3) Perioperative Complications

7/23/2019 3) Perioperative Complications

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Post-operative complications

Classification of post-operative complications

General / Specific

Immediate / Early / Late

Anaesthetic / Surgical / Combined

ICD-10-CM post-operative complication codes

Various other classification systems

Complications - defined as any deviation from the normal postoperative course

Sequelae - is an “after-effect” of surgery that is inherent to the procedure (e.g. inability to walk after

amputation of the leg).

Failure to cure - If the original purpose of surgery has not been achieved, this is not a complication (e.g.

residual tumour after surgery).

Risk Factors

Patient

- Presentation

o Age

o Co-morbids

smoking history and pre-existing respiratory disease

Obesity

CVD and PVD

Diabetes

Immune status (includes steroid and immune suppression therapy)

Other drug therapy (aspirin, antiplatelet, antibiotic therapy, NSAID agents or substance

abuse) include alcohol Renal disease

Metabolic factors including nutritional status

Presence of infection

Need for blood transfusion

o

Uncomplicated/Complicated (Re-operative_

o Elective/ Urgent

- Pathology

o Bening/Malignant/Infective

Surgical risk factors

- Type and complexity of surgery (includes re-operation) -> expose pt to higher risk of wound/healing

challenges

- Timing of surgery: Elective / urgent / emergency allow less time for pre-operative preparation

- Surgery for trauma grater tissue trauma/contamination

-

Surgical approach: Open / minimally invasive lower incidence of complications

-

Duration of procedure longer op, increases risk of infection

-

Surgeon skill /case volume

- Anaesthetic issues

System factors efficiency of hospital, experience of staff

Surgical safety checklist to reduce complication rate

Complication rate: reduced from 11% to 7%

Mortality rate: reduced from 1.5% to 0.8%

Managing these issues

1) Good handover

2)

Prioritise

3)

Seek help if swamped

4)

Go and see patient

5)

Turn the lights on so you can

adequately assess the patient



Post-operative complications

General

-

Pain

-

Nausea and vomiting

- Haemorrhage

- Respiratory

-

Cardiac Wound- Fever/Sepsis

o Wound

o Pneumonia

o UTI

o

Surgical Site

Abscesses

Prosthesis (grafts, valves, joints etc)

o

Drip site

o

Gastrointestinal

o

Neurological/cerebrovascular

o Renal /Urinary

o VTE (DVT & PE)

o Vascular

o Electrolyte disturbance

o Metabolic

Specific post-operative fever

Early Day 1 usually low grade (up to 38.5) unless

bacteraemia/septicaemia

(bacteraemia or septicaemia – fever more significant)

Think

- Residuum of contaminated operative site.

- Reactive to blood/blood products transfusion

-

Phlebitis -

Atelectasis (common)

Early Day 2-3: if temperature gradually rising Think: pulmonary origin

- Inhalation pneumonia

- Mendelson syndrome : chemical pneumonitis

due to aspiration esp in preggers pt

-

Lobar collapse/developing pneumonia

Then think: Urinary tract – especially catherised patient

- Wounds and surgical sites

-

Lines. Catheters and ports

Day 5/10 Think

-

Hidden abscess (Subphrenic/Pouch of Douglas)

-

Spiking pyrexia gravity allows collection into

most posterior part of body

- DVT/PE

- Prosthetic infection

- C/difficile colitis (if diarrhoea present)

Extravasation fluid retained in the dependent aspect of arm due to gravity



Risk for post-operative atelectasis

-

COAS/ asthma/smokers – poor

respiratory reserve

- Anaesthesia

o Emergency procedure

o Difficult intubation (risk of

inhalation)

o

Relative hypo-ventilation

On fixed volumane or

pressure cycle

ventilators

-

Post-operative pain esp narcotic

use

-

Diaphragm dysfunction

o

Obesity – abdominal binders

o

Upper abdominal / intercostal

thoracic procedures

-

Immobilisation for orthopaedictrauma

Post-operative pneumonia

- Fever, cough, dyspnoea, sputum,

severe sepsis

- Remember emergence of gram-ve in

hospital acquired pneumonia

Right middle lobe consolidation apparent on lateral chest X-ray

-

Lateral view wedge shaped dense opacification of middle lobe

-

Middle lobe pneumonia commonly associated with inhalation pneumonia

- Behind the middle lobe, lower lobe extends to above the level of the middle lobe, upper lobe also extends

below at least half of the middle lobe

- Mid zone opacity on straight PA film is unlikely to give clear indication of site of pathology of lobes

