Complications of Surgery

Question 1

Consider post-op pain in tibial or supracondylar fractures - what might you be concerned about? How would you manage?

Answer 1

Compartment syndrome - check PCA in situ, having analgesia etc. Examine neurovascular status and check passive stretch of compartment. Senior review, keep NBM in meantime and consider bivalving cast Consider either intracompartmental pressure measurement or proceed straight to fasciotomy

Question 2

When measuring intracompartmental pressure in ?compartment syndrome, what pressures would be abnormal and what would be diagnostic?

Answer 2

over 20 abnormal, over 40 diagnostic

Question 3

What are 4 complications of compartment syndrome?

Answer 3

Muscle ischaemia and necrosis - debride and consider amputating Incomplete decompression of deeper muscles due to incisions being too small Ischaemic contractures Renal failure secondary to rhabdomyolysis

Question 4

Why is rhabdomyolysis a problem? What medication can you consider alongside hydration?

Answer 4

Creates circulating pool of myoglobin, which can form casts and obstruct nephron to cause ATN Consider loop diuretic

Question 5

3 categories of stoma complication?

Answer 5

Local early, local late and systemic

Question 6

What are 4 local early complications of stoma?

Answer 6

Ischaemia/necrosis, retraction, obstruction and separation

Question 7

What are 4 local late complications of stoma?

Answer 7

Prolapse, stenosis, parastomal hernia and skin changes

Question 8

Systemic complications of stoma?

Answer 8

High output causing electrolyte derangement, arrhythmias and renal dysfunction

Question 9

Give some abdominal incisions?

Answer 9

Question 10

What is abdominal compartment syndrome?

Answer 10

Sustained increase in intra-abdominal pressure over 20mmHg resulting in tissue hypoperfusion and end-organ dysfunction

Question 11

What is normal intra-abdominal pressure, what may be associated with hypoperfusion and what is definitive for abdominal compartment syndrome?

Answer 11

Normal 5-7mmHg

High is 15 - may have microvascular hypoperfsuion

Over 20 is definitely abnormal

Question 12

3 main risk factors for abdominal compartment syndrome?

Answer 12

Long complex abdominal surgeries with extensive tissue handling

Tissue hypoxia and subsequent reperfusion

Complex abdominal wall closure e.g. with incisional hernias - reduced functional size of abdominal cavity

Question 13

How do you diagnose abdominal compartment syndrome?

Answer 13

Insert transurethral catheter intravesicularly with pressure transducer to measure pressure

Sustained pressure over 20mmHg with evidence of end organ dysfunction suggestive of abdominal compartment syndrome

Question 14

Management of abdominal compartment syndrome?

Answer 14

If stable - insert NG tube, urinary catheter

Perform CT for ?collections that may be drainable percutaneously

Improve abdo wall compliance e.g. with muscle relaxants, sedation

If unstable or conservative measures unsuccessful - theatre for laparotomy and laparostomy with bogota bag or vac system, for later relooks and delayed closure

Question 15

What is the most common cause of surgical site infection?

Answer 15

S aureus

Question 16

6 factors minimising risk of surgical site infections?

Answer 16

Not shaving wound - or using disposable clipper if needed

Good PPE, hand hygiene etc.

Peri-operative prophylactic antibiotics where indicated

Chlorhexidine to clean skin and approriate use

Use of iodophor impregnated drapes rather than incise

Avoid tissue hypoxia/excessive bipolar

Question 17

3 general example of where prophyalctic antibiotics are recommended peri-opeartively?

Answer 17

Prosthesis

Clean-contaminated surgeries

Contaminated surgeries

Question 18

What are the 3 phases of the WHO safety checklist?

Answer 18

Prior to induction of anaesthetic (sign in - brief)

Prior to incision (time out)

End of procedure (sign out - debrief)

Question 19

What is the WHO checklist?

Answer 19

Series of safety checks introduced by WHO to minimise chance of patient harm during surgery, consisting of 3 domains of cross-checks to identifal potential hazards during surgery and minimise risks of these

Question 20

WHO checklist - prior to anaesthetic induction?

Answer 20

Check identity and confirm surgical site

Confirm consent signed

Check site marked

Confirm anaesthetic equipment working

Significant blood loss anticipated?

Airway issues?

Check allergies

Question 21

WHO checklist - prior to incision?

Answer 21

Introduce team by name and role

Reconfirm patient details, procedure, site and position incl site markings

Highlight procedure specific equipment, investigations

Any anticcipated critical incidents and key steps

Intraoperative imaging required?

Sterility of instruments

ASA

Antibiotics

Sugar control

Hair removal

Warming

Diathermy

VTE prophylaxis

Question 22

WHO checklist - end of procedure?

Answer 22

Name of procedure

Instrument, swab and sharp counts complete and correct

Specimens labelled and packaged correctly

Equipmetn issues

Any post-op concerns

Question 24

4 complications of splenectomy?

Answer 24

Haemorrhage - due to short gastrics or splenic hilar vessels

Pancreatic fistula due to damage to pancreatic tail

Thrombocytosis -give aspirin

Encapsulated bacterial infection e.g. s pneumoniae, h influenzae, n meningitidis