Surgical iatrogenesis Flashcards
What is surgical iatrogenesis
Causation og harm or disease by medical intervention
What does surgical iatrogenesis encompass
Recognised risk of surgery
Medical/surgical error
Expected sequelae of surgery
Pscyhological/social/cultural effects of surgical procedure
How are surgical complucations classified
Timing
Anatomical
Severity
Examples of immediate complications in surgery
Bleeding
Nerve injury
Perforated viscus
What are early surgical complications (when) and what
<30 days post
Sepsis or wound dehiscence
Anaemia
Shock
Pain
Neuropraxia (will recover)
Late complications of surgery
After 30 days
Stenosis
Adhesions
Fistulae
Weakness/loss of funciton
What are local surgical complications
Nerve palsy/paralysis
Wouna dehiscence
infection
Haemotoma
What are systemic complications of surgery
Resp compromise
Anaemia
Hypocalcaemia/thyroidism from thyroid surgery
Shock/CVS instability
Sespsis
VTE
Delirium
Classifications of surgical complications
I-V
I - no treatment but deciation
V - death
What is grade II surgical complication defined as
Pharmacological treatment needed
What is grade III surgical complication defined as
Surgical/endoscopic/radiological intervention
eg haematoma, perforation, bleed
What is grade IV surgical intervention
Life threatening complication eg multi organ failure or CVS instability
What do when unsure of complication
Revise steps of procedure so far
Double check anatomical landmarks
Verbalise thought process to assistants/colleagues
Ask for help
How to manage a surgical bleed
Pressure
Washout - saline
Fix source of bleed
Transfusion
Prophylactic antibiotics
Check haemostasis once bleed controlled
Small vs large vessel bleed management
Small - cautery
Larger - ligate vs repair
If can’t control a bleed from a vessel
Get help
Pack
Stabilise patient + leave 24 -48 hours before 2nd look
Managing a perforation in surgery
Suction/wash to clean leakage, assess damage
Repair depends on location
Antibiotic prophtlaxis
What do with pharynx/cervical oesophagus perforation
- most left to heal, rest with NGT
How to manage a small vs large thoracic oesophagus
Small - endoscopic glue
Large - endoscopic stent or surgical repair
How to manage bowel perforation
Small - endoscopal mucosal clipping
Large - open surgery
Ureter vs bladder perforation repair
ureter stent or repair
Bladder - surgical repair
What consider post perforation
Bowel - feeding enteral vs parenteral - need to rest area
Antibiotic prophylaxis - if faecal contents into abdomen
What to assess for nerve complications
Assess nerves for deficit to identify nerve
Complete or partial transection (unlikely need repair)
How quickly do opposed axons repair
1mm per day
What nerves are repaired
Important motor nerves for function (if sensory left)
How to repair a nerve
Ensure nerves left in opposing position for spontaneous repair
Suture peri-neurium (one either side of nerve)
Microscopic surgery - pllastic srugery
Unlikely to regain full function
How to communicate a complication to a patient
HONESTY
explain events to patient and relatives
Apologise for outcome
Discuss impact of injury
arrange physio/rehab/psych support
Discuss with colleagues and reflect - individual or system error
Managing pain after surgery
Analgesic ladder
Patient controlled anaesthesia
Local anesthesia block/spinal
Respiratory compromise what do after op
Breathing exercises/physio
Pre hab
AW compromuse after op
Prolonged intubation
Tracheotomy (if exceeding 48 hrs post surgery)
Uro/GI compromise in surgery
Urinary catheter
NGT - drainage
Flatus tube - gas pass prevent volvulus
Enteral vs parenteral feeding
Treatment for anaemia, sepsis, VTE
transfusion/preload
Antibiotics prophylaxis (clean or contaminated)
VTE prophylaxis
Whrere go if close observation or multiple organ support needed
ICU
What are surgical NEVER events
Significant patient safety incidents considered preventable
Examples of NEVER events in surgery
Wrong site surgery - wrong side or incorrect procedure
Wrong implant/prosthesis
Retained foreign objects
Why do things go wrong in surgery - individual factors
Situational awareness
Decision making
Training issues eg unfamiliar procedure or equipment
Situation awareness surgical failings
Failure to gather/review appropriate information
Anomalies ovdrlooked ie anatomical variants
Failure to recofnise increased risks
Decision making failures surgery
Failure to double check if uncertain, reliance upon assumptions not checking
INstitutional factors
Team work/communcaiton
Organisation and management factors
Patient factors
Team work/communication factors in surgery
Failure of team members to speak up
INadequate exchange of information prior to case
Organsiation and management factors surgical iatrgoensis
Pooled operating lists
Poor dcoumentation
Patient factors -> surgical iatrogenesis
Bilateral lesions
Anatomical complexity
Patient instability creating urgency
Where did the WHO checlist originate from
Global safety challenge - safe surgery save lives
500,000 deaths from surgery a year preventable world wide
What is on teh surgical safety cheklist - before induction of anaesthesia
Confirm identity of patient, site, procedure, consent
Is site marked
Anaesthesia machine nad medication check complete
Pulse oximeter on patient and functioning
Known allergies
Difficult AW, aspiration risk
Risk of >500ml blood loss, 7ml/kg in children
Surgical safety checklist before skin incision
Confirm all team members have introduced themselves by name and role
Confirm patients name, procedure and where incision will be made
Antibiotic prophylaxis in last hour?
Surgeon - critical or non routine steps, how long will take, anticipated blood loss
Anaesthetist - patient specific concerns
Nursing team - sterility incl indicator results been confirmed? equipment issues or concerns?
Essential imaging displayed?
Srugical safety checklist fater op before patient leaves room
Nurse verbally confirms - name of procedure completion of instrument, sponge and needle counts
Specimen labelling - read aloud and patients name
Whether equipment problems adressed
Key concerns for recovery and management from surgeon and naesthetist
What are NatSSIP and LocSSIP
National standards and local standards for safety in invasive procedures
What procedures under local/regional anaesthesia are performed outside of theatre
Line insertion
Interventional radiology
Endoscopic procedures
Still do equipment count
Situational awareness CIA
Collect information
Interpret information
Anticipate future state
STAR tool
Stop
Think
Assess
Review
Respond
Closed loop communication
Sender initiates message
Receiver accepts message, provides feedback confirmation
Sender verifies messaeg received
Books to read
Safety sharp end - a guide to non technical skills
The invisible gorilla and other ways our intuition deceives us
Primary vs secondary post tonsilectomy bleeding
1 - 24 hrs
2 - up to 2 weeks after
Damage to what nerve causes a hoarse voice?
Recurrent laryngeal
What can thyroid haematoma cause
AW obstruction - pressure and prevents venous drainage of larynx -> upper AW oedema
Immediate anagement of thyroid haemotoma
open wound to relieve AW pressure
What is the immediate management of thyroid haematoma with worsening breathing difficulty
Call for help, ask the nurse to bring the emergency trolley.
Increase O2 to 15L via non-rebreathe mask.
Open neck wound immediately – do not worry about bleeding, releasing the pressure upon the airway is the priority (A comes before B).
Prepare for emergency front of neck access to stabilise airway if needed.
