3Seroma Collection of liquified fat, serum and lymphatic fluid under an incisionFluid is clear, yellow and somewhat viscousMastectomy, axillary dissection, groin dissection,large ventral herniasPresents as localized , well circumscribed swelling , presssure discomfort and sometimes clear drainageaspiration under sterile conditionsIf persist of becomes infected – open and allow to heal by secondary intention
4HematomaAbnormal collection of blood in subcutaneous layer of recent incisionMore worrisome than seromas – because of infection potentialReason:Inadequate hemostasisRough handling of tissueCoagulopathy
5Hematoma Presents as purplish/blue discoloration Localized wound swellingDrainage of dark red fluidIn patients who have had neck dissection, a hematoma can develop postoperatively that is life threateningCompression of soft tissues surrounding the airwayImmediate and emergent evacuation can be a lifesaving maneuver
6Hematoma Prevention The most important principle is careful hemostasis Correct all clotting abnormalitiesDiscontinue medications that can prolong bleeding timeWounds with large sking flaps should be drained
7Wound DehiscenceSeparation of fascial layers early in post operative courseGreat concern because of possibility of evisceration ( protrusion of intestines through the fascial layer)
8Wound DehiscenceScenario: 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 staplesProbe the wound with sterile cotton tipped swabCall the ORWhat do you do if pt eviscerates on the floor?
9Wound Dehiscence Etiology Technical error Placing sutures too close to edgeToo far apartToo much tensionA multitude of other factors
11Wound Dehiscence Approx 2% of patients undergoing abd surgery In healthy patients, no difference in dehiscence rate between continuous versus interrupted techniqueHigh risk patients – interrupted may occasionally be a wise choice
12Wound Dehiscence Management Condition of the fasciaIf tech error and fascia is strong and intact, merely be closedIf infected or weak – debride and close with retention suturesLook for evidence of anastomotic leak or other infection
13Wound DehiscenceIf significant amount of fascia needs to be debrided because of infection – do not close
16Wound Infection Also referred to as SSI ( Surgical Site Infection) Superficial IncisionalSkin and Subcutaneous tissueDeep IncisionalFascia and muscleOrgan SpaceInternal organs
17Superficial Incisional Infection less than thirty days after operationInvolves skin and tissue only plusPurulent drainageDiagnosis of superficial SSI by surgeoSx of erythema, pain, local edema
18Deep IncisionalLess than 30 days after op with no implant or soft tissue involvementInfection less than one year after op with implant and infection involves deep soft tissue ( fascia/muscle) plusPurulent drainage from the deep space but no extension into organ spaceAbscess found in the deep space on direct or radiologic exam or on re-opDx of deep SSI by SurgeonSx of fever, pain and tenderness lead to dehiscence of wound or opening by a surgeon.
19Organ SpaceLess than 30 days after op with no implant or soft tissue involvementInfection less than one year after op with implant and infection involves any part of the op opened or manipulated plusPurulent drainage from a drain placed into the organ spaceCx organisms from material aspirated from organ spaceAbscess found on direct or radiologic exam or during re-opDx of organ space infection by surgeon
20Risk factors for wound infection PatientOperationAdvanced ageIn adequate preop prepDiabetesDuration of opMalnutritionNo Abx when indicatedMorbid ObesityInstrument contaminationImmunosuppressionBreak in techniqueCoexisting remote infectionForeign body in woundColonization with bacteriaIschemic tissuePrior radiationDevitalized tissueSmokingAmt of intraop contamination ( spillage)
21Classification of Surgical Wounds CategoryCriteriaInfection rateCleanNo hollow viscus enteredPrimary wound closureNo inflammationNo breaks in aseptic techElective procedure1 – 3%Clean contaminatedHollow viscus entered but controlledMinor breaks in aseptic techBowel prep preop5-6%ContaminatedUncontrolled spillage from viscusInflammation apparentOpen,traumatic woundMajor break in aseptic tech20 – 25%DirtyUntreated, uncontrolled spillagePus in op woundOpen suppurative woundSevere inflammation30 – 40%
22What is the most common pathogen associated with post operative wound infection? STAPHYLOCOCCUS AUREUS
23Presentation and management Commonly occur 5-6 days post op may present sooner.80 -90% occur within thirty days after surgerySuperficial wound infectionStaples removed, allow efflux of purulent material,explored, irrigateddebridement of non viable tissueif fascia is intact, no further concernsIf fascia seperated – re xplore
24Scenario #2On 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 woundTypically what organisms?
