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Post Operative Care
&
Surgical Complications
Dr. Apirak Chetpaophan
Department of Surgery, Faculty of Medicine.
Prince of Songkla University
Pre operative management
Post operative management
Surgery
Intraoperative management
Pre&Post Operative Care and Surgical Complications
Pre Operative evaluation :
History & Physical Examinations
Investigations and Radiologic diagnostic Tools
Routine lab, EKG, etc.
Effect of Hormonal response in relation to :
Post Operative Care
Post Operative Complications
Summary of Preoperative
Evaluation
1. Cardiovascular
History of stable/unstable angina, arrhythimias,
MI, CHF, cardiac surgery, rheumatic fever,
valvular disease, endocarditis, stroke,
claudication
Summary of Preoperative
Evaluation
2. Pulmonary
Recent pneumonia, exposure to pulmonary
irritants, dyspnea, productive/non-productive
cough, wheezing, hemoptysis, history of
pulmonary tuberculosis, asthma, bronchitis,
fungal exposure, smoking history, cyanosis or
aspiration, availability of previous chest film or CT
scans.
Summary of Preoperative
Evaluation
3.Renal
Renal insufficiency( recent or in the past),
renal stone
Summary of Preoperative
Evaluation
4. Hematologic
History of blood transfusion, bleeding disorders,
easy bruising, use of NSAID, aspirin or antiplatelet
medications , previous history of DVT or PE,
information regarding blood donation and
autologous blood program
Summary of Preoperative
Evaluation
5. Gastrointentinal
History of GI bleeding or previous
operation for ulcers or carcinoma, GER
disease
Summary of Preoperative
Evaluation
6. Endocrine
history of DM, thyroid disease, longterm steroid use, pituitary or adrenal
insufficiency
Summary of Preoperative
Evaluation
7. Infection
History of bacterial or viral pneumonia,
chronic bronchitis, pulmonary TB, fungal
infection, hepatitis, CMV or HIV
Summary of Preoperative
Evaluation
8. Medication
Use of prescription and nonprescription
drugs, previous radiation or
chemotherapy.
Summary of Preoperative
Evaluation
9. Previous operation
Especially thoracic and abdominal
operations
Summary of Preoperative
Evaluation
10. Nutrition
Note overall appearance of nutritional
status, weight loss or gain, obesity and
overall eating habit
Summary of Preoperative
Evaluation
11. Patient directives&Health Care
Organ donation, living will, next of kin,
privacy request, points of contact
perioperatively, logistical and social issues
regarding costs, home care, rehabilitation,
case cancellation protocols, preoperative
counseling.
Classification of Post Operative Complications
- Avoidable (Preventible, non Preventible)
- Physiological, Biochemical ; Anemia, Coagulopathy
- Related to timing
Related to timing
Immediate 0-24 Hrs.
Organ
Systems
Other Systems
Anesthesia
Pain
Bleeding
Shock, Renal failure
Intermediate 1-30 days [avr. 7 day] (LOS)
Late > 30 Days, after D/C.
Surgical Complications
- Postoperative Fever and Infection
- Infective causes of postoperative fever
- Miscellaneous causes of postoperative fever
- Noninfective causes of postoperative fever
- Wound Complications
- Hematoma and seroma
- Wound infection
- Wound failure
Respiratory Complications
- Atelectasis and Pneumonia
- Pulmonary Aspiration
- Pulmonary Edema
- Immediate Postoperative Respiratory Depression
- Acute Respiratory Failure
* SHOCK
- Hypovolemic shock (Immediate phase)
- Cardiogenic shock
- Septic shock
- Subphrenic abscess
* RENAL FAILURE
Deep Vein Thrombosis and Pulmonary Embolism
- Prophylaxis
- Fat embolism
Fluid, Electrolyte, and pH Imbalance
- Potassium imbalance
- Acid-Base imbalance
Alimentary Tracy Dysfunction
- Acute gastric dilatation
- Gastroduodenal mucosal hemorrhage
- Intestinal obstruction
- Postoperative fecal impaction
- Colitis
- Anastomotic leak
- Hepatobiliary complications and jaundice
* Complications of Minimal-Access Surgical Procedures
* Neurologic Complications
- Prolonged alteration of consciousness
- Convulsions
Common Post Operative Complication
;Post Operative Pain
;Bleeding : Hypovolemia
;Hypoxia : Hypoventilation
;Hemodynamic Unstable
;Fluid&Electrolyte imbalance
;Wound Complication :
Hematoma, infection
Dehiscent, Keloid
Hematoma, Seroma
Risk
Chemical
Pathological - Mechanical
CVS, arrhythmia, Hypovolemia
Contractility (MI)
Post Op Pulmonary edema, CHF
;Post Operative infection : wound (Site of Operation)
;Post Operative Renal Failure
- Liver Failure
- Hematological disorder: Coagulopathy
;Post Operation Sepsis : ARDS
;Post Operative Respiratory Failure : Atelectasis, Pneumonia,
MOF.
