Post operative complications

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Content• Wound complication• Thermal regulation complication• Pulmonary complication• Endocrine complication• Cardiovascular complication• Neurological complication• Renal complication• GI complication• HEENT complication

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WOUND COMPLICATIONS

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Wound Complications

1. Wound infection2. Wound hematoma3. Wound seroma4. Wound dehiscence

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Surgical and environment factorPre-op, Intra-op, Post-op

Microbial factorStaphylococcus aureusEnteric organism in the boweloperations

Host factor U/D

Wound infection

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Classification of operative wounds and risk of infection

Classification Criteria Risk (%)Clean Elective, not emergency, nontraumatic,

primarily closed; no acute inflammation; no breka in technique; respiratory, gastrointestinal, biliary and genitourinary tracts not entered

2<

Clean-contaminated

Urgent or emergency case that is otherwise clean; elective opening of respiratory, gastrointestinal, biliary or genitourinary tract with minimal spillage (e.g., appendectomy) not encountering infected urine or bile; minor technique break

10<

Contaminated Nonpurulent 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

Approx. 20

Dirty Purulent inflammation(e.g., abscess); preoperative perforation of respiratory, gastrointestinal, biliary or genitourinary tract; penetratinbg trauma > 4 hours old

Approx. 40

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Clinical presentation

• Inflammatory sign– Pain – Swollen and edematous– redness and cellulitis– warmth

• Fever , Heart rate increase

• Day 5th – 8th postoperative days

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Mangement

• Depends on the extent of destruction and the type of the wound infection

• Simple collection of purulent material in skin and subcutaneous.

• Opening the incision and drainage

• Debridement

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Wound hematoma

• Caused by inadequate hemostasis• Pain and swelling• Serosanguinous in drainage

• Wound opened and evacuated • Closed suction (predisposing factor/ hemostasis)• Correct hemostasis problem

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Wound seroma• Lymph collection• Large area of lymph-bearing tissues are transected• Fertile ground for bact wound infect

• Management repeat aspiration/ closed suction drainage

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Wound dehiscence

• The seperation within the fascial layer

• Usually of the abdomen

• Generally caused by technical factor

• Incision in vertical horizontal incision

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Wound dehiscence (Cont.)

• Factors– Malnutrition– Hypoproteinemia – morbid obesity– Malignancy w/ immunologic deficiency– Uremia– DM – Coughing increase abd. Pressure– Remote infection

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Wound dehiscence (Cont.)

• Local factors

– Midline vertical incision

– Hemorrhage

– Wound infection

– Poor technique

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Prevention

• Correct factor : infection, nutrition, blood sugar

• Midline incision oblique, transverse incision

• Mass closure suture

• Suture material

• Chromic catgut dehiscence

• Nylon, prolene, steel wire

• Dexon, vicryl

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Thermal regulation complications

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Thermal regulation

1. Fever2. Malignant Hyperthermia3 . Hypothermia

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Post-operative fever

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Pathophysiology• Fever >38ºC is common after surgery• Usually inflammatory stimulus of surgery and resolves

spontaneously• Fever = response to cytokine release

– Fever-associated cytokines are released by tissue trauma and do not necessarily signal infection

– Cytokines produced by monocyte, macrophages, endothelial cells

– Fever-associated cytokines = IL-1, IL-6, TNF-alpha, IFN-gamma

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•Wind, POD1-2: the lungs, i.e. pneumonia, aspiration, and pulmonary embolism, but not atelectasis•Water, POD3-5: urinary tract infection•Walking (or VEINS, which then sounds like "Weins"), POD4-6: deep vein thrombosis or pulmonary embolism•Wound, POD5-7: surgical site infection, which in obstetrics or gynaecology, may refer to the Womb.•Wonder drugs or “What did we do?”, POD7+: drug fever, infections related to intravenous lines

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Causes of Postoperative Fever

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Malignant Hyperthermia

• After exposure to a triggering GA (anesthetic complications)

• Occurs rare in 1 in 30,000 to 50,000 adults .

