2.

6
September 19,2013
Hazel Z. Turingan, MD, FPCS, FPSGS, DPBTCVS, DMCC Patient Safety, Errors
Obedience is the mother of success and is wedded to safety. -Aeschylus & Complications
[TransGroup‘s Note: Texts in orange and tables and figures with
orange borders are those that have asterisks on Dr. Turingan‘s ppt.
Italicized texts are mostly Dr. Turingan‘s words.]

OUTLINE PAGE
Introduction 1
Types of Medical Errors 1
Creating a Culture of Safety 2
Communication Tools 2
Surgical Safety Checklist 3
Quality Patient Safety Indicators 4
Surgical Care Improvement Project Measures 4
National Quality Forum 4
Compliacations in Minor Procedures 5 If you see something, say it. Kahit mahina lang boses mo.
Organ System Complications Wag mong isipin na, “Ah, clerk pa lang ako, 4th year pa lang
Wounds, Drain and Infection ako.” You have to say what you saw because you might be
SIRS, Sepsis and MODS the only one who saw it. You‟re part of the medical team.
Issues in Caring for Obese Patients and
Patients at the Extremes of Ages TYPES OF MEDICAL ERRORS

INTRODUCTION  Injury caused by medical management

 Patient harm due to medical mistakes can be catastrophic rather than the patients‘s underlying
consequences for condition
o the patient  Prolongs hospitalization, produces a
o the surgeon ADVERSE
disability at discharge, or both
o the institution EVENT
 Classified as preventable or unpreventable
 Patient safety  It‟s not really part of the complication, it is
o science that promotes the use of evidence-based unexpected
medicine commonsense improvements in an attempt to  Eg. MI in a very young patient
minimize the impact of human error on the routine  Care that falls below a recognized standard
delivery of services of care
 Poor communication contributes to approximately 70% of  Standard of care
the sentinel events reported to the Joint Commission on o considered to be care a reasonable
Accreditation of Healthcare Organizations physician of similar knowledge, training,
 Operating room briefings and experience would use in similar
o are team discussions of critical issues and potential NEGLIGENCE circumstances
hazards that can improve the safety of the operation  eg. Surgeon transected the area where the
o shown to improve operating room culture decrease hernia is. He SHOULD know that he should
operating room delays not transect that area but rather isolate it,
 Patient rapport retract it.. But he did it anyway. Under
o most important determinant of malpractice claims standard of care yung ginawa niya. He can
against a surgeon be sued here.
 An error that does not result in patient
harm
 Analysis of near misses provides the
opportunity to identify and remedy system
failures before the occurrence of harm
 Ito, minor lang, it can be prevented.
 Eg. The patient is coughing so you gave
him ambroxol. But it is actually secondary
NEAR MISS to the surgery kasi the patient was
intubated. Binigyan ng inhalation
anesthesia, so you expect a certain
atelectasis in the lungs. So the patient
cannot breathe well, hindi nageexpand
yung lungs niya so the patient keeps on
coughing. So you saw it, did something to
it, so the error was reversed. That‟s a near
miss. (in Filipino, kamuntikan na!)
 Unexpected occurrence involving death or
SENTINEL serious physical or psychological injury,
EVENT injury involves loss of limb or function
requires immediate investigation and

