surgical complications john cosgrove, md facs chairman and residency program director bronx lebanon...

Surgical Complications

John Cosgrove, MD FACSChairman and Residency Program DirectorBronx Lebanon Hospital Center

Primum no nocere

Think before you act.

Complications can be deadly…

Logarithmic increase in bile duct injuries after the introduction of laparoscopic cholecystectomy.

SCIP

Antibiotics Normothermia VTE Prophylaxis

Morbidity and Mortality Conference

Mainstay quality program of general surgery residency programs.

Mortalities

Morbidities

Cardiorespiratory Wound Urinary tract

Wound

Seroma Hematoma Dehiscence Evisceration

Wound

Superficial Deep Organ space

Pathogens

Staphylococcus(coagulase neg) 25% Enterococcus(D) 11.5% Staph aureus 8.7% E. coli 6.5%

Wound classification

Clean Clean contaminated Contaminated Dirty

Temperature regulation

Issues of hypothermia

Malignant hyperthermia

1 in 30,000 cases Mortality less than 10% Autosomal dominant with variable

penetrance Altered calcium metabolism Halothane, isoflurane, succinylcholine Cause rise myoplasmic calcium

MH

Tachycardia Arrhythmia Raised temperature Acidosis Muscle rigidity Tachypnea Flushing (inability to open mouth)

Treatment

Discontinue triggering anesthetic Hyperventilate with 100% oxygen Terminate surgery Dantrolene 2.5mg/kg as bolus and repeat every 5

minutes Monitoring Sodium bicarbonate Beta blockers Lidocaine Lasix

Pulmonary complications

Atelectasis Pneumonia Pulmonary embolism Aspiration Pulmonary edema ARDS

Weaning criteria

RR <25 breaths/min Pa02 >70mmHg(Fi02 of 40%) PaC02<45 mm Hg MV 8-9L/m TV 5-6mL/kg NIF -25cm H20

Cardiac

Greatest risk in first 48 hours Non-Q wave, non ST segment elevation

Prevention

Major predictors of risk Unstable chest pain, CHF, sympotomatic

arrhythmias, severe valvular disease

Management

Cardiology consult Tachyarrhythmia Unstable-cardioversion SVT-Beta blocker, esmolol, amiodarone PSVT-vagal stimulation, adenosine, amiodarone MAT-B blocker or amiodarone VTach-lidocaine or amiodarone Brady-atropine Heart block-high grade second or third degree-

insertion of permanent pacemaker

Amiodarone

Phosphodiesterase inhibitor Inhibits breakdown of camp Increase cardiac output and decreases

preload and after load without increasing myocardial oxygen demand

May cause vasodilitation and GI problems and thrombocytopenia

Adrenal

Chronic use of steroids causes suppression of the HPA axis

Potentially life threatening Give 250ug cosyntropin intravenousl

Hemodialysis indications

Serum potassium >5.5 BUN>80-90 Persistent metabolic acidosis Acute fluid overload Uremic symptoms(pericarditis, encephalopathy,

anorexia) Removal of toxins Platelet dysfunction Hyperphosphatemia with hypercalcemia

SIADH

Common cause of chronic normovolemic hyponatremia

Serum sodium<135 Treat underlying disease process Fluid restriction Rapid correction may result in seizures

Gastrointestinal

Ileus Early SBO Compartment syndrome GI bleeding Stomal complications C. difficile colitis

Anastomotic leak

Strategies for prevention Low anterior resection

Enterocutaneous fistula

Low output <200 cc/24h Moderate 200-500 cc/24 h High >500 cc/24 h

“The Checklist”

Provonost Gawande

Airline Industry

Crew resource management Communication No hierarchy Checklist, checklist, checklist Debriefing

Universal Protocol

Preprocedure Verification Presurgical “timeout” Post procedure “debriefing”

Prospective Case Conference

Dr. Judson Randolph 1988-Childrens Hospital Center, Washington,

DC A priori discussion of all upcoming pediatric

surgery cases involving multiple disciplines

Interdisciplinary teamwork

GI/bleeds/biliary Radiology/bleeds/abscess Medicine/evaluation/cardiac Anesthesia/PST/surgical readiness

“Never events”

CMS