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year 4 CDM 2 > Surgical iatrogenesis > Flashcards

Surgical iatrogenesis Flashcards

1
Q

Ways to avert potential surgical complications

A
  • World Health Organisation checklist- now mandatory prior to all operations
  • Prophylactic antibiotics
  • Assess DVT/ PE risk and ensure adequate prophylaxis
  • MARK site of surgery
  • Use tourniquets with caution and with respect for underlying structures
  • With end arteries avoid using adrenaline containing solutions and monopolar diathermy.
  • Devitalised tissue serves as a nidus for infection
  • Be wary of the potential for coupling injuries when using diathermy during laparoscopic surgery
  • Be aware of the inferior epigastric artery in laparoscopic ports and surgical drains
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2
Q

Damage to the Accessory, Sciatic, Common peroneal and Long thoracic nerve

A
  • Accessory= Posterior triangle lymph node biopsy
  • Sciatic= Posterior approach to hip
  • Common peroneal= Legs in Lloyd Davies position
  • Long thoracic= Axillary node clearance
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3
Q

Damage to pelvic autonomic nerves, Recurrent laryngeal nerves, Hypoglossal nerve, Ulnar and Median nerve

A
  • Pelvic autonomic nerves: Pelvic cancer surgery
  • Recurrent laryngeal nerves: During thyroid surgery
  • Hypoglossal nerve: During carotid endarterectomy
  • Ulnar and median nerves: During upper limb fracture repair
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4
Q

Damafe to Thoracic duct, Parathyroid gland and ureters

A
  • Thoracic duct: During thoracic surgery e.g. Pneumonectomy, oesphagectomy
  • Parathyroid glands: During difficult thyroid surgery
  • Ureters: During colonic resections/ gynaecological surgery
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5
Q

Surgical damage causing Bowel perforation, Bile duct injury and to the facial nerve

A
  • Bowel perforation: Use of Verres Needle to establish pneumoperitoneum
  • Bile duct injury: Failure to delineate Calots triangle carefully and careless use of diathermy
  • Facial nerve: Always at risk during Parotidectomy
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6
Q

Surgical damage to the tail of the Pancreas, Testicular vessels, Hepatic veins

A

-Tail of pancreas: When ligating splenic hilum
- Testicular vessels: During re-do open hernia surgery
- Hepatic veins: During liver mobilisation

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7
Q

Investigations for surgical Iatrogenesis

A
  • Full blood count, urea and electrolytes, C- reactive protein (trend rather than absolute value), serum calcium, liver function tests, clotting (don’t forget to repeat if on-going bleeding)
  • Arterial blood gases
  • ECG (+cardiac enzymes if MI suspected)
  • Chest x-ray to identify collapse/ consolidation
  • Urine analysis for UTI
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8
Q

Special tests for surgical iatrogenesis

A
  • CT scanning for identification of intra-abdominal abscesses, air and if luminal contrast is used an anastamotic leak
  • Gatrograffin enema- for rectal anastamotic leaks
  • Doppler USS of leg veins- for identification of DVT
  • CTPA for PE
  • Sending peritoneal fluid for U+E (if ureteric injury suspected) or amylase (if pancreatic injury suspected)
  • Echocardiogram if pericardial effusion suspected post cardiac surgery and no pleural window made.
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9
Q

Iatrogenesis

A

Iatrogenesis is causation of harm or disease by medical intervention

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10
Q

Surgical Iatrogenesis

A

Harm resulting from a surgical procedure and includes:
- Recognised risk of surgery
- Medical / surgical error
- Expected sequelae of surgery
- Psychological / social / cultural effects of surgical procedure

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11
Q

Classification of surgical complications: timing

A
  • Immediate: bleeding, nerve injury, perforated viscus
  • Early (<30 days): sepsis, anaemia, shock, pain, neuropraxia (loss of function of nerve which will then recover due to bruising)
  • Late (>30 days): stenosis, adhesions, fistulae, weakness/loss of function
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12
Q

Classification of surgical complications: anatomical

A
  • Local: nerve palsy/paralysis, wound dehiscence, infection, haematoma
  • Systemic: respiratory compromise, shock/cardiovascular instability, sepsis, VTE, delirium
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13
Q

Classification of surgical complications: severity

A
  • Grade I: any deviation from expected post op course, no treatment required
  • Grade II: Requires pharmacological treatment i.e. wound infection
  • Grade III: Requires surgical / endoscopic / radiological intervention i.e. haematoma or perforation
  • Grade IV: Life threatening complication i.e. sepsis
  • Grade V: Death
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14
Q

Managing surgical complications: Bleeding control

A
  • Pressure
  • Communicate with anaesthetist
  • Get help / prepare scrub team: make there is adequate light and retraction
  • Identify source: Suction / saline wash
  • Consider anatomy: Small vessel – cautery. Larger vessel – ligate vs repair. May have to call vascular surgery
  • Check haemostasis: ask to raise BP and see if re-bleeds
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15
Q

Surgical Iatrogenesis: if unable to gain control of bleeding

A
  • Get help
  • Pack
  • Stabilise patient and leave in ITU with ventilation and intubation for 24-48hrs before 2nd look
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16
Q

