Prevention of complications. - Pre-op care: Stop smoking, loss of weight, control of chronic disease, prophylactic antibiotics, respiratory exercise, correction of any bleeding tendency and good surgical tech.post-op care: Early mobilization, respy. Care and fluids and electrolytes needs. Routine
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1. Pre & Postoperative care & complications Fuad Ammari May result from primary dis., the operation, or others. e.g MI after Bleeding
The usual clinical signs of disease are blurred in the post operative period
Early detection of postop. Comp. Requires repeated evaluation of the patient by the operating team.
2. Prevention of complications
- Pre-op care: Stop smoking, loss of weight, control of chronic disease, prophylactic antibiotics, respiratory exercise, correction of any bleeding tendency and good surgical tech.
post-op care: Early mobilization, respy. Care and fluids and electrolytes needs
3. Routine preop. Evaluation History:
Resp. dis., smoking,
CVS disease including DVT,
Previous gen. anesthesia, drugs and alcohol intake.
4. Goldman cardiac risk factors in non cardiac surgical operations Listed in descending order
Signs of cong. heart failure----------------- 11
Myocardial. Infarction in the last 6 months--10
Premature ventricular beats 5or more----------7
Age-70y or more--------------------------------- 5
Thoracic, up. Abdo.surg, vasc., ao.stenosis---3
5. Clinical Predictors of Increased Risk for Perioperative Cardiac Complications MAJOR
Recent myocardial infarction (within 30 days)
Unstable or severe angina
Decompensated congestive heart failure
Significant arrhythmias (high-grade atrioventricular block, symptomatic ventricular arrhythmias with underlying heart disease, supraventricular arrhythmias with uncontrolled rate)
Severe valvular disease
6. Clinical Predictors INTERMEDIATE
Prior myocardial infarction by history or electrocardiogram
Compensated or prior congestive heart failure
Diabetes mellitus Renal insufficiency
7. Clinical Predictors MINOR
Abnormal electrocardiogram Rhythm other than sinus (e.g., atrial fibrillation)
Poor functional capacity
History of stroke
Uncontrolled hypertension (e.g., diastolic blood pressure >10 mm Hg)
8. prevention O/E: • Nutrition, mental status.
Dentures, abnormalities of jaw and neck.
Resp. & CVS disease.
Investigations: Hb, Blood group, urinalysis. CXR & ECG
Pt. Above 50y, smokers, CVS, & Resp. dis.
Urea and electrolytes.
9. Physical status scale: American Society of Anesthesiologists ASA class Physical state
1 A normally healthy individual
2 Pt.with mild to moderate disturbances
controlled DM or Hypertension
3 severe systemic disease not incapacitating • Heart dis.with limited exercise tolerence, • Uncontrolled hypertension or DM
10. Physical status scale 4. Incapacitating systemic dis. That is a constant threat to life with or without
surgery eg. CCF & severe angina.
.5 A moribund patient who is not expected to live and where surgery is performed as a last resort e.g. ruptured aortic aneurysm
.6 A pt. Who requires an emergency surgery
11. High risk group Eldery patients, resp.dis., smokers. CV dis.,
Obese pt., DM.,
Chronic drug medication
Oral contraceptive pills.
12. Elderly patient Due to limited mobility
Diminished cardiac, respiratory and renal reserve
Higher postoperative wound infection
Longer hospital care
DVT and delirium.
13. Respiratory dis. & smoking Obstructive airway disease increase the risk of post-op pulmonary complications and require careful pre-op evaluation.
Blood gas analysis
Exercise tolerance test
14. Resp. & Smoking Breathing exercise.
Cessation of smoking: Due to Viscid
secretions and impaired clearance of mucus
Pulmonary collapse & infection results
15. Obese patients Increased risk of
Wound Infections & Dehiscence
Limited mobility & hypertension
Encourage weight reduction
16. Postoperative care Immediately after surgery
Patient care of assurance, mobilization, oral fluids and prevention of complication
Pain control and analgesia
Bleeding, breathing and urinary output.
Initial and post op. tests e.g. Hb, CXR, KFT …..etc.
17. Routine daily checks in postoperative care “SOAP” Subjective:
Greet the patient, ask him how he is doing, assess consciousness and morale
Passed flatus and urine
Complaint of abnormal neurovascular status
18. SOAP Objective:
Gen. look, cyanosis, pain, shock.
breathing, cough, sputum and pyrexia.
• Pulse, BP, temp, RR.
• Skin turgor, moist tongue, urinary output. Fluid balance,
19. SOAP objective • drains and bowel sounds
• Wound discharge, blood or sero-sanguinous
• Pressure areas
• Results of requested lab. or radiol. tests.