Agatep. Detera. Doong. Rodriguez. Tejano. Villacorta Page 1 of 10


response
 Hemolytic transfusion reaction involving
administration of blood or blood products
having major blood incompatibilities
 Wrong-site, wrong-procedure, or wrong-
patient surgery
 A medication error or other treatment-
related error resulting in death
 Unintentional retention of a foreign body in
a patient after surgery
 Eg. You did an arterial line, or BP
monitoring, or arterial puncture for an ABG.
Tapos biglang nangitim yung kamay ng
bata, that‟s a sentinel event. Nagthrombose
yung artery that can lead to amputation of
the hand.
CREATING A CULTURE OF SAFETY
 An acknowledgment of the high-risk, error-prone nature of
an organization's activities
 A nonpunitive environment where individuals are able to
report errors or close calls without fear of punishment or
retaliation
 An expectation of collaboration across ranks to seek
solutions to vulnerabilities
 A willingness on the part of the organization to direct
resources to address safety concerns
 In the Philippines, especially in government institutions, we
will see this recording of these errors because we‟re afraid.
We try to cover it up. And covering it up will not actually
solve the problem. But when you report it, we would know
what should be done to prevent it from happening.
COMMUNICATION TOOLS:
Operating Room Briefings
FIVE-POINT OPERATING ROOM BRIEFING
 What are the names and roles of the team members?
o Pagpasok ng room: “Hi! I‟m Dr. Hazel Turingan. I am
a thoracic cardiovascular surgeon. And I‟ll be operating
the patient.” Tapos sabihin mo naman: “Hi I‟m Dr. X,
5th year resident, and I‟ll be the first assist.”
o Then usually, there are two nurses: one is a circulating
nurse—the one you call when you need something and
she takes care of everything in the OR—and the other
is scrub nurse—the one who will take care of the
instruments and hand it to the surgeon. Pag may ibang
tao dun, “Sino ka? Anong ginagawa mo dito?”
 Is the correct patient/procedure confirmed?
[Joint Commission Universal Protocol (TIME-OUT)]
 Have antibiotics been given? (if appropriate)
 What are the critical steps of the procedure?
 What are the potential problems for the case?
TIME OUT!
Is this the right patient?
Do we have the right location?
Are we doing the right procedure?
 Verify the person, site and procedure
o Whenever possible, always ask the patient—at
admission, during your pre-operative check and just
before the procedure—what procedure they are having
and where
“Tanungin mo siya pasyente. Kahit sabihin niyang, eto
oh, nakasulat sa, let‟s say band ko. You have to ask to
confirm. It might sound corny, alam mo naman mga
Agatep. Detera. Doong. Rodriguez. Tejano. Villacorta
Patient Safety, Errors & Complications
Pilipino, it may be awkward. But then now that I‟m a
surgeon, I realized the importance of these things.”
o Double check the patient‘s identification when they are
transferred between units.
o Re-check the patient‘s identification when they arrive
at the O.R. and again in the O.R.
 Always check
o Patient history, consent and other documents
o Radiological studies needed
o Implants and prosthesis if required
o Patient identification or arm band
 Mark the procedure site
o A licensed independent practitioner (or other provider
who is privileged or permitted by the organization to
perform the intended procedure) marks the procedure
site.
o Use the surgeon‘s or proceduralist‘s initials
(preferably), with or without a line representing the
proposed incision.
o The type of mark made should be used consistently
throughout the organization.
 Time out for the team
o Correct patient
o Correct procedure
o Correct side and site
o Agreement that we are set to go
 Help prevent wrong side, wrong site, wrong patient, and
wrong procedures in your organization with the help of our
"Time Out" Poster.
o Poster highlights all of the important steps that must
be taken to prevent wrong side, wrong site, wrong
patient and wrong procedures in your organization.
o Poster should be hung in the OR staff lounge, in patient
pre-operative areas and procedure rooms, as any place
an invasive procedure may occur in your facility.
o Help to ensure that staff is continuously reminded that
‗time out‘ will ensure or minimize surgical identification
errors.
PRE OP CHECKLIST DAY OF SURGERY
 Client teaching completed
 Consent form signed
 NPO
o hindi dahil sadista yung mga nasa OR. You don‟t feed
them because when you intubate the patient, they might
aspirate. Because when you put something in your
throat, you‟re tendency is to cough, and the vomitus
might obstruct your airway. Kahit fluids, bawal din.
 In gown
 Allergy & ID Bands on
o this is an example of a near miss. Ask the patient kung
may allergy ba siya sa, let‟s say NSAIDs. You can prevent
such to happen if you ask the patient.
 No jewelry-bands taped
o always remove jewelry. Because whenever you do
cautery, whatever metal is on your body, it might burn
on those areas where the metal is. Your wrist where you
place your watch. Even the metal in your bra. That‟s why
you don‟t wear bra or even the garter of the brief during
surgery. Cotton lang allowable.
 Voiding prior to transfer
o ―This happened to me when I was in college, second year
or first year I guess, when I had my appendectomy. They
didn‟t let me void prior to surgery, before putting my
spinal anesthesia. After the surgery, there were no
sensations below my umbilicus. Well, I can move my feet
but I don‟t have control. I can feel my bladder about to
burst to the point na I wanna sceam „Will somebody
Page 2 of 10