Managing a Perforation at different locations

A
  • Pharynx / cervical oesophagus : most can be left to heal, rest with NGT
  • Thoracic oesophagus: small perforation = endoscopic glue. Large perforation = endoscopic stent or surgical repair
  • Bowel= if small: endoscopic mucosal clipping. If large: open surgery
  • Ureter : stent or surgical repair
  • Bladder: surgical repair
17
Q

Managing a perforation principles

A
  • Suction/wash to clean leakage, assess damage
  • Consider feeding: enteral (to rest the pharynx and oesophagus) vs parenteral (to rest the gut)
  • Antibiotic prophylaxis: if leak of faecal content into the abdomen
18
Q

Managing a complication: Nerve injury

A
  • Identify nerve – assess expected deficit from injury. Sensory nerves tend to be left whilst important motor nerves are repaired
  • Assess damage: Complete vs partial transection. If complete more likely to need repair
  • Opposed axons repair 1mm per day so just need to align them
  • Principle of nerve repair is to ensure optimal position for axonal repair: Suture peri-neurium together whilst ensuring there is no tension at the closure. Microscopic surgery – plastic surgery
  • Repaired nerve will not regain full function
19
Q

Managing expected surgical sequelae

A
  • Pain: Analgesic ladder, patient controlled anaesthesia, local anaesthetic block/spinal
  • Respiratory compromise (pan or respiratory depression): breathing exercises/physio, if pre-existing respiratory compromise may need to optimise it with exercises in pre-habitation before surgery
  • Airway compromise (head and neck surgery): prolonged intubation (day or two), tracheostomy (longer term)
  • Uro/Gi compromise: Urinary catheter, NGT (drainage), flatus tube (pass gases-prevent volvulus), Enteral vs parenteral feeding (to rest the bowel)
  • Anaemia: transfusion/ pre-load with iron
  • Surgical sepsis: Antibiotic prophylaxis (depends whether clean or contaminated)
  • VTE prophylaxis
20
Q

What is a Never event

A

Significant patient safety incident that is considered preventable i.e. wrong site surgery (wrong side or incorrect procedure), Wrong implant/prosthesis or retained foreign object

21
Q

Why do thing go wrong in surgery

A
  • Individual factors: i.e. failure to gather appropriate information, unfamiliarity with procedure, reliance upon assumptions
  • Institutional factors: failure of team members to speak up, poor documentation
  • Patient factors: patient instability creating urgency
22
Q

When is the WHO checklist carried out

A
  • before induction of anaesthesia
  • before skin incision
  • before patient leaves operating surgery
23
Q

What are natSSIPS and locSSIPs

A

National and local standards for safety in invasive procedures. These are procedures performed under local anaesthesia outside theatre e.g. endoscopy, interventional radiology or line insertion. Checklist for each procedure with an equipment count.

24
Q

Organophosphates MoA

A

Commonly used pesticides in developing countries

MoA: Inhibition of cholinesterase enzymes, particularly acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE). This leads to accumulation of acetylcholine at muscarinic receptors, nicotinic receptors and in the central nervous system. Leads to permanent activation of nerve as acetylcholine is not broken down. Accumulation of acetylcholine causing a cholinergic effect

25
Q

Clinical effects of Organophosphates: Cholinergic crisis

A
  • Nicotinic effects
  • Respiratory difficulty: respiratory arrest, diaphragmatic weakness
  • Muscle Weakness: fasciculations, clonus, tremor
  • Stimulation of sympathetic nervous system: Mydriasis, hypertension, tachycardia, re-entrant dysrhythmias, cardiorespiratory arrest
  • Muscarinic effects
  • CNS effects
26
Q

Cholinergic crisis: Muscarinic effects

A
  • DUMBELLS
  • D iarrhoea
  • U rination
  • M iosis
  • B radycardia, Bronchorrhoea, Bronchospasm
  • E mesis
  • L acrimation
  • S alivation
27
Q

Cholinergic crisis: CNS effects

A
  • Malaise
  • Memory loss
  • Confusion
  • Disorientation
  • Delirium
  • Seizures
  • Respiratory centre depression or dysfunction
  • Coma
28
Q

Organophosphate management

A
  • ABCDE
  • Atropine
  • Second line: Cholinesterase reactivators (Pralidoxime and obidoxime) often given with Atropine. They reactivate the enzyme AChE. Must be given quickly before the organophosphate complex ages
29
Q

Atropine

A
  • Triggers for giving: pinpoint pupils, sweating, difficulty breathing (gasping)
  • May need large doses over prolonged cause: can be given in infusion
  • Repeat every 10 minutes until signs of atropinisation (flushed red skin, tachycardia, dilated pupils, dry mouth)
  • Reverses the cholinergic effects of organophosphate compounds
30
Q

Organophosphate overdose: supportive care

A
  • Clearing the airway
  • Ensure adequate ventilation
  • Give high flow oxygen
  • Manage in intensive care unit
  • Atropine for excessive secretions
  • Diazepam for seizures
31
Q

Organophosphate overdose: investigations

A
  • ECG: bradycardia
  • Urea, electrolytes and glucose
  • Red cell cholinesterase activity: takes time, clinical effects are more useful

year 4 CDM 2 (39 decks)

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