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INCIDENCE

• 1:12 000 - 1:40 000

• Male = Female

• No racial difference

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• Susceptibility to MH is inherited as an

AD disease (mutation)

Altered Ca2+ regulation in skeletal muscle

Abnormal release of Ca2+

Prolonged activation of muscle filaments

Excessive generation of heat .

• If untreated : myocyte death rhabdomyolysis hyperK & myoglobulinuria .

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Clinical presentation

• Rapid rise in body temp ,usually during the initiaton of a GA after admin. of succinylcl.or potent inhalation agent ,particularly halothane

• Metabolic acidosis & e’lyte imbalance (hyperCa2+)

• Hypotonicity of skeletal muscle (acidosis)

• >42 C hypercapnia, cardiac arrhythmia

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FULMINANT CRISIS

• Tachycardia

• Metabolic acidosis, O2 sat, pCO2

• Muscle rigidity• Electrolyte disturbance• Arrhythmias• Myoglobinuria• Hyperthermia

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DIAGNOSIS, consider MH if

• Masseter muscle spasm after sux• Unexplained, unexpected

tachycardia• Unexplained, unexpected

increase in end - tidal CO2

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EARLY MANAGEMENT 1

• STOP ALL ANAESTHETIC VAPOURS

• CHANGE TO CLEAN ANAESTHETIC BREATHING SYSTEM

• ABANDON SURGERY IF FEASABLE

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EARLY MANAGEMENT 2

• DANTROLENE

• MEASURE ABGs, K+ AND CK

• MEASURE CORE TEMP

• COOL PATIENT

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Hypothermia

• Core temperature below 35° C• 80% of elective operative procedu

res are associated with a drop in body temperature

• 50% of trauma patients are hypot hermic on arrival in the operating

suite.

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Risk Factors for Decreased Thermostability

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• C ool ambient room temp.

• R apid administration of IV fluids or blood.

• Prolonged surgical procedure

• Advanced age

• Opioid analgesia

• Propofol causes vasodilation and significant redistribution hypothermia

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Degrees of Hypothermia

Mild

(32-35C)

CNS depression

Increased metabolic rate

Increased pulse

Shivering thermogenesis

Dysarthria, amnesia, ataxia, apathy

Moderate

(28-32C)

Further CNS and vital sign depression

Loss of shivering

Arrhythmias common, QT prolonged, J waves

Inability to rewarm spontaneously

Cold diuresis

Severe

< 28C)

Comatose and areflexic

Profoundly depressed vitals

Little respiratory stimulation 2º to low CO233

• A core temperature < 35°C after surgery

• Hypertension (S ympathetic NE vasoconstricti on elevated arterial blood pressure)

• Shivering, uncomfortable cold sensation

Clinical presentation

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• Core To < 35°C

• Early postoperative ischemia

• Ventricular tachyarrhythmia.

• Coagulation defect bleeding– Impairs platelet function – Reduces the activity of coagulation factors

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• Poor healing and infection.

– Impaired macrophage function

– Reduced tissue oxygen tension

– Impaired collagen deposition

– Relative diuresis

– Compromised hepatic function

– Neurologic manifestations .

• Impaired - acid base balance

• In severe cases the patient

– Bradycardia low BP

– Decrease RR

– Comatose

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• Monitoring core temperature, – Undergoing body cavity surgery– Surgery lasting longer than 1 hour– Children and the elderly– General-epidural anesthesia

• Anesthetized and during skin preparation significant evaporative cooling can take place the patient is kept warm by increasing the ambient temperature and using heated humidifiers and warmed IV fluid .

Prevention

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Treatment

• Warm blankets• Forced-air warming devices• Infusion of blood and IV fluids through a warming

  device• Heating and humidifying inhalational gases   •   Peritoneal lavage with warmed fluids• In rare cases, cardiopulmonary bypass

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