Post operative complications(1).ppt

1、Post operative complications,Ghiath Al Saied,How common are post operative complications,Pick post operative complications Incisional Pain conversion from laparoscopic to open Prolonged surgery/prolonged hospitalization Vomiting 3 hours after hernia surgery Wound opening at day 7 Asthma exacerbation

2、 Cancer recurring after 4 months?,Monitoring,Clinical CNS (pain, LOC, GCS) Resp (auscultate, RR, distress, cough, sats) CVS (BP, HR, skin, urine output, Hg) Renal(urine output, Cr, BUN, hematuria) GI (BM/flatus, N/V, distension, pain, NG output, drains) Heme(fever, skin color),Monitoring,By ancillar

3、y measures CNS (ICP monitor) Resp (CXR, O2 sats, ABGs) CVS (JVP/CVP, swan) Renal(Cr, BUN, sodium excretion ratio) GI (Abdo xray/CT) Heme/ID(WBC, Hg, Plt, coagulopathy, blood film, cultures),Case 1,26 year old surgery resident post operative day 2 small bowel resection No past medical hx Resection fo

4、r meckels, acute Midline laparotomy Vomited 3 times,Case 1 Hx,Vomiting Green, large, relieved abdominal distension 1.5 L No other vitals changed No fever, no abdo pain, but some cramps Dx?,GI Comps,Nausea and vomiting Early is due to anesthesia and medications Late is due to post operative ILEUS SB

5、quickest to return (almost immediately) Stomach with 48 hours Colon up to 5 days ANY LONGER is definitely an ileus,GI Comps,Causes of ileus ?Normal Electrolytes (Hypokalemia most common) Diabetes Intra-abdominal infection Existing intestinal problem Need to differentiate from early SBO,GI Comps,Comp

6、lications of ileus Aspiration Malnutrition Abdominal distention wound stress Respiratory function decline poor cough infc Prolonged hospital stay Prevention/Rx Treat cause (fix Dm, fix lytes, drain abscesses) Gentle tissue handling Time/nutrition (Ambulation),Case 2,57 yo post laparotomy for spleene

7、ctomy (ITP) Past Hx smoker, diabetic Good respiratory function preop Normal ECG Post operative day 1 Tachypnea (32) fever (38.0), tachycardia 110, and need for O2 (4 L) Differential (give me 10),Resp complications,Major clinically significant complications: Atelectasis Infection (incl pneumonia and

8、bronchitis) Exacerbation of underlying chronic lung disease Hypoxia - Respiratory failure - Difficulties weaning Bronchospasm,Resp complications,also: Upper airway obstruction Pleural effusions Chemical (aspiration) pneumonitis Non-cardiogenic pulmonary edema/ARDS Tracheal laceration/rupture Pulmona

9、ry Embolism,Resp complications,Very common Pain is a major factor Immobility Ciliary dysfunction Smoking: Increased risk of pulmonary complications, even in absence of chronic lung disease 3- to 4-fold reduction in complication rate if smoking cessation 8 weeks,Resp complications,Prevention of posto

10、perativepulmonary complications:,Post-operative measures which are benificial: Deep breathing exercises incentive spirometry in high risk patients Epidural analgesia in lieu of parenteral opioids Epidural analgesics reduce the incidence of pulmonary complications compared to parenteral opioids (HR 0

11、.51- 0.58) Intercostal nerve block (?superior to traditional parenteral analgesics?) CPAP: may decrease the incidence hypoxia and need for intubation in patients who develop PaO2/FiO2 300 following abdominal surgery Early patient mobilization and ambulation,Case 3,Post operative Day 1 perforated app

12、endix 14 year old Fever 38.4 RR 38 HR 145 BP 80/40 Differential,CVS complications,Differential?,CVS,Bleeding Pale, cool extremities, pale conjunctiva, Hypotension and tachycardia Septic shock Flushed, warm extremities, hyperactive circulation HypoBP and tachy,CVS,JVP will be ? Rx?,Case 4,Post umbelical hernia POD 3 with pus from wound Red, tender, swallen, slight fever Dx: infection DDx? ,Wound infection,Factors to increase wound infection POD1 infection POD 4 infection,Urinary output,What is the fluid