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complications in minor procedures
Complications in Minor Procedures

Directed by Dr.M.A.Sahebi

The decision to obtain central venous access must be a thoughtful one, and the data regarding the risk and cost of complications must be underscored. Steps to decrease complications include the following:
  • 1.Ensure that the patient's condition indeed warrants central venous access. Experienced personnel should insert the line with proper positioning and sterile technique. Controversy exists as to whether or not placing the patient in Trendelenburg position facilitates access.
central venous access lines
Central Venous Access Lines
  • 2.Antibiotic-coated catheters may decrease the rate of central line sepsis, although they initially are more expensive 3.Routine central line changes should not be performed, and the lines should be removed as soon as adequate peripheral intravenous access can be established for medications that do not require central access.
One of the most common complications of central venous access is pneumothorax. It is not just inexperienced clinicians that create these iatrogenic injuries, but pneumothorax rates appear to be higher among the inexperienced. Pneumothorax occurrence rates from both subclavian and internal jugular vein approaches are on the order of 1 to 6%.
  • The first step in prevention is proper positioning of the patient during the procedure. Even if a pneumothorax is not suspected to have occurred during the procedure, a chest x-ray is still needed to confirm the presence or absence of a pneumothorax following the line insertion.
The decision regarding the need for a thoracostomy tube is similar to that described for bronchoscopy; if the patient is stable, then expectant observation may be adequate, but if any concerns about the patient's clinical condition exist, a thoracostomy tube should be placed.
Occasionally, a delayed presentation of pneumothorax will manifest as late as 48 to 72 hours after central venous access attempts. This usually creates significant clinical compromise such that a tube thoracostomy is required.
Other complications that bear mentioning for both central venous and pulmonary artery catheters include transient arrhythmias during catheter insertion, arterial puncture with hematoma formation or persistent bleeding, and occasionally loss of a guidewire in the vena cava.
Arrhythmias (the most common complication) result from myocardial irritability secondary to the guidewire placement, and usually will resolve when the catheter or guidewire is withdrawn from the right heart.
Arterial puncture with bleeding can be troublesome, but the majority will resolve with direct pressure on or near the arterial injury site. It is only the rare case that will require angiography, stent placement, or surgery to repair the puncture site, but these patients usually will do well following the procedure, and have no significant arterial abnormalities over the long term
A lost guidewire or catheter now can be readily retrieved with interventional angiography techniques, and no longer represents an automatic need for surgical exploration to retrieve the lost material.
Another error with central access lines involving either a venous line or a pulmonary artery line is that of air embolus. These are estimated to occur in 0.2 to 1% of patients. However, when an air embolism does occur, the results often can be dramatic and mortality can reach 50%. Treatment may prove futile if the diagnosis is ignored, especially if the air embolism bolus is larger than 50 mL.
Clinical auscultation over the precordium often is nonspecific, so a portable chest x-ray may be required if the patient will tolerate the procedure. Nonetheless, aspiration via a central venous line accessing the heart may assist in decreasing the volume of gas in the right side of the heart, and minimize the amount traversing into the pulmonary circulation
Maneuvers to entrap the air in the right heart include placing the patient in the left lateral decubitus position and in Trendelenburg position, so the entrapped air can then be aspirated or anatomically stabilized within the right ventricle..
The advantage of the operative approach is that the resources needed to salvage the patient are more readily available in the operating suite, should there be an acute deterioration in the patient's condition.
perhaps the most dreaded complication of the pulmonary artery catheter is a pulmonary artery rupture. There usually is a sentinel bleed noted when a pulmonary artery catheter balloon is inflated, and then the patient begins to have uncontrolled coughing with hemoptysis..
Reinflation of the catheter balloon is the initial step in management, followed by immediate airway intubation with mechanical ventilation, an urgent portable chest x-ray, and notification of the operating room that an emergent thoracotomy may be required.
If there is no further bleeding after the balloon is reinflated, and the x-ray shows no significant consolidation of lung fields from ongoing bleeding and the patient is easily ventilated, then a conservative nonoperative approach may be considered
This approach might include observation alone if the patient has no signs of bleeding or hemodynamic compromise; however, more typically today a pulmonary angiogram with angioembolization or vascular stenting is the next step in treatment.
For hemodynamically unstable patients after pulmonary artery rupture, unless the patient is already in the operating room having thoracic surgery, attempts at salvaging these catastrophic situations often is unsuccessful because of the time needed to perform the thoracotomy and identify the branch of the pulmonary artery that has ruptured.
