Download - POSTOPERATIVE COMPLICATIONS
POSTOPERATIVE COMPLICATIONS
Samaad Malik, MD, MSc, FRCSCSamaad Malik, MD, MSc, FRCSCClinical Fellow, CMASClinical Fellow, CMASMcMaster UniversityMcMaster UniversityAugust 20, 2008August 20, 2008
Objectives
Case BasedClinical ApproachExamination Preparation
POS Question sample
1. What enzyme facilitates access of snake venom into the human lymphatics?HyaluronidasePeroxidaseAcethycholinesteraseCrotalase
We shall not cease from exploration And the end of all our exploring Will be to arrive where we started And know the place for the first time.
T.S. Eliot
Surgical Complications
Surgical Wound Complications Complications of Thermal Regulation Pulmonary Complications Cardiac Complications Renal and Urinary Tract Complications Endocrine Complications Gastrointestinal Complications Hepatobiliary Complications Neurologic Complications Ear, Nose, and Throat Complications
Approach
PageElevator thoughtsQuick Bedside LookABCSelective H+PManagement
Case
85 yo elderly malePOD #3 Laparoscopic Colectomy Painful R cheek while eating
What are your thoughts?Diagnosis
How do you want to proceed??Treatment
Parotitis
Decrease in the secretory activity of the gland with inspissation of parotid secretions that become infected by staphylococci or gram-negative bacteria from the oral cavity
Parotitis
Potentially seriousElderlyPoor oral hygienePoor nutritional stateDehydration
Post operative Parotitis
Results in inflammation, accumulation of cells that obstruct large and medium-sized ducts, and, eventually, formation of multiple small abscesses
These lobular abscesses, separated by fibrous bands, may dissect through the capsule and spread to the periglandular tissues to involve the auditory canal, the superficial skin, and the neck
If the disease is not treated at this stage, it may produce acute respiratory failure from tracheal obstruction
ORAL HYGIENE?
Diagnosis
ClinicalPain or tenderness at the angle of the jawSwelling and redness in the parotid areaHigh fever and leukocytosis develop
InvestigationsUltrasound
Treatment
Clindamycin/Vancomycin should be started while the results of cultures are awaited
Warm moist packs and mouth irrigations may be helpful
Rehydrate
Case
68 yo malePOD #1 Lap APRDesaturated to 85%
What are your thoughts?
Case
ApproachABCHx and Px Investigations
BloodworkCEA
Consultation
Thromboembolisms
Mechanisms:Alterations in normal blood flow Injuries to vascular endotheliumAlterations in the constitution of blood
Symptoms and Signs of Pulmonary Embolism
Pleuritic chest pain[] Sudden Dyspnea[] Tachypnea Hemoptysis[] Tachycardia[] Leg swelling[*] Pain on palpation of the leg[*] Acute right ventricular dysfunction Hypoxia Fourth heart sound[*] Loud second pulmonary sound[*] Inspiratory crackles[*]
Investigations
CXR, ECG, ABGD-dimerCT scanV/Q scanDuplex U/SPulmonary AngiogramEcho
Treatment
Depends on hemodynamic stabilityUnstable
Get helpThrombolytics?
StableAnticoagulate intrinsic fibrinolysis restores pulmonary
blood flow
Heparin
ComplicationsBLEEDINGosteoporosisHIT
No increased risk of bleed INCREASED risk of Thrombosis
BOTH ARTERIAL AND VENOUS Increased for a period of 1 month
Heparin
Prevents formation of new thrombi and stops propagation of thrombi
Enhances antithrombotic activity of antithrombin III
ContraindicationsConsider IVC filterOvert bleeding
HIT
can occur with LMWH as wellUsually after 5-10 days
HIT
TreatmentGet help – HematologyDiscontinue HeparinOther anticouagulants
ArgatrobanDanaparoid
IVC Filter placement
IndicationsRecurrent PE despite adequate
anticoagulationContraindications to anticoagulation
DVT
Investigationspresentationsmanagementmedical
Cardiac
Mortality no h/o MI 1-1.2% 6 or more months 6% 3 months 16-37% age more than 70 AS medical conditions emergency operations
Intraoperative hypotension
Preoperative CHF Preoperative
Hypotension Angina
Cardiac Pearls
Inpatient HR 101
Intravascular volume depletion till proven otherwise
PainFever
Case
67 yo femalePOD #3, Ivor Lewis EsophagectomyHR= 168
BP= 80/60
What to do next?
ApproachABCACLS protocolCall for help!!
Catch!
Cardiac ArrythmiasUnderlying cause
Extracardiac – sepsisAnastomotic leak
Pulmonary
Smoking Obesity Age Home oxygen Unable to walk 1 flight of stairs w/o respiratory
compromise Major lung resection
Screen with PFTs, CXR
PFT’s
Studies demonstrate that any patient with an FEV1 greater than 2 L will probably not have serious pulmonary problems
Conversely, patients with an FEV1 less than 50% of the predicted value will probably have exertional dyspnea.
Ventilator
Criteria for Weaning From the VentilatorRespiratory rate<25 breaths/minPao2 >70 mm Hg (Fio2 of 40%)PaCo2 <45 mm HgMinute ventilation 8-9 L/minTidal volume 5-6 mL/kgNegative inspiratory force- 25 cm H2O
Case
POD #4, Whipple’sTemp, feverCXR shows collapse consolidation of
RLL consistent with pneumonia
Treat?
Community-acquired pneumonia (CAP) infection that begins outside of the hospital is diagnosed within 48 h after admission to
the hospital in a patient who has not resided in a long-term facility for 14 days or more before the onset of symptoms
Hospital-acquired pneumonia (HAP) infection of lung parenchyma occurring
more than 48 h after admission to a hospital
Empiric Therapy
HAPCefotaxime+ gentamycinTazocin
CAPFluoroquinolones
LevofloxacinMacrolides
azithromax
Postop Fever
Courtesy of DiagnosaurusWind: pneumonia, atelectasis Water: urinary tract infection Wound: wound infection
Superficial vs deepWalking: deep vein thrombosis (DVT) from
immobilization Wonderdrugs: drug feverWanes: CVL, peripheral lines
Postop Fever
Tubes: N/Gsinusitis
Surgery: anastomosisSpinal: epidural abscessCardiac – EndocarditisColorectal: perianal abscessHPB – acalalculous cholecystitis
Acute Renal Failure
Defined as urine output <25cc/hr, increasing Cr, increasing BUN
Associated mortality, >50%Differential dx
PrerenalRenalPost renal
Thyroid Storm
Thyrotoxic crisisAcute life threatening exacerbation of
thyrotoxicosisUsually in patient with discontinued
antithyroid medication or more commonly undiagnosed hyperthyroidism
Thyroid Storm
ClinicalAcute onset hyperpyrexia (temp>40 ‘C)DiaphoreticMarked tachycardia (Afib)Nausea, vomitingAgitationDeliriumTremulousness
Thyroid Storm
Precipitants:SurgeryDKASepsisMITraumaDrugs Iodinated contrast
Thyroid Storm
DiagnosisSerum T4, T3, free T4, free T3 elevatedTSH suppressed
Thyroid Storm
TreatmentABCGet help – Endocrinology/Medicine, ICUTreat the underlying causeSpecific
PropanalolPropylthiouracilMethimazoleKISteroids?
Take Home Messages
Clinical:Have a good approach to common
clinical scenariosAcknowledge your limitationsDo not hesitate to access
multidisciplinary approach
Take Home Messages
ExaminationDO NOT READ SCHWARTZ from
beginning to endOld exams
QUESTIONS?