Surgical Complications

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Surgical Complications
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Wound Complications

• Seroma
• Hematoma
• Wound Dehiscence
• Wound Infection
• Chronic Wounds

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Seroma

• Collection of liquified fat, serum and
• lymphatic fluid under an incision
• Fluid is clear, yellow and somewhat viscous
• Mastectomy, axillary dissection, groin
  dissection,
• large ventral hernias

Presents as localized , well circumscribed
swelling , presssure discomfort and sometimes
clear drainage aspiration under sterile
conditions If persist of becomes infected open
and allow to heal by secondary intention
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Hematoma

• Abnormal collection of blood in subcutaneous
  layer of recent incision
• More worrisome than seromas because of
  infection potential
• Reason
• Inadequate hemostasis
• Rough handling of tissue
• Coagulopathy

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Hematoma

• Presents as
• purplish/blue discoloration
• Localized wound swelling
• Drainage of dark red fluid

In patients who have had neck dissection, a
hematoma can develop postoperatively that is life
threatening Compression of soft tissues
surrounding the airway Immediate and emergent
evacuation can be a lifesaving maneuver
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Hematoma

• Prevention
• The most important principle is careful
  hemostasis
• Correct all clotting abnormalities
• Discontinue medications that can prolong bleeding
  time
• Wounds with large sking flaps should be drained

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Wound Dehiscence

• Separation of fascial layers early in post
  operative course
• Great concern because of possibility of
  evisceration ( protrusion of intestines through
  the fascial layer)

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Wound Dehiscence

• Scenario You are called to see a patient post op
  day one with large amount of clear, salmon
  colored fluid from his laparotomy incision. WHAT
  DO YOU DO?
• Open a few staples
• Probe the wound with sterile cotton tipped swab
• Call the OR
• What do you do if pt eviscerates on the floor?

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Wound Dehiscence

• Etiology
• Technical error
• Placing sutures too close to edge
• Too far apart
• Too much tension
• A multitude of other factors

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Wound Dehiscence
Factors associated with Wound Dehiscence

• Technical error
• Intra abd infection
• Malnutrition
• Advanced age
• Chronic steroid use
• Wound complications ( hematoma, infection etc)
• Underlying diseases ( DM, RF, CA, chemo,
  irradiation )
• Increased intra-abd pressure ( ascites, coughing,
  etc)

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Wound Dehiscence

• Approx 2 of patients undergoing abd surgery
• In healthy patients, no difference in dehiscence
  rate between continuous versus interrupted
  technique
• High risk patients interrupted may occasionally
  be a wise choice

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Wound DehiscenceManagement

• Condition of the fascia
• If tech error and fascia is strong and intact,
  merely be closed
• If infected or weak debride and close with
  retention sutures
• Look for evidence of anastomotic leak or other
  infection

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Wound Dehiscence

• If significant amount of fascia needs to be
  debrided because of infection do not close

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Wound Infection

• Also referred to as SSI ( Surgical Site
  Infection)
• Superficial Incisional
• Skin and Subcutaneous tissue
• Deep Incisional
• Fascia and muscle
• Organ Space
• Internal organs

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Superficial Incisional

• Infection less than thirty days after operation
• Involves skin and tissue only plus
• Purulent drainage
• Diagnosis of superficial SSI by surgeo
• Sx of erythema, pain, local edema

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Deep Incisional

• Less than 30 days after op with no implant or
  soft tissue involvement
• Infection less than one year after op with
  implant and infection involves deep soft tissue (
  fascia/muscle) plus
• Purulent drainage from the deep space but no
  extension into organ space
• Abscess found in the deep space on direct or
  radiologic exam or on re-op
• Dx of deep SSI by Surgeon
• Sx of fever, pain and tenderness lead to
  dehiscence of wound or opening by a surgeon.

