Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Common Complications in Surgery Assoc. Prof Hamish Ewing The Northern Hospital October 2008 “The Ward Round” Avoid complications by anticipating them • • • • • • • • • Vital signs Chest Operation site care Fluid balance Medications VTE prophylaxis Diet (ERAS/enteral/parenteral) Pressure care Psyche Complications of Surgery General & Local GENERAL • Respiratory • Haemorrhage (primary/reactionary/secondary) • Urinary • Thrombosis • Electrolyte imbalance • Pressure sores • Faecal impaction/Diarrhoea LOCAL • Wound infection • Wound haematoma • Wound dehiscence • Intra-abdominal abscess • Enteric fistula • Drain tube issue What to do? “Simple” wound infection • Recognition • Management? Management of wound infection -open wound at point of discharge or fluctuance -simply undertaken in ward/OOPD setting by: removing some/all sutures insert tips of artery forceps open and allow pus to drain freely analgesia not usually necessary insert small gauze wick to keep skin edges apart antibiotics only if toxic or marked spreading cellulitis send pus M&C in case of ongoing issues More “complex” infection • What is the issue here? Pulse 125 BP 90 systolic Shallow breathing Looks moribund . What to do? This is ‘gas gangrene’ • • • • • Resuscitate/ICU (Gram positive spore forming rods) Gram stain High dose penicillin Debride ALL dead tissue in theatre Consider hyperbaric oxygen Wound Dehiscence • Superficial • Deep Superficial dehiscence Healing by ‘second intention’ Deep wound dehiscence • Deep layers give way ……”pink sign”may precede ? Case 1 • Mr.W is a 73 yr. old under your care following an anterior resection for cancer. • Surgery Friday 23/11/07 • Managed in HDU over weekend, returns Unit D Sunday evening, all stable and looks great. Monday (day 3)commences free fluids Tuesday (day 4) is off food and feels full. Q. How to assess this? Case 1 ……p.2 • • • • • TPR chart Only change minor rise pulse to 98 from 80 Temp. 37.5 several days now Abdomen a little distended and silent No drain tube ………….what to do? • Suspect intra-abdominal mischief, leak/abscess Case 1…..p3 • Today Wed. (day 5) patient now looks unwell.. • Obs. P 110, sweaty, lower abdominal pain, silent distended abdomen, T38.5 • Your approach? • …………………………………… Case 1 ……….p4 • CT scan reveals a little free gas and large volume intraperitoneal fluid. • Laparotomy and Hartmann’s procedure • Gets home after 3 weeks, but,…now has stoma Case 1 ………summary • Normal - management of feeds. Lot of surgeon difference. Lot of evidence shows improved results with early (Day 1) feeding. • Normal management drains. Surgeons vary. Common to leave until bowels open. • Daily round review routine? Must check TPR, chest, abdomen, I/V site and Fluid balance & electrolytes • Newspaper and glasses? Good sign if present, worry if disappears! Case 2 • 42 yr old woman admitted acute cholecystitis Friday evening. • Only issue is pain RUQ • Kept fasted over weekend as hopeful of emergency cholecystectomy • In fact still nil by mouth (NBM) Tuesday round. • Noted to have had temp 38.5 overnight. • Your approach? Case 2 …...p2 • TPR chart • Full examination - abdomen soft & non-tender • Investigations WCC 17.9 LFT bili 23 AST 230 ALP 140 GGT 80 Case 2 ……….p3 • Examination revealed peripheral line in left forearm purulent & red • Blood cultures MRSA • Echo …..vegetations on aortic valve Case Summary • Don’t forget I/V lines. Need to be changed every 48-72 hrs. May always be site for life threatening sepsis. CASE 3 • 81 yr. Old woman with diabetes admitted to ward for routine observation after straightforward balloon dilation of stenosis in left common iliac artery. • You are called by nurse as P 80, BP 100/60 & she looked pale. How would you respond? • Examination confirms obs. and she is peripherally shut down. • What else would you do? • Review of left leg revealed no puncture site swelling & weak posterior tibial pulse. Also some mild discomfort in LIF. • What now? Review of left leg revealed no puncture site swelling & weak posterior tibial pulse. Also some mild discomfort in LIF. What now? Case 3 cont’d. • Drug chart shows Beta-blocker & a pre-procedure BP 160/90. • What now? Remember beta-blocker will prevent a tachycardia. • Non-sustained response to 500ml colloid. What now? • Must call Vascular Surgery Team, best to have done this prior to this point. • Laparotomy reveals large bleed from ruptured common iliac artery. • What is role for CT?... Only relevant if bleeding not critical. If clearly haemorrhaging the treatment is to stop the bleeding, ie. operate • Learning point - a Radiological intervention = an operation. CASE 4 • 35 yr.old woman underwent uncomplicated lap.chole 8 hours ago. • You are night intern called by nurse as patient anxious and complaining of right shoulder tip pain. The nurse is worried. How will you respond? • Answer: “Go & see the patient” • Obs. P 120. BP 90/50. RR 21. T 37.0 Redivac contains 40ml haemoserous fluid. What now? “..a terrible mistake made at the bedside will be better received than most expert management rendered from the resident’s TV room” Case 4 cont’d • Patient is clearly bleeding internally. • Needs resuscitation and surgery to stop the