1. POST – OPERATIVE COMPLICATIONS COMPLICATIONS General Surgery rotation Y. Edden MD Department of General Surgery

2. When does it end ?

4. I would like to see the day when somebody would be appointed surgeon somewhere who had no hands, for the operative part is the least part of the work. I would like to see the day when somebody would be appointed surgeon somewhere who had no hands, for the operative part is the least part of the work. -Harvey W. Cushing

5. Surgery Personal responsibility, Ego, Conservatism Y. Edden MD

6. Post-Op Fever 25-50% of patients Will have fever in 1 st 24 hr post-op 1-2 days post-op: Atelectasis 3-4 days post-op: Phlebitis, Pneumonia 5 days post-op: Wound infection 7 days post-op: Anastomotic leak or disruption

7. Respiratory Complications 30-50% of surgical patients Atelectasis & Pneumonia Most common pulmonary complication Most common pulmonary complication Collapse of alveolar segments causing shunts Collapse of alveolar segments causing shunts Non cleared pulmonary secretions infected causing Non cleared pulmonary secretions infected causing pneumonia pneumonia 10-20% of ICU patients suffer from pneumonia 10-20% of ICU patients suffer from pneumonia

8. Respiratory Complications Clinical Presentation Low grade fever Low grade fever Decreased breath sounds over lower lung fields Decreased breath sounds over lower lung fields Crepitations Crepitations Secretions Secretions Pneumonia- Fever, WBC , CXR with infiltrates, Fever, WBC , CXR with infiltrates, infected thick secretions infected thick secretions

9. Respiratory Complications Prevention: Cease smoking 2-4 weeks pre-op Cease smoking 2-4 weeks pre-op Optimal analgesia Optimal analgesia Aggressive pulmonary toilet Aggressive pulmonary toilet Early ambulation Early ambulation Incentive spirometry Incentive spirometry

10. Respiratory Complications Aspiration Inhalation of gastric fluid – ‘Mendelson aspiration’ Inhalation of gastric fluid – ‘Mendelson aspiration’  Low pH of gastric content : pulmonary Edema, Hemorrhage, atelectasis, alveoli necrosis Hemorrhage, atelectasis, alveoli necrosis 50% will have bacterial contamination and severe 50% will have bacterial contamination and severe pneumonia pneumonia Contributing Factors Altered mental status Altered mental status Altered swallowing mechanism Altered swallowing mechanism NGT NGT

11. Post-Op Fever 25-50% of patients will have fever in 1 st 24 hr post-op 1-2 days post-op: Atelectasis 3-4 days post-op: Phlebitis, Pneumonia 5 days post-op: Wound infection 7 days post-op: Anastomotic leak or disruption

12. Phlebitis Can happen any timeCan happen any time Large diameter > more infectionsLarge diameter > more infections Change every 3 daysChange every 3 days Usually poor techniqueUsually poor technique

13. Post-Op Fever 25-50% of pts. Will have fever in 1 st 24 hr post-op 1-2 days post-op: Atelectasis 3-4 days post-op: Phlebitis, Pneumonia 5 days post-op: Wound infection 7 days post-op: Anastomotic leak or disruption

14. Wound Complications Contributing Factors: Inadequate surgical technique Inadequate surgical technique Increased presuure/ tension on closure (bowel Increased presuure/ tension on closure (bowel distention. Ascites, cough) distention. Ascites, cough) Inadequate wound healing: Age, DM, Inadequate wound healing: Age, DM, malnutrition, CRF, Steroids, CTx, Rad malnutrition, CRF, Steroids, CTx, Rad

15. Wound Complications Surgical Site Infection Most common infection in surgical patients (40%) Most common infection in surgical patients (40%) 2/3 involve superficial or deep incisional tissue 2/3 involve superficial or deep incisional tissue 1/3 involve organs/ space operated 1/3 involve organs/ space operated Source: Flora of skin/ mucous membranes and hollow viscera Pathogens: 20% Staph Aureus, 15% Coag. Neg. Staph, 12% Enterococcus, 8% E. Coli 12% Enterococcus, 8% E. Coli

16. Wound Complications Contributing Factors.. Patient:Operation: AgeDuration of scrub (6min=2min) MalnutritionDuration of operation DiabetesForeign material Co-existant infectionSkin antisepsis Immune deficiencySurgical technique Presentation ‘Rubor’ ‘Calor’ ‘Dolor’ ‘Tumor’ Usually on 5 th day Low grade fever Progression of cellulitis

17. Wound Complications Treatment Opening wound, culture, mechanical drainage ABx only if marked cellulitis or systemic signs Necrotizing Fasciitis- Early appearance ! Day 1 Step. A, Clostridium Perfringens (G+ rods) Step. A, Clostridium Perfringens (G+ rods) Prevention: Bowel prep (?) Peri-op IV Abx Control of Diabetes Treatment of coexistent infections 2-4 weeks non smoking

18. Wound Complications Wound Hematoma Inadequate hemostasis Inadequate hemostasis Coagulopathy Coagulopathy Myeloproliferative Disorder Myeloproliferative Disorder NSAIDs NSAIDs Wound seroma Collection of serum & lymph in SQ tissue Collection of serum & lymph in SQ tissue Usually not infected Usually not infected Discomfort, swelling Discomfort, swelling Treatment: Aspiration (infecting) Treatment: Aspiration (infecting) Closed suction drain Closed suction drain

19. Wound Complications Wound Dehiscence 2% of Abdominal operations 2% of Abdominal operations Dehiscence- separation of fascial layer in early Dehiscence- separation of fascial layer in early post operative post operative Evisceration- large dehiscence allowing Evisceration- large dehiscence allowing protrusion of viscera protrusion of viscera

20. ‘Salmon Pink’

21. Venous Thromboembolism DVT & PE 100,000 death per year from PE in the USA Surgical patients are in increased risk for DVT 90% clot originates from ileofemoral vessels 90% clot originates from ileofemoral vessels Clinical significance according to clot size and patient’s Clinical significance according to clot size and patient’s status status Other forms: Fat embolism, Amniotic fluid embolism Other forms: Fat embolism, Amniotic fluid embolism Air embolism, Foreign body embolism Air embolism, Foreign body embolism

22. Venous Thromboembolism Risk Factors Age>40 Paralysis Chronic heart diseaseProlonged immobilization Malignancy Prolonged surgery Inherited Coag deficienciesMultiple trauma Previous DVTObesity Treatment Resuscitation (Oxygen, Intubation, Cardiac arrest) Diagnosis- ABG, CXR, ECG, V/Q scan, Angio, CT scan Anticoagulation, IVC filter

23. Venous Thromboembolism Prevention Prevention Prophylaxis Prophylaxis Mechanical- pneumatic compressive devices Mechanical- pneumatic compressive devices Elastic stockings Elastic stockings Mobilization Mobilization Pharmacological- Anticoagulants Pharmacological- Anticoagulants (Heparin, Clexane, Warfarin) (Heparin, Clexane, Warfarin) IVC Filter IVC Filter

24. IVC Filter

25. הפסקה !

26. GI Tract Complications Post-op Ileus Uncomplicated recovery from abdominal surgery Uncomplicated recovery from abdominal surgery SB motility returns almost immediately SB motility returns almost immediately Gastric motility returns in 2-3 days Gastric motility returns in 2-3 days Colonic motility returns in 3-5 days Colonic motility returns in 3-5 days Contributing factors for prolonged ileus Opioids Opioids Upper GI surgery Upper GI surgery Pre-op obstruction Pre-op obstruction Diabetic neuropathy Diabetic neuropathy Retroperitoneal hematoma Retroperitoneal hematoma Excessive trauma to the bowel Excessive trauma to the bowel

27. GI Tract Complications GI Bleeding Stress gastritis common in critically ill patients (Burn, Trauma, Major Abd surgery, CNS inj, Sepsis, AMI) Treatment Resuscitation (IV fluids, Blood, correct anticoag, treat sepsis) Upper endoscopy- diagnosis and treatment Prevention Reducing intragastric acid production- Antacids, H2 blockers Healing of gastric mucosa- Sucralfate (PGE2↑, mucous↑)

28. Cardiac Complications Perioperative Ischemia & Infarction Leading cause of death in elderly patients after non cardiac surgery Previous AMI- Major risk factor AMIRe-infarction rate 3mo30% 3-6mo10% >6mo5-8% (general risk)

29. Cardiac Complications Prevention Identification of high risk patients Identification of high risk patients Optimization of cardiac function peri-op Optimization of cardiac function peri-op High index of suspicion High index of suspicion

30. Cardiac Complications Arrhythmias Intrinsic cardiac disease Intrinsic cardiac disease Thoracic or mediastinal surgeries Thoracic or mediastinal surgeries Electrolyte abnormalities Electrolyte abnormalities Cardiac medications Cardiac medications Catecholamine stress response Catecholamine stress response Endocrine abnormalities Endocrine abnormalities Treatment According to ACLS

31. Renal & Urinary Tract Complications Urinary Retention Inability to empty urine filled bladder Especially after Inguinal Hernias, anorectal procedures Causing Factors: Post-op pain Epidural analgesia prevent  adrenergic inhibition Overly vigorous IV fluids Presentation Urgency Urgency Discomfort Discomfort Pain Pain Enlarged palpable bladder ‘Globe vesicle’ Enlarged palpable bladder ‘Globe vesicle’

32. Renal & Urinary Tract Complications TreatmentCatheterization Prevention Void before surgery  Blockers Min fluids peri-op

33. Acute Renal Failure Common complication (5-10% of surgical patients) Mostly in CABG, vascular, transplant, urologic surgeries Pre-renal Hypotension Hypotension Hypovolemia Hypovolemia Cardiac failure Cardiac failure Arterial stenosis or occlusion Arterial stenosis or occlusion Renal & Urinary Tract Complications

34. Intra-renal Toxins (Rad contrast, endotoxins) Toxins (Rad contrast, endotoxins) Pigment (myoglobin) Pigment (myoglobin) Post-renal Ureteral obstruction (stone, trauma, surgical injury) Ureteral obstruction (stone, trauma, surgical injury) Bladder distention (nerve injury, drugs) Bladder distention (nerve injury, drugs) Uretheral obstruction (Trauma, BPH, malignancy) Uretheral obstruction (Trauma, BPH, malignancy) Renal & Urinary Tract Complications

35. Neurological Complications CVA & TIA Non hemorrhagic stroke: Cardiac or extra-cranial vascular lesion (AF, Carotid stenosis) Hemorrhagic stroke: Uncontrolled HTN Uncontrolled anticoagulation

36. If you can’t stand the heat stay out of the kitchen… Harry S. Truman 33 rd US president 1945-1953