please get me a foley catheter!‟ That bad! Because
someone didn‟t let me void prior to surgery. And then
they‟re putting a lot of fluid to me, kasi when you‟re
operating they‟re resuscitating you eh. So lahat yan, nasa
bladder ko. I was hold onto my capacity. So now, I‟m
very aware of that to my patients.
 PreOp meds
 Side rails  after PreOp
 Contact lens out
 Dentures/Bridges out
o One time, the patient was not asked to remove her
dentures. And when they inserted the laryngoscope, the
dentures were dislodged. The patient swallowed it. So the
team had to do surgery in the esophagus because of that
foreign body
 Nail polish removed
o Bakit bawal? Kasi nangingitim ka na, hindi pa nakikita
because you‟re wearing black nail polish. So tinatanggal
yan prior to surgery
 Vitals within 4 hours of surgery or 30 minutes after PreOp
 PreOp labwork on chart
 Abnormal lab values
o Always tell the surgeon. Kahit sa tingin mo insignificant
lang naman, tell it pa rin.
 Skin prep
 Hx of Aspirin, Antidepressant, Steroid, NSAID‘s
WORLD HEALTH ORGANIZATION (WHO)
 Developed a comprehensive perioperative checklist as a
primary intervention of the "Safe Surgery Saves Lives"
program—an effort to reduce surgical deaths across the
globe
 WHO checklist includes
o prompts to ensure that infection prevention measures
followed
o potential airway complications are precluded
 e.g., anesthesia has necessary equipment and
assistance for a patient with a difficult airway
o groundwork for effective surgical teamwork is
established
 e.g., proper introductions of all OR personnel
o Aspects of the Joint Commission's preprocedure
"Universal Protocol" (or "time-out") also are included in
the checklist
 e.g., checks to ensure operation performed on
correct patient and correct site
SURGICAL SAFETY CHECKLIST: Universal Protocol
developed by WHO
1. Before induction of anesthesia
(With at least nurse and anesthetist)
Has the patient confirmed his/her identity, site,
procedure, and consent?
□ Yes
Is the site marked?
□ Yes
□ Not applicable
Is the anesthesia machine and medication check
complete?
□ Yes
Is the pulse oximeter on the patient and functioning?
□ Yes
Does the patient have a:
Known allergy?
□ No
□ Yes
Agatep. Detera. Doong. Rodriguez. Tejano. Villacorta
Patient Safety, Errors & Complications
Difficult airway or aspiration risk?
□ No
□ Yes, and equipment / assistance available
Risk of >500 ml blood loss (7ml/kg in children)?
□ No
□ Yes, and two IVs / central access an fluids
planned
2. Before skin incision
(With nurse, anaesthetist and surgeon)
□ Confirm all team members have introduced
themselves by name and role.
□ Confirm the patient‘s name, procedure, and where
the incision will be made.
Has the antibiotic prophylaxis been given within the last
60 minutes?
□ Yes
□ Not applicable
Anticipated critical events
To surgeon:
□ What are the critical or non-routine steps?
□ How long will the case take?
□ What is the anticipated blood loss?
To anaesthetist:
□ Are there any patient-specific concerns?
To nursing team:
□ Has sterility (including indicator results) been
confirmed?
□ Are there equipment issues or any concerns?
Is essential imaging displayed?
□ Yes
□ Not applicable
3. Before patient leaves operating room
(With nurse, anaesthetist and surgeon)
Nurse verbally confirms:
□ The name of the procedure
□ Completion of instrument, sponge and needle counts
□ Specimen labeling (read specimen labels aloud,
including patient name)
□ Whether there are any equipment problems to be
addressed
o The circulating nurse counts how many instruments were
given and were used. She counts how many OS
(operating sponge) were given. Dati, eto yung ginagawa.
Example, the nurse gave you 5 OS. Eh you need more 5
OS then wala yung circulating nurse. So you ask the
intern or clerk to get 5 more OS. He/she‟s supposed to
tell it to the circulating nursekung ilan yung dinagdag.
Bakit? Kapag kasi after the surgery, 9 ang bilang ng
nurse sa OS, eh 10 yung binigay at ginamit. Nasan na
yung isa? So hanap sila ulit. They will open again the
abdomen to search for the missing OS. Pero ngayon, the
better hospitals, the tertiary hospitals use OS that are
radilogic. They have this tag, usually blue or orange na
pag nag-xray, makikita, hence, alam agad na nasa loob
ng patient yung OS.
To surgeon, Anaesthetis and Nurse
□ What are the key concerns for recovery and
management of this patient?
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 Patient Safety, Errors & Complications