Post Operative
Hemodynamic evaluation
Physical signs of shock
( Pulse pressure, BP, tachycardia, confusion syncope)
Physical signs of venous pressure
(neck veins, chest auscultation)
Low venous pressure
Hypovolemia
Metabolic
Paralysis, anaphylaxis
Sepsis
High venous pressure
Cardiac failure, PE,
Tamponade, pneumothorax
Chest radiograph, EGG, CVP
ICU, response to initial Rx
Improved
Not improved
Is Do2 adequate for Vo2 (Vsat>65)?
PA catheter
Is perfusion adequate?
Yes
No
No acute Rx needed
CO, Vsat
Mechanical
Intrathoracic pressure
PE
Tamponade
Valve malfunction
Tachycardia
Inotropes until Rx
Reduce pressure
Treat PE, valve
Treat arrhythmia
Yes
Hypovolemic
Crystalloid
Plasma
PRBC
No
Needs acute Rx
Ensure volume status
PCWP>10
CVP>5
Normovolemic
Measure cardiac output and Vsat
CO, Vsat
Normal CO, Vsat
Contractility
Ischemia
Metabolic
Toxic
Inotropes
Hypocalcemia
Hypoglycemia
Addison disease
Systemic hypertension
Inotropes until chemical balance
Consider vasodilation but do not treat SVR
Vasodilation
Peripheral dilation due
to sepsis, paralysis
Treat infection with œ agonist:
Phenylephinine
Epinepherine
Norepinephrine
Balloon pump or LVAD
Hemodynamic algorithm. (After Bartlett RH. University of Michigan critical care handbook. 1991)
Common Causes of Elevated Temperature in Surgical Patients
Hyperthermia
Environmental
Malignant hyperthermia
Neuroleptic malignant syndrome
Thyrotoxicosis
Pheochromocytoma
Carcinoid syndrome
Iatrogenic
Central/hypothalamic responses
Pulmonary embolism
Adrenal insufficiency
Hyperpyrexia
Sepsis
Infection
Drug reaction
Transfusion reaction
Collagen disorders
Factitious syndrome
Neoplastic disorders
Common Causes of Postoperative Hypoxemia
Atelectasis
Alveolar infiltrates
Aspiration
Cardiac-associated pulmonary edema
Noncardiac-associated pulmonary edema
(e.g., capillary leak, neurogenic, negative pressure)
Pulmonary embolus
Pneumothorax
Bronchospasm
Mucus plugging
Pulmonary contusion/hemorrhage
Common Causes of Postoperative Hypercapnia
Residual volatile anesthetics
Residual neuromuscular blockade
Narcotic overdose
Sedative overdose
High regional block
Cerebrovascular event
Neuromuscular disorders
Hypothyroidism
Insufflated carbon dioxide (laparoscopic procedures)
Metabolic alkalosis
Malnutrition
Hypermetabolism
Sepsis
Increased physiologic dead space
Respiratory Parameters
Post op. Respiratory Failure
Parameter
Normal
Failure
Respiratory rate
Inspiratory force (cm H2 O)
Vital capacity (ml/kg)
FEV1 (ml/kg)
Compliance (ml/cm H2 O)
Pao2 (mm Hg)
A-a DO2 (mm Hg)
Qs/Qt
PaCO2 (mm Hg)
VD/VT (%)
12-18
-75 to -125
65-75
50-60
> 100
80-95
25-65
5-8
35-45
20-30
> 35
< -25
< 15
< 10
< 30
< 70
> 450
> 15-20
> 55
> 60
A-a DO2, Alveolar-arterial oxygen delivery; FEV1, forced expiratory rate in one second; Qs/Qt, ration of shunted
cardiac output to total cardiac output; VD/VT, ration of dead space volume to tidal volume.
Risk Factors for Postoperative Pulmonary
Complications
Risk Factor
Relative Risk
Age > 70
Age 50-69
Major abdominal surgery
Emergency surgery
Chronic obstructive pulmonary disease
Age 30-49
General anesthesia > 180 minutes
7.46
4.14
3.90
3.49
3.13
2.29
1.52
Mechanical RX
Treat pneumothorax,
hydrothorax
Large ET tube
Tracheostomy?
Bronchoscopy
Bronchodilators?
Rx ascites
consider PE if PA
Systolic > 40
Paco2 40
Stable
Paco2 40
Acute respiratory failure (tube, vent, Fi02 > 0.5)
(arterial catheter, oximeter PA catheter)
Ventilator RX
Systemic RX
Fluid Status
Ventilation
TV 5 mL/kg
rate 10
TV, rate
to Paco2 40
Limit: PIP 40
Oxygenation
F102 0.5
PEEP 5
PEEP to Vsat max
F102 to Vsat max
Limit: F1020.6
PIP 40
Maximize O2
delivery
Sata > 95%
PRBC to Hct > 14
CO to V sat > 70
Limit : PCWP 20
> Dry weight
Diurese
Filter
PRBC or albumin
Limit: CO
Dry weight
Paco2 > 45
TV, rate
(Limit: PIP 40)
Vco2
Paralysis
Cool
Lipid feed
Paco2 > 45
ECMO adapt to
acidosis
Decrease Vo2
Treat infection
Sedation
Paralysis
Cool?