• Check previous illnesses
20. SOAP Active problems and assessment
Analysis of key problems arising from the subjective and objective findings.
e.g. shortness of breath, low urinary output, or acute abdominal or chest pain
Plan: the action to be taken according to analysis of findings
21. Wound complications Hematoma:- Due to
Imperfect hemostasis during operation, bleeding tendencies, aspirin, heparin and warfarin.
Vigorous cough or straining may initiate bleeding
Clinically; swelling, discoloration of the wnd. edges, discomfort, blood ooze from skin edges
22. Hema-cont Neck hematomas expand rapidly, deviate & compress the trachea. It needs immediate evacuation
Small hematomas may be absorbed but it predisposes to wnd infection
Evacuatn under GA may be necessary with ligation of bleeding and closure
23. Seroma Collection of fluid “serum”
Increases the risk of wnd infection
Often follow elevation of skin flaps that leeds to lymphatic damage
Can be prevented by pressure dressing
Aspiration or incision and evacuation
24. Wound Dehiscence Partial or total disruption, it occurs between 5th-8th.post op days, serosanguinous fluid or evisceration
It is due to:
Systemic causes: Elderly, diabetics, jaundice, cancer, immunocompromised, hypoproteinemia, obesity, corticosteroids
25. Wnd. dehiscence- cont. Local causes:
1-In the wound:- Improper closure of anatomic layers.- Devitalized tissues due to rough handling
-Suture material, - Dead space, - FBs and - drains
2- Increased intra-abdominal pressure; ileus, obesity , ascitis, and COPD
3-Infection: hematoma, seroma and FBs
26. Wnd. Deh. cont Management:
Prevention by proper preop. Preparation
Cover with moist sterile towels
Closure under GA
If neglected it will led to incisional hernia
27. Chronic pain Due to:
28. Respiratory complications Most common single cause of morbidity
Second most common cause of death in patients older than 60 y
It occurs more frequently in:
Upper abdo. & chest surg., emergency, elderly, ch. Bronch. And asthma, smoking & obesity
29. Atelectasis It is the most common pulm. Complications
It occurs within the first 48 h of surg. In about 25% of pts. With abdo. Surg. & responsible for over 90% of febrile episodes during that peroid
Pathogenesis:1- Obstruction: by secretions, blood clots & malpositioning of endotracheal tube.
2- Non obstructive: closure of the bronchioles due to shallow breathing
30. Atelect. Cont. Clinically manifested by fever, tachypnoea, tachycardia.
O/E Scattered rales, decreased air entry & elevation of the diaphragm on that side.
. Prevenetd by preop. proper treatment of resp. disease, stop smoking (6w), early mobilization,and encourage deep breathe & cough in the postop period
. Managed by chest percussions and breathing exercises, Nasotrach. Aspiration, broncho-dilators and mucolytics. Usually recover uneventful
31. Pulmonary Aspiration Normally prevented by GO & Pharyngo-oesoph sphincters
Predisposed by NG & endotrach tubes, depression of the CNS by drugs, trauma, GO. Reflux, intestinal obstruction, pregnancy & pt. Positioning.
Minor degrees of aspn. Can be found in 15% of abdo. Surg. & may occur during sleep and are well tolerated
32. pul. Aspn. cont The magnitude of injury depends on: pH, frequency & volume of aspirate.
Pathogen; chemical pneumonitis- oedema- inflammation-infection. Obst. Of bronci or bronchioles by large food particles– atelect.
Prevention by preop. fasting ,proper positioning & careful intubation
Treatment: Bronchoscopy, intubation, & suction
fluid resuscitation, hydrocortisone, antibiotics & chest physioth.
33. Post-op. pneumonia The main cause of death after surg.
Predesposed by Atelect.,aspiration, or copious secretions associated with infections & prolonged intubation
Causative bacteria: staph, pseudomonas, klebsiela & G-ve bacilli.
Clinically; fever, tachycardia, tachypnoea, & features of consolidation- CXR
Treated by breathing exercise & cough, antibiot., mucolytics & bronchdilators
34. Deep vein thrombosis It is associated with a high mortality rate esp in the elderly.
The cause is usually multi factorial Virchow’s triad;
1- Stasis can occur with venous insufficiency, severe heart failure, prolonged bed rest or immobility & surgery or fractures of the pelvis or hip joint
35. DVT Cont. 2-Endothelial vascular damage by cannulation or irritation by chemicals
3- Hypercoagulable state either;
In cancers of the lung, pancreas, prostate, breast & ovaries
36. DVT b-inherited e.g;
• Deficiency of antithrombin III.
