Surgical complications and optimizing outcomes Flashcards
What should antibiotic prophylaxis be used?
In pts w/ high-risk cardiac conditions or within 2 yrs of a total joint replacement in the following situations
- Surgery in oral mucosa, groin/leg, wedge excision of lip or ear, nasal flaps, and all grafts.
What are considered high-risk cardiac conditions for patients being considered for antibiotic prophylaxis?
Prosthetic heart valve, history of infective endocarditis, unrepaired congenital heart disease, and cardiac transplant patients with cardiac valvulopathy
What are considered high-risk joint replacement situations for patients being considered for antibiotic prophylaxis?
Total joint replacements that occurred within 2 years, previous joint infections, type I diabetes, or immunosuppressive states or hemophilia
What is the most common timeline for a surgical wound infection?
4-8 days post-surgery
What are the sx’s of an infected surgical wound?
Rubor, dolor, calor, and swelling, can also have a purulent discharge, lymphangitic spread, fever, chills
What other differential dx items can be considered w/ surgical wound infection and how can they be differentiated?
Contact dermatitis: look for a geometric pattern to bandaid, hx of topical antibx us, and itch > pain
Inflammatory suture reaction: later prevention
What sites should antibiotic prophylaxis be considered in any patient (not just high-risk)?
If operating on inflamed skin or high risk areas (lower legs and groin)
When is the highest risk of post-operative bleeding present?
First 48 hrs postoperatively
How long does aspirin alter platelet function for and when should it be stopped prior to surgery?
Affects platelets for 6-10 days –> can withhold 10 days prior to surgery IF not being used for stroke or myocardial infarction
What should the INR ideally be before starting surgery?
<3
What are some herbs that increase bleeding risk?
Feverfew, fish oil, garlic, ginger, ginkgo, ginseng, bilberry, chondroitin, vitamin E, licorice, devil’s claw, danshen, dong quai, and alcohol
What are the clinical sx’s of a hematoma?
Gelatin-like clot formed in the dead space of a wound: pain, swelling, and red-purple discoloration
What is the presentation and treatment of a small hematoma?
Sx’s: pressure sensation
Small and stable can be left to self resolve, can use warm compress
What is the presentation of a large hematoma and what should be done?
Acute throbbing pain, expanding size
Requires wound exploration, irrigation, evacuation of hematoma, and/or drain placement
What are two areas where hematomas (acute) are considered medial emergencies?
Periorbital and neck
How can an early vs organizing hematoma present clinically?
Early (first 48 hrs): Fluctuant
Organizing (≥1 week post-op), thick, fibrous, adherent to adjacent tissue
What is the management of early hematoma?
Aspirate w/ a 16-18 gauge needle (or for flaps or enlarging, open and address bleeding)
What is the management of organized hematomas?
Cannot be aspirated except @ two weeks postop these undergo liquefaction and can sometimes be aspirated (or left to absorb over months)
Bromelain can also be used to help expedite hematoma resolution
What can be given to help expedite the breakdown of a hematoma?
Bromelain (Ananase/Traumanase): oral concentrate of proteolytic enzymes
What is the first clinical sign of ischemia?
Pallor
What is the difference in flap survival between arterial insufficiency and venous congestion?
Arterial insufficiency: flaps remain viable for 12-14 hrs
Venous congestion: Flaps undergo rapid necrosis (<3-4 hrs)
What are the clinical signs of arterial insufficiency?
Decreased skin temperature, lack of bleeding following pinprick test
What are the clinical signs of venous congestion?
Cyanotic-purple skin color, increased dark purple bleeding after pinprick test
What things can cause ischemia/necrosis after surgery?
Hematoma, infection, high wound tension
What are some patient-related risk factors for ischemia/necrosis?
Smoking, nicotine-containing products
What procedure-related risk factors exist for ischemia/necrosis?
To much undermining (especially too superficial), postoperative edema, sutures tied too tightly, and insufficient or excessive electrocoagulation
Should necrotic tissue be debrided?
NO! Unless there are signs of infection (serves as a biologic dressing)
How can ischemia/necrosis risk be minimized?
Suture replacement to decrease tension, the elevation of the surgical area (decrease edema), heat application (increased circulation), hyperbaric oxygen
When is a wound at the highest risk of dehiscence?
Time of suture removal
(can remove sutures in stages if more support is needed)
What is the treatment for dehiscence?
Classic teaching/boards: Resuture if <24 hrs after surgery, if >24 hrs then secondary intention healing
Newer studies suggest that if there is no infxn, hematoma, necrosis then resuturing can be done
If surgery is performed on the ear and significant pain is noted after surgery what is this? and how is it treated?
Chondritis, very painful, can occur on any ear procedure involving cartilage. Can be associated with pseudomonas
Tx w/ NSAIDs for pain, quinolone if suspected infection
What is a risk factor test for ectropion that can be done?
The “snap test” (lower eyelid is pulled down, this should snap back normally, but if it takes a while (or doesn’t) go back to being against the eye this is a risk factor). Medial and lateral canthus test as well (these are pulled, there should not be much laxity here, more is abnormal)
if these are abnormal, higher risk
What degree of eyebrow lift is ok for the closure of surgical wounds?
≤3mm is ok, > 3mm should be avoided (wont self resolve)
What surgical sites are most common for keloids?
Anterior neck, chest, and scars crossing jawline
What are some risk factors for trapdoor/pincushioning defects?
Often from concentric forces, so curved incision lines like bilobed flaps, nasolabial fold transposition flaps
How can pincushioning/trapdoor defects be avoided?
Wide undermining, sizing the flap properly, and good flap adherence to the wound base
What sutures have the highest risk of spitting?
Vicryl sutures placed superficially
When do spitting sutures usually occur and how can they be addressed?
1-3 months postop, can be removed if possible
How can ectropion be prevented when working near the lower eyelid?
Periosteal tacking sutures, Frost suspension sutures (a stitch is thrown in the lower eyelid, near the medial canthus, and attached to the skin of the upper eyelid suspending/holding the lower eyelid up)
What is the highest risk suture for suture granuloma?
Vicryl (polyglactin-910)
When do suture granulomas generally occur postop and what should be done?
1-3 months, resolves itself but can use intralesional triamcinolone to help things along
How are post-surgical telangiectasias treated?
Pulsed dye laser
How can thickened scars be treated?
Massage or intralesional steroid
What can be done to treat webbed or contracted scars?
Z-plasty revision
How can motor nerve damage be avoided when operating on the face?
Staying above the SMAS
What can be done to minimize abnormal sensation issues after surgery on the forehead?
Orienting excisions vertically rather than horizontally if possible, can decrease the number of sensory nerve branches transected