Area in left mid-zone, semi-opacified. Elevation of left-

hemidiaphragm normally sits lower than right, loss of lung

volume indicating significant atelectasis



Mid zone opacity, lower lobe unaffected but pathology in upper lobe

Right upper lobe pathology also raise possibility of inhalation

Post-operative pneumonia

Treatment:

- Broad spectrum antibiotics (ceftriaxone) until sensitivities known

-

Physiotherapy

- Early consult: ICU, respiratory service infections disease as required

- Remember: emergence of gram –ve in hospital acquired pneumonia late development of lung abscess

Pneumothorax

remember to order expiratory film

- Consider who have had subclavian or jugular vein insertion lines

- Untreated pneumothorax, especially in ventilated patient may lead to development of tension

pneumothorax presents with hypotension and cardiogenic shock



o

Due to angulation of IVC at diaphragm by mediastinal displacement

o Medical emergency require intercostal drainage

o

High index of suspicion esp in ventilated patient

-

Appearance of pneumothorax in lower costal phrenic region in right lung in inspiratory film but large defect

in expiatory film

Tension pneumpthroax

Aspiration pneumonia

-

Develop rapidly into lung abcesso Unconscious patients

o Emergency operations

o Trauma patients especially head

trauma

o Intoxicated or drug-induced

diminished consciousness

o Obstetric patient undergoing urgent

caesarean section

- Suspect if gastric contents in airway (blood,

trauma patients)

-

Symptoms

o Generally obvious wheeze, hypoxia,

cyanosis, tachycardia

o Initially chemical pneumonitis then

severe pneumonia in >50%

o Likelihood of later lung abscess

development

Management of aspiration pneumonia

- Airway toilet removing foreign bodies

-

NG tube

-

H2 antagonist, PPI

-

Bronchodilators

-

Antibiotics

Right upper lobe lung abscess, presence of air-spaces

(pockets of air, diagnostic feature) spreading radially

throughout opacification in upper zone. due to pus

http://www.wikidoc.org/images/7/7b/Pneumothorax_302.jpg



- Intubation if appropriate for bronchial toilet

Mendelson syndrome common in obstetric patients

-

Aspiration pneumonia after general anaesthetic

o

Presence of gastric contents + rush to anaesthesia + increase abdominal pressure

- Occurs within 1-2 days after inhalation

Fat embolism

- Diffuse patchy consolidation dn petechial in fat embolism

- Especially in pt with history of trauma

- Rare unless long bone trauma

- May also have cerebral infarcts (may precede lung by 6-12 hrs)

- Respiratory distress

-

Fever and tachycardia

- Hypoxia

-

Low platelets, low serum calcium, elevated Serum lipase

-

Trhombocytopenia due to disseminated intravascular co-agultion

Wound complications

Early

- Haematoma

o

Vary from suffusion through tissue to large collection needing evacuation to avoid risk of secondary

infection



Infection/abscess

o

Predisposing factors

Trauma and contaminate wound

Duration and nature of surgery

immune compromise/chronic disease/ malnourished

Pre-existing ulcers/infection

Ischaemic tissue

o

Signs and symptoms often first presentation

Pain, red, swelling,

Unexpected level of pain often first presentation

o Superficial

o

Deep

o

When to use prophylactic antibiotics

When risk of infection is significant without their use

When consequences of infection would be catastrophic even though the risk is low

6Rs

Right patient

Right drug Right dose

Right route

Right timing of administration

Right duration of prophylaxis/therapy

-

Necrosis

o

Ischemia leads to skin necrosis if skin has been approximated too tightly

o Require skin grafting

- Necrotizing fasciitis

o Strep pyrogens, staph aureaus

o

Clostridium perfringes, bacteroides fragilis- Lymph fistula

- Wound Seroma

o Lymphatic disruption mainly causation

o Remember other conditions can contribute to development of seroma

Myeloproliferative/haematological disorders

Coagulopathies

Cardiac disease

o

Treatment drainage

Wound

Classification

Definition Expected SSI

rate withoutprophylaxis

Expected SSI

withprophylaxis

Clean Elective, not emergency, non-traumatic, primarily closed; no acute

inflammation; no break in technique; respiratory, gastrointestinal,

biliary and genitourinary tracts not entered.

1-2% 2.1%

Clean

contaminated

Urgent or emergency case that is otherwise clean; elective opening of

respiratory, gastrointestinal, biliary or

Genitor-urinary tract with minimal spillage (e.g. appendectomy) not

encountering infected urine or bile; minor technique break.

