Surgical Complications Flashcards by Aliya Hussain

Classifications of complications of surgery?

General (any operation)

Specific (particular operation)

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How should complications be approached?

Systematically:
CVS
Respiratory
GI
Urinary 
Neurological
Wound

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What are the CVS complications of surgery?

Haemorrhage
MI
DVT

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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

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Presentation of haemorrhage?

Overt

With loss of blood, blood pressure decreased and, in compensation, tachycardia occurs

Oliguria

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Prevention of haemorrhage?

Meticulous technique

Avoidance of sepsis

Correction of coagulation disorders e.g: medications and some Jaundice patients cannot absorb vitamin K

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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

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How does peri-operative MI present?

Often silent, due to anaesthesia

Cardiac failure/cardiogenic shock

Arrhythmias

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Prevention of a peri-operative MI?

Delay surgery after MI

Avoidance of peri-operative hypotension

Correction of ischaemic heart disease

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Risk factors for DVT?

Age >40
Previous DVT
Major surgery
Obesity
Malignancy

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Causes of DVT?

Immobility during surgery

Hypercoagulable state

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Presentation of DVT?

Low grade fever within 5-14 days

Unilateral ankle swelling; calf/thigh tenderness

Increased leg diameter

Shiny skin

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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

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Prevention of DVT?

Compression stockings

Low-dose subcutaneous heparin

Early mobilisation

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Respiratory complications of surgery?

Atelectasis

Pneumonia

Pulmonary embolus (PE)

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What is atelectasis and how can it cause pneumonia?

Partial collapse or incomplete inflation of the lung; this can lead to infection

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Causes of atelectasis and pneumonia?

Anaesthesia

Increases secretion
Inhibits cilia

Postoperative pain
- Inhibits coughing

Aspiration
- Stomach contents

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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

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Prevention of post-operative chest infection?

Stopping smoking

Adequate analgesia

Physiotherapy, part, for those who have lung disease

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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