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POSTOPERATIVE COMPLICATIONS

POSTOPERATIVE COMPLICATIONS. Samaad Malik, MD, MSc, FRCSC Clinical Fellow, CMAS McMaster University August 20, 2008. Objectives. Case Based Clinical Approach Examination Preparation. POS Question sample. 1. What enzyme facilitates access of snake venom into the human lymphatics?

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POSTOPERATIVE COMPLICATIONS

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  1. POSTOPERATIVE COMPLICATIONS Samaad Malik, MD, MSc, FRCSC Clinical Fellow, CMAS McMaster University August 20, 2008

  2. Objectives • Case Based • Clinical Approach • Examination Preparation

  3. POS Question sample • 1. What enzyme facilitates access of snake venom into the human lymphatics? • Hyaluronidase • Peroxidase • Acethycholinesterase • Crotalase

  4. We shall not cease from exploration And the end of all our exploring Will be to arrive where we started And know the place for the first time. T.S. Eliot

  5. Surgical Complications • Surgical Wound Complications • Complications of Thermal Regulation • Pulmonary Complications • Cardiac Complications • Renal and Urinary Tract Complications • Endocrine Complications • Gastrointestinal Complications • Hepatobiliary Complications • Neurologic Complications • Ear, Nose, and Throat Complications

  6. Approach • Page • Elevator thoughts • Quick Bedside Look • ABC • Selective H+P • Management

  7. Case • 85 yo elderly male • POD #3 Laparoscopic Colectomy • Painful R cheek while eating

  8. What are your thoughts? • Diagnosis • How do you want to proceed?? • Treatment

  9. Parotitis • Decrease in the secretory activity of the gland with inspissation of parotid secretions that become infected by staphylococci or gram-negative bacteria from the oral cavity

  10. Parotitis • Potentially serious • Elderly • Poor oral hygiene • Poor nutritional state • Dehydration

  11. Post operative Parotitis • Results in inflammation, accumulation of cells that obstruct large and medium-sized ducts, and, eventually, formation of multiple small abscesses • These lobular abscesses, separated by fibrous bands, may dissect through the capsule and spread to the periglandular tissues to involve the auditory canal, the superficial skin, and the neck • If the disease is not treated at this stage, it may produce acute respiratory failure from tracheal obstruction

  12. ORAL HYGIENE?

  13. Diagnosis • Clinical • Pain or tenderness at the angle of the jaw • Swelling and redness in the parotid area • High fever and leukocytosis develop • Investigations • Ultrasound

  14. Treatment • Clindamycin/Vancomycin should be started while the results of cultures are awaited • Warm moist packs and mouth irrigations may be helpful • Rehydrate

  15. Case • 68 yo male • POD #1 Lap APR • Desaturated to 85% • What are your thoughts?

  16. Case • Approach • ABC • Hx and Px • Investigations • Bloodwork • CEA • Consultation

  17. Thromboembolisms • Mechanisms: • Alterations in normal blood flow • Injuries to vascular endothelium • Alterations in the constitution of blood

  18. Symptoms and Signs of Pulmonary Embolism • Pleuritic chest pain[*]   • Sudden Dyspnea[*]   • Tachypnea   • Hemoptysis[*]  • Tachycardia[*]   • Leg swelling[*]  • Pain on palpation of the leg[*]  • Acute right ventricular dysfunction  • Hypoxia   • Fourth heart sound[*]  • Loud second pulmonary sound[*] • Inspiratory crackles[*]

  19. Investigations • CXR, ECG, ABG • D-dimer • CT scan • V/Q scan • Duplex U/S • Pulmonary Angiogram • Echo

  20. Treatment • Depends on hemodynamic stability • Unstable • Get help • Thrombolytics? • Stable • Anticoagulate • intrinsic fibrinolysis restores pulmonary blood flow

  21. Heparin • Complications • BLEEDING • osteoporosis • HIT • No increased risk of bleed • INCREASED risk of Thrombosis • BOTH ARTERIAL AND VENOUS • Increased for a period of 1 month

  22. Heparin • Prevents formation of new thrombi and stops propagation of thrombi • Enhances antithrombotic activity of antithrombin III • Contraindications • Consider IVC filter • Overt bleeding

