POST OPERATIVE COMPLICATIONS Dr Muath Eid

Outline General Consideration Wound Complication Post Operative Infection Pulmonary Complication Postoperative Shock Postoperative Renal complication Gastrointestinal Complication

General Considerations: Complications are made in the operating rooms. Minimize the risk: Rigorous preoperative evaluations Meticulous operative technique Careful monitoring of patients preoperatively Fever: 1st postop day --> atelectasis/aspiration/UTI 4th-5th postop --> wound infection /anastomotic leak Hypotension: Immediate --> continuous hge / depressive drugs Later ---> sepsis

Wound Complications: Wound dehiscence: Separation of an abd. wound involving the anterior fascial and deeper layers 0.5 – 3.0% Causes: General factors: Age: < 45y/o = 1.3% > 45% = 5.4% Debilitated pts. w/ poor nutrition carcinoma, hyponatremia, obesity Causes of increase intra-abd. pressure pulmonary & urinary problem

Wound Complications: Wound dehiscence: Causes: Manifestation: Local Factors: Hemorrhage Infection Poor technique: Excessive suture material Drain and stoma placed along incision Type of incision (> in vertical insicion) Manifestation: Sero-sanguinous drainage (pathognomonic) Postoperative ventral hernia

Wound Complications: Wound dehiscence: Treatment: Prognosis: secondary operative procedure (if medical condition allows) conservatively with an occlusive wound dressing and binder ----> postoperative hernia. Prognosis: Mortality = 0.5 – 0.3% due to pathologic conditions

Wound Complications: Wound Infection: Major factors: Breaks in surgical technique Host parasite relationship Potential sources of contamination: Patients themselves Operating room and personels Organisms: Staphylococcus aureus Enteric organism (E. coli, Bacteroides, Proteus, Klebsiella, Pseudomonas)

Wound Complications: Wound Infection: Factors: Nature of the wound: Clean atraumatic and uninfected operative wound (3.3%) GIT / Respiratory / Urinary tract entered but w/ out unusual contamination (10.8%). Open, traumatic wounds w/ major break in sterile technique (16.3%) Traumatic wound involving abscesses of perforated viscera (28.6%). Age Presence of medical problems (diabetes/steroid tx) Duration of operations and preoperative stay in the hospital

Postoperative Infections: (nosocomial) Local factors: Adequacy of tissue blood supply: Devitalized tissues Dead space ----> hematoma, seroma Foreign bodies Systemic factors: Age: very young (neonates) and elderly Obesity: poor blood supply in adipose tissue Systemic illnesses: Malignancy Diabetes Hepatic cirrhosis Medications taken (steroids)

Postoperative Infections: (nosocomial) Pulmonary infections: Atelectasis Endotracheal intubation and ventilation Aspiration pneumonia Urinary tract infection: indwelling urinary catheter E. coli, Pseudomonas, klebsiella Intra-abdominal infection: abdominal abscess Sites: Sub-phrenic ---> most common Pelvis Liver Lateral gutters / intestinal loop Treatment: drain ---> explor lap / needle aspiration Wound infection

Postoperative Pulmonary Complications Atelectasis: 90% postoperative pulmonary complications Etiology: Obstruction of the tracheobronchial airway Changes in bronchial secretions Defects in expulsion mechanism(Cough) Reduction in bronchial caliber Pulmonary insufficiency (hypoventilation) Decrease surfactant

Postoperative Pulmonary Complications Atelectasis: Predisposing factors: Smoking Pulmonary problem (bronchitis, asthma, COPD, etc) Anesthesia: GA - duration and depth Postop narcotics – depress cough reflex Depress cough reflex Chest pain Immobilization Splinting w/ bandages NGT – increased secretions and predisposed aspiration Congestion of the bronchial walls Loss of the lung capacity Increased age Obesity Surgical incision in the thorax or abdomen (pain)

Postoperative Pulmonary Complications Atelectasis: Etiology: Aspiration → aspiration pneumonia. Retention of secretions → collapse of alveolar segments → atelectasis. Bacterial or viral colonization of the secretions may occur → pneumonia.

Postoperative Pulmonary Complications Atelectasis: Manifestations: 1st 24 hrs postop ----> fever, tachycardia, rales, decrease breath sound ----> persist ----> pneumonia (increase fever, dyspnea, tachycardia and cyanosis) ---> lung abscess

Postoperative Pulmonary Complications Atelectasis: Investigations: Elevated WBCs. Presence of infiltrates on chest x-ray.

Postoperative Pulmonary Complications Atelectasis: Treatment: Preop prophylaxis: No smoking (2 wks) Treatment of pulmonary problem Fasting for at least 6-8 hours before operation Postop prophylaxis: Minimal use of depressant drugs Prevent pain Early ambulation Changes body position Deep breathing and coughing exercises Drugs: Expectorants Mucolytic Bronchodilators Antibiotics (culture based) Ventilation

Postoperative Pulmonary Complications Pulmonary Aspiration: General anesthesia – pts are in supine position and absence of normal protective reflexes. Increased risk: Pregnant Elderly Obese Pts w/ bowel obstruction

Postoperative Pulmonary Complications Pulmonary Aspiration: Prevention: NPO 6hrs prior to surgery Emergency – NGT do gastric lavage/suction and give antacid to prevent dev. of Mendelian’s Syndrome. Treatment: Continuous mechanical ventilation antibiotics

Postoperative Pulmonary Complications Pulmonary Edema: Etiology: Circulatory overload (infusion of fluid during operation) Most common cause Left ventricular failure (incomplete cardiac emptying) Due to anesthetic, narcotic or hypnotic agents w/c decrease myocardial contractility Decrease peripheral perfusion -----> peripheral vasoconstriction ----> cause blood to shift centrally ----> pulmonary edema Negative pressure in airway.

