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Surgical Complications

Surgical Complications. John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center. Primum no nocere. Think before you act. Complications can be deadly…. Logarithmic increase in bile duct injuries after the introduction of laparoscopic cholecystectomy.

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Surgical Complications

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  1. Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

  2. Primum no nocere • Think before you act.

  3. Complications can be deadly… • Logarithmic increase in bile duct injuries after the introduction of laparoscopic cholecystectomy.

  4. SCIP • Antibiotics • Normothermia • VTE Prophylaxis

  5. Morbidity and Mortality Conference • Mainstay quality program of general surgery residency programs.

  6. Mortalities

  7. Morbidities • Cardiorespiratory • Wound • Urinary tract

  8. Wound • Seroma • Hematoma • Dehiscence • Evisceration

  9. Wound • Superficial • Deep • Organ space

  10. Pathogens • Staphylococcus(coagulase neg) 25% • Enterococcus(D) 11.5% • Staph aureus 8.7% • E. coli 6.5%

  11. Wound classification • Clean • Clean contaminated • Contaminated • Dirty

  12. Temperature regulation • Issues of hypothermia

  13. Malignant hyperthermia • 1 in 30,000 cases • Mortality less than 10% • Autosomal dominant with variable penetrance • Altered calcium metabolism • Halothane, isoflurane, succinylcholine • Cause rise myoplasmic calcium

  14. MH • Tachycardia • Arrhythmia • Raised temperature • Acidosis • Muscle rigidity • Tachypnea • Flushing • (inability to open mouth)

  15. Treatment • Discontinue triggering anesthetic • Hyperventilate with 100% oxygen • Terminate surgery • Dantrolene 2.5mg/kg as bolus and repeat every 5 minutes • Monitoring • Sodium bicarbonate • Beta blockers • Lidocaine • Lasix

  16. Pulmonary complications • Atelectasis • Pneumonia • Pulmonary embolism • Aspiration • Pulmonary edema • ARDS

  17. Weaning criteria • RR <25 breaths/min • Pa02 >70mmHg(Fi02 of 40%) • PaC02<45 mm Hg • MV 8-9L/m • TV 5-6mL/kg • NIF -25cm H20

  18. Cardiac • Greatest risk in first 48 hours • Non-Q wave, non ST segment elevation

  19. Prevention • Major predictors of risk • Unstable chest pain, CHF, sympotomatic arrhythmias, severe valvular disease

  20. Management • Cardiology consult • Tachyarrhythmia • Unstable-cardioversion • SVT-Beta blocker, esmolol, amiodarone • PSVT-vagal stimulation, adenosine, amiodarone • MAT-B blocker or amiodarone • VTach-lidocaine or amiodarone • Brady-atropine • Heart block-high grade second or third degree-insertion of permanent pacemaker

  21. Amiodarone • Phosphodiesterase inhibitor • Inhibits breakdown of camp • Increase cardiac output and decreases preload and after load without increasing myocardial oxygen demand • May cause vasodilitation and GI problems and thrombocytopenia

  22. Adrenal • Chronic use of steroids causes suppression of the HPA axis • Potentially life threatening • Give 250ug cosyntropin intravenousl

  23. Hemodialysis indications • Serum potassium >5.5 • BUN>80-90 • Persistent metabolic acidosis • Acute fluid overload • Uremic symptoms(pericarditis, encephalopathy, anorexia) • Removal of toxins • Platelet dysfunction • Hyperphosphatemia with hypercalcemia

  24. SIADH • Common cause of chronic normovolemic hyponatremia • Serum sodium<135 • Treat underlying disease process • Fluid restriction • Rapid correction may result in seizures

  25. Gastrointestinal • Ileus • Early SBO • Compartment syndrome • GI bleeding • Stomal complications • C. difficile colitis

  26. Anastomotic leak • Strategies for prevention • Low anterior resection

  27. Enterocutaneous fistula • Low output <200 cc/24h • Moderate 200-500 cc/24 h • High >500 cc/24 h

  28. “The Checklist” • Provonost • Gawande

  29. Airline Industry • Crew resource management • Communication • No hierarchy • Checklist, checklist, checklist • Debriefing

  30. Universal Protocol • Preprocedure Verification • Presurgical “timeout” • Post procedure “debriefing”

  31. Prospective Case Conference • Dr. Judson Randolph • 1988-Childrens Hospital Center, Washington, DC • A priori discussion of all upcoming pediatric surgery cases involving multiple disciplines

  32. Interdisciplinary teamwork • GI/bleeds/biliary • Radiology/bleeds/abscess • Medicine/evaluation/cardiac • Anesthesia/PST/surgical readiness

  33. “Never events” • CMS

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