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Post-operative complications

Classification of post-operative complications

General / Specific
Immediate / Early / Late
Anaesthetic / Surgical / Combined

ICD-10-CM post-operative complication codes


Various other classification systems

Complications - defined as any deviation from the normal postoperative course


Sequelae - is an after-effect of surgery that is inherent to the procedure (e.g. inability to walk after
amputation of the leg).
Failure to cure - If the original purpose of surgery has not been achieved, this is not a complication (e.g.
residual tumour after surgery).

Risk Factors
Patient
-

Presentation
o Age
o Co-morbids
smoking history and pre-existing respiratory disease
Obesity
CVD and PVD
Diabetes
Immune status (includes steroid and immune suppression therapy)
Other drug therapy (aspirin, antiplatelet, antibiotic therapy, NSAID agents or substance
abuse) include alcohol
Renal disease
Metabolic factors including nutritional status
Presence of infection
Need for blood transfusion
o Uncomplicated/Complicated (Re-operative_
o Elective/ Urgent
Pathology
o Bening/Malignant/Infective

Surgical risk factors


-

Type and complexity of surgery (includes re-operation) -> expose pt to higher risk of wound/healing
challenges
Timing of surgery: Elective / urgent / emergency allow less time for pre-operative preparation
Surgery for trauma grater tissue trauma/contamination
Surgical approach: Open / minimally invasive lower incidence of complications
Duration of procedure longer op, increases risk of infection
Surgeon skill /case volume
Anaesthetic issues
Managing these issues

System factors efficiency of hospital, experience of staff

Surgical safety checklist to reduce complication rate


Complication rate: reduced from 11% to 7%
Mortality rate: reduced from 1.5% to 0.8%

1)
2)
3)
4)
5)

Good handover
Prioritise
Seek help if swamped
Go and see patient
Turn the lights on so you can
adequately assess the patient

Post-operative complications
General
-

Pain
Nausea and vomiting
Haemorrhage
Respiratory
Cardiac Wound
Fever/Sepsis
o Wound
o Pneumonia
o UTI
o Surgical Site
Abscesses
Prosthesis (grafts, valves, joints etc)
o Drip site
o Gastrointestinal
o Neurological/cerebrovascular
o Renal /Urinary
o VTE (DVT & PE)
o Vascular
o Electrolyte disturbance
o Metabolic

Specific post-operative fever


Early Day 1 usually low grade (up to 38.5) unless
bacteraemia/septicaemia
(bacteraemia or septicaemia fever more significant)

Early Day 2-3: if temperature gradually rising

Day 5/10

Think
- Residuum of contaminated operative site.
- Reactive to blood/blood products transfusion
- Phlebitis
- Atelectasis (common)
Think: pulmonary origin
- Inhalation pneumonia
- Mendelson syndrome : chemical pneumonitis
due to aspiration esp in preggers pt
- Lobar collapse/developing pneumonia
Then think: Urinary tract especially catherised patient
- Wounds and surgical sites
- Lines. Catheters and ports
Think
- Hidden abscess (Subphrenic/Pouch of Douglas)
- Spiking pyrexia gravity allows collection into
most posterior part of body
- DVT/PE
- Prosthetic infection
- C/difficile colitis (if diarrhoea present)

Extravasation fluid retained in the dependent aspect of arm due to gravity

Risk for post-operative atelectasis


-

COAS/ asthma/smokers poor


respiratory reserve
Anaesthesia
o Emergency procedure
o Difficult intubation (risk of
inhalation)
o Relative hypo-ventilation
On fixed volumane or
pressure cycle
ventilators
Post-operative pain esp narcotic
use
Diaphragm dysfunction
o Obesity abdominal binders
o Upper abdominal / intercostal
thoracic procedures
Immobilisation for orthopaedic
trauma

Post-operative pneumonia
-

Fever, cough, dyspnoea, sputum,


severe sepsis
Remember emergence of gram-ve in
hospital acquired pneumonia

Area in left mid-zone, semi-opacified. Elevation of lefthemidiaphragm normally sits lower than right, loss of lung
volume indicating significant atelectasis

Right middle lobe consolidation apparent on lateral chest X-ray


-

Lateral view wedge shaped dense opacification of middle lobe


Middle lobe pneumonia commonly associated with inhalation pneumonia
Behind the middle lobe, lower lobe extends to above the level of the middle lobe, upper lobe also extends
below at least half of the middle lobe
Mid zone opacity on straight PA film is unlikely to give clear indication of site of pathology of lobes

