Postoperative complications II
General Principles of Surgery
Dr. Badri Kobalava
bkobalava@newvision.ge
https://sites.google.com/newvision.ge/bkobalava
Postoperative complications
Postoperative parotitis
● Poor oral hygiene
● Dehydration
● Decrease in the secretory activity
● Inspissation of parotid secretions
Staphylococci or gram-negative
bacteria from the oral cavity.
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Postoperative parotitis
● Pain or tenderness at the angle of the
jaw.
● High fever and leukocytosis
● Swelling and redness in the parotid area.
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Postoperative parotitis
● Multiple small abscesses
● Periglandular tissues
● Superficial skin and the neck
● Acute respiratory failure from
tracheal obstruction
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Postoperative parotitis
Prophylaxis
Treatment
● Adequate fluid intake
● Avoiding the use of anticholinergics ● Antibiotics
○ Culture
● Minimizing trauma during intubation
○ Vancomycin
● GOOD ORAL HYGIENE (frequent
gargles, mouth irrigation, and other ● Warm moist packs
mouth cleansing and moistening) ● Mouth irrigations
● Stimulation of salivary flow with ● Surgical draining
chewing gum, hard candy, etc ○ Incisions parallel to the branches of the
facial nerve.
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GASTROINTESTINAL
MOTILITY DISORDERS
● Anesthesia and surgical
manipulation→postoperative ileus
● Opioids 24h
● Electrolyte abnormalities
● Inflammatory conditions
● Abdominal distention
● Absent bowel sounds
● Mild cramps 12h
● Passage of flatus
● Return of appetite
48h 72h
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Gastric dilation
Massive distention High intragastric
of the stomach by pressure
gas and fluid
Venous obstruction
of the mucosa,
Stomach hangs Peritonitis
down across the Ischemic necrosis
duodenum and perforation.
Bleeding
The distended
stomach pushes
Respiratory failure
Mechanical gastric the diaphragm
outlet obstruction upward
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Gastric dilation
● Pressure of gastric contents on mucosa
● Compression of veins in submucosa
● Gastric wall ischemia → necrosis
● Perforation
● Peritonitis
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Gastric dilation
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● Gastric dilation
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Gastric dilation
Symptoms Treatment
● Abdominal distention ● Decompression with a
● Hiccup. nasogastric tube
● Hypochloremia, hypokalemia, ● Gastric necrosis→gastrectomy
and alkalosis
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Paralytic ileus
● Decreased peristalsis
● Paralytic ileus
● Opioids decrease GI motility
● NG tube
● Return of appetite
● Audible peristalsis
● Passage of flatus
NORMAL ABDOMIONAL X-RAY
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Mechanical obstruction
● Postoperative adhesions
● Internal (mesenteric) hernia
NORMAL ABDOMIONAL X-RAY
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Bowel Obstruction
Intestinal adhesions
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Intussusception
Intussusception
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Postoperative Fecal Impaction
● Colonic ileus
● Impaired perception of rectal fullness
● Elderly
● Opioid analgesics and anticholinergics
● Barium remaining in the colon
Rectal examination
Enemas and purgation
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Postoperative pancreatitis
● Trauma to the pancreas or its blood supply
● Operations in the vicinity of the pancreas
● Operations on the biliary tract
● Corticosteroids or azathioprine
● Hyperparathyroidism
● Viral infection - Acute changes in calcium
Postoperative pancreatitis is frequently of the necrotizing or hemorrhagic type
● Hyperamylasemia
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Hepatic encephalopathy
Amino acids ⇨ Ammonia ⇨ Liver ⇨ urea ⇨ excreted into the intestines or urine. 19
Portal Hypertension
Caput Medusae
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Postoperative Hepatic Dysfunction
HEME
Biliverdin
Unconjugated Kidney
bilirubin
Conjugated bilirubin
Liver Enterohepatic
circulation
Urobilinogen
Urobilinogen
Urobilin
Stercobilin
Colon 21
● Prehepatic jaundice (bilirubin overload)
○ Hemolysis (drugs, transfusions, sickle cell crisis)
○ Reabsorption of hematomas
● Hepatocellular jaundice (Hepatocyte insufficiency)
○ Viral hepatitis
○ Drug-induced (anesthesia, others)
○ Ischemia (shock, hypoxia, low-output states)
○ Sepsis
○ Liver resection (loss of parenchyma)
○ Others (total parenteral nutrition, malnutrition)
● Posthepatic jaundice (Obstructive to bile flow)
○ Retained stones
○ Injury to ducts
○ Tumor (unrecognized or untreated)
○ Cholecystitis
○ Pancreatitis
○ Occlusion of biliary stents
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CLOSTRIDIUM DIFFICILE COLITIS
● Diarrhea, fever, nausea, and abdominal pain • Handwashing, minimizing antibiotic use.