 Prophylactic antibiotics discontinued within 24 hrs after

surgery end time (48 hrs for cardiac patients)
 Cardiac surgery patients with controlled 6 A.M.
postoperative serum glucose
 Surgery patients with appropriate hair removal
 Colorectal surgery patients with immediate postoperative
normothermia

VENOUS THROMBOEMBOLISM
 Surgery patients with recommended venous
thromboembolism prophylaxis ordered
 Surgery patients who received appropriate venous
thromboembolism prophylaxis within 24 hrs before surgery
to 24 hrs after surgery

CARDIAC EVENTS
Incidence of identification errors observed per 1000  Surgery patients on a beta blocker prior to arrival who
specimens (n = 21,351). received a beta blocker during the perioperative period

AGENCY FOR HEALTHCARE RESEARCH AND QUALITY PROPOSED OUTCOME MEASURES

PATIENT SAFETY INDICATORS
INFECTION
PROVIDER-LEVEL PATIENT SAFETY INDICATORS  Postoperative wound infection diagnosed during index
 Complications of anesthesia hospitalization
 Death in low mortality diagnosis-related groups
 Decubitus ulcer VENOUS THROMBOEMBOLISM
 Failure to rescue  Intra- or postoperative pulmonary embolism diagnosed
 Foreign body left in during procedure during index hospitalization and within 30 days of surgery
 Iatrogenic pneumothorax  Intra- and postoperative deep vein thrombosis diagnosed
 Selected infections due to medical care during index hospitalization and within 30 days of surgery
 Postoperative hip fracture
 Postoperative hemorrhage or hematoma CARDIAC EVENTS
 Postoperative physiologic and metabolic derangements  Intra- or postoperative acute myocardial infarction
 Postoperative respiratory failure diagnosed during index hospitalization and within 30 days
 Postoperative PE or DVT of surgery
 Postoperative sepsis
 Postoperative wound dehiscence in abdominopelvic surgical
GLOBAL MEASURES
patients
 Accidental puncture and laceration  Mortality within 30 days of surgery
 Transfusion reaction  Readmission within 30 days of surgery
 Birth trauma – injury to neonate  If the patient dies within one month after surgery, that‟s
 Obstetric trauma – vaginal delivery with instrument still your mortality. The cause, regardless, is still your
 Obstetric trauma – vaginal delivery without instrument surgery.
 Obstetric trauma – cesarean delivery
NATIONAL QUALITY FORUM
AREA-LEVEL PATIENT SAFETY INDICATORS NEVER EVENTS
 Foreign body left in during procedure  Errors in medical care that are clearly:
 Iatrogenic pneumothorax o Identifiable
 Selected infections due to medical care o Preventable
 Postoperative wound dehiscence in abdominopelvic surgical o Serious in their consequences for patients
patients  Indicate a real problem in the safety and credibility of a
 Accidental puncture and laceration health care facility
 Transfusion reaction
 Postoperative hemorrhage or hematoma SURGICAL NEVER EVENTS
 Surgery performed on the wrong body part
THE SURGICAL CARE IMPROVEMENT PROJECT  Surgery performed on the wrong patient
MEASURES  Wrong surgical procedure performed in a patient
 Unintended retention of a foreign object in a patient aftery
PROCESS OF PERFORMANCE MEASURES surgery or other procedure
 Intraoperative or immediately postoperative death in an
ASA Class I patient (normaly healthy individual. Review the
INFECTION ASA Class in Trans 2.5. :D)
 Prophylactic antibiotic received within 1 hr before
surgical incision
 Prophylactic antibiotic selection for surgical patients

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 Patient Safety, Errors & Complications

RETAINED SURGICAL ITEM • Central venous catheters should be exchanged only for
 Refers to any surgical item that is found to be inside a specific indications (not as a matter of routine) and should
patient after he or she has left the OR requiring a second be removed as soon as possible.
operation to remove the item
 Estimates of retained foreign bodies in surgical procedures
1/8,000 to 18,000 operations, or approximately 1,500
cases per year in the US