Postoperative Pulmonary Complications Pulmonary Edema: Treatment: Provide oxygen (increase inspired concentration) Remove obstructing fluid (diuretics, head up or sitting position, phlebotomy, spinal anesthesia, ganglionic blocking agents) Correcting the circulatory overload Increase airway pressure (PEEP)

Postoperative Pulmonary Complications D. Pulmonary embolism The embolus passes through the Rt atrium to the Rt ventricle to the pulmonary artery → pulmonary artery obstruction.

Postoperative Pulmonary Complications D. Pulmonary embolism Etiology: Embolism usually originate from DVT Fat embolism after long bone fractures. Arterial or venous air embolism. Amniotic fluid embolism during prolonged labor and delivery. Foreign body embolism.

Postoperative Pulmonary Complications D. Pulmonary embolism Presentation: Sudden chest pain. Hypotension and tachycardia. Respiratory distress & may be hemoptysis. Mild tachypnea or severe sudden cardiopulmonary arrest.

Postoperative Pulmonary Complications D. Pulmonary embolism Investigations: Arterial blood gases. Plain chest x-ray. ECG. CT Angiography for pulmonary artery (investigation of choice) Radionucleotide ventilation-perfusion scans.

Postoperative Pulmonary Complications D. Pulmonary embolism Treatment: ICU Support and resuscitation: - O2 therapy & morphine. Anticoagulation: - I/V heparin to minimize the propagation of thrombus formation. Direct or systemic thrombolysis: - Streptokinase or urokinase. Pulmonary embolectomy.

Postoperative Pulmonary Complications D. Pulmonary embolism Prevention: preoperative screening and risk stratification. Prophylactic anticoagulation. Inferior vena cava (IVC) filter.

Postoperative Pulmonary Complications E. Respiratory Failure: 25% of postoperative deaths PaO2 is below 50 mmhg, while the patient is breathing room air; PaCO2 is above 50 mmhg in the absence of metabolic alkalosis Usually seen in patients who underwent operations for major trauma or who have multisystem disease. Mechanism is unknown

Postoperative Pulmonary Complications E. Respiratory Failure: Etiologic Factors: Sepsis Massive transfusion Fat embolism Pancreatitis Aspiration Associated w/ a decreased Functional Residual Lung Capacity, indicating that the amount of air within the lung at the end of normal expiration is reduced ----> diminished ventilation-perfusion ratio and ultimately arterial hypoxemia Treatment: Mechanical ventilation (PEEP)

Postoperative Shock Poor tissue perfusion ---> hypotension, pallor, sweating, tachycardia, oliguria, peripheral vasoconstriction ----> progressive metabolic acidosis ----> multiple organ failure ---> death. Hypotension in early post-operation: Over sedation Effect of anesthesia

Postoperative Shock Categories: Hypovolemia – most common Uncorrected volume deficit (preop, intraop, postop) Continuing hge postop period 30-40% loss of ECV Monitored w/ UO/hr, CVP Crystalloid hydration / blood transfusion

Postoperative Shock Categories: Cardiogenic shock (MI / cardiac tamponade) Septic shock: Due to gram (-) infection; nosocomial Uro-genital infection (foley catheter) > resp. tract > wound infection

Postoperative Renal Failure Oliguria – considered acute renal failure Etiologies: Catheter obstruction Pre-renal failure; Diminished circulating blood volume Acute parenchymal renal failure Fluid restriction (daily allowance 500ml plus previous 24 hrs. UO) Electrolyte imbalance (hyperkalemia) Hemodialysis

Diabetes Mellitus: Challenge to the surgeon for: Impairment of homeostatic mechanism for glucose (ketoacidosis/hypoglycemia) Associated incidence of generalized vascular disease. Pathogenesis: Defect is decrease insulin Hyperglycemia due to decrease utilization of peripheral tissue, increase output in the liver Catabolism of FA (ketoacidosis) Osmotic diuresis ---> dehydration/loss of Na and K

Diabetes Mellitus: Effect of Anesthetic agents to CHO metabolism Hyperglycemia Exaggerates the hyperglycemia epinephrine response and increase resistance to exogenous administration of insulin Type of anesthesia: Spinal anesthesia – little tendency to cause hyperglycemia GA – (NO2, trichloroethylene, halothane) least effect on CHO metabolism

Diabetes Mellitus: Surgery is not done until the level is below 200md/dl Ketoacidosis in frank diabetic coma ----> no surgical treatment regardless of indication Treatment: Continuous low dose insulin Correct fluid and electrolyte imbalance

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