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Organ Space

• Less than 30 days after op with no implant or
  soft tissue involvement
• Infection less than one year after op with
  implant and infection involves any part of the op
  opened or manipulated plus
• Purulent drainage from a drain placed into the
  organ space
• Cx organisms from material aspirated from organ
  space
• Abscess found on direct or radiologic exam or
  during re-op
• Dx of organ space infection by surgeon

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Risk factors for wound infection
Patient Operation
Advanced age In adequate preop prep
Diabetes Duration of op
Malnutrition No Abx when indicated
Morbid Obesity Instrument contamination
Immunosuppression Break in technique
Coexisting remote infection Foreign body in wound
Colonization with bacteria Ischemic tissue
Prior radiation Devitalized tissue
Smoking Amt of intraop contamination ( spillage)
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Classification of Surgical Wounds
Category Criteria Infection rate
Clean No hollow viscus entered Primary wound closure No inflammation No breaks in aseptic tech Elective procedure 1 3
Clean contaminated Hollow viscus entered but controlled No inflammation Primary wound closure Minor breaks in aseptic tech Bowel prep preop 5-6
Contaminated Uncontrolled spillage from viscus Inflammation apparent Open,traumatic wound Major break in aseptic tech 20 25
Dirty Untreated, uncontrolled spillage Pus in op wound Open suppurative wound Severe inflammation 30 40
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• What is the most common pathogen associated with
  post operative wound infection?

STAPHYLOCOCCUS AUREUS
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Presentation and management

• Commonly occur 5-6 days post op may present
  sooner.
• 80 -90 occur within thirty days after surgery
• Superficial wound infection
• Staples removed, allow efflux of purulent
  material,
• explored, irrigated
• debridement of non viable tissue
• if fascia is intact, no further concerns
• If fascia seperated re xplore

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Scenario 2

• On POD 1, colostomy take down called to see pt
  with fever 102.5, HR 115, grayish dishwater
  colored fluid from wound. WHAT DO YOU DO?
• and crepitus along wound
• Typically what organisms?

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• C.perfringens and group A Betalytic Strep
• Necrotizing fascitis/clostridiomyonecrosis
• OR wound opened and aggressive debridement
• Cx wound

• Group A streptococcal infection
• Recent studies suggest that clindamycin is
  superior to penicillin in the treatment of
  experimental necrotizing fasciitis/myonecrosis.
• recommend the administration of penicillin G (4
  million units intravenously every four hours in
  adults gt60 kg in weight and with normal renal
  function) in combination with clindamycin (600 to
  900 mg intravenously every eight hours)

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Wound Infection - Prevention

• Stop smoking
• Lose weight
• Tight glucose control
• Wean steroids
• Bowel prep
• Hemostasis
• Careful handling of tissue
• Adequate blood supply
• Voluminous irrigation
• Abx proph when indicated

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Chronic Wounds

• Wounds that that have not healed within 30 90
  days
• Corticosteroids, chemo, malnourihed, obese
• Management
• great deal of patience
• Debride as needed
• Skin graft
• Skin flaps
• Wound Vacs

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• Fifteen minutes into doing a mastectomy, the
  nurse anesthesist tells you that the patient has
  a temperature of 104.5 deg ,HR of 132 and high
  ETCO2.

What is your most likely diagnosis and
management of this patient?
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Malignant Hyperthermia
Monitoring
Signs and Symptoms
Active Cooling

• End tidal CO2 Tachycardia Fever 2C per
  hour Cyanosis Mottling of skin Tachypnoea
  Arrhythmias Rigidity Sweating Hypercarbia
  Labile blood pressure Intense masseter spasm

Ice packs Cooling blankets Fans Cold
intravenous fluids Intragastric, intracystic
cooling Peritoneal dialysis using cold
diasylate Extracorporeal cooling if equipment
is available
Core temperature Arterial line and CVP line
Urinary catheter ECG Pulse oximetry
capnography Blood gases Serum glucose Serum
potassium Blood for CPK Urine for myoglobin
Terminate anaesthesia and surgery as soon as
possible Hyperventilate with 100 oxygen Give
Dantrolene Transfer to ICU as soon as possible
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Malignant Hyperthermia
DANTROLENE 2.5 mg/kg IV Repeat as required at
5.10 min intervals to a maximum cumulative dose
of 10 mg/kg. Favorable response indicated by (a)
fall in heart rate(b) abolition of
arrhythmia(c) decline in body temperature(d)
reduced muscle tone

• ARRHYTHMIASIf these persist despite Dantrolene
  givePROCAINAMIDE 1 mg/kg/ml IVMaximum dose 15
  mg/kg

• HYPERKALAEMIAControl if necessary using glucose
  and INSULIN 0.1 units/kg in 2 ml/kg 50 dextrose
  IV

• ACIDOSISCorrection withSODIUIM BICARBONATE0.5
  - 1.0 mmol/kg/dose IVRepeated as necessary