bleeding……”contact the surgeon” Case 6 • • • • 84 yr. old elective right hemicolectomy. Previously fit & lives independently No medications Post-op course fantastic, all delighted…glasses on &reading the Herald-Sun • Day 6 called as in rapid AF • Your approach? Case 6 ………p2 • o/e P 150 AF BP 95/60 • What now? • Timing would suggest, again, intrabdominal complication first and a medical complication second. “Think surgery” Case 6 ……..p3 • Overnight deteriorated tranferred ICU with hypotension. • Laparotomy revealed leaking anastamosis. Medical complications • Always consider a surgical cause for a medical complication first when dealing with a surgical patient Drain tube caveats A drain tube is no guarantee to prevent fluid accumulation A drain is no substitute for good surgical haemostasis Drain tubes do get colonized, so bacteria can migrate inwards from skin Too much suction can cause damage Drain tubes can ‘fall-in’ as well as ‘fall-out’ Part of a drain can be left behind in body! A drain in the peritoneal cavity will not drain the whole peritoneum Beware the drain that stops draining dramatically ISBAR • • • • • I - Identify S - Situation B - Background A - Assessment R - Request 41 I - Identify • Identify yourself - name, position, location • Identify the person you are talking to if not already done • Identify the patient and unique ID number “Hello. My name is Jasmine Sass, I’m a Division 1 RN working on Ward 2 at …. Hospital. Are you the medical registrar on for ward referrals today? … I didn’t catch your name?…I’m calling about a patient - Terry Jones - a 56 year old man in our surgical ward at ….. Hospital” 42 S - Situation • Explanation of WHY you are calling “I am calling you about a patient, Mr Jones*. He is a 56 year old man, 2 days post hernia repair who has developed new atrial fibrillation with a blood pressure of 105/66. He looks pale and feels unwell. I would like you to come and assess this patient please” • If urgent, make this clear at the start “Mr Jones is a 56 year old man who is 2 days post hernia repair. He has gone into atrial fibrillation. He is stable at present with a blood pressure of 105/66 but he is normally hypertensive. He looks pale and feels unwell. I am concerned about him and would appreciate it if you could come and help us to stabilise him” *No need to repeat patient’s name age and sex if already included in IDENTIFY 43 B - Background • Tell the story “I’ll tell you the story…” “I’ll give you the background information…” • Provide RELEVANT information only. Deciding what is relevant is a skill that comes with experience • Don’t forget ‘less is often more’ – you may get the message across better with less information • Include aspects of history, examination, investigations and management where relevant 44 A - Assessment • State what you think is going on. Give your interpretation of the situation • Don’t leave the receiver to guess what you are thinking - tell them • Stating the obvious is helpful here • Include your degree of certainty 45 R - Request • State what you want from them “We would be grateful for your opinion regarding the need for surgery” “I need help urgently, are you able to come now? … If not, who should I call?” • Ask questions “What would be the most appropriate antibiotic in this situation?” “What are the priority tasks for me while you are on your way?” 46 ISBAR can be done briefly - 1 • I - “Hi, I’m Joe, an intern in ED” • S - “I would like to refer a 66 year old man with pneumonia” • B - “He has been on oral antibiotics for 1 week with no improvement. He is stable and we have commenced IV antibiotics” • A - “His presentation of pneumonia is classic” • R - “Are you able to see him with a view to admission?” 47 Case 5 • A 69 yr.old man undewent TURP three hours ago. He has just returned to the ward. Nurse rings you as she is “not happy” with the way he looks as he is shaking uncontrollably. You are scrubbed in Theatre when she pages. How would you respond? • A: “ Go & see the patient” • Obs. P 110 BP 95/60 T 39.0. Returned fluid in urine bag is pink and no clots seen. • What now? • What is differential diagnosis? • How to proceed? Case 5 cont’d • Resuscitate with fluids. • Most likely diagnosis is Gram negative sepsis….hypotension, vasodilated and febrile. Other possibility is relative underfillling from spinal, but, is febrile with rigors. • Needs blood and urine cultures plus antibiotics Case 7 Case 7 cont’d “Go and see the patient” Case 7 cont’d • This is the serious complication of postthyroidectomy bleeding. • Can present in several ways: Neck swelling and pain Blood per drains Stridor and difficulty breathing Hypoxia with agitation,confusion or somnolence • Needs urgent removal of all layers os neck sutures, ideally in theatre but ,in extremis, on the ward, ie. YOU Case 8 Case 8 • Low grade fever one day after abdominal surgery = ATELECTASIS, until proven otherwise. • Treatment of this condition is…..? Case 9 Case 9 • Low grade fever over a week after surgery, especially if resting bed with surgery to the lower limb….think of DVT Case 10 Case 10 • Swinging (spiking) temp. 5-7 days after surgery = pus somewhere. • Inspect wound, consider intra abdominal (pelvic/subphrenic/perisurgery) and CT scan.