Avoid complications by anticipating them + Vital signs ee + Chest Common Complications in * Operation site care Surge + Fluid balance ca + Medications + VTE prophylaxis + Oiet + Pressure care + Psyche Complications of Surgery General & Local GENERAL + Respiratory + Haemormhage * Urinary + Thrombosis + Electrolyte imbalance + Pressure sores + Faecal impaction/Diarthoea Medical complications Locat * Always consider a surgical cause for ‘a medical complication first when dealing with a surgical patient Wound infection Wound haematoma ‘Wound dehiscence Intra-abdominal abscess Enteric fistula Drain tube issue“Simple” wound infection * Recognition + Management? ‘Management of wound infection More “complex” infection + What is the issue here? Pulse 125 8P 90 systolic “nay nde ten ar 20P0 sting smerupcruneyocr Shallow breathing Sao centemany Looks moribund Invert sal nr wi thc ges pa . What to do? seb oy formate pean cout serps MC meat of een cesThis is ‘gas gangrene’ + Resuscitate/ICU + Gram stain * High dose penicilin * Debride ALL dead tissue in theatre + Consider hyperbaric oxygen Wound Dehiscence * Superficial + Deep Superficial dehiscence Healing by ‘second intention’ Deep wound dehiscence layers give way "pink sign’may precede a Neel) Drain tube caveats Panatacramcanbe i eh boy entethesran tha ogee saaCase1 * Mr.W isa 73 yr. old under your care following an anterior resection for cancer. * Surgery Friday 23/11/07 + Managed in HDU over weekend, returns Unit D Sunday evening, al stable and looks great. Monday (day 3}]commences free fluids Tuesday (day 4) is off food and feels ful. Q. How to assess this? + TPR chart * Only change minor rise pulse to 98 from 80 * Temp. 37.5 several days now * Abdomen a little distended and silent * No drain tube -what to do? * Suspect intra-abdominal mischief, leak/abscess Case 1.....p3 Today Wed. (day 5) patient now looks unwell Obs. P 110, sweaty, lower abdominal pain, silent distended abdomen, T38.5 Your approach? * CT scan reveals a little free gas and large volume intraperitoneal fluid * Laparotomy and Hartmann’s procedure * Gets home after 3 weeks, but,..now has stoma Case 1........summary Normal- management of feeds. Lot of surgeon ditference. Lot of evidence shows improved results with early (Day 1) feeding. Normal management drains. Surgeons vary. Common to leave until bowels open, Daily round review routine? Must check TPR, chest, abdomen, Iv site and Fluid balance & electrolytes Newspaper and glasses? Good signif present, worry i disappears! Case 2 42 yr old woman admitted acute cholecystitis Friday evening. Only issue is pain RUQ Kept fasted over weekend as hopeful of ‘emergency cholecystectomy {In fact stil nil by mouth (NBM) Tuesday round. Noted to have had temp 38.5 overnight. Your approach?Case 2 + TPR chart * Full examination + Investigations forearm purulent & red, + Blood cultures MRSA * Echo ....vegetations on aortic valve wee 17.9 LT bili 23, AST 230 ALP 140 * Don’t forget i/V lines. Need to be changed Geto every 48-72 hrs. May always be site for life threatening sepsis. CASE 3 81 yr. Old woman with diabetes admitted to ward for routine observation after straightforward balloon dliation of stenosis in left common lac artery. You are called by nurse as P 80, 6P 100/60 & she looked pale. How would you respond? Examination confirms obs. and she is peripherally shut down, + What ele would you do? Review of left leg revealed no puncture site ‘swelling & weak posterior tibial pulse. Also some mild discomfort in UF What now? Review of left leg revealed no puncture site Swelling & weak posterior tibial pulse. Also some mild discomfort in LIF What now? Case 3 cont'd * Drug chart shows Beta-blocker & a pre-procedure BP 160/80. * What now? Remember beta-blocker will prevent a tachycardh * Non-sustained response to 500m colloid. What now? + Must cal Vascular Surgery Team, best to have done this prior to this point. Remember, a Radiological * Laparotomy reveals large bleed from ruptured ‘common iliac artery, *+ What is role for CT?... Only relevant if bleeding not critical. If clearly haemorrhaging the treatment is to stop the bleeding, ie. operateCASE 4 + 35 yrcold woman underwent uncomplicated lap.chole 8 hours ago. You are night inter called by nurse as patient anxious and complaining of right shoulder tip pain, ‘The nurse is worried. How will you respond? ‘Answer: “Go & see the patient” Obs. P 120. BP 90/50. AR 21. T 37.0 Redivac contains 40m haemoserous fluid. What now? Case 4 cont'd * Patient is clearly bleeding internally. + Needs resuscitation and surgery to stop the bleeding....”contact the surgeon” Case S ‘8.69 yr.old man undewent TURP three hours ago. He has just returned to the ward. Nurse rings you as she. is “not happy” with the way he looks as he fs shaking uncontrollably. You are serubbed in Theatre when she pages. How would you respond? ‘A: Go & see the patient” Obs. P 110 BP 95/60T 39.0, Returned fluid in urine bag is pink and no cots seen, + What now? What is differential diagnosis? How to proceed? Case 5 cont’d * Resuscitate with fluids. * Most likely diagnosis is Gram negative sepsis... hypotension, vasodilated and febrile. Other possibilty is relative underflling from spinal, but, Is febrile with rigors. + Needs blood and urine cultures plus antibiotics Case 6 + 84,yr. old elective right hemicolectomy. Previously fit & lives independently + No medications * Post-op course fantastic, all delighted...lasses on &reading the Herald-Sun + Day 6 called asin rapid AF + Your approach? Case 6 sofe 150 AF BP 95/60 * What now? * Timing would suggest, again, intrabdominal complication first and a medical complication second. “Think surgery”Case 6 ......p3 + Overnight deteriorated tranferred ICU with hypotension, + Laparotomy revealed leaking anastamosis. Case 7 Case 7 cont'd “Go and see the patient” Case 7 cont'd * This isthe serious complication of post- thyroidectomy bleeding. + Can present in several ways: Neck swelling and pain Blood per drains Stridor and dfficuty breathing Hypoxia with agitation confusion or somnolence + Needs urgent removal of all layers os neck sutures, {dealy in theatre but in extremis, on the ward, youCase 8 Case 8 + Low grade fever one day after abdominal surgery = ATELECTASIS, until proven otherwise. * Treatment of this condition is. Case 9Case9 Case 10 + Low grade fever over a week after surgery, especially if resting bed with surgery to the lower limb...think of DVT Case 10 *+ Swinging (spiking) temp. 5-7 days after surgery = pus somewhere. * Inspect wound, consider intra abdominal (pelvic/subphrenic/perisurgery) and CT scan.