• URINE OUTPUTMANNITOL 0.5 - 1.0 g/kg(2.5 -
  5ml/kg of 20 solution) and/orFUROSEMIDE 1 mg/kg
  IVto maintain urine output (gt 1 ml/kg/hr)

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• Where is temperature modulation managed?
• ANTERIOR HYPOTHALAMUS

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Postoperative Fever -Host of infectious and
noninfectious agents may cause postoperative
fever.
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FIVE Ws of post op fever

• Wind ( lungs)
• Atelectasis, pneumonia
• Wound
• Water ( Urinary tract )
• Waste ( lower GI tract )
• Wonder drug

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Atelectasis and Pneumonia

• Atelectasis is the most common cause of post op
• fever in first 48 hrs .
• Result of
• Anesthesia
• Abdominal incision
• Post op narcotics
• Peripheral alveoli collapse and shunt may
• occur, also build up of secretion --- pneumonia

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Atelectasis and Pneumonia

• Use of
• Incentive spirometry
• Deep Breathing
• Coughing
• Will resolve most of the time
• If aggressive toilet is not instituted, pneumonia
  may develop.

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Atelectasis and Pneumonia

• Pt with pneumonia will have
• Fever
• Change in secretion
• Leukocytosis
• CXR infiltrates
• Sent sputum Cx
• Broad spectrum, antibiotics
• Aggressive pulm toilet

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• You are called to see a pt few hours post-op in
  the ICU, this is the tracing on the monitor.

No prior history of this.
Case 1. BP 70, HR160 Case 2.BP125/67 , HR86
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• Atrial Fibrillation
• Irregular P waves gt 300/min, irregular
  ventricular rhythm
• Associated Conditions
• MI.HTN,hypoxia,Hyperthyroidism,electrolyte
  imbalance, pulmonary embolus
• If Unstable ( Case 1)
• Cardioversion 200 360 J
• Initial Therapy
• Diltiazem 0.25mg/kg , then 10-15mg/hr
• Digoxin 0.5mg , then 0.25mg Q2hrs
• Esmolol, procainamide, amiodarone
• Subsequent therapy
• Procainamide, Digoxin, anticoagulation

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Following laparotomy - return of function MATCH
THE FOLLOWING
Small bowel Stomach Colon
48hrs 3-5days 24hrs
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Causes of Adynamic Ileus

• Inflammation e.g. appendicitis, pancreatitis
• Retroperitoneal disorders e.g. ureter, spine,
  blood
• Thoracic conditions e.g. pneumonia
• Systemic disorders e.g. sepsis, hyponatremia,
  hypokalemia, hypomagnesemia
• Drugs e.g opiates, Ca-channel blockers,
  psychotropics

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Partial vs Complete

• Complete obstipation
• No residual colonic gas on AXR
• SBFT may differentiate early complete from
  high-grade partial
• Almost all should be operated on within 24h

• Flatus
• Residual colonic gas above peritoneal reflection
  /p 6-12h
• Adhesions
• 60-80 resolve with non-operative Mx
• Must show objective improvement, if none by 48h
  consider OR

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Is there strangulation?

• 4 Cardinal Signs
• fever, tachycardia, localized abdominal
  tenderness, leukocytosis
• 0/4 0 strangulated bowel
• 1/4 7
• 2-3/4 24
• 4/4 67
• process accelerated with closed-loop obstr.

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55 year old POD5, from thoracotomy with severe
foul smelling diarrhea, WBC 40,000, 15 bands.
General surgery consult, colonscopy shown below.
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Pseudomembranous Colitis

• Pseudomembranes compromised of fibrin, mucus and
  necrotic epithelial cells
• Mostly in rectosigmoid
• Accessible to sig-scope
• C.diff toxin is agent responsible
• found in 90 -100 of pts with Pseudomembranous
  colitis
• Mortality 20 - if untreated
• Progression perforation, toxic megacolon
• TREATMENT
• Flagyl 250mg PO Q 6 hrs 7 10days
• If unsuccessful
• Vancomycin 125 mg Q6 hrs

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Abdominal Compartment Syndrome

• TNICU PTD 2, Ex-lap, GradeII liver injury
  splenectomy. You are called at 0100 to see pt.
• Increase peak airway pressures
• Low urine output
• Abdominal distention
• WHAT DO YOU DO DOC?

