POST OPERATIVE COMPLICATIONS


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good references very well informative presentation.nicely done. Thubs up !!!!!!!!!!!!!!!!!!!!!!!
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1 : Postoperative Complications Presented By : DR. HOSAIN SANDUGJI SUP BY ; DR FIAZ FAZILI
2 : Wound complications Postoperative fever Postoperative urinary retention Respiratory complications Postoperative parotitis GIT complications
3 : Wound complication Wound infection Wound hematoma Wound seroma Wound dehiscence
4 : Wound infection Operative wound classification : I clean 3.3-4 % II clean-contaminated 8-10 % III contaminated & IV dirty (infected) 28 %
5 : Wound infection Influencing factors : Source of bacteria Type of bacteria Bacterial virulence Bacterial antibiotic resistance Size of bacterial inoculum Skin preparation Duration of operation Extent of tissue damage Presence of hematoma or seroma Presence of foreign body Inappropriate use of electrocautery Patient age Hypoxemia Hypothermia Presence of chronic illness (e.g., renal failure, liver failure, chronicobstructive pulmonary disease, malignancy, diabetes mellitus) Hypotension or shock Malnutrition Use of immunosuppressive drugs Obesity Corticosteroids Chemotherapeutic agents Carrier of S. aureus
6 : Wound infection Clinical manifestation : ( Dolor ) : pain ( Tumor ) : swollen & edematous ( Rubor ) : redness & cellulitis ( Calor ) : warm to touch
7 : Wound infection Wound infections are classified as : Minor ( purlent material around skin suture sites) Major ( discrete collection of pus within the wound )
8 : Wound infection Wound infections are classified as : Superficial infection ( limited to skin & subcutanous tissue ) Deep infection ( involve area of the wound below the fascia ) Organs or spaces
9 : Wound infection Prevention : Skin preparation Bowel preparation Prophylactic antibiotic Meticulous technique Temperature maintenance Appropriate drainage
10 : Wound infection Management : Incision should be opened for drainage Debridement if there is necrosis Antibiotic if there is cellulitis
11 : Wound Hematoma Caused by inadequate hemostasis Good media for bacteria Manifested by pain & swelling Drain should be used Must be evacuated in certain location The wound should be opened in OR
12 : Wound Seromas Are lymph collections Operation in which large areas of lymph-bearing tissues are transected Closed-suction drain with pressure dressing Repeated aspiration is indicated Fertile ground for bacteria
13 : Wound Dehiscence Dehiscence ( is separation within the fascial layer , usually of abdomen ) Evisceration (extrusion of peritoneal contents through the fascial separation) Incidence : 0.5 – 3.0 % in all abdominal procedures .
14 : Wound Dehiscence Related factors : Imperfect technical closure Increased intra-abdominal pressure from bowel distention, ascites, coughing, vomiting, or straining Hematoma with or without infection Infection Metabolic diseases such as diabetes mellitus, uremia, Cushing's disease, Vit C def. Malignant disease Radiation
15 : Wound Dehiscence Detected by the classical appearance of salmon colored fluid draining from wound occurs in about 85 % of cases about fourth or fifth postoperative days Present late as an incisional hernia
16 : Wound Dehiscence Abdominal wall defect caused by wound dehiscence following breakdown of a tube caecostomy temporarily repaired with a polypropylene mesh A piece of Permacol™ surgical implant is sutured to the anterior abdominal wall fascia
17 : Wound Dehiscence Completed repair using 8 pieces of Permacol™ surgical implant sutured together covering a total area of 550cm2 The skin and subcutaneous tissue were closed and the patient was discharged 28 days later
18 : Postoperative Fever Causes of Postoperative Fever Infectious Abscess Acute cholecystitis Acute sinusitis Bacteremia Candidiasis Endocarditis Hepatitis Herpes virus infections Infectious diarrhea Osteomyelitis Parotitis Peritonitis Pharyngitis PneumoniaPostperfusion syndrome Prosthetic device infection Suppurative thrombophlebitis Transfusion-related infection Urinary tract infection Wound infection Noninfectious Acute gout Adrenal insufficiency Atelectasis Dehydration Drug fever Head trauma Malignancy Myocardial infarction Pancreatitis Pheochromocytoma Pulmonary embolus Thrombophlebitis Thyrotoxicosis Transfusion reaction
19 : Postoperative Fever 40 % after major surgery First 48 hours [[ Atelectasis After 2nd postoperative day : Catheter related phlebitis Pneumonia UTI
20 : Postoperative Fever After 5 days : Wound infection Anastomosis breakdown Intra-abdominal abscess
21 : Postoperative Fever After 1 week : Allergy to drug Transfusion related fever Septic pelvic vein thrombosis Intra-abdominal abscess
22 : Urinary retention Frequently in male Rarely in female Incidence : major abd. Surgery : 4 – 5 % Anorectal surgery : > 50 %
23 : Urinary retention Stress ,pain ,spinal anesthesia & anorectal reflexes lead to increased Alpha-adrenergic stimulation , which prevent release of musculature around the bladder neck Urgency ,discomfort , fullness ,enlarged bladder Catheterization to relive retention