Another complication that may well be underreported is central venous line infections. 1–4 The Centers for Disease Control and Prevention (CDC) reports mortality rates of 12 to 25% when a central venous line infection becomes systemic, and this carries a cost of approximately $25,000 per episode.
The CDC does not recommend routine central line changes, but when the clinical suspicion is high, the site of venous access must be changed. Additionally, nearly 15% of hospitalized patients will acquire central venous line sepsis (defined as >15 colony-forming units [CFU] on an agar roll plate, or >103 CFU on sonication).
In many instances, once an infection is recognized as central line sepsis, removing the line is adequate. Staphylococcus aureus infections, however, present a unique problem because of the potential for metastatic seeding of bacterial emboli. The treatment for this situation is 4 to 6 weeks of tailored antibiotic therapy
arterial lines
Arterial Lines
  • Arterial lines are placed to facilitate arterial blood gas draws and to optimize hemodynamic monitoring. They often are not removed when central venous access is not in place so ongoing phlebotomy can easily be performed, a practice that may lead to higher complication rates.
Arterial access is preferably obtained via a sterile Seldinger technique, and a variety of arteries are utilized, such as the radial, femoral, brachial, axillary, dorsal pedis, and superficial temporal arteries
complications generally occur less than 1% of the time, when present they can be catastrophic. Complications include arterial spasm, bacteremia, thrombosis (the most common complication), bleeding (second most common), hematoma, pulselessness, and infection (0 to 10%). .
One could argue that should thrombosis or distal embolization occur, a hand is more precious than a foot, yet the literature suggests that the risk is nearly the same for both femoral and radial cannulation. This also is true for infection rates between the two sites as well.
For complications related to thrombosis, bleeding, and infected catheters with bacteremia, the catheters should all be removed and direct pressure placed for 5 to 10 minutes following removal.
Thrombosis with distal tissue ischemia often can be treated with anticoagulation, but occasionally a surgical intervention is required to reestablish adequate inflow. The occurrence of pseudo-aneurysms and arteriovenous fistulae is remarkably low for these catheters.
endoscopy and bronchoscopy
Endoscopy and Bronchoscopy
  • For gastrointestinal endoscopy, the most dreaded risk is perforation. Perforation may occur for 1:10,000 patients with endoscopy alone, but carries a higher incidence rate when performed with biopsy (0 to 30%).
This increased risk often occurs due to complications of intubating a gastrointestinal diverticulum (either esophageal or colonic), and also from the presence of weakened tissue in the wall of the intestine related to an inflammatory response secondary to infection (e.g., diverticulitis) or glucocorticoid use (e.g., inflammatory bowel disease).
Recognition that a perforation has occurred often is straightforward, but on occasion may be difficult. Patients will usually complain of diffuse abdominal pain shortly after the procedure, and then will quickly progress with worsening abdominal discomfort on examination.
For patients that are difficult to evaluate, a change in clinical status may take several hours, and occasionally as long as 24 to 48 hours, to become manifest. When concern for a perforation exists, the patient should immediately have radiologic studies to assess for free intraperitoneal air, retroperitoneal air, or a pneumothorax.
A delay in diagnosis of an endoscopic perforation creates the potential for ongoing gastrointestinal contamination and systemic sepsis
Recognition that a perforation has occurred often is straightforward, but on occasion may be difficult. Patients will usually complain of diffuse abdominal pain shortly after the procedure, and then will quickly progress with worsening abdominal discomfort on examination.
Treatment for a gastrointestinal endoscopy perforation is usually surgical exploration to locate the perforation, decontaminate the surrounding tissues, and then to surgically close the perforation site. The exact type of surgery depends on the site of perforation and the degree of contamination or sepsis that is found at surgery.
There are some patients in whom surgical exploration is not required; however, these are the exception rather than the rule. The patient who may be a candidate for nonoperative management usually is one for whom suspicions for perforation arise during an elective, bowel-prepped, endoscopy, and yet the patient does not have significant pain or clinical signs of perforation.
With the concern for perforation, an x-ray is usually performed that then shows free air. If the patient remains without significant pain and with a benign abdominal exam, then this type of patient may be observed in a monitored setting, kept on strict dietary restriction, placed on broad-spectrum antibiotics, and closely observed for 48 to 72 hours to detect any deterioration in clinical status.