A Foley catheter attached to a manometer
accurately reflects intra-abdominal pressure in
the supine patient.
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Metabolic Complications

• Thyroid Storm
• Adrenal Insufficiency
• Hyperthyroidism
• SIADH

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Thyroid Storm

• a decompensated state of thyroid hormoneinduced,
  severe hypermetabolism involving multiple
  systems.
• Thyroid storm is the most extreme state of
  thyrotoxicosis.

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Thyroid Storm

• TRIGGERED BY
• Palpation of gland during surgery
• Emotional stress
• Iodine/iodide administration (without prior PTU)

• MANIFESTATIONS
• Tachycardia rates that can exceed 140 beats/min
• Hyperpyrexia to 104 to 106º F is common
• CNS signs Agitation, delirium, psychosis,
  stupor, or coma are common

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Thyroid Storm

• The therapeutic regimen
• A beta-blocker to control the symptoms induced by
  increased adrenergic tone.
• A thionamide, such as methimazole, to block new
  hormone synthesis.
• An iodinated radiocontrast agent to inhibit the
  peripheral conversion of T4 to T3.
• An iodine solution to block the release of
  thyroid hormone.
• Glucocorticoids to reduce T4-to-T3 conversion and
  possibly treat the autoimmune process in Graves'
  disease.

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A 56 year old wm , s/p AAA repair, in the ICU on
the vent,with the following

• persistent hypotension despite fluids and
  pressors
• PCWP - 20
• CVP15
• hyponatremia
• hypoglycemia

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Causes of adrenal insufficiency in surgical
setting, as well as clinical and laboratory
findings

• Causes of postoperative primary adrenal
  insufficiency include
• Autoimmune disease, TB, fungal disease,
  malignancy, AIDS, and drug suppression.
  Hemmorhage is a common cause in the ICU
• Secondary causes (decreased ACTH) include
• suppresion by glucocorticoid therapy, ACTH
  secreting tumors, pituitary operation,
  irradiation, head trauma.
• Clinical findings anorexia, malaise,
  hypoglycemia, hypotension
• Low CO and high SVRI or High CO and low SVRI
• Dx is by measuring free cortisol and cosyntropin
  stim.test
• Tx is with fluids and steriods (dexamethasone
  followed by hydrocortisone)

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Adrenal Insufficiency

• Random cortisol level of less than 20µg/dl is
  suggestive
• Cosyntropin test - 250 µg of cosyntropin
• Check cortisol level at 30 and 60 minutes
• Failure to increase greater than 20 µg is
  diagnostic or by 9 over baseline
• Administer Dexamethasone - it does not affect
  cosyntropin test

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Syndrome of Inappropriate ADH Release

• The diagnosis of SIADH is made when hyponatremia
  coexists with serum hypo-osmolality (lt280 mOsm
  per kg H 2 O) and a urine osmolality of more than
  100 mOsm per kg H 2 O.

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Disorders Associated With SIADH

• Carcinomas(e.g,bronchogenic and pancreatic)
• Pulmonary disorders(e.g ,tuberculosis, pneumonia)
• Central nervous system disorders(e.g, trauma,
  stroke, meningitis)
• Drugs(thiazides, NSAIDS, ACE inhibitors etc)

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Treatment of SIADH

• removal of all offending drugs
• management of mild hyponatremia with fluid
  restriction (lt800 ml per day) alone.
• In moderate hyponatremia, fluid restriction and
  0.9 sodium chloride infusion are necessary
• hyponatremia should be corrected at a rate of 0.5
  mmol per liter per hour to achieve a sodium level
  of 125 mmol per liter
• In severe cases, associated with coma, hypertonic
  (3) sodium chloride infusion may be necessary.
• Rapid correction (within 24 hours) of
  long-standing hyponatremia that has persisted for
  more than 2 days has caused central pontine
  myelinolysis.

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Delirium,Dementia and Depression
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Delirium

• Virtually any medical condition can precipitate
  delirium in a susceptible host
• multiple underlying conditions are often found .
• Fluid and electrolyte disturbances (dehydration,
  hypo/hypernatremia)
• Infections (urinary tract, respiratory tract,
  skin and soft-tissue)
• Drug toxicity
• Metabolic disorders (hypoglycemia, hypercalcemia,
  uremia, liver failure)
• Low perfusion states (shock, heart failure)
• Withdrawal from alcohol and sedatives.

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Delirium
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The end!