25C.perfringens and group A Betalytic Strep Necrotizing fascitis/clostridiomyonecrosisOR – wound opened and aggressive debridementCx woundGroup A streptococcal infectionRecent 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)
26Wound Infection - Prevention Stop smokingLose weightTight glucose controlWean steroidsBowel prepHemostasisCareful handling of tissueAdequate blood supplyVoluminous irrigationAbx proph when indicated
27Chronic Wounds Wounds that that have not healed within 30 – 90 days Corticosteroids, chemo, malnourihed, obeseManagementgreat deal of patienceDebride as neededSkin graftSkin flapsWound Vacs
28What is your most likely diagnosis and management of this patient? 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 diagnosisand management of this patient?
29Malignant Hyperthermia Signs and SymptomsMonitoringActive CoolingEnd 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 myoglobinTerminate anaesthesia and surgery as soon as possibleHyperventilate with 100% oxygenGive DantroleneTransfer to ICU as soon as possible
30Malignant Hyperthermia DANTROLENE 2.5 mg/kg IVRepeat 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 toneARRHYTHMIAS If these persist despite Dantrolene give: PROCAINAMIDE 1 mg/kg/ml IV Maximum dose: 15 mg/kgHYPERKALAEMIA Control if necessary using glucose and INSULIN 0.1 units/kg in 2 ml/kg 50% dextrose IVACIDOSIS Correction with SODIUIM BICARBONATE mmol/kg/dose IV Repeated as necessaryURINE OUTPUT MANNITOL g/kg ( ml/kg of 20% solution) and/or FUROSEMIDE 1 mg/kg IV to maintain urine output (> 1 ml/kg/hr)
31ANTERIOR HYPOTHALAMUS Where is temperature modulation managed?ANTERIOR HYPOTHALAMUS
32Postoperative Fever -Host of infectious and noninfectious agents may cause postoperative fever.
33FIVE W’s of post op fever Wind ( lungs)Atelectasis, pneumoniaWoundWater ( Urinary tract )Waste ( lower GI tract )Wonder drug
35Atelectasis and Pneumonia Atelectasis is the most common cause of post opfever in first 48 hrs .Result of:AnesthesiaAbdominal incisionPost op narcoticsPeripheral alveoli collapse and shunt mayoccur, also build up of secretion --- pneumonia
36Atelectasis and Pneumonia Use ofIncentive spirometryDeep BreathingCoughingWill resolve most of the timeIf aggressive toilet is not instituted, pneumonia may develop.
37Atelectasis and Pneumonia Pt with pneumonia will haveFeverChange in secretionLeukocytosisCXR – infiltratesSent sputum CxBroad spectrum, antibioticsAggressive pulm toilet
38No prior history of this. You are called to see a pt few hours post-op in the ICU, this is the tracing on the monitor.No prior history of this.Case 1. BP 70, HR160Case 2.BP125/67 , HR86
40Atrial FibrillationIrregular P waves > 300/min, irregular ventricular rhythmAssociated Conditions:MI.HTN,hypoxia,Hyperthyroidism,electrolyte imbalance, pulmonary embolusIf Unstable ( Case 1)Cardioversion – 200 – 360 JInitial TherapyDiltiazem 0.25mg/kg , then 10-15mg/hrDigoxin 0.5mg , then 0.25mg Q2hrsEsmolol, procainamide, amiodaroneSubsequent therapyProcainamide, Digoxin, anticoagulation
41Following laparotomy - return of function MATCH THE FOLLOWING Small bowelStomachColon48hrs3-5days24hrs
42Causes of Adynamic Ileus Inflammation e.g. appendicitis, pancreatitisRetroperitoneal disorders e.g. ureter, spine, bloodThoracic conditions e.g. pneumoniaSystemic disorders e.g. sepsis, hyponatremia, hypokalemia, hypomagnesemiaDrugs e.g opiates, Ca-channel blockers, psychotropics
43Partial vs Complete Complete obstipation No residual colonic gas on AXRSBFT may differentiate early complete from high-grade partialAlmost all should be operated on within 24hFlatusResidual colonic gas above peritoneal reflection /p 6-12hAdhesions60-80% resolve with non-operative MxMust show objective improvement, if none by 48h consider OR
4555 year old POD#5, from thoracotomy with severe foul smelling diarrhea, WBC 40,000, 15 bands. General surgery consult, colonscopy shown below.