RISK FACTORS FOR RETAINED SURGICAL SPONGE

 Emergency surgery
 Unplanned changes in procedure
 Patient with higher body-mass index
 Multiple surgeons involved in same operation
 Multiple procedures performed in same patient CENTRAL VENOUS CATHETER COMMON
 Involvement of multiple operating room nurses / staff COMPLICATIONS
members  Pneumothorax
 Case duration covers multiple nursing ―shifts‖ o Occurrence 1 to 6%
o higher among the inexperienced operators
WRONG SITE SURGERY o stable, pneumothorax is small (<15%) observation
 Any surgical procedure performed in the: may be adequate
o Wrong patient  Arrhythmias
o Wrong body part  Arterial Puncture
o Wrong side of the body o Carotid artery may be punctured
o Wrong level of a correctly identified anatomic site  Lost Guidewire
 Air Embolus >50ml
BEST PRACTICES FOR OPERATING ROOM SAFETY  Pulmonary Artery Rupture
 Conduct the Joint Commission Universal Protocol (―time- o ("Swan-Ganz") catheters
out‖) to prevent wront-site surgery  pulmonary artery rupture due to excessive
 Perform an operating room briefing (checklist) to identify advancement of the catheter into the pulmonary
and mitigate hazards early circulation
 Promote a culture of speaking up about safety concerns o sentinel bleed noted when a PA catheter balloon is
 Use a screening x-ray to detect foreign bodies in high-risk inflated
cases o uncontrolled hemoptysis
 Benign patient sign-outs with the most likely immediate o Treatment :
safety hazard  Re-inflation of the catheter balloon,
 immediate airway intubation with mechanical
COMMON CAUSES OF LAWSUITS IN SURGERY
ventilation, urgent portable chest x-ray,
 Positional nerve injury  notification of the OR that an emergent
 Common bile duct injury thoracotomy may be required.
 Failure to diagnose or delayed diagnosis  Central Venous Line Infection (CDC)
 Failure to treat, delayed treatment, or wrong treatment o 12 to 25% mortality rate when a central venous line
 Inadequate documentation infection becomes systemic
 Inappropriate surgical indication o 15% of hospitalized patients will acquire central venous
 Failure to call a specialist line sepsis.
 Cases resulting in amputation / limb loss o once an infection is recognized as central line sepsis,
removing the line is adequate
COMPLICATIONS
o If your patient is having chiils, suspect already a
Individual errors catheter infection. Do culture na.
 Cause minor or major complications during or after a o Staphylococcus aureus infections present a unique
surgical procedure problem due to its potential for metastatic seeding of
 May not be publicized as much as wrong-site surgery or a bacterial emboli
retained surgical item o Treatment: 4 to 6 weeks antibiotic therapy
 Can still lead to surgical complications that prolong the
course of illness, lengthen hospital stay, increase morbidity
ARTERIAL LINES
and mortality rates
Sa A-line, maglalagay ka ng probe, and this actually
measures second-by-second systolic and diastolic pressure.
COMPLICATIONS IN MINOR PROCEDURES

CENTRAL VENOUS CATHETERS

Steps to decrease complications include the following:
• Ensure that central venous access is indicated
• Experienced (credentialed) personnel should insert the
catheter, or should supervise the insertion.
• Use proper positioning and sterile technique.

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 Patient Safety, Errors & Complications

ARTERIAL LINES COMPLICATIONS

 Thrombosis
o AKA embolization of an extremity can result in the
loss of a digit, hand, or foot,
o Risk is nearly the same for both femoral and radial
cannulation.
o Treatment:
 anticoagulation,
 surgical intervention required to re-establish
adequate inflow
 Bleeding
 Hematoma
 Arterial Spasm (nonthrombotic pulselessness)
 Infection
The problem with stiff catheter (Seldinger technique), if you
TRACHEOSTOMY hit it low, you might hit the bladder and may give you false
positive. When you hit it high, you might hit the stomach and
TRACHEO-INNOMINATE ARTERY FISTULA (TIAF) give you falce positive result as well. Dapat yan periumbilicus.
 occurs rarely (~0.3%)
 50 - 80% mortality rate ORGAN SYSTEM COMPLICATIONS
 can occur as early as 2 days and as late as 2 mos. after
tracheostomy NEUROLOGIC SYSTEM
 Neurapraxia
o improper positioning and/or padding during operations
o Treatment
 clinical observation
 spontaneous resolution 1 - 3 months
 Direct injury to nerves during a surgical intervention:

NERVE SURGICAL INTERVENTION

facial nerve superficial parotidectomy
hypoglossal carotid endarterectomy
nerve
Prostatectomy
nervi erigentes
 erectile impotence when injured
inguinal herniorrhaphy
THORACOSTOMY  chronic groin pain at 6 months
ilioinguinal nerve  groin numbness
 postoperative sensory loss at the
groin region

DIAGNOSTIC PERITONEAL LAVAGE

 Nasogastric and bladder catheter decompression is
mandatory before DPL to avoid injury during the procedure
 The small or large bowel, or the major vessels of the  The nerve injury
retroperitoneum also can be punctured inadvertently, and o stretch injury
these injuries require surgical exploration and repair o an unintentionally severed nerve
 Consequence:
o loss of function
o severed nerves - painful neuroma that may require
subsequent surgery

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 Patient Safety, Errors & Complications

EYES, EARS, NOSE RESPIRATORY SYSTEM

 Corneal abrasions  Pulmonary Atelectasis
o inadequate protection of the eyes during anesthesia o loss of functional residual capacity (FRC)
 Conjunctivitis o can predispose to pneumonia
o overlooked contact lenses in a trauma patient o poor pain control in the postoperative period
contributes to poor inspiratory effort and collapse of
the lower lobes in particular
o Treatment:
 increase in FRC by ≥ 700 mL
 accomplished by sitting patients up >45°
 mechanically ventilated patients, simply placing
the head of the bed at 30 to 45° elevation
improves pulmonary outcomes
Inclusion Criteria for Acute Respiratory Distress
Syndrome (ARDS)
 Acute onset
 Predisposing condition
 PaO2:FiO2 < 200 (regardless of positive end-expiratory
 Persistent epistaxis pressure)
o NGT placement or removal,  Bilateral infiltrates
o Treatment:  Pulmonary artery occlusion pressure < 18 mmHg
 nasal packing  No clinical evidence of right heart failure
 persistent direct pressure on external nares
CARDIAC SYSTEM
 Atrial fibrillation
o most common arrhythmia
o occurs between 3-5 postoperative day high-risk
patients
o when patients begin to mobilize their interstitial fluid
into the vascular fluid space
o rate control more important than rhythm control
o First-line treatment: beta blockade and/or calcium
channel blockade

MUSCULOSKELETAL SYSTEM
 Decubitus ulcers
o preventable complications of prolonged bedrest due to
VASCULAR PROBLEMS OF THE NECK traumatic paralysis, dementia, chemical paralysis, or
 Carotid Sinus coma
o baroreceptors maintains blood pressure innervated by o ischemic changes in the microcirculation of the skin can
the Sinus nerve of Herring, branch of glossopharyngeal be significant after 2 hours of sustained pressure
nerve (IX)
 Carotid Body Turning schedule
o small cluster of chemoreceptors at the bifurcation of
the CA
o detects changes in partial pressure of O2 & CO2
o sensitive to changes in pH and Temp
 Carotid Endarterectomy
o Complications:
 central or regional neurologic deficits
 bleeding with an expanding neck hematoma

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 Patient Safety, Errors & Complications

Pressure Ulcer Prevention Guide RATE OF VIRAL TRANSMISSION IN BLOOD PRODUCT

TRANSFUSIONS
HIV 1:1.9 million
HBV 1: 137,000
HCV 1: 1 million
Note that bacterial transmission is 50 to 250 times higher
than viral transmission per transfusion

WOUNDS, DRAIN AND INFECTION

WOUND (SURGICAL SITE) INFECTION

 General trend toward providing a single preoperative
dose, as antibiotic prophylaxis may not impart any benefit
at all beyond the initial dosing
 Irrigation of the operative field and the surgical wound with
saline solution has shown benefit in controlling wound
inoculum
 Irrigation with an antibiotic-based solution has not
demonstrated significant benefit in controlling postoperative
infection
 70% isopropyl alcohol:
o best bactericidal effect
o flammable
o hazardous when electrocautery used
 chlorhexidine gluconate +isopropyl alcohol,
povidone-iodine, iodophor with alcohol
o more advantageous

