L16: Surgical Complications (Ellison) Flashcards
infection
proliferation of micro-organisms within wound
dehiscence
separation of wound
etiology of wound infection/dehiscence
- inadequate aseptic technique
- improper suturing technique
- self mutilation
- drugs and medical conditions: steroids, Cushings, chemotherapy, anemia
- surgery time-hypothermia
- anesthetic agents: propofol
types of wound dehiscence
Superficial separation: can be:
-uninfected (re-suture or staple)
-infected (hot soak, abx, may or may not require 2ary closure)
Herniation with Evisceration
abx selection for dehiscence
- staphylococcus, strep: amoxicillin, clavamox, cephalosporins
- E. coli proteus: baytril
- Anaerobic bacteria: metronidazole
Incisional swelling
- some swelling is normal in all wounds
- differentiate b/w edema vs. seroma vs. hernia with palpation, FNA, ultrasound
- if can push up into abdomen, most likely a hernia
seroma/hematoma
- seroma: pocket of clear serous fluid that sometimes develops in the body after surgery
- hematoma: blood “ “
- tx: tap (often recurs), drains (may infect), usually resolve spontaneously
most important closure
SC closure
-if animal chews up skin sutures, prevents evisceration. If deeper sutures break, prevents hernia
incisional hernia
- herniation with skin intact
- tx: elective sx, may have to resect herneal sac
Tx of herniation with evisceration wound dehiscence
- emergency sx
- may have to resect and anastomose
iatrogenic burns
clipper burns
thermal burns
peritonitis
inflamm. of the abd. cavity
-can be:
localized (ie. sponge left in)
generalized (ie. uroabdomen/uroperitoneum)
chemical (ie. tear in bile duct w/ powerful inflamm. response)
septic (ie. leaking anastomosis)
combined
examples of chemical peritonitis
pancreatitis bile leakage trauma urine leakage gastric perforation
ex. of septic peritonitis
surgical contamination
sharp trauma
extension of reproductive or urinary tract infection
bowel perforation
ex. of localized peritonitis
- local vasodilation + pain
- extravasation of plasma
- neutrophil migration
- platelet aggregation
- fibrin clots
- fibrous adhesions
ex. of generalized peritonitis
- fluid + protein shifts
- hemoconcentration + ____
- hypovolemic shock
consequences of bacteria + endotoxins
- neuts to abdomen
- hypoglycemia
- metabolic acidosis
- septic shock
dx of peritonitis
- PE, Rads, BW
- U/S (including abdominocentesis, diagnostic peritoneal lavage (DPL))
what does peritonitis look like on rad
- generalized abdominal hazinees
- loss of visceral detail
- free abdominal air*
- ileus
Fluid sample processing
- cytology
- assess glucose, creatinine, and lactate vs. serum lvls
- if creatinine > serum –> urine leakage
- if amylase > 1000 = pancreatic inflammation
tx of peritonitis
-medical management of hypovolemic or septic shock
-tx of infection/sepsis
-correction of the underlying cause
-providing peritoneal drainage when necessary
“dilution is a solution of pollution”
abx therapy of peritonitis
- E. coli, Proteus sp., Staph aureus, Enterococcus, Bacteroides
- Cefoxitin, Cefazolin, Baytil, Metronidazole (gram negs), imipenum
surgical management of peritonitis
- STOP THE CONTAMINATION
- close perforations, resection and anastamosis
- omental wrap, serosal patch, jejunal onlay graft
Serosal patching indications
- intestinal perforations
- gastric ulcer
- FB
- gun shot wound
- buttress any hollow
- organ sx - bladder, uterus, diaphragm
Serosal patching: technique
- usually use jejunum
- no tension or twist
- suture 3-4mm beyond margins
- 3-0 polypropylene
- mucosa migrates over defect
peritoneal drains
- silicone or latex
- sealed by fibrin and omentum in 6hrs
- don’t “drain” peritoneal cavity
- effective for localized peritonitis
drain effectiveness
gauze: 20%
penrose: 30%
penrose sump: 50-60%
triple lumen sump: 70%
triple lumen + suction: 80%
(drains don’t work very well unless they have active drainage)
intermittent peritoneal lavage (S.O.!)
- Ingress-Egress system
- Peritoneal dialysis catheter
- 20ml/kg LRS, 0.9 NaCl, BID
- hypoproteinemia, hypokalemia
Open peritoneal drainage - indications
- generalized septic peritonitis
- anaerobic bacteria
- blood components
- good support staff
Open peritoneal drainage
- gap linea alba 1-2cm
- skin + SC antibiotic ointment
- non-adherent bandage
- sterile cotton roll
- changed 12-24hr intervals
- wound closed in 1-5d
complications of open peritoneal drainage
- dehydration
- hypoproteinemia
- high mortality
controversial therapes
- intraperitoneal povidone iodine
- intraperitoneal antibiotics
- intraperitoneal heparin
- peritoneal drainage
intraperitoneal abx:
- don’t excedd parenteral levels
- don’t increase survival
- may be indicated for prophylaxis
