ward&emergencies& when&things&go&wrong:&& … · pneumonia subarachnoid...

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When things go wrong: Less common surgical ward presenta;on of trauma and surgical emergencies

Sean P C leary MD , MSc , MPH, FRCSC

Associate Professor Hepatobiliary Surgical Oncology and General Surgery

University of Toronto

C APA O c t 2 5 , 2 015

Ward Emergencies

•  Post-‐opera;ve complica;ons •  Trauma post-‐admission complica;ons

•  We have not invented risk free surgery….

Objec;ves

•  Iden;fy the risk factors for deteriora;on in the post-‐opera;ve period

•  Describe the pathophysiology of deteriora;on in the post-‐opera;ve period

•  Describe the steps and ra;onale required in the assessment and treatment of pa;ents with rapidly-‐developing deteriora;on in the post-‐opera;ve period

Overall Objectives

I.  Develop an approach to the diagnosis and management of common post-‐operative complications in general surgery

Postoperative Complications

Complica;ons

•  Pre-‐exis;ng Pa;ent Factors •  Lifestyle-‐Obesity, Smoking •  Comorbidi;es-‐ Diabetes, COPD, CAD •  Medica;ons •  Performance stats/frailty, Age

•  Injury/Procedure factors •  Specific to opera;on/trauma

•  Severity of injury

CCrISP (Care of the Critically ill Surgical Patient Immediate management

ABCDE

Full Pa/ent Assessment chart review, history,

examina;on, results, scans

Decide and Plan

Stable Pa/ent (Daily

Management Plan)

Unstable Pa/ent/Unsure

(Diagnosis Required)-‐Specific

Inves;ga;ons

Defini/ve Care

(Medical, Surgical,

Radiological)

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Outline

•  Common Presenta;ons: – Fever – Dyspnea – Wound Problems – Abdominal Distension – Hypotension


Case 1

§  42 year old woman POD 5 from a laparoscopic gastrectomy for gastric cancer

§  NotiNied by the nursing staff that the patient has a fever of 38.9 C, HR 120, BP 80/60, RR 25


Case 1


Causes of Postoperative Fever

Infectious Noninfectious

Abscess Acute hepatic necrosis

Acalculous cholecystitis Adrenal insufficiency

Bacteremia Allergic reaction

Decubitus ulcers Atelectasis

Device-related infections Dehydration

Empyema Drug reaction

Endocarditis Head injury

Fungal sepsis Hepatoma

Hepatitis Hyperthyroidism

Meningitis Lymphoma

Osteomyelitis Myocardial infarction

Pseudomembranous colitis Pancreatitis

Parotitis Pheochromocytoma

Perineal infections Pulmonary embolus

Peritonitis Retroperitoneal hematoma

Pharyngitis Solid organ hematoma

Pneumonia Subarachnoid hemorrhage

Retained foreign body Sinusitis Systemic inflammatory response syndrome

Soft tissue infection Thrombophlebitis

Tracheobronchitis Transfusion reaction

Urinary tract infection Withdrawal syndromes

Wound infection

Postoperative Fever

Timing is important


Early (<12-‐48h) <5 days >5 Days

Atelectasis UTI Pneumonia IV/Central line Catheters PE/DVT

Wound infec;ons Intra-‐abdominal infec;ons Anastomo;c leaks C.Diff Coli;s

Fever

•  Atelectasis –  First 24-‐48 hours. –  Low risk of bacterial infec;on –  Can lead to pneumonia, hypoxia, confusion –  Chest physio, incen;ve spirometry, pain control

•  > 48 hours –  Infec;on work-‐up

•  Cultures-‐ blood, urine, drains •  Imaging-‐ CXR, CT scan (>5 days)

–  An;bio;cs •  Unstable/sick-‐ broad spectrum •  Focused Abx therapy based on cultures/e;ology

•  Any;me: transfusion reac;on, allergy

Fever

•  Simple reminder: 5 Ws – Water (UTI) – Walking (PE/DVT) – Wind (Atelectasis/pneumonia) – Wound (infec;on)

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Aspiration

•  Oropharyngeal or gastric contents into the respiratory tract = serious complication

•  Aspiration pneumontitis – acute lung injury from gastric/other contents (early)

•  Aspiration pneumonia – aspirated contents colonized with pathogenic bacteria causing infection in addition to lung injury (later)


Aspiration

Pre-‐disposing factors: •  Altered mental status (Trauma, EtOH, drugs)

•  GERD •  NG Tube placement (+/-‐) •  Emergency intubation •  Bowel obstruction/GI motility problem


Aspiration

Prevention is the key: •  Rapid sequence intubation •  If NG feeds – check residuals, HOB elevated

•  NG to low suction Treatment •  Supportive care (O2, Intubation) •  Antibiotics (Anaerobic coverage


Case 2

80 yo female admitted to ER after MVA. •  CT Scan shows mild Spleen and liver laceration, mesenteric hematom multiple rib fractures (Seatbelt sign), Hip fracture.

•  14 hours post admission –  Short of breath with RR 30, O2 Sats 80%

Differential and Management?


Dyspnea

Patients who undergo abdominal or thoracic incisions/inury have a signiNicant alteration in respiration

– Pain – Narcotics – Supine – Fluid – Patient factors


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Dyspnea post trauma

•  Differen;al Dx – Atelectasis (pain control) – Pulmonary contusion – Pulmonary Embolism (clot/fat) – COPD exacerba;on – Pulmonary edema (CHF) – ARDS – Transfusion lung injury (TRALI) – Pneumothorax

Dyspnea

•  CXR •  ECG •  ABG •  Bloodwork •  CT PE •  Sputum C+S •  Others as indicated


Pneumothorax

•  Needle decompression – 2ICS large gauge needle

– Chest tube

Pulmonary Contusion


Pulmonary Embolism

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Pulmonary Embolism

•  A source of preventable morbidity and mortality (100,000 deaths/year)

•  Responsible for a signiNicant number of all in-‐hospital deaths (estimated 5-‐10%).

•  Most PE’s orginate from DVT of iliofemoral vessels. – Other sources:

•  Fat (long bone #s), Air, Amniotic Nluid (post-‐partum)


Pulmonary Embolism

Risk Factors for PE


Pulmonary Embolism

•  Pleuritic chest pain •  Sudden onset dyspnea •  Tachypnea •  Hemoptysis •  Leg swelling •  Hypoxia •  ECG changes – RBBB, RAD •  Hemodynamic instability/Death


Pulmonary Embolism

Diagnosis VQ Scan-‐ historical, not useful in surgical/trauma pt CT arteriography (PE protocol) US-‐for DVT Echocardiogram-‐ R heart strain, high RVSP


Pulmonary Embolism

•  Preven;on is key – DVT prophylaxis – Compression stockings/devices – Early mobiliza;on

•  Treatment – An;coagula;on (if safe) –  IVC filter

Case

•  32 yo Male presents to ER with 3 stab wounds to abdomen

•  Trauma laparotomy – ++ contamina;on. No signif bleeding – Repair of transverse colon injury (x2) – Small bowel resec;on

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•  POD 2 •  Significant abdominal and incisional pain

– Not responsive to pain meds

•  Fever 39.4 •  Confusion •  Wound

– Murky discharge – Purple discolora;on

Wound infection

Clinical manifestations: •  Local

– Dolor : pain – Tumor : swollen & edematous – Rubor : redness & cellulitis –  Calor : warm to touch

•  Systemic –  Fever, sepsis


Wound infection

•  Open incision •  Debridement •  Wound care – secondary intention •  ?Antibiotics


Wound infection

•  Technical factors – Duration of operation – Extent of tissue damage –  Contamination –  hematoma/seroma/foreign body – Hypoxemia – Hypothermia – Hypotension or shock


Wound infection

•  Patient factors – Age – Presence of chronic illness (e.g., renal failure, liver failure, COPD, malignancy, diabetes)

– Malnutrition – Use of immunosuppressive drugs, chemotherapeutic agents

– Obesity –  Corticosteroids


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Wound infection

Prevention : •  Skin preparation •  Bowel preparation •  Prophylactic antibiotic •  Meticulous technique •  Temperature maintenance •  Oxygen supplementation


Case

42 year old M has had a colectomy for Colon cancer cancer. NotiNied by the nursing staff that the patient has redness and a gush of sero-‐sanguinous drainage from wound. Vitals are stable, afebrile. Management?


Eviscera;on Dehiscence

 Dehiscence - is separation within the fascial layer

 Evisceration - extrusion of peritoneal contents through the fascial separation

 Incidence : 0.5 – 3.0 % in all abdominal procedures .

Dehiscence Early <48 hours-‐ Technical

Imperfect technical closure Broken Suture Slipped Knot

Late >48 hours (5days)-‐ Patient factors Increased intra-‐abdominal pressure from bowel distention, ascites, coughing, vomiting, or straining

Hematoma with or without infection Infection Metabolic diseases

Diabetes mellitus, uremia, Cushing's disease, Vit C def. Malignant disease Radiation

Dehiscence

•  Dehiscence -‐ is separation within the fascial layer

•  Evisceration -‐ extrusion of peritoneal contents through the fascial separation

•  Incidence : 0.5 – 3.0 % in all abdominal procedures


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Dehiscence

•  Detected by the classical appearance of salmon colored Nluid draining from wound

•  occurs on fourth or Nifth postoperative days in ~ 85% of cases

•  Present late as an incisional hernia

•  What factors would predispose to this?


Dehiscence

•  Imperfect technical closure •  Increased intra-‐abdominal pressure from bowel distention, ascites, coughing, vomiting, or straining

•  Hematoma with or without infection •  Infection •  Metabolic diseases such as diabetes mellitus, uremia, Cushing's disease, Vit C def

•  Malignancy •  Radiation


Case

70 year old female, POD#3 laparoscopic right hemicolectomy for colon cancer. You are notiNied that she has now developed signiNicant abdominal distension. Management?


I leus

•  Postoperative ileus is “normal” – Small intestinal motility usually recovers 0-‐24 hours

– Gastric motility usually recovers 24-‐48 hours postop

– Colonic motility usually last, around 48-‐72 hours

•  Prolonged ileus occurs in about 25% of patients


I leus

•  Functional obstruction of small bowel •  Multiple causes

– Surgery – abdominal or extra-‐abdominal – Metabolic/electrolytes – Medications


I leus

•  Inhibitory splanchnic reNlexes •  Inhibitory sympathetic activity •  InNlammatory stress response •  Peptides (VIP, substance P, CGRP) •  Opioids •  Starvation •  Fluid Excess


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Ileus

•  Correct metabolic/Nluid/electrolytes problems

•  Address underlying cause •  Supportive treatment

–  IVF – NG decompression – Meds usually not helpful


I leus

•  Prevention of ileus – Epidural analgesis – Minimally invasive surgery – Early feeding – Fluid restriction Also: Chewing gum, NSAIDs


Case

•  72 y.o F •  POD 2 from lapaproscopic low anterior resec;on from rectal cancer

•  BP 90/55 HR 123 O2 sats 92% on 2L NP •  Abdomen distended •  Pale •  Flat JVP/neck veins

what you may see?

Management plan?

•  Make sure IV access is good •  Bolus 2L NS •  Foley catheter to accurately assess I+O •  Blood Work (Hb)

– post op: 123 – POD1 : 112 – POD2 8am: 110 – POD2 now: 104

Haemorrhagic Shock Parameters I II III IV Bloods loss(ml)

<750 750-1500 1500-2000 >2000

Blood loss(%) <15 15-30 30-40 >40 Heart rate <100 >100 >120 >140 Blood Pressure

normal orthostatic hypotension severe hypotension

Urine output(ml)

>30 20-30 5-15 negligible

CNS symptoms

normal anxious confused obtunded

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Management of post-‐op hemorrhage

•  Fluid resuscita;on (ABC’s) •  Stable

–  Correct Coagulopathy –  CT scan –  ?Angiography –  ? OR to evacuate hematoma

•  Unstable