► Carcinomas (e.g, ► Carcinomas (e.g,bronchogenic and pancreatic) ► Pulmonary disorders (e.g, ► Pulmonary disorders (e.g,tuberculosis, pneumonia) ► Central nervous system disorders (e.g, ► Central nervous system disorders (e.g, trauma, stroke, meningitis) ► Drugs ( ► Drugs (thiazides, NSAIDS, ACE inhibitors etc)
Treatment of SIADH ► ► removal of all offending drugs ► ► management of mild hyponatremia with fluid restriction (<800 ml per day) alone. ► ► In moderate hyponatremia, fluid restriction and 0.9% sodium chloride infusion are necessary ► ► hyponatremia should be corrected at a rate of 0.5 mmol per liter per hour to achieve a sodium level of 125 mmol per liter ► ► In severe cases, associated with coma, hypertonic (3%) sodium chloride infusion may be necessary. ► ► Rapid correction (within 24 hours) of long-standing hyponatremia that has persisted for more than 2 days has caused central pontine myelinolysis.
Delirium,Dementia and Depression
Delirium Virtually any medical condition can precipitate delirium in a susceptible host; multiple underlying conditions are often found. ► ► Fluid and electrolyte disturbances (dehydration, hypo/hypernatremia) ► ► Infections (urinary tract, respiratory tract, skin and soft-tissue) ► ► Drug toxicity ► ► Metabolic disorders (hypoglycemia, hypercalcemia, uremia, liver failure) ► ► Low perfusion states (shock, heart failure) ► ► Withdrawal from alcohol and sedatives.