5-10% 3.3%

Contaminated Non-purulent inflammation; gross spillage from gastrointestinal tract;

entry into biliary or genitourinary tract in the presence of infected bile

or urine; major break in technique; penetrating trauma <4 hours old;chronic open wounds to be grafted or covered.

15-20% 6.4%

Dirty Purulent inflammation (e.g. abscess); preoperative perforation of

respiratory, gastrointestinal, biliary or genitor-urinary tract;

penetrating trauma >4 hours old.

40% 7.1%



o

Common areas

Post breast surgery

After axillo-fermoral bypass

- Dehiscence

o

Partial

o Compound infection plete

o Contributory factors to wound dehiscence

Wound infection

Obesity

Diabetes

COAD

Malnutrition

Malignancy/immune suppression

Poor technique

o

Presentation

Sero-sanguinous fluid leak (85%) despite apparent healing of skin (skin more vascular

than subcutaneous tissue and heals better)

Treatment, sterile moist towels. Ideally return to OT and wash and re-suture

Evisceration No evisceration and poor health: sterile dressing and allow to granulate

Late wound complication

-

Incisional hernia

-

Wound bone

- Keloid hypertrophic scar growing beyond boundaries

- Post-operative confusion

o Infection

o Hypoxia (pulmonary, cardiac)

o Acid/base disturbance/metabolic: renal/bowel/muscle

o

Drug related

Anaesthetic

Narcotics

Diuretics

Antihypertensive

Sedatives

Anti-epileptics

o

Drug withdrawal (alcohol, benzodiazepines)

o

Cerebro-vascular CVA

- Perioperative myocardial infarction

o Diagnosis often difficult clinically

o May present with shock/arrhythmia/CCF

o Often masked by analgesia

o High mortality after surgery

o Most occur in first 3 days

o Most deaths within 48 hours

Cardiac –MI

MI at risk patient MI treatment

Goldman criteria, Eagle criteria Correct volume load and Hb

Arterial surgery Beta-blockade, GTN

Valve disease Heparin

Previous cardiac event Oxygen

SOBOE, PND, angina Emergency PTCA or CABG

Time between previous

MI & surgery

Peri-operative

MI risk

Within 3 months 27%

3 to 6 months 11%

After 6 months 5%



Revised Goldman Cardiac Risk Index – Independent predictors of major cardiac complications

-

High-risk operation (intra-peritoneal, intra-throacic , supra inguinal vascular

procedures)

- Hx of ischemic heart disease

- Hx of heart failure

- Hx of cerebro-vascular disease

- DM requiring insulin

-

Preoperative serum creatinine >2.0mg/dL (renal dysfunction)

Eagle criteria

- Q Waves on ECG

- Hx of angina

-

Hx of ventricular ectopy requiring treatment

- DM requiring therapy other than diet

-

Age above 70years

Gastrointestinal complications

-

Ileus –

common remember electrolyte disturbances especially hypokalaemia

o

Radialogical appearance of dilated loops of bowel

o Absence of bowel sounds

- May be due to obstructions

- Remember fecal impaction

- Anastomotic leaks and fistulas

o High fever, significant leucocytosis, abdominal pain and nausea and vomiting

- Ulceration and perforation of viscus

o Vertical chest X-ay showing subphrenic air

Might be difficult to interpret after laparoscopy (CO2 insufflation of air)

Pressure sore development

Stage 1 – Non-blanchage erythema of intact skin, heralding lesion of skin

ulceration. May also include changes in skin, colour, skin temperature. May

also include changes in skin colour, skin temperature, skin stiffness and/or

sensation (pain)

Stage 2 – Partial thickness skin loss involving epidermis and/or dermis. The

ulcer is superficial and presents clinically as an abrasion, blister or shallow

crater.

Stage 3 – Full thickness skin loss involving damage or necrosis ofsubcutaneous tissue; may extend down to but not through underlying

fascia. Presents clinically as a deep crater with or without undermining of

adjacent tissue.

Stage IV – Full thickness skin loss with extensive destruction, tissue necrosis

or damage to muscle, bone and/or supporting structures, e.g., tendon, joint

capsule.

Rate of cardiac death

MI and cardiac arrest

-

0 RF: 0.4%

-

1 RF: 1/0%

- 2 RF: 2.4%

-

3+RF: 5.4%

3) Perioperative Complications

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