Mid zone opacity, lower lobe unaffected but pathology in upper lobe
Right upper lobe pathology also raise possibility of inhalation

Post-operative pneumonia
Treatment:
-

Broad spectrum antibiotics (ceftriaxone) until sensitivities known


Physiotherapy
Early consult: ICU, respiratory service infections disease as required
Remember: emergence of gram ve in hospital acquired pneumonia late development of lung abscess

Pneumothorax remember to order expiratory film


-

Consider who have had subclavian or jugular vein insertion lines


Untreated pneumothorax, especially in ventilated patient may lead to development of tension
pneumothorax presents with hypotension and cardiogenic shock

o
o
o

Due to angulation of IVC at diaphragm by mediastinal displacement


Medical emergency require intercostal drainage
High index of suspicion esp in ventilated patient

Appearance of pneumothorax in lower costal phrenic region in right lung in inspiratory film but large defect
in expiatory film

Tension pneumpthroax

Aspiration pneumonia
-

Develop rapidly into lung abcess


o Unconscious patients
o Emergency operations
o Trauma patients especially head
trauma
o Intoxicated or drug-induced
diminished consciousness
o Obstetric patient undergoing urgent
caesarean section
Suspect if gastric contents in airway (blood,
trauma patients)
Symptoms
o Generally obvious wheeze, hypoxia,
cyanosis, tachycardia
o Initially chemical pneumonitis then
severe pneumonia in >50%
o Likelihood of later lung abscess
development

Management of aspiration pneumonia


-

Airway toilet removing foreign bodies


NG tube
H2 antagonist, PPI
Bronchodilators
Antibiotics

Right upper lobe lung abscess, presence of air-spaces


(pockets of air, diagnostic feature) spreading radially
throughout opacification in upper zone. due to pus

Intubation if appropriate for bronchial toilet

Mendelson syndrome common in obstetric patients


-

Aspiration pneumonia after general anaesthetic


o Presence of gastric contents + rush to anaesthesia + increase abdominal pressure
Occurs within 1-2 days after inhalation

Fat embolism
-

Diffuse patchy consolidation dn petechial in fat embolism


Especially in pt with history of trauma
Rare unless long bone trauma
May also have cerebral infarcts (may precede lung by 6-12 hrs)
Respiratory distress
Fever and tachycardia
Hypoxia
Low platelets, low serum calcium, elevated Serum lipase
Trhombocytopenia due to disseminated intravascular co-agultion

Wound complications
Early
-

Haematoma
o Vary from suffusion through tissue to large collection needing evacuation to avoid risk of secondary
infection

Infection/abscess
o

Predisposing factors
Trauma and contaminate wound
Duration and nature of surgery
immune compromise/chronic disease/ malnourished
Pre-existing ulcers/infection
Ischaemic tissue
o Signs and symptoms often first presentation
Pain, red, swelling,
Unexpected level of pain often first presentation
o Superficial
o Deep
o When to use prophylactic antibiotics
When risk of infection is significant without their use
When consequences of infection would be catastrophic even though the risk is low
6Rs
Right patient
Right drug
Right dose
Right route
Right timing of administration
Right duration of prophylaxis/therapy
Necrosis
o Ischemia leads to skin necrosis if skin has been approximated too tightly
o Require skin grafting
Necrotizing fasciitis
o Strep pyrogens, staph aureaus
o Clostridium perfringes, bacteroides fragilis
Lymph fistula
Wound Seroma
o Lymphatic disruption mainly causation
o Remember other conditions can contribute to development of seroma
Myeloproliferative/haematological disorders
Coagulopathies
Cardiac disease
o Treatment drainage

Wound
Classification

Definition

Expected SSI
rate without
prophylaxis
1-2%

Expected SSI
with
prophylaxis
2.1%

Clean

Elective, not emergency, non-traumatic, primarily closed; no acute


inflammation; no break in technique; respiratory, gastrointestinal,
biliary and genitourinary tracts not entered.

Clean
contaminated

Urgent or emergency case that is otherwise clean; elective opening of


respiratory, gastrointestinal, biliary or
Genitor-urinary tract with minimal spillage (e.g. appendectomy) not
encountering infected urine or bile; minor technique break.