If the patient remains with an uneventful course, a diet is gradually increased and the antibiotics discontinued after 3 to 7 days. If the patient clinically deteriorates at any time, immediate surgery is required.
Bronchoscope, however, has several indications but relatively less-severe complications compared with perforation. Indications for bronchoscopy include removal of foreign bodies, biopsy for cancer, difficult intubations, diagnosis for pneumonia, and delivery of medications.
The contraindications are relatively few and include a partial arterial pressure of oxygen (PO2) less than 60 mm Hg on 100% supplemental oxygen, an evolving myocardial infarction, and therapeutic anticoagulation.
The complications of bronchoscopy include bronchial plugging (the most common complication), hypoxemia, pneumothorax, lobar collapse, and bleeding. When each of these is diagnosed appropriately and in a timely fashion, they are rarely life-threatening
bleeding is usually quick to resolve and rarely requires surgery, but occasionally may require repeat endoscopy for thermocoagulation or fibrin glue application. The presence of a pneumothorax necessitates placement of a thoracostomy tube only when significant oxygenation deterioration occurs or the pulmonary mechanics are significantly compromised;
otherwise expectant observation is adequate. The presence of a lobar collapse or mucous plugging usually will respond to aggressive pulmonary toilet, but occasionally requires repeat bronchoscopy.
One of the oldest operations performed is that of the tracheostomy, and when performed correctly, it leads to decreased ventilator days, decreased length of intensive care unit (ICU) or hospital stay, and improved pulmonary toilet. Tracheostomies are now performed open, percutaneously, with or without bronchoscopy, and with or without Doppler guidance, and yet complications still arise.
Some of the complications tend to be minor and include changes in levels of partial pressure of arterial carbon dioxide (PCO2), radiographic changes in the postprocedure x-rays, and minor fluctuation in the pulse oximetry saturation levels
The indications for tracheostomy are important when deciding how and when to commit to a surgical airway. Historically, those patients on a moderate to high level of positive end-expiratory pressure (PEEP) have been considered not to be the best candidates for early tracheostomy for various reason
Hypercarbia is known to contribute to intracranial hypertension for traumatic brain injury patients. Using fiberoptic bronchoscopy (FOB) in percutaneous tracheostomy will contribute to hypercapnia if the endotracheal tube (ET) is small (<7.5 mm), or if the minute ventilation is such that adequate ventilation is not administered during the procedure
A recent study examined PEEP and hypoxemia at 1 and 24 hours postprocedure. The study concluded that it was safe to perform percutaneous dilatational tracheostomy on patients with high PEEP settings because the patients did not have adverse oxygenation at 1 and 24 hours status postprocedure. 5
. Croce and colleagues examined FOB performed on patients with closed head injury when evaluating for pneumonia, and were able to confirm that intracranial pressure (ICP) did rise with a concomitant decrease in the cerebral perfusion pressure (CPP). 6
Recent studies evaluating the incidence of pneumothorax and the need for routine posttracheostomy chest x-ray do not support their routine use after either percutaneous or open tracheostomy. 7,8 However, one reason for continuing to perform routine chest x-ray after a tracheostomy is for identifying and resolving significant lobar collapse that occurs from copious tracheal secretions or mechanical obstruction from any number of etiologies.
The most dramatic complication involving the tracheostomy is a tracheoinnominate artery fistula (TIAF). 9,10 These fistulas rarely occur ( 0.3%), but when present, carry a 50 to 80% mortality rate. TIAFs can occur as quickly as 2 days after tracheostomy, but also as late as 2 months postprocedure. The prototypical patient at risk for a TIAF is a thin woman with a long, gracile neck.
The patient may have a sentinel bleed, which occurs in 50% of TIAF cases, followed by a most spectacular bleed. Should a sentinel bleed be suspected, the patient should be transported immediately to the operating room for fiberoptic evaluation
Although survival to this level is rare, for patients who are initially surviving, the conduct of the team identifying a TIAF during exsanguination is as follows (Figs. 11-1 and 11-2):
  •   1. Inflate the tracheostomy balloon cuff to high pressure in order to attempt compression of the innominate artery.  2.Reintubate the patient with an endotracheal tube via the orotracheal or nasotracheal route.   3.   If needed, remove the tracheostomy, and place a finger through the tracheostomy site in order to apply direct pressure anteriorly for compression of the innominate artery.  
