1. POST OPERATIVE COMPLICATIONS
Dr Muath Eid

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

3. 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

4. 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

5. 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

6. 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

7. 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)

8. 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

9. 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)

10. 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

11. 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

12. 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)

13. 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.

14. 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

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

16. 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

17. 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

18. 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

19. 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.

20. 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)

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

22. 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.

23. 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.

24. 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.

25. 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.

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

27. 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

28. 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)

29. 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

30. 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

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

32. 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

33. 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

34. 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

35. 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

36. Thank You