Surgical Complications

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Surgical Complications

• John Cosgrove, MD FACS
• Chairman and Residency Program Director
• Bronx Lebanon Hospital Center

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Primum no nocere

• Think before you act.

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Complications can be deadly

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

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SCIP

• Antibiotics
• Normothermia
• VTE Prophylaxis

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Morbidity and Mortality Conference

• Mainstay quality program of general surgery
  residency programs.

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Mortalities
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Morbidities

• Cardiorespiratory
• Wound
• Urinary tract

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Wound

• Seroma
• Hematoma
• Dehiscence
• Evisceration

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Wound

• Superficial
• Deep
• Organ space

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Pathogens

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

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Wound classification

• Clean
• Clean contaminated
• Contaminated
• Dirty

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Temperature regulation

• Issues of hypothermia

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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

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MH

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

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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

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Pulmonary complications

• Atelectasis
• Pneumonia
• Pulmonary embolism
• Aspiration
• Pulmonary edema
• ARDS

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Weaning criteria

• RR lt25 breaths/min
• Pa02 gt70mmHg(Fi02 of 40)
• PaC02lt45 mm Hg
• MV 8-9L/m
• TV 5-6mL/kg
• NIF -25cm H20

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Cardiac

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

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Prevention

• Major predictors of risk
• Unstable chest pain, CHF, sympotomatic
  arrhythmias, severe valvular disease

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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

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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

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Adrenal

• Chronic use of steroids causes suppression of the
  HPA axis
• Potentially life threatening
• Give 250ug cosyntropin intravenousl

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Hemodialysis indications

• Serum potassium gt5.5
• BUNgt80-90
• Persistent metabolic acidosis
• Acute fluid overload
• Uremic symptoms(pericarditis, encephalopathy,
  anorexia)
• Removal of toxins
• Platelet dysfunction
• Hyperphosphatemia with hypercalcemia

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SIADH

• Common cause of chronic normovolemic hyponatremia
• Serum sodiumlt135
• Treat underlying disease process
• Fluid restriction
• Rapid correction may result in seizures

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Gastrointestinal

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

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Anastomotic leak

• Strategies for prevention
• Low anterior resection

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Enterocutaneous fistula

• Low output lt200 cc/24h
• Moderate 200-500 cc/24 h
• High gt500 cc/24 h

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The Checklist

• Provonost
• Gawande

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Airline Industry

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

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Universal Protocol

• Preprocedure Verification
• Presurgical timeout
• Post procedure debriefing

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Prospective Case Conference

• Dr. Judson Randolph
• 1988-Childrens Hospital Center, Washington, DC
• A priori discussion of all upcoming pediatric
  surgery cases involving multiple disciplines

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Interdisciplinary teamwork

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

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Never events

• CMS