5-10%

3.3%

Contaminated

Non-purulent inflammation; gross spillage from gastrointestinal tract;


entry into biliary or genitourinary tract in the presence of infected bile
or urine; major break in technique; penetrating trauma <4 hours old;
chronic open wounds to be grafted or covered.

15-20%

6.4%

Dirty

Purulent inflammation (e.g. abscess); preoperative perforation of


respiratory, gastrointestinal, biliary or genitor-urinary tract;
penetrating trauma >4 hours old.

40%

7.1%

Common areas
Post breast surgery
After axillo-fermoral bypass
Dehiscence
o Partial
o Compound infection plete
o Contributory factors to wound dehiscence
Wound infection
Obesity
Diabetes
COAD
Malnutrition
Malignancy/immune suppression
Poor technique
o Presentation
Sero-sanguinous fluid leak (85%) despite apparent healing of skin (skin more vascular
than subcutaneous tissue and heals better)
Treatment, sterile moist towels. Ideally return to OT and wash and re-suture
Evisceration No evisceration and poor health: sterile dressing and allow to granulate

Late wound complication


-

Incisional hernia
Wound bone
Keloid hypertrophic scar growing beyond boundaries
Post-operative confusion
o Infection
o Hypoxia (pulmonary, cardiac)
o Acid/base disturbance/metabolic: renal/bowel/muscle
o Drug related
Anaesthetic
Narcotics
Diuretics
Antihypertensive
Sedatives
Anti-epileptics
o Drug withdrawal (alcohol, benzodiazepines)
o Cerebro-vascular CVA
Perioperative myocardial infarction
o
o
o
o
o
o

Diagnosis often difficult clinically


May present with shock/arrhythmia/CCF
Often masked by analgesia
High mortality after surgery
Most occur in first 3 days
Most deaths within 48 hours

Cardiac MI
MI at risk patient
Goldman criteria, Eagle criteria
Arterial surgery
Valve disease
Previous cardiac event
SOBOE, PND, angina

MI treatment
Correct volume load and Hb
Beta-blockade, GTN
Heparin
Oxygen
Emergency PTCA or CABG

Time between previous


MI & surgery
Within 3 months
3 to 6 months
After 6 months

Peri-operative
MI risk
27%
11%
5%

Revised Goldman Cardiac Risk Index Independent predictors of major cardiac complications
-

High-risk operation (intra-peritoneal, intra-throacic , supra inguinal vascular


procedures)
Hx of ischemic heart disease
Hx of heart failure
Hx of cerebro-vascular disease
DM requiring insulin
Preoperative serum creatinine >2.0mg/dL (renal dysfunction)

Rate of cardiac death


MI and cardiac arrest
-

Eagle criteria
-

Q Waves on ECG
Hx of angina
Hx of ventricular ectopy requiring treatment
DM requiring therapy other than diet
Age above 70years

Gastrointestinal complications
-

Ileus common remember electrolyte disturbances especially hypokalaemia


o Radialogical appearance of dilated loops of bowel
o Absence of bowel sounds
May be due to obstructions
Remember fecal impaction
Anastomotic leaks and fistulas
o High fever, significant leucocytosis, abdominal pain and nausea and vomiting
Ulceration and perforation of viscus
o Vertical chest X-ay showing subphrenic air
Might be difficult to interpret after laparoscopy (CO2 insufflation of air)

Pressure sore development


Stage 1 Non-blanchage erythema of intact skin, heralding lesion of skin
ulceration. May also include changes in skin, colour, skin temperature. May
also include changes in skin colour, skin temperature, skin stiffness and/or
sensation (pain)
Stage 2 Partial thickness skin loss involving epidermis and/or dermis. The
ulcer is superficial and presents clinically as an abrasion, blister or shallow
crater.
Stage 3 Full thickness skin loss involving damage or necrosis of
subcutaneous tissue; may extend down to but not through underlying
fascia. Presents clinically as a deep crater with or without undermining of
adjacent tissue.
Stage IV Full thickness skin loss with extensive destruction, tissue necrosis
or damage to muscle, bone and/or supporting structures, e.g., tendon, joint
capsule.

0 RF: 0.4%
1 RF: 1/0%
2 RF: 2.4%
3+RF: 5.4%