4.   Sterile preparation of the patient for a median sternotomy should include the assistant's hand in the operative field.   5.   Once exposed, surgically ligate the innominate artery proximally and distally to the injury.   6.   Mobilize a soft tissue flap to protect the injured tracheal site from recurrent fistula
percutaneous endogastrostomy
Percutaneous Endogastrostomy
  • Technical errors usually are to blame for endoscopically-misplaced feeding tubes. Although it is not absolutely imperative to transilluminate the abdomen, doing so may decrease the margin for error and prevent inadvertent colotomies.
While an unplanned colotomy is potentially catastrophic, other frustrating common errors include the overzealous retrograde pulling of the wire lasso through the abdominal wall and out the oropharynx, the antegrade pulling of the percutaneous endogastrostomy (PEG) tube disc out of the anterior gastric wall during placement, and progressive erosion of the PEG tube through the anterior abdominal wall over the first few weeks following PEG placement
A misplaced PEG that is still being utilized for administration of tube feeds may create intra-abdominal sepsis with peritonitis and/or an abdominal wall abscess with necrotizing fasciitis. As in other minor procedures, the initial placement techniques must be fastidious in order to avoid these complications.
Usually the colotomies, intraperitoneal leakage of tube feeds with peritonitis, and abdominal wall abscesses manifest slowly over time, but once present require surgery to correct the complications and to replace the PEG with an alternate feeding tube, usually a jejunostomy
Other issues are more related to direct patient management, such as wrist restraints for the confused and combative, sedation and/or anxiolysis, or unexplained removal. There should be timely replacement of the tube with an alternative tube within 6 to 8 hours of dislodgment, because the gastrostomy site closes rapidly.
Once replaced, the new tube should not be utilized until a simple contrast x-ray has been performed to confirm the new tube's intragastric position.
tube thoracostomy
Tube Thoracostomy
  • Tube thoracostomy is performed for pneumothorax, hemothorax, and pleural effusions or empyemas. The aforementioned diagnoses are commonly found on chest x-ray, but also can be seen on ultrasound and computed tomographic (CT) scans. A chest tube can be easily placed with a combination of local analgesia and light conscious sedation
Common complications include inadequate analgesia or sedation, incomplete penetration of the pleura with formation of a subcutaneous track for the tube, lacerations to the lung or diaphragm, intraperitoneal placement of the tube through the diaphragm, and bleeding related to these various lacerations or injury to pleural adhesions.
Additional problems are related to maintenance of the tubes, with slippage of the tubes out of position, or mechanical problems related to the drainage system.
All of these complications can be avoided with proper initial insertion techniques, plus a daily review of the drainage system and follow-up radiographs. Occasionally these tubes will need replacement due to malfunctions or clogging of the tubes, but the replacement techniques are the same as for the original insertion.
Removal of these tubes occasionally will create a residual pneumothorax if the patient does not maintain positive intrapleural pressure during tube removal and initial dressing application.
Replacement of a tube in this setting depends on the clinical status of the patient, but expectant observation of the residual pneumothorax is acceptable. The development of an empyema related specifically to the presence of the thoracostomy tube itself is a debatable topic, but some centers now are moving to a protocol of antibiotics for the duration of the chest tube placement as an attempt to decrease empyema rates.
diagnostic peritoneal lavage
Diagnostic Peritoneal Lavage

Diagnostic peritoneal lavage (DPL) is less commonly performed in the emergent trauma setting, but the indications are chiefly for the hemodynamically-unstable patient who arrives in the emergency department with neurologic impairment and an uncertain etiology for blood loss.

Should such a patient have life-threatening hemodynamic lability and an obvious source is yet to be found after initial resuscitation measures, then an emergent DPL is performed—especially when an abdominal trauma ultrasound is not available or is not reliable in a particular institution
It is imperative that the stomach and bladder be decompressed via nasogastric tube and bladder catheterization prior to DPL, as both of these organs can be lacerated during the procedure (Fig. 11-3). It also has been recognized that the small or large bowel and the major vessels of the retroperitoneum can be punctured inadvertently.
While the renal system is not usually involved, the occasional horseshoe or pelvic kidney may become lacerated. All of these injuries usually will require surgical exploration and repair, because of the difficulty of making an accurate diagnosis, as well as the potential for confounding a trauma resuscitation with untreated iatrogenic injuries.
complications with angiography
Complications with Angiography
  • As vascular stent strategies evolve and the use of angiography by surgeons increases beyond intraoperative studies or for trauma cases, the complications related to angiography are becoming more readily recognized.
