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 cesThis 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 saaCase1
* 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.
operateCASE 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,
youCase 8
Case 8
+ Low grade fever one day after abdominal
surgery = ATELECTASIS, until proven
otherwise.
* Treatment of this condition is.
Case 9Case9
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.