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Postoperative comlications

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					Postoperative comlications
Lukasz Lebkowski
Possible postoperative
complications include:



•   postoperative fever
•   postoperative atelactasis
•   wound infection
•   embolism
•   deep vein thrombosis
    postoperative complications
                early
• pyrexia
• paralytic ileus
• secondary haemorrhage often as a
  result of infection
• pneumonia
• wound or anastomosis dehiscence
• deep venous thrombosis
• urinary retention
• urinary tract infection
• wound infection
• bowel obstruction due to fibrinous
  adhesions
• confusion
Postoperative pyrexia

• Pyrexia is a common
  problem seen after surgery
• Underlying cause may be
  identified clinically
  depending on:
  – Time since operation
  – Type of surgery undertaken
  – Associated clinical features
    Postoperative pyrexia. Time since
               operation.
•   Specific complications often occur at certain
    times after operation
•   The following time scales should be regarded as
    a guide and not absolute rules
•   First 24 hours
     –   Systemic response trauma
     –   Pre-existing infection
•   24 to 72 hours
     –   Pulmonary atelectasis
     –   Chest infection
•   3 to 7 days
     –   Chest infection
     –   Wound infection
     –   Intraperitoneal sepsis
     –   Urinary tract infection
     –   Anastomotic leak
•   7 to 10 days
     –   Deep venous thrombosis
     –   Pulmonary embolus
       Postoperative pyrexia.
           Investigations.
• Useful investigations may
  include:
• Chest x-ray
• ECG
• Arterial blood gases
• Ventilation / perfusion scan
• Abdominal ultrasound or
  CT scan
Wound dehiscence.
• Affects about 2% of mid-line
  laparotomy wounds
• Serious complication with a mortality
  of up to 30%
• Due to failure of wound closure
  technique
   – Broken sutures or slipped knots
   – Inadequate muscle bites
• Usually occurs between 7 and 10 days
  post operatively
• Often heralded by serosanguinous
  discharge from wound
• Should be assumed that the defect
  involves the whole of the wound
           Wound dehiscence.
             Management.
• Opiate analgesia
• Sterile dressing to wound
• Fluid resuscitation
• Early return to theatre
• Resuture under general anaesthesia
• Exact technique is variable
• Interrupted or mass closure with non-
  absorbable sutures often used
• The use of 'deep tension' sutures is
  controversial
• Believed by some to strangulate
  muscle and weaken the closure
• Also painful and associated with
  increased risk of infection
 Postoperative pulmonary complications
       Postoperative hypoxia
• Lack of alveolar ventilation
   – Hypoventilation (airway
     obstruction, opiates)
   – Bronchospasm
   – Pneumothorax
   – Arteriovenous shunting (collapse,
     atelectasis)
• Lack of alveolar perfusion
   – Ventilation-perfusion mismatch
     (pulmonary embolism)
   – Impaired cardiac output
• Decreased alveolar diffusion
   – Pneumonia
   – Pulmonary oedema
    Postoperative pulmonary complications
                          Atelectasis
•   Hypoxaemia is often seen during the first 48
    hours after most major operations
•   Due to a reduction in functional residual
    capacity
•   Significant atelectasis is more often seen
     –   In those with pre-existing lung disease
     –   With upper rather than lower abdominal incisions
     –   Obese patients
     –   Cigarette smokers
•   The basic mechanisms leading to atelectasis
    are:
     – Increased volume of bronchial secretions
     – Increased viscosity of secretions
     – Reduced tidal volume and ability to cough
     Treatment
     – Intensive chest physiotherapy
     – Nebulised bronchodilators
     – Antibiotics for associated infection
Pneumonia
• Nosocomial pneumonia occurs in 1%
  of all patients admitted to hospital
• Occurs in 15-20% of unventilated ITU
  patients
• Occurs in 40-60% of ventilated ITU
  patients
• Organisms involved include
• Gram-negative bacteria
  (Pseudomonas aeruginosa,
  Enterobacter)
• Staph. aureus
• Anaerobes
• Haemophilus influenzae
• No evidence that prophylactic
  antibiotics reduce the risk of
  pneumonia
Aspiration pneumonitis
•   Aspiration of gastric
    contents results in a
    chemical
    pneumonitis
•   Most commonly
    seen in apical
    segments of right
    lower lobe
•   If unrecognised or
    inadequately
    treated it can result
    in a secondary
    bacterial infection
•   Secondary infection
    is usually with gram-
    negative and
    anaerobic
    organisms
Perioperative cardiovascular
complications

•   Hypotension
•   Hypovolaemia
•   Ventricular failure
•   Cardiogenic shock
•   Arrhythmias
•   Conduction defects
•   Hypertension
 Causes of perioperative
 arrhythmias
• Physiological disturbances
   –   Acidosis
   –   Hypercapnia
   –   Hypoxaemia
   –   Electrolyte imbalance
   –   Vagal manoeuvres
   –   Hypovolaemia
• Pathological disturbances
   – Myocardial ischaemia or infarction
   – Pulmonary embolus
   – Phaeochromocytoma
• Pharmacological causes
   – General anaesthesia
   – Local anaesthetic toxicity
   – Positive and negative inotropes
Causes of postoperative
hypertension


•   Pain
•   Pre-existing hypertension
•   Hypoxaemia
•   Hypercapnia
•   Positive inotropic drugs
•   Hyper-reninaemia
Urinary tract infections
•   10% of patients admitted to hospital have a
    urinary catheter inserted
•   Risk of catheter-related infection depends on:
     –   Age and sex of patient
     –   Duration of catheterisation
     –   Indication for catheterisation
•   Bacterial colonisation of catheters is common
•   If catheter required for more than 2 weeks 90%
    patients will develop bacteriuria
•   Commonest organisms are enterobacter and
    enterococci
•   Does not require treatment unless patient is
    systemically unwell
•   Infection can be prevented by:
     –   Maintaining closed drainage system
     –   High infection control standards
     –   Preventing backflow from catheter bag
Postoperative confusion
•   Occurs in 10% of postoperative patients
•   Associated with increased morbidity and morality
•   Leads to increased duration of hospitalisation
•   Clinical features include
     –   Reduced level of consciousness
     –   Impaired thinking
     –   Impaired memory
     –   Perceptional abnormalities
     –   Disturbed emotion
     –   Psychomotor disturbance
Causes
• Hypoxia - respiratory disease, cardiac failure,
   arrhythmia
• Trauma - head injury
• Infection - intracranial, extracranial
• Neoplasia - primary and secondary cerebral tumours
• Vitamin deficiency - Thiamine (Wernicke's
   encephalopathy), B12 deficiency
• Endocrine - hypothyroidism, hyperthyroidism, Addison's
   disease
• Degenerative
• Vascular - CVA, TIAs
• Drugs
• Metabolic derangement