Dissection of a cannulated artery can lead to a variety of vascular malperfusion findings that include (but are not limited to) ischemic stroke from a carotid artery dissection or occlusion, mesenteric ischemia from dissection of the superior mesenteric artery, or a more innocuous finding of "blue toe syndrome" from a dissected artery in a peripheral limb with thromboembolic disease
The important initial step is for recognition of the ischemic tissue bed, and confirmation of the diagnosis with clinical findings and/or a combination of invasive or noninvasive imaging studies. The severity of the ischemia and the extent of the dissection will then determine if full anticoagulation and aspirin would be adequate therapy, or whether the patient shall require urgent surgical exploration to repair the dissection.
Bleeding secondary to angiography usually is related to bleeding at the vascular access site, but also may be related to a ruptured vessel at the distal portion of the angiography catheter. Local access site bleeding usually is readily detected, but may not be visible when the blood loss is tracking into the retroperitoneal tissue planes.
These patients can present with hemorrhagic shock of an undetermined etiology, and so the angiography site needs to be closely inspected, and an abdominopelvic CT scan done to delineate the extent of bleeding into the retroperitoneum. The initial management is direct compression at the access site and clinical observation with resuscitation as indicated.
For those patients that do not respond to resuscitation measures and continue to have decreasing hematocrit levels with evidence of hemodynamic compromise, there should be plans for urgent surgical exploration to control the bleeding site..
Patients with a similar clinical picture that likely have bleeding at the more distal portions of the original angiography study path should have repeat angiography in order to define the bleeding source so that angioembolization techniques can be utilized to control the bleeding. However, surgery is needed for those cases where angio-embolization is unsuccessful.
Renal-related complications of angiography occur in approximately 1 to 2% of patients. Contrast nephropathy often is a temporary and possibly a preventable complication of radiologic work-ups utilizing contrast dye for CT, angiography, and/or venography. The research results have been mixed regarding the prevention of acute tubular necrosis from intravenous contrast with administration of n-acetylcysteine.
There are some studies that suggest an overall improvement of renal function with n-acetylcysteine use, and other studies that report that its use has no overall benefit. If n-acetylcysteine is to provide benefit, twice-daily dosing 24 hours before and on the day of the radiographic study is suggested. It also is suggested that the greatest benefit with n-acetylcysteine is derived from improved intravenous hydration before and after the procedure.
Nonionic contrast also may be of benefit in higher-risk patients. The contemporary literature does not support the use of other adjuncts such as administration of furosemide or mannitol prior to angiography, and these practices may add to overall morbidity rather than salvage renal function.
As a current minimum, improved intravenous hydration before and after the procedure is still likely the simplest and most efficient method for providing renal protection from dye contrast.
complications with biopsies
Complications with Biopsies
  • Biopsies are performed for multiple reasons, including cosmesis, pathologic diagnosis, and prognostic evaluation. Lymph node biopsies have direct and indirect complications. Direct complications include bleeding, infection, lymph leakage, and seromas.
Measures to prevent direct complications include proper surgical hemostasis, proper wound preparation with chlorhexidine, gluconate/isopropyl alcohol, or a similar preparation, and possibly a single preoperative dose of antibiotic to cover skin flora 30 to 60 minutes before incision. Bleeding at a biopsy site usually will manifest shortly after the procedure, but often can be controlled with direct pressure.
Infection at a biopsy site will generally not manifest for 5 to 10 days postoperatively, and will usually require opening of the wound to drain the necrotic infected tissue in order to facilitate wound healing. Seromas or lymphatic leaks may be difficult to manage at times.
Depending on the volume and duration of leakage, control of a leak may take up to a few weeks to resolve with aspiration of seromas and the application of pressure dressings.
If a seroma or leak does not resolve, it may be necessary to take the patient back to the operating room in order to place some form of closed suction drain into the wound. This usually is not necessary, and conservative management prevails
Some surgeons prefer to place a closed suction drain in the vicinity of the dissection at the time of biopsy. At the time of drain placement and for the duration of the indwelling drain, antibiotics may be given, depending on the location of the drain, patient allergies, or the available formulary. Should a patient suffer an adverse event related to the antibiotics, this would exemplify an indirect complication.