24 : Respiratory complication 5 – 35 % of postop. Deaths Predisposing factors : smoking , age , obesity , COPD , cardiac disease
25 : Respiratory complication Atelectasis Aspiration Pulmonary edema ARDS Pulmonary embolism
26 : 1) Atelectasis : Collapse of alveoli Anesthesia ,diaphragmatic dysfunction , postop. Incisional pain Lung inflation in postop. period Most frequently used techniques : CDB , CPPD , IPPB , CPAP , Incentive spirometry
27 : 2) Aspiration : During induction of anesthesia CXR show progression of local damage & infiltration Prevention is only effective treatment
28 : 3) Pulmonary edema : Most common causes are fluid over load or myocardial insufficiency Occur during : * resuscitation * postop. Period
29 : 3) Pulmonary edema : CXR : - Bat’s wing appearance - Vascular prominence - Septal lines ( Kerley’s B lines ) - Peribronchial , perivascular cuffing Simple therapy including O2 , digitalization & upright position
30 : 4) Acute respiratory distress syndrome Syndrome that include : 1- Acute change in lung function 2- bilateral infiltrates on CXR 3- PaO2 / FIO2 less than 200 4- pulmonary – capillary wedge pressure less than 19mmHg with no evidence of CHF
31 : 4) Acute respiratory distress syndrome Mortality rate 50 – 65 % Management should be supportive to maintain O2 delivery to the peripheral tissues Intubation & mechanical ventilation is important in sever respiratory failure
32 : 5) Pulmonary embolism : 100’000 patients died in US per year 90 % originate from DVT of iliofemoral ves. Other form of PE : * fat embolism * arterial or venous air embolism * amniotic fluid embolism * foreign body emblism
33 : 5) Pulmonary embolism : Mild tachypnea to sudden cardiopulmonary arrest Diagnosis require combination of : - ABG - CXR - ECG - Doppler studies for lower extremities - Radionucleotide ventilation – perfusion scan
34 : 5) Pulmonary embolism : Management options : * intensive supportive measures & resuscitation. * direct or systematic thrombolysis. * surgical pulmonary ebolectomy. * IVC filter. Prevention of PE by using mechanical devices or pharmacologic inhibition of coagulation
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37 : Postoperative Parotitis Serious complication High mortality rate Rt. & Lt. equally involved Bilaterally 10 – 15 % of cases 75 % of patients are 70 year or older Poor oral hygiene , dehydration , use of anticholinergic drugs
38 : Postoperative Parotitis Majority of infections are from staphylococi Lack of oral intake to stimulate parotid secretions predisposes to bacterial invasion of Stensen’s duct Interval between operation & the onset varies from hours to many weeks
39 : Postoperative Parotitis Present with : pain in the parotid region swelling & tenderness cellulitis on face & neck temperature & leukocyte high Prophylaxis includes adequate hydration & good oral hygiene
40 : Postoperative Parotitis Antibiotic should be started against staphylococi Surgical drainage ( by incision made ant. to ear extending to mandible angle ) In 80 % of patient treated with incision & drainage the parotitis was palliated or cured
41 : GIT complications Ileus Anastomotic leaks Fistulas Stomal complication
42 : 1) Ileus : Non-mechanical obstruction that prevents normal postop. Bowel function Arise from neural inhibition that interferes with intrinsic bowel motor activity & effective peristalsis Increased with manipulation ,inflammation , peritonitis & blood left in peritoneal cavity
43 : 1) Ileus : Blood in retroperitoneum often produces ileus Hypokalemia , hypocalcemia , hyponatremia & hypomagnesemia prolong postop. Ileus Treatment is purely supportive
44 : 2) Anastomotic leaks : Three etiology factors : 1) poor surgical tech. 2) distal obstruction 3) inadequate proximal decompression Risk increase with S.Albumin < 3.0 mg/dl
45 : 2) Anastomotic leaks : Three technical factors play roles in a proper anastomosis : 1- both end of bowel should have adequate blood supply 2- anastomosis should lie in tension-free manner 3- adequate hemostasis
46 : 3) Fistulas : Abnormal communication between two epithelial surfaces Common problem of GIT surgery Can occur between : ( enterocutanous fistula ) , ( enteroenteric fistula ) ( enterovesical fistula ) , ( enterovaginal fistula )
47 : 3) Fistulas : Most common cause is anastomotic leakage Persistence secondary to ( FRIEND ) ( F.B. , Radiation , Infection , Epithiallization , Neoplasm , Distal obstruction ) Spontaneous closure usually occurs within 5 weeks with adequate nutrition If persist >5 weeks operation is indicated
48 : 4) Stomal complications : Stomal necrosis & retraction ( inadequate blood supply lead to ischemia ) Stomal stricture ( late complication , caused by development of serositis ) Peristomal hernia & prolapse ( resecting the stomal prolapse & fixing it again in place ) Skin complication
49 : THANK YOU

 

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