WOUND (SOFT TISSUE) INFECTION

 >105 CFU per gram of tissue
 warrants expeditious & proper antibiotic/antifungal
treatment
 clinical signs raise enough suspicion that the patient is
treated before a confirmatory culture is undertaken.
 clinical signs of wound infection include rubor, tumor,
calor, and dolor (redness, swelling, heat, and pain),
 most definitive treatment: remains open drainage

HEMATOLOGIC SYSTEM
 The transfusion guideline
o maintaining the hematocrit level in all patients >30% is
NO longer valid
 Only those patients who requires increased oxygen-carrying DRAIN MANAGEMENT
capacity to adequately perfuse end organs, requires higher Four Indications for applying a surgical drain are:
levels of hemoglobin:  To collapse surgical dead space in areas of redundant
o symptomatic anemia tissue (e.g., neck and axilla)
o significant cardiac disease  To provide focused drainage of an abscess or grossly
o critically ill patient infected surgical site
 Other than those select patients, the decision to transfuse  To provide early warning notice of a surgical leak (either
should generally not occur until the hemoglobin level bowel contents, secretions, urine, air, or blood)—the so-
reaches 7 mg/dL or hematocrit reaches 21% called sentinel drain
 To control an established fistula leak

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 Patient Safety, Errors & Complications

 Treatment
o surgical emergency
o wide débridement of the necrotic tissue to the level of
bleeding, viable tissue

SYSTEMIC INFLAMMATORY RESPONSE SYNDROME,

SEPSIS, AND MULTI-ORGAN DYSFUNCTION SYNDROME

SIRS
 result of proinflammatory cytokines related to tissue
malperfusion or injury
 dominant cytokines
o interleukin-1,
o interleukin-6,
o tissue necrosis factor (TNF).
 other mediators include
o nitric oxide
URINARY CATHETERS
o inducible macrophage-type nitric oxide
 catheter be inserted its full length up to the hub o synthase
 urine flow established before balloon inflated o prostaglandin I2
 misplacement of the catheter in the urethra with premature
inflation of the balloon can lead to tears and disruption of INCLUSION CRITERIA
the urethra
Temperature >38OC or <36OC
Heart rate >90 beats/min
Respiratory rate >20 breathes/min or PaCO2 <32mmHg
White blood cell count of <4000 or >12000 cells/mm3 or
>10%immature forms

Mortality Associated with Patients Exhibiting Two or

More Criteria for SIRS
PROGNOSIS Mortality %
2 SIRS criteria 5
3 SIRS criteria 10
4 SIRS criteria 15-20

SEPSIS
 Categorized as
o Sepsis
 SIRS + infection
o Severe Sepsis
EMPYEMA  sepsis + signs of cellular hypoperfusion or end-
 (Gr. en, within + pyon, pus) organ dysfunction
 infection of the pleural space (pyothrax) o Septic Shock
 Etiology:  sepsis associated with hypotension after adequate
o overwhelming pneumonia fluid resuscitation
o retained hemothorax,
o systemic sepsis, MULTIPLE-ORGAN DYSFUNCTION DYSNDROME (MODS)
o esophageal perforation from any cause, infections with  culmination of septic shock and multiple end-organ failure
a predilection for the lung (e.g., tuberculosis)
SIRS/MODS
ABDOMINAL ABCESS  Management
 vague complaints intermittent abdominal pain o aggressive global resuscitation
 fever o support of end-organ perfusion,
 leukocytosis o correction of the inciting etiology,
 change in bowel habits o control of infectious complications,
o management of iatrogenic complications
*CT scan usually required. When a fluid collection within the  Adjuncts for supportive therapy
peritoneal cavity is found on CT scan, treatment options are o tight glucose control
antibiotics and percutaneous drainage of the collection. o low tidal volumes in ARDS
o vasopressin in septic shock
NECROTIZING FASCITIS o steroid replacement therapy
 fulminant soft tissue infection
 30 to 70% mortality GLYCEMIC CONTROL
o Group A streptococcal (M types 1, 3, 12, and 28)  50% reduction in mortality in the critical care setting
o Clostridium perfringens  serum glucose was maintained between 80 and 110 mg/dL
o C. septicum with insulin infusion