Sata < 90
Satv < 70
F102 0.6 1.0
Prone position
Tolerate hypoxemia?
ECMO
Respiratory failure algorithm. (After Bartlett RH. University of Michigan critical care handbook. 1991)
Nutrition
Positive balance
Energy
Protein
Sata > 90
Satv > 70
Wean
F102 to 0.4
PEEP to 5
PIP to 25
Acute renal failure
in
surgical patients
Conditions Associated with Acute Renal Failure (ARF)
Setting
Frequency of ARF (%)
General surgery
Elective abdominal surgery
Open heart surgery
Cardiac surgery performed with
cardiopulmonary bypass
Severe burns
Intensive care unit
Sepsis
Radiocontrast exposure
Rhabdomyolysis
3-5
1-5
3-15
8-30
20-60
10-25
20-50
10-30
10-30
Common Complications of Acute Renal Failure
Metabolic: hyperkalemia, acidemia, hyponatremia,
hypocalcemia
Cardiovascular: pulmonary edema, arrhythmias,
myocardial infarction, pericardial disease
including cardiac tamponade
Gastrointestinal: nausea, vomiting
Neurologic: mental status change, seizure, asterixis
Hematologic: anemia, bleeding
Infectious: pulmonary, urinary, peritoneal cavity,
sepsis
Oliguria
Bladder catheter
Ultrasound
Rule out urinary obstruction
Ensure good renal blood flow
Blood volume
Cardiac output
Dopamine?
Confirm by urine
electrolytes
and clearance
Dx: renal parenchymal disease
Furosemide, 100-500 mg
Polyuria
Diuretic trial
Oliguria
Dx: no nephrons functional
Dx: some nephrons functional
- Continue diuretics
- Expect azotemia
- Full nutrition
- Intermittent hemodialysis as
needed for solute clearance
Renal recovery
Isolated renal failure
- Full nutrition
- Intermittent hemodialysis
or PD as needed for volume
and solute control
Dx: some or all nephrons recovered
Acute renal failure management algorithm. (After Mault JR, Bartlett RH. Acute renal failure, In:
Greenfield LJ, ed. Complications in surgery and trauma, ed 2. Philadelphia, JB Lippincott,
1989:149-162
Multiple-organ failure
- Full nutrition
- CAVH for volume
- CAVHD for solute control
Chronic renal failure
Dx: no nephrons recovered
Chronic dialysis
Post Operative
Surgical Infection
Risk Factors for Development of Surgical Site Infections
Patient factors
Older age
Immunosuppression
Obesity
Diabetes mellitus
Chronic inflammatory process
Malnutrition
Peripheral vascular disease
Anemia
Radiation
Chronic skin disease
Carrier state (e.g., chronic Staphylococcus carriage)
Recent operation
Local factors
Poor skin preparation
Contamination of instruments
Inadequate antibiotic prophylaxis
Prolonged procedure
Local tissue necrosis
Hypoxia, hypothermia
Microbial factors
Prolonged hospitalization (leading to nosocomial organisms)
Toxin secretion
Resistance to clearance (e.g., capsule formation)
Wound Class, Representative Procedures,
and Expected Infection Rates
Wound Class
Clean (class I)
Clean/contaminated
(class II)
Contaminated
(class III)
Dirty (class IV)
Examples of Cases Expected Infection Rates
Hernia repair, breast
1.0 - 5.4%
Biopsy
Cholecystectomy,
2.1 - 9.5%
Elective GI surgery
Penetrating abdominal
3.4 - 13.2%
trauma, large tissue
injury, enterotomy
during bowel
obstruction
Perforated diverticulitis,
3.1 - 12.8%
necrotizing soft tissue
infections
Causes of Abdominal wound dehiscence
Imperfect technical closure
Increased intra-abdominal pressure from bowel distention,
ascites, coughing, vomiting, or straining
Hematoma with or without infection
Infection
Metabolic diseases such as diabetes mellitus, uremia, CushingK s
Tissues inadequate for strong closure
Inclusion Criteria for the Acute Respiratory Distress Syndrome
(ARDS)
Acute onset
Predisposing condition
Pao2: F102 ratio < 200 (regardless of positive end-expiratory pressure)
Bilateral infiltrated
Pulmonary artery occlusion pressure <18 mm Hg
No clinical evidence of right heart failure
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References
; .Schwartzs . Principle of surgery . 8th ed. McGraw Hill. 2005
; .Sabiston DC ed. Textbook of Surgery. 16th ed. WB Saunders 2001
; .Greenfield LJ. Surgery: Scientific principles and practice. 3rd ed.
Lippincott William&Wilkins. 2001
; .Bailey&Loves. Short practice of Surgery. 23rd ed. Arnold. 2000
The End