Escolar Documentos
Profissional Documentos
Cultura Documentos
General / Specific
Immediate / Early / Late
Anaesthetic / Surgical / Combined
Risk Factors
Patient
-
Presentation
o Age
o Co-morbids
smoking history and pre-existing respiratory disease
Obesity
CVD and PVD
Diabetes
Immune status (includes steroid and immune suppression therapy)
Other drug therapy (aspirin, antiplatelet, antibiotic therapy, NSAID agents or substance
abuse) include alcohol
Renal disease
Metabolic factors including nutritional status
Presence of infection
Need for blood transfusion
o Uncomplicated/Complicated (Re-operative_
o Elective/ Urgent
Pathology
o Bening/Malignant/Infective
Type and complexity of surgery (includes re-operation) -> expose pt to higher risk of wound/healing
challenges
Timing of surgery: Elective / urgent / emergency allow less time for pre-operative preparation
Surgery for trauma grater tissue trauma/contamination
Surgical approach: Open / minimally invasive lower incidence of complications
Duration of procedure longer op, increases risk of infection
Surgeon skill /case volume
Anaesthetic issues
Managing these issues
1)
2)
3)
4)
5)
Good handover
Prioritise
Seek help if swamped
Go and see patient
Turn the lights on so you can
adequately assess the patient
Post-operative complications
General
-
Pain
Nausea and vomiting
Haemorrhage
Respiratory
Cardiac Wound
Fever/Sepsis
o Wound
o Pneumonia
o UTI
o Surgical Site
Abscesses
Prosthesis (grafts, valves, joints etc)
o Drip site
o Gastrointestinal
o Neurological/cerebrovascular
o Renal /Urinary
o VTE (DVT & PE)
o Vascular
o Electrolyte disturbance
o Metabolic
Day 5/10
Think
- Residuum of contaminated operative site.
- Reactive to blood/blood products transfusion
- Phlebitis
- Atelectasis (common)
Think: pulmonary origin
- Inhalation pneumonia
- Mendelson syndrome : chemical pneumonitis
due to aspiration esp in preggers pt
- Lobar collapse/developing pneumonia
Then think: Urinary tract especially catherised patient
- Wounds and surgical sites
- Lines. Catheters and ports
Think
- Hidden abscess (Subphrenic/Pouch of Douglas)
- Spiking pyrexia gravity allows collection into
most posterior part of body
- DVT/PE
- Prosthetic infection
- C/difficile colitis (if diarrhoea present)
Post-operative pneumonia
-
Area in left mid-zone, semi-opacified. Elevation of lefthemidiaphragm normally sits lower than right, loss of lung
volume indicating significant atelectasis
Mid zone opacity, lower lobe unaffected but pathology in upper lobe
Right upper lobe pathology also raise possibility of inhalation
Post-operative pneumonia
Treatment:
-
o
o
o
Appearance of pneumothorax in lower costal phrenic region in right lung in inspiratory film but large defect
in expiatory film
Tension pneumpthroax
Aspiration pneumonia
-
Fat embolism
-
Wound complications
Early
-
Haematoma
o Vary from suffusion through tissue to large collection needing evacuation to avoid risk of secondary
infection
Infection/abscess
o
Predisposing factors
Trauma and contaminate wound
Duration and nature of surgery
immune compromise/chronic disease/ malnourished
Pre-existing ulcers/infection
Ischaemic tissue
o Signs and symptoms often first presentation
Pain, red, swelling,
Unexpected level of pain often first presentation
o Superficial
o Deep
o When to use prophylactic antibiotics
When risk of infection is significant without their use
When consequences of infection would be catastrophic even though the risk is low
6Rs
Right patient
Right drug
Right dose
Right route
Right timing of administration
Right duration of prophylaxis/therapy
Necrosis
o Ischemia leads to skin necrosis if skin has been approximated too tightly
o Require skin grafting
Necrotizing fasciitis
o Strep pyrogens, staph aureaus
o Clostridium perfringes, bacteroides fragilis
Lymph fistula
Wound Seroma
o Lymphatic disruption mainly causation
o Remember other conditions can contribute to development of seroma
Myeloproliferative/haematological disorders
Coagulopathies
Cardiac disease
o Treatment drainage
Wound
Classification
Definition
Expected SSI
rate without
prophylaxis
1-2%
Expected SSI
with
prophylaxis
2.1%
Clean
Clean
contaminated
5-10%
3.3%
Contaminated
15-20%
6.4%
Dirty
40%
7.1%
Common areas
Post breast surgery
After axillo-fermoral bypass
Dehiscence
o Partial
o Compound infection plete
o Contributory factors to wound dehiscence
Wound infection
Obesity
Diabetes
COAD
Malnutrition
Malignancy/immune suppression
Poor technique
o Presentation
Sero-sanguinous fluid leak (85%) despite apparent healing of skin (skin more vascular
than subcutaneous tissue and heals better)
Treatment, sterile moist towels. Ideally return to OT and wash and re-suture
Evisceration No evisceration and poor health: sterile dressing and allow to granulate
Incisional hernia
Wound bone
Keloid hypertrophic scar growing beyond boundaries
Post-operative confusion
o Infection
o Hypoxia (pulmonary, cardiac)
o Acid/base disturbance/metabolic: renal/bowel/muscle
o Drug related
Anaesthetic
Narcotics
Diuretics
Antihypertensive
Sedatives
Anti-epileptics
o Drug withdrawal (alcohol, benzodiazepines)
o Cerebro-vascular CVA
Perioperative myocardial infarction
o
o
o
o
o
o
Cardiac MI
MI at risk patient
Goldman criteria, Eagle criteria
Arterial surgery
Valve disease
Previous cardiac event
SOBOE, PND, angina
MI treatment
Correct volume load and Hb
Beta-blockade, GTN
Heparin
Oxygen
Emergency PTCA or CABG
Peri-operative
MI risk
27%
11%
5%
Revised Goldman Cardiac Risk Index Independent predictors of major cardiac complications
-
Eagle criteria
-
Q Waves on ECG
Hx of angina
Hx of ventricular ectopy requiring treatment
DM requiring therapy other than diet
Age above 70years
Gastrointestinal complications
-
0 RF: 0.4%
1 RF: 1/0%
2 RF: 2.4%
3+RF: 5.4%