Patient Safety, Errors and

Complications in Surgery

Facebook: Happy Friday Knight

Department of Surgery
Thailand
The Science of Patient Safety
 High Reliability Organization
• High-risk system:
– Have a potential to create a catatrophe
– Complex and poorly understood
– Tightly coupled
• However, the theory suggests that proper
oversight of people, process, and technology
can keep the errors low
Conceptual Model
• Structure: Do the right tools, equipment, policies exist?
• Process: Are the right tools, equipment, and policies being
used?
• Outcome: How often are the patients harmed?
Creating a Culture of Safety
Teamwork and Communication
Risk Management
Complications
 Central Venous Access Catheters
• Common
• Ultrasound before placement
• Steps to decrease the complications:
– Indication?
– Experience? Supervision needed?
– Proper position and sterile technique
– Use ultrasound
– Exchanged only for specific indication
– Remove as soon as possible
 Central Venous Access Catheters
• Pneumothorax
• Arrhythmia
• Arterial puncture
• Lost guidewire
• Air embolus
• Pulmonary artery rupture
• CRBSI
 Arterial Line
• Thrombosis
• Bleeding
• Hematoma
• Arterial spasm
• Infection
• Pseudoaneurysm
• AVF
 Endoscopy and Brochoscopy
• Perforation: higher incidence when biopsy is
performed
– Presents with abdominal pain and clinical course
may take 24 – 48 hrs
• In Bronchoscopy include bronchial plugging,
hypoxemia, pneumothorax, lobar collapse,
bleeding
 Tracheostomy
• For the most dramatic: tracheoinnominate
artery fistula (TIAF)
– Can occur 2 day to 2 months after tracheostomy
performed
– Emergency management: remove tracheostomy,
digital pressure on tracheostomy site and
innominate artery while preparation for definite
management
Percutaneous Endogastrostomy (PEG)

• Misplaced
– can cause intraabdominal sepsis
– Require alternate feeding tube, usually
jejunostomy
 Tube Thoracostomy (ICD)
• Inadequate analgesia
• Incomplete penetration to pleura causing
subcutaneous track formation
• Lung and diaphragm laceration
• Intraperitoneal placement
• Bleeding
 Angiography
• Intramural dissection
– Cause stroke, mesenteric ischemia, or blue to
syndrome
– Management: anticoagulation, surgery
• Bleeding from vascular access site
• Renal complications
– IV hydration
Organ System Complications
 Neurologic
• Motor or sensory deficit
• Mental status change
• Neurapraxia secondary to improper positioning
during operation
• Direct injury to nerves
• Hypotension and hypoxemia: causes of
cerebrovascular accident in atherosclerotic
patients
 Eyes, Ears, Nose
• Corneal abrasions
• Epitaxis from NG tube insertion
• Ototoxicity from aminoglycoside – 10%
 Thyroid and Parathyroid Glands
• Hypocalcemia
• Recurrent laryngeal nerve injury
• Superior laryngeal nerve injury: loss of
projection of the voice
 Respiratory
• Factors that cause pulmonary problems in surgical
patients: malnutrition, inadequate pain
control/mechanical ventilation/pulmonary toilet,
and aspiration
• Pneumothorax and hemothorax
• Atelectasis
• Pneumonia
• ALI/ARDS
• PE
 Cardiac
• Arrhythmia
– Most common: AF
– Treatment: CCB, BB
• Cardiac ischemia
 Gastrointestinal
• Postoperative ileus
– Excessive narcotic use may delay bowel function
– Limitation use of NG and early feeding: earlier
return function
• Small bowel obstruction: adhesion, technical
errors, infection and abscess
• Fistulae: FREINDS
• GI bleeding: poorly tied suture, nonhemostatic
staple line, missed injury
 Hepatobiliary-Pancreatic
• Usually due to technical errors
• Ischemic injury of CBD
• Bile leak
• Hyperbilirubinemia
• Pyogenic liver abscess
• pancreatitis
 Renal
• Prerenal/renal/postrenal failure
• Oliguria: initially evaluated by flushing the
urinary catheter
• CIN
• Nephrotoxic ATN: aminoglycoside,
vancomycin, furosemide
 Musculoskeletal
• Compartment syndrome
• Decubitus ulcer
• Contractures
 Hematologic
• Keeping Hct 30% is no longer value
• Symptomatic anemia, significant cardiac
disease, critically ill, other than these “the
decision to transfuse should generally not
occur until the hemoglobin level reached 7
mg/dL or Hct 21%”
 Hematologic
• Transfusion reaction
• Infectious complications from blood
transfusion: bacteria and viruses
• thrombocytopenia
 Abdominal Compartment Syndrome

• >20 mmHg: intraabdominal hypertension

• > 25 mmHg: with one of the following:
– Compromised respiratory ventilation
– Oliguria
– Increasing intracranial pressure
Require open abdominal incision to release the
abdominal fascia
 Drain Management
• Indications:
– To collapse surgical dead space
– To provide focused drainage of abscess
– Early warning notice of a surgical leak (bowel
contents, secretion, air, urine, blood): sentinel
drain
– To control an establish fistula leak
 Drain management
• Open drain
– Use for large contaminated wound:
perirectal/perianal fistula, subcutaneous abscess
cavities
– Prevent premature closure of cavity
• Closed suction drainage system
– More common in surgical site
– Whether protect anastomosis or create a suction
injury
Metabolism-Related Complications
• No need for stress dose steroid if the patients
receive 5 – 15 mg/day of prednisolone
• For patients with prednisolone > 20mg/day =>
stress dose for 2 days
• Adrenal insufficiency
– Presents with hypotension not response to fluid
resuscitation
• Thyroid hormone abnormalities
 Hypothermia
• Core temperature is less than 35oC
• Trauma: vicious cycle
• Coagulopathy
• Cardiac abnormality: bradycardia
• Renal dysfunction: paradoxic polyuria
• Neurologic dysfunction: coma
• Induced hypothermia still had poor outcome
• Treatment: rewarming by warm air and blanket,
IV, NG, ICD, peritoneal lavage, and ECMO
 Hyperthermia
• Core temperature > 38.6oC
• Environmentally induced: summer heat
• Iatrogenically induced: heat lamps,
medications
• Endocrine in origin: thyrotoxicosis
• Neurologically induced: hypothalamus
 Hyperthermia
• Malignant hyperthermia
– After exposure of succinylcholine and halothane-
based inhalational anesthetics
– Treatment: Dantrolene, aggressive cooling
• Thyrotoxicosis
– Thyroid storm can occur when patient going
surgery with unrecognized or inadequate treated of
Graves’ disease
 References
Brunicardi FC et al. Schwartz’s Principles of
Surgery. 10th ed. McGraw-Hill Education, 2015.

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ั น์ ลลม
53: Fundamental Surgical Science. กรุงลทพฯ: กรุงลทพ
ลวชสาร, 2558. หน้ า 424-465, 537-562