Agatep. Detera. Doong. Rodriguez. Tejano. Villacorta Page 9 of 10

 Patient Safety, Errors & Complications

 Secondary findings included Pulmonary embolism

o an improvement in overall morbidity, Adrenal insufficiency
o decreased percentage of ventilator days, less renal  Malignant Hyperthermia
impairment, o exposure to agents
o lower incidence of bloodstream infections  succinylcholine
 halothane-based inhalational anesthetics
PROBLEMS WITH THERMOREGULATION o Symptoms:
 dramatic
HYPOTHERMIA  with rapid onset of increased temperature
 Core Temperature <35°C (95°F),  rigors
 myoglobinuria related to myonecrosis
Mild [35 to 32°C, (95 to 89.6°F)]
o Treatment:
Moderate [32 to 28°C (89.6 to 82.4°F)]
 Medications must be discontinued immediately
Severe [<28°C, (<82.4°F)]
 Dantrolene (2.5 mg/kg every 5 minutes) until
 Shivering  symptoms subside.
o body's attempt to reverse effects of hypothermia,  Aggressive cooling methods
occurs 37 - 31°C (98.6 and 87.8°F)  alcohol bath
o ceases at <31°C (87.8°F)  packing in ice
 Triad  Severe Malignant Hyperthermia
o metabolic acidosis o mortality rate is nearly 30%
o coagulopathy  Patients who are moderately hypothermic are at higher risk
o hypothermia for complications than are those who are more profoundly
 commonly found in long operative cases patients hypothermic
with blood dyscrasias
 The enzymes that contribute to the clotting cascade and ISSUES IN CARING FOR OBESE PATIENTS & PATIENTS
platelet activity are most efficient at normal body AT THE EXTREMES OF AGE
temperatures;
 Surgery with multiple risks
 therefore all measures must be used to reduce heat loss
 Important to optimize prior to surgery
intraoperatively
 Preoperatively:
 Arrhythmia
o dietary modifications
o most common cardiac abnormality when body
o exercise
temperature drops below 35°C
o pulmonary toilet issues
 Bradycardia
 Obese Conditions
o occurs with temperatures below 30°C
o eccentric left ventricular hypertrophy,
 Hypothermia may induce CO2 retention resulting in
o right ventricular hypertrophy
respiratory acidosis
o congestive heart failure.
 Renal dysfunction of hypothermia manifests itself as a
o significant sleep apnea
paradoxic polyuria, related to an increased GFR,
o gastroesophageal reflux disease
 potentially perplexing in patients undergoing resuscitation
o Poor Glycemic control
for hemodynamic instability,
o contributes significantly to infection & DM
 brisk urine output provides a false sense of an adequate
o decrease in antithrombin III levels,
intravascular fluid volume
o higher risk of DVT and PE
 Methods used to warm patients include
 Measures to optimize physiologic function:
o warm air circulation over the patient,
o keep head of the bed elevated at all times.
o heated IV fluids,
 can improve FRC by almost 1 liter
 More Aggressive Measures
 ↓ atelectasis and pneumonia complications
o bilateral chest tubes with warm solution
o Proper glycemic control
o lavage
 tight insulin sliding scale
o intraperitoneal rewarming lavage
o risk of DVT may be attenuated by
o extracorporeal membrane oxygenation
 immediate use of prophylactic LMWH
 rate of temperature rise of 2 to 4°C/h considered adequate,
 early ambulation
 Most common complication for nonbypass rewarming is
 Elderly vs Very Young
arrhythmia with ventricular arrest
Elderly Very Young
HYPERTHERMIA End-organ underdeveloped or anomalous
insufficiency organ function
Immune response Immune response compromised
Common Causes Of Elevated Temperature In Surgical
compromised
Patients
may not be capable resolve fevers overnight, and
HYPERTHERMIA HYPERPYREXIA
of mounting a febrile the cause may remain
Environmental Sepsis
response undiagnosed
Malignant hyperthermia Infection
 Extremes of Ages
Neuroleptic malignant syndrome Drug reaction
o other alterations in these groups include:
Thyrotoxicosis Transfusion reaction  amount and distribution of
Pheochromocytoma Collagen disorder – total body water
Carcinoid syndrome Factitious syndrome – total body fat
Iatrogenic Neoplastic disorder o communication
Central/ hypothalamic response o involvement of family members

Agatep. Detera. Doong. Rodriguez. Tejano. Villacorta Page 10 of 10