● Identification of a specific cytopathic toxin in the • Treatment: metronidazole or oral vancomycin.
stool or culture of the organism from stool
samples or rectal swabs.
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Postoperative
Urinary Retention
● Postoperative Urinary Retention
● Pelvic operations
● Spinal anesthesia
Prophylactic bladder
● Bladder overfilled (> 500 mL) catheterization
● Prostate adenoma 24
Postoperative Cerebrovascular Accidents
● Ischemic neuronal damage due to ● Irreversible brain damage occurs
poor perfusion during or after after about 4 minutes of total
surgery ischemia.
● High risk:
○ Elderly patients with severe ● Aspirin for prevention
atherosclerosis (Embolization from
::
atherosclerotic plaques)]
■ Carotid bruit ● Seizures
■ Previous stroke or transient ischemic attacks ○ Epilepsy
and postoperative atrial fibrillation
○ Hypocalcemia after thyroid or parathyroid
○ Atrial fibrillation
surgery
○ Hypotension (mean pressure <55 mmHg)
○ Liver of kidney failure and medications
○ Carotid endarterectomy, clamping of
aorta or carotid, open heart surgery using
extracorporeal circulation
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Postoperative psychosis
● Mood disturbances - depression ● Elderly,
● Delirium
● History of depression or chronic
● Visual hallucinations and the "black patch
syndrome“ pain
● Meperidine, cimetidine, and
Anxiety and fear are normal corticosteroids
● Motivation for surgery in
schizophrenics
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THE ICU SYNDROME
● Environmental Causes ● Medical Causes
○ Sensory deprivation - no windows, away from ○ Pain which may not be adequately controlled in
family, friends, and all that is familiar and an ICU
comforting. ○ Critical illness: The pathophysiology of the
○ Sleep disturbance and deprivation: The disease, illness or traumatic event can cause a
constant disturbance and noise variety of symptoms.
○ Continuous light levels: Continuous disruption ○ Medication (drug) reaction or side effects
of the normal biorhythms ○ Infection creating fever and toxins in the body.
○ Stress: Patients in an ICU frequently feel the ○ Metabolic disturbances:
almost total loss of control over their life. ■ Electrolyte imbalance,
■ Hypoxia
○ Lack of orientation: A patient's loss of time and ■ Elevated liver enzymes.
date. ○ Dehydration
● POSTCARDIOTOMY DELIRIUM
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Delirium tremens
● Alcoholics who stop drinking suddenly ● Personality changes, anxiety, Tremor
● Readaptation to ethanol-free metabolism ● Hallucinations, restlessness, confusion,
requires about 2 weeks overactivity
● Seizures
● Hyperthermia, diaphoresis and dehydration
● Hyperdynamic cardiorespiratory and
● Prevention – small doses of alcohol metabolic
● Dehiscence of a fresh laparotomy incision
● Treatment
○ Nutrition
○ Benzodiazepines
○ Vitamin B (thiamine)
○ Magnesium sulfate
○ Rehydration
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SEXUAL DYSFUNCTION
• Prostatectomy
• Abdominoperineal resection
• Heart and aortic surgery
• Injury to the peripheral branches of the
sacral plexus
• Psychogenic
• Etiology is unclear.
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Air embolism
● Air lodges in the right atrium,
● Hypotension, jugular venous distention,
and tachycardia.
● Prevention - Trendelenburg position
during insertion of central line
● Aspiration of the air with a
● syringe.
● Right side up and head down
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Phlebitis
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Phlebitis
● Triad ● Suppurative phlebitis
○ Induration, ○ Infected thrombus
○ Staphylococci
○ Edema ○ High fever and positive blood cultures
○ Tenderness
● Aseptic techniques
Incision
● Frequent change of tubing (ie,
every 48–72 hours),
● Rotation of insertion sites
● Hypertonic solutions
● should be infused only into veins
with substantial flow
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Ischemic Necrosis of the Finger
After insertion of a radial or femoral
arterial line
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● Evaluating the patency of the ulnar artery ● Modified Allen test
(Allen test) before establishing the radial ○ The hand is elevated and the patient is
line asked to clench their fist for about 30
● Changing arterial line sites every 3-4 days. seconds.
○ Pressure is applied over the ulnar and the
radial arteries so as to occlude both of them.
○ Still elevated, the hand is then opened. It
should appear blanched (pallor may be
observed at the finger nails).
○ Ulnar pressure is released while radial
pressure is maintained, and the colour
should return within 5 to 15 seconds.
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