46Pseudomembranous Colitis Pseudomembranes compromised of fibrin, mucus and necrotic epithelial cellsMostly in rectosigmoidAccessible to sig-scopeC.diff toxin is agent responsiblefound in % of pts with Pseudomembranous colitisMortality 20% - if untreatedProgression – perforation, toxic megacolonTREATMENT:Flagyl – 250mg PO Q 6 hrs – 7 – 10daysIf unsuccessfulVancomycin – 125 mg Q6 hrs
47Abdominal Compartment Syndrome TNICU – PTD #2, Ex-lap, GradeII liver injury & splenectomy. You are called at 0100 to see pt.Increase peak airway pressuresLow urine outputAbdominal distentionWHAT DO YOU DO DOC?A Foley catheter attached to a manometer accurately reflects intra-abdominal pressure in the supine patient.
49Thyroid Storma decompensated state of thyroid hormone– induced, severe hypermetabolism involving multiple systems.Thyroid storm is the most extreme state of thyrotoxicosis.
50Thyroid Storm TRIGGERED BY MANIFESTATIONS Palpation of gland during surgeryEmotional stressIodine/iodide administration (without prior PTU)MANIFESTATIONSTachycardia: rates that can exceed 140 beats/minHyperpyrexia: to 104 to 106º F is commonCNS signs: Agitation, delirium, psychosis, stupor, or coma are common
51The therapeutic regimen Thyroid StormThe therapeutic regimenA 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.
52persistent hypotension despite fluids and pressors PCWP - 20CVP15hyponatremiahypoglycemiaA 56 year old wm , s/p AAA repair, in the ICU on the vent,with the following
53Causes of adrenal insufficiency in surgical setting, as well as clinical and laboratory findings Causes of postoperative primary adrenal insufficiency includeAutoimmune disease, TB, fungal disease, malignancy, AIDS, and drug suppression. Hemmorhage is a common cause in the ICUSecondary 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 SVRIDx is by measuring free cortisol and cosyntropin stim.testTx is with fluids and steriods (dexamethasone followed by hydrocortisone)
54Adrenal Insufficiency Random cortisol level of less than 20µg/dl is suggestiveCosyntropin test µg of cosyntropinCheck cortisol level at 30 and 60 minutesFailure to increase greater than 20 µg is diagnostic or by 9 over baselineAdminister Dexamethasone - it does not affect cosyntropin test
55Syndrome 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.
56Disorders Associated With SIADH Carcinomas(e.g,bronchogenic and pancreatic)Pulmonary disorders(e.g ,tuberculosis, pneumonia)Central nervous system disorders(e.g, trauma, stroke, meningitis)Drugs(thiazides, NSAIDS, ACE inhibitors etc)
57Treatment 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 necessaryhyponatremia should be corrected at a rate of 0.5 mmol per liter per hour to achieve a sodium level of 125 mmol per literIn 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.
59multiple underlying conditions are often found . DeliriumVirtually 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 toxicityMetabolic disorders (hypoglycemia, hypercalcemia, uremia, liver failure)Low perfusion states (shock, heart failure)Withdrawal from alcohol and sedatives.