  23. HIT • can occur with LMWH as well • Usually after 5-10 days

  24. HIT • Treatment • Get help – Hematology • Discontinue Heparin • Other anticouagulants • Argatroban • Danaparoid

  25. IVC Filter placement • Indications • Recurrent PE despite adequate anticoagulation • Contraindications to anticoagulation

  26. DVT • Investigations • presentations • management • medical

  27. Mortality no h/o MI 1-1.2% 6 or more months 6% 3 months 16-37% age more than 70 AS medical conditions emergency operations Intraoperative hypotension Preoperative CHF Preoperative Hypotension Angina Cardiac

  28. Cardiac Pearls • Inpatient HR 101 • Intravascular volume depletion till proven otherwise • Pain • Fever

  29. Case • 67 yo female • POD #3, Ivor Lewis Esophagectomy • HR= 168 • BP= 80/60 • What to do next?

  30. Approach • ABC • ACLS protocol • Call for help!!

  31. Catch! • Cardiac Arrythmias • Underlying cause • Extracardiac – sepsis • Anastomotic leak

  32. Pulmonary • Smoking • Obesity • Age • Home oxygen • Unable to walk 1 flight of stairs w/o respiratory compromise • Major lung resection • Screen with PFTs, CXR

  33. PFT’s • Studies demonstrate that any patient with an FEV1 greater than 2 L will probably not have serious pulmonary problems • Conversely, patients with an FEV1 less than 50% of the predicted value will probably have exertional dyspnea.

  34. Ventilator • Criteria for Weaning From the Ventilator • Respiratory rate<25 breaths/min • Pao2 >70 mm Hg (Fio2 of 40%) • PaCo2 <45 mm Hg • Minute ventilation 8-9 L/min • Tidal volume 5-6 mL/kg • Negative inspiratory force- 25 cm H2O

  35. Case • POD #4, Whipple’s • Temp, fever • CXR shows collapse consolidation of RLL consistent with pneumonia • Treat?

  36. Community-acquired pneumonia (CAP) • infection that begins outside of the hospital • is diagnosed within 48 h after admission to the hospital in a patient who has not resided in a long-term facility for 14 days or more before the onset of symptoms

  37. Hospital-acquired pneumonia (HAP) • infection of lung parenchyma occurring more than 48 h after admission to a hospital

  38. Empiric Therapy • HAP • Cefotaxime+ gentamycin • Tazocin • CAP • Fluoroquinolones • Levofloxacin • Macrolides • azithromax

  39. Postop Fever • Courtesy of Diagnosaurus • Wind: pneumonia, atelectasis • Water: urinary tract infection • Wound: wound infection • Superficial vs deep • Walking: deep vein thrombosis (DVT) from immobilization • Wonderdrugs: drug fever • Wanes: CVL, peripheral lines

  40. Postop Fever • Tubes: N/G • sinusitis • Surgery: anastomosis • Spinal: epidural abscess • Cardiac – Endocarditis • Colorectal: perianal abscess • HPB – acalalculous cholecystitis

  41. Acute Renal Failure • Defined as urine output <25cc/hr, increasing Cr, increasing BUN • Associated mortality, >50% • Differential dx • Prerenal • Renal • Post renal

  42. Thyroid Storm • Thyrotoxic crisis • Acute life threatening exacerbation of thyrotoxicosis • Usually in patient with discontinued antithyroid medication or more commonly undiagnosed hyperthyroidism

  43. Thyroid Storm • Clinical • Acute onset hyperpyrexia (temp>40 ‘C) • Diaphoretic • Marked tachycardia (Afib) • Nausea, vomiting • Agitation • Delirium • Tremulousness

  44. Thyroid Storm • Precipitants: • Surgery • DKA • Sepsis • MI • Trauma • Drugs • Iodinated contrast

  45. Thyroid Storm • Diagnosis • Serum T4, T3, free T4, free T3 elevated • TSH suppressed

  46. Thyroid Storm • Treatment • ABC • Get help – Endocrinology/Medicine, ICU • Treat the underlying cause • Specific • Propanalol • Propylthiouracil • Methimazole • KI • Steroids?

  47. Take Home Messages • Clinical: • Have a good approach to common clinical scenarios • Acknowledge your limitations • Do not hesitate to access multidisciplinary approach

  48. Take Home Messages • Examination • DO NOT READ SCHWARTZ from beginning to end • Old exams

  49. QUESTIONS?

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