Surgical Complications Flashcards
Classifications of complications of surgery?
General (any operation)
Specific (particular operation)
How should complications be approached?
Systematically: CVS Respiratory GI Urinary Neurological Wound
What are the CVS complications of surgery?
Haemorrhage
MI
DVT
Types of haemorrhage in surgery?
Reactionary (most common) - occurs immediately post-operative
Secondary (uncommon due to antibiotics)- due to infection; occurs within 5-10 days
Presentation of haemorrhage?
Overt
With loss of blood, blood pressure decreased and, in compensation, tachycardia occurs
Oliguria
Prevention of haemorrhage?
Meticulous technique
Avoidance of sepsis
Correction of coagulation disorders e.g: medications and some Jaundice patients cannot absorb vitamin K
When is MI risk in an operation increased?
If there is severe angina
If the person has had a previous MI:
30% within 3 months
Stabilises at 5 months in 6 months
How does peri-operative MI present?
Often silent, due to anaesthesia
Cardiac failure/cardiogenic shock
Arrhythmias
Prevention of a peri-operative MI?
Delay surgery after MI
Avoidance of peri-operative hypotension
Correction of ischaemic heart disease
Risk factors for DVT?
Age >40 Previous DVT Major surgery Obesity Malignancy
Causes of DVT?
Immobility during surgery
Hypercoagulable state
Presentation of DVT?
Low grade fever within 5-14 days
Unilateral ankle swelling; calf/thigh tenderness
Increased leg diameter
Shiny skin
Investigations for DVT?
D-dimer (degradation product of fibrin) test is a good rule-out test; if normal, it is unlikely to be a DVT
Proceed with other investigation if abnormal or if there is a high clinical suspicion of DVT:
Doppler ultrasound
Venography
Prevention of DVT?
Compression stockings
Low-dose subcutaneous heparin
Early mobilisation
Respiratory complications of surgery?
Atelectasis
Pneumonia
Pulmonary embolus (PE)
What is atelectasis and how can it cause pneumonia?
Partial collapse or incomplete inflation of the lung; this can lead to infection
Causes of atelectasis and pneumonia?
Anaesthesia
- Increases secretion
- Inhibits cilia
Postoperative pain
- Inhibits coughing
Aspiration
- Stomach contents
Presentation of chest infection?
Low grade fever (0-2 days) - most people will have this following surgery
High grade fever (4-10 days)
Dyspnoea
Productive cough
Confusion
Prevention of post-operative chest infection?
Stopping smoking
Adequate analgesia
Physiotherapy, part, for those who have lung disease
Risk factors for PE?
Same as for DVT (cause): Age > 40 Previous PE Major surgery Obesity Malignancy
Presentation of PE?
Tachypnoea Dyspnoea Confusion Pleuritic pain Haemoptysis Cardiopulmonary arrest
Tests for PE?
V/Q scan (abnormal) - mismatch will be present; there will be ventilation but less perfusion
CTPA is gold-standard
Prevention of PE?
Compression stockings
Low-dose subcutaneous heparin
Early mobilisation
Anti-coagulation in presence of DVT
GI complications of surgery?
Ileus - paralysis of intestinal motility
Anastomotic dehiscence - Breakdown of anastomosis, e.g: intestinal, vascular, urological
Adhesions - fibrin (inflammatory response) is laid down to produce a fibrous tissue, e.g: bowel-bowel, bowel-abdominal wall and other structures and lung-chest wall
Causes of ileus?
Handling of bowel Peritonitis Retroperitoneal injury Immobilisation Hypokalaemia Drugs
Presentation of ileus?
Vomiting
Abdominal distension
Dehydration
Silent abdomen
Prevention of an ileus?
Minimal operative trauma
Laparoscopy
Avoidance of intra-abdominal sepsis
Causes of anastamotic dehiscence?
Poor technique
Poor blood supply
Tension on anastomosis (stretching)
Presentationof anastamotic dehiscence?
Intestinal - peritionitis, abscess, ileus, fistula
Vascular - bleeding/haemotoma
Urological - leakage of urine/urinoma
Prevention of anastamotic dehiscence?
Good technique
Good blood supply
No tension
Causes of adhesions?
Inflammatory response
Ischaemia
Presentation of adhesions?
Asymptomatic, e.g: to chest wall
Commonest cause of intestinal obstruction causing vomiting, pain, distension and constipation
Prevention of adhesions?
No powder on gloves
Avoidance of infection
Laparoscopic surgery
Sodium hyaluronidate - decreased risk, part. in people who are having surgery for an adhesion complication
Wound complications?
Infection - contamination from intestinal contents is usually the cause
Dehiscence
Incisional hernia - bowel contents can push out, below the skin
Types of surgical wound infections?
Trauma is the main exogenous cause
Intestinal surgery (endogenous)
Presentation of wound infection?
Pyrexia (5-8 days) Redness Pain Swelling Discharge
Prevention of wound infection?
Pre-op preparation (empty bowel to reduce potential of intestinal contents leaking out)
Skin cleansing and aseptic technique
Avoidance of contamination
Prophylactic antibiotics (a single dose before the surgery to increased tissue levels of antibiotic)
Urinary complications of surgery?
Acute retention of urine, part. in males
UTIs (catheterisation)
Urethral stricture (prolonged catheterisation)
Acute renal failure
Neurological complications of surgery?
Confusion
Stroke
Peripheral nerve lesions (avoid compression of nerves and position correctly) : Ulnar nerve Radial nerve Sciatic nerve Common peroneal nerve
Causes of confusion?
Hypoxia:
Chest infection
PE
MI
Oversedation
Sepsis
Electrolyte imbalance
Stroke
Hyper or hyopglycaemia, part. in diabetics
Alcohol or tranquilliser withdrawal
Presentation of confusion?
Disorientation:
Time
Place
Paranoia
Hallucinations
Prevention of confusion?
Maintain oxygenation
Avoid dehydration
Avoid sepsis
Send home as soon as possible
How to minimise complications and their effects?
Patient selection and preparation
Careful surgery
Constant vigilance
What is Enhanced Recovery After Surgery (ERAS)?
Multimodal programme of enhanced care
To minimise post-operative complications and return patient to normality ASAP
Objectives are to promote:
Pain control
GI function
Mobility
Components of the ERAS pathway?
Pre-operative
Peri-operative
Post-operative
Pre-operative components of the ERAS pathway?
Pre-admission counselling
Fluid and CHO loading
No prolonged fasting
No/selective bowel preparation
Antibiotic prophylaxis
Thromboprophylaxis
No pre-medication
Peri-operative components of the ERAS pathway?
Short acting anaesthetic agents
Mid-thoracic epidural anaesthesia/ analgesia
No drains
Avoidance of salt and water overload
Maintenance of normothermia (body warmer/warm intravenous fluids)
Post-operative components of the ERAS pathway?
Mid-thoracic epidural anaesthesia/analgesia
No NG tubes
Prevention of N&V (nausea and vomiting)
Avoidance of salt and water overload
Early removal of catheter
Early oral nutrition
Non-opioid oral analgesia/ NSAIDs
Early mobilisation
Stimulation of gut motility
Audit of compliance and outcomes