• Protein C & S
• As a result of nephrotic synd., liver failure, & DIC.
4- Advanced age, obesity, CCP, multiparity, Infly bowel dis.
37. DVT. Cont. It occurs most frequently in the calf veins & spread to the proximal veins (25%) that can led to venous insufficiency or fatal pul. Embolism
1-Pain in the thigh or calf, sometimes with oedema. 50% are asymptomatic
2- Hx of recent surgery,trauma, cancer, CCP, or immobilization.
38. DVT. Cont. 3- Homan’s sign positive in 50% of cases
4-Venous duplex U/S is diagnostic.
Prevention by elastic stocking with sequential compression & low dose unfractionated heparin or LMWH
Treatment: The primary treatment is by systemic anticoagulation, initially with heparin then continue with warfarin
39. Fat embolism It is relatively common but only rarely causes symptoms.
Fat particles are present in the pulmonary bed in 90% of long bone fractures.
Exogenous sources are; Bld. transfusion, IV. Lipid in parenteral nut., or bone marrow transplantn.
40. Fat emb. Fat emb. Syndrome: It occurs 12- 72 h after injury.
Petechiae of axilla, chest & arms
The findings of fat droplets in sputum & urine.
Treated by positive pressure ventn. & diuretics until symptoms disappear
41. Cardiac complications To avoid compln.
Preexisted card. Dis. Should be properly evaluated by a cardiologist.
Evaluatn. Of Lt. Vent. Ejection- fraction to identify pts. at high risk.
Ao. Stenosis limits the ability of the heart to respond to increased demand.
Bleeding & hypo-proteinemia--- compn.
42. Card. Compl. Dysrhythemias; appear during the operation & within 3/7 after surgery eg. Chest surg.
Supra vent. Dysrhythemia
Ventricular premature beats
43. Postop. MI. Precipitated by hypoxia & hypotension
Asymptomatic in 50% of cases
Chest pain & hypotension are the main features
Monitor in CCU, ECG changes
Anticoagulants & O2 inhalation
44. Card. Failure Fluid overload in pts. With limited card. Reserve
Postop. MI, sepsis, multiple injuries.
Progressive dyspnoea & hypoxia Normal PCO2 & decreased PaO2.
Diffuse congestion in CXR.
Treat in CCU; Dopamine is the best drug for inotropic support, Diuretics, fluid restriction, digoxin & respiratory support “ventilation”
45. Peritoneal comp. Hemoperitoneum: Bleeding is a common cause of shock within 24h after surg. Mainly due to tech. Problems.
Coagulopathy may play a role
Clinicaly; hypovolemia & shock
Increasing abdo. Girth
If persisted--- Re-operate; evacuate clots & ligate bleeding vessels.
46. Periton. Comp. Complications of drains
Erosion of viscera
May cause leakage from anastomosis
Prevention by closed suction drains with soft selastic tubes
47. GI. complications Gastric dilatation; massive distention of the stomach by gas & fluid predisposed by gastric outlet obstruction, drinking with paralytic ileus, splenectomy & Anorexia nervosa.
Distention--- increased pressure--- congested veins--- bleeding– ischemia– necrosis.
48. Gastric dilatation Clinically -ill, hiccups,
-collapse of the lower lobe of the Lt lung may occur
Treated by: -NPO, NG tube,
-fluid and electrolytes replacement.
49. GI.comp. Bowel obstruction
Mech. Obstn. Adhesions or hernias.
Treated by NG. Suction, fluid &electrolytes corrections for few days.
If no response--- Surgery.
50. Urinary complications Urinary retention
Over distention of urinary bladder inhibit contraction
Interference with the neural mechanism
catheterization if operation is taking 3h or more.& to empty the bladder after retention. Look for features of BPH.
51. Urinary tract infection Instrumentation, retention & catheterization.
Clinically; dysuria, fever, flank & supra-pubic tenderness
Diagnosis; urine analysis & culture.
Treatment; Hydration, antibiotics & catheterization
52. CNS comp. CVA
Convulsions; in ulcerative colitis, & crohn’s for unknown reasons
Psychosis “ post-op”, mood disturbances, delirium “ d. tremens in alcoholics”
Sexual dysfunction, confusion, fear & disorientation.
53. Post- operative fever It occurs in about 40% after major surgery,it resolves without specific treatment in most patients.
Within 48h--- atelectasis
After 2 days--- Wound infection, anastomatic breakdown,& intra-abdo. Abscesses
After 1 w--- Allergy to drugs, transfusion reactions & pelvic and abdo. Abscesses.
Temp. >38.5`C, CT abdo. & pelvis