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, long-
term 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 Anesthesia
Immediate 0-24 Hrs. Pain
Bleeding
Shock, Renal failure
Organ
Systems Intermediate 1-30 days [avr. 7 day] (LOS)
Other Systems

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)

High venous pressure Low venous pressure

Cardiac failure, PE, Hypovolemia
Tamponade, pneumothorax Metabolic
Paralysis, anaphylaxis
Chest radiograph, EGG, CVP Sepsis
ICU, response to initial Rx
Not improved Improved
PA catheter Is Do2 adequate for Vo2 (Vsat>65)?
Yes No Needs acute Rx
Is perfusion adequate?
Yes No Ensure volume status
PCWP>10
No acute Rx needed Hypovolemic CVP>5
Crystalloid Normovolemic
Plasma
PRBC Measure cardiac output and Vsat
CO, Vsat CO, Vsat
Normal CO, Vsat

Mechanical Contractility Hypocalcemia Peripheral dilation due

Intrathoracic pressure Ischemia Hypoglycemia to sepsis, paralysis
PE Metabolic Addison disease
Tamponade Toxic Systemic hypertension
Valve malfunction
Tachycardia Inotropes Treat infection with agonist:
Inotropes until chemical balance Phenylephinine
Epinepherine
Inotropes until Rx Consider vasodilation but do not treat SVR Norepinephrine
Reduce pressure Vasodilation
Treat PE, valve Balloon pump or LVAD
Treat arrhythmia
Hemodynamic algorithm. (After Bartlett RH. University of Michigan critical care handbook. 1991)
Common Causes of Elevated Temperature in Surgical Patients
Hyperthermia Hyperpyrexia
Environmental Sepsis
Malignant hyperthermia Infection
Neuroleptic malignant syndrome Drug reaction
Thyrotoxicosis Transfusion reaction
Pheochromocytoma Collagen disorders
Carcinoid syndrome Factitious syndrome
Iatrogenic Neoplastic disorders
Central/hypothalamic responses
Pulmonary embolism
Adrenal insufficiency
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 12-18 > 35
Inspiratory force (cm H2 O) -75 to -125 < -25
Vital capacity (ml/kg) 65-75 < 15
FEV1 (ml/kg) 50-60 < 10
Compliance (ml/cm H2 O) > 100 < 30
Pao2 (mm Hg) 80-95 < 70
A-a DO2 (mm Hg) 25-65 > 450
Qs/Qt 5-8 > 15-20
PaCO2 (mm Hg) 35-45 > 55
VD/VT (%) 20-30 > 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 7.46
Age 50-69 4.14
Major abdominal surgery 3.90
Emergency surgery 3.49
Chronic obstructive pulmonary disease 3.13
Age 30-49 2.29
General anesthesia > 180 minutes 1.52
 Acute respiratory failure (tube, vent, Fi02 > 0.5)
(arterial catheter, oximeter PA catheter)
Mechanical RX Ventilator RX Systemic RX
Treat pneumothorax, Fluid Status
hydrothorax Ventilation Oxygenation
Large ET tube TV 5 mL/kg F102 0.5 Maximize O2
Tracheostomy? rate 10 PEEP 5 delivery > Dry weight
Bronchoscopy TV, rate PEEP to Vsat max Sata > 95% Diurese
Bronchodilators? to Paco2 40 F102 to Vsat max PRBC to Hct > 14 Filter
Rx ascites Limit: PIP 40 Limit: F1020.6 CO to V sat > 70 PRBC or albumin
consider PE if PA PIP 40 Limit : PCWP 20 Limit: CO
Systolic > 40
Dry weight
Paco2 > 45 Decrease Vo2
Paco2 40 TV, rate
(Limit: PIP 40) Treat infection Nutrition
Vco2 Sedation Positive balance
Paralysis Paralysis Energy
Stable Cool Cool? Protein
Lipid feed Sata < 90 Sata > 90
Satv < 70 Satv > 70
Paco2 40
Paco2 > 45 F102 0.6 1.0 Wean
ECMO adapt to Prone position F102 to 0.4
acidosis Tolerate hypoxemia? PEEP to 5
ECMO PIP to 25
Respiratory failure algorithm. (After Bartlett RH. University of Michigan critical care handbook. 1991)
Acute renal failure
in
surgical patients
Conditions Associated with Acute Renal Failure (ARF)
Setting Frequency of ARF (%)
General surgery 3-5
Elective abdominal surgery 1-5
Open heart surgery 3-15
Cardiac surgery performed with 8-30
cardiopulmonary bypass
Severe burns 20-60
Intensive care unit 10-25
Sepsis 20-50
Radiocontrast exposure 10-30
Rhabdomyolysis 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
Rule out urinary obstruction Bladder catheter
Blood volume Ultrasound
Cardiac output Ensure good renal blood flow
Dopamine?
Confirm by urine
Dx: renal parenchymal disease electrolytes
and clearance
Furosemide, 100-500 mg Diuretic trial
Polyuria Oliguria
Dx: some nephrons functional Dx: no nephrons functional
- Continue diuretics Isolated renal failure Multiple-organ failure
- Expect azotemia - Full nutrition - Full nutrition
- Full nutrition - Intermittent hemodialysis - CAVH for volume
- Intermittent hemodialysis as or PD as needed for volume - CAVHD for solute control
needed for solute clearance and solute control Chronic renal failure
Renal recovery
Dx: no nephrons recovered
Dx: some or all nephrons recovered
Chronic dialysis
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
 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 Examples of Cases Expected Infection Rates
Clean (class I) Hernia repair, breast 1.0 - 5.4%
Biopsy
Clean/contaminated Cholecystectomy, 2.1 - 9.5%
(class II) Elective GI surgery
Contaminated Penetrating abdominal 3.4 - 13.2%
(class III) trauma, large tissue
injury, enterotomy
during bowel
obstruction
Dirty (class IV) 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