Presentation on theme: "بسم الله الرحمن الرحيم. Post Operative Complications Dr. Khalid Jamal Hamdi."— Presentation transcript:
بسم الله الرحمن الرحيم
Post Operative Complications Dr. Khalid Jamal Hamdi
Classification Anaesthetic Surgical Local General (Operation site) (Other systems) respiratory cardiovascular urological
Surgical Immediate (within first 24 hs.) Early (2nd day- 3 weeks) Late (after discharge)
Other Post-op. Complications Post.op. pancreatitis ( 10% of all cases of acute pancreatitis) Operations in vicinity of pancreas e.g. 1% after cholecystectomy and 8% after CBD exploration. Post-op. Parotitis. C.V.A. ( 1-3% after carotid endarterectomy) Post-op. cholecystitis. Complications of I.V. Therapy ( air embolism, phlebitis.)
I. Pre-hepatic jaundice (bilirubin overload) Haemolysis (drugs, Transfusion, sickle cell crisis) Reabsorption of haematomas. II. Hepatocellular insufficiency Viral hepatitis. Drug-induced (anesthesia, others) Ischemia (shock, hypoxemia, low-output states) Sepsis Liver resection (loss of parenchyma) III. Post-hepatic obstruction to bile flow Retained stones Injury to ducts Tumour (unrecognized or untreated) Cholecystitis Pancreatitis Post-op. jaundice.
Wound Infection After After open surgerylaparoscopic surgery 10% <2% ● large wound size ● small ● open to atmosphere ● not ● more manipulation ● less ● poor blood supply ● better
Aetiology Pre-operative Operative Post-operative (exist before surgery) (during operation) (after patient’s return to ward) ● perforated organ. ● inadequate sterilization ● cross ● compound of instruments, surgeon’s infection fracture hands or dressings between ● skin infection patients (boils) ● nasal carriers of ● contamination Staphylococci among during dressing nurses and surgeons. ● operations on alimentary, biliary or urinary tracts
Clinical Picture Occurs a few days or even weeks after surgery. Pain and swelling of site of operation. General manifestations e.g. malaise, vomiting or anorexia. Swinging temperature (hic tic). Wound is also red and tender. Pus may be expressed out on pressure.
Treatment ProphylacticTherapeutic ● good sterilization. ● drainage of pus ● scrupulous O.R. and ● antibiotics if dressing techniques. associated ● isolation of infected cases. with spreading ● elimination of carriers with cellulitis cold or septic lesions among nurses and surgical teams
Burst Abdomen Total (early) Partial (late) ● all layers gape ● Skin is intact which leads to including skin, so weak scar leading to viscera comes out incisional hernia
Clinical Picture Usually occurs on the 10 th post- operative day. Pinkish discharge (pink fluid sign). Viscera may come out after a strain e.g. coughing or sneezing.
Treatment Sedation to alleviate fear. Cover contents with sterile saline packs Re-suturing of wound using strong nylon through all layers of abdominal wall (tension sutures). Usually heals rapidly and soundly.
Post-operative sinus or fistula Gastrointestinal Biliary Pancreatic
Causes Poor surgical technique. Poor blood supply at anastomotic site. Sepsis leading to suture line break-down. Poor patient’s condition e.g. uraemia, anaemia, protein deficiency or cachexia. Distal obstruction e.g. missed CBD stone.
Clinical Picture Usually obvious due to escape of bowel contents or bile. Oral methylene blue test. Testing fistula fluid for bile or pancreatic enzymes e.g. amylase. Injection of contrast to delineate the tract. Sinogram / Fistulogram
Management ● protect skin ● replace fluid and ● reduce sepsis by from ulceration electrolytes judicious ● vitamins and drainage of nutrients pus ● antibiotic therapy
Post-operative Pyrexia (high temperature for more than 48 hours) Causes : Wound haematoma. Pelvic abscess. D. V. T. Chest infection (collapse, pneumonia, infarction or sub-phrenic abscess). U. T. I. Enterocolitis. Possible drug sensitivity.
Pulmonary Collapse It is a common post-operative complication after abdominal or thoracic surgery. Due to mucous retention blocking fine bronchi. Usually involves basal lung segments. May become secondarily infected by inhaled organisms or blood born.
Aetiology Pre-operativeOperative Post-operative ● pre-existing ● irritant ● pain acute or anaesthetic ● immobilization chronic lung agents infection. ● atropine which ● emphysema. Makes secretions viscid ● heavy Smoking
Clinical Picture Occurs within first 48 hours post- operative Dyspnea, tachycardia and fever. May be cyanosis. Fruity cough. Impaired chest movement particularly on the affected side. Basal dullness and crepitations with diminished air entry. CxR opacity of involved segments.
Treatment Pre-operative Post-operative ● breathing ● breathing exercises exercises. ● encourage coughing. ● stop smoking. ● small doses of ● antibiotics for sedatives for pain infection. ● antibiotics if sputum is infected
Deep Vein Thrombosis (D. V. T.) Usually occurs at time of operation. Manifest itself during the second post-operative week. Involves the deep veins of lower limbs and pelvis. Pain and swelling of the leg and calf muscles. Skin temperature is increased with dilated superficial veins. May be mild pyrexia. Homan’s sign may be positive.
Investigations VenogramI 125 labeled Doppler fibrinogen ultrasound ● very valuable ● very sensitive ● simple and sensitive. ● can be repeated at ● non-invasive ● can not be short intervals. ● can detect loss repeated frequently ● only useful for of doppler detection of veins effect on the below knee occluded (excreted in urine veins and held in bladder).
Prophylactic active and early mobilization post-operatively. elevation of legs. elastic graded compression stocking. use of inflatable bags. electrical stimulation of leg muscles. prophylactic S.C. doses of heparin. Therapeutic heparinization. oral anticoagulants. ligation of I.V.C. I.V.C. umbrella. Treatment
Pulmonary Embolism Due to dislodgement of a clot from deep veins of lower limbs or pelvis. A massive embolus can obstruct the right heart out put and causes death. Less severe cases give rise to shock, breathlessness and cyanosis with severe retro- sternal pain and discomfort. Mild cases present with pleural pain, dyspnea and haemoptesis in 50% of cases. Might lead to lung infarction if patient has cardiac failure due to lung congestion.
Clinical Picture Difficult to diagnose clinically. Helpful signs are : pleural rub crepitations diminished air entry May be silent.
Investigations CxR → normal in early stage, but shows patchy shadowing later-on. E.C.G. → Changes of right heart strain. Perfusion lung scan → uneven circulation through the lungs with multiple perfusion defects. Ventilation scan → normal in absence of pre- existing pulmonary diseases. Arteriogram (diagnostic) → shows filling defect due to embolus in pulmonary artery.
Treatment Morphia for pain. Oxygen. Lysis of embolus with streptokinase if seen early. Heparinization. Embolectomy in critically ill patients using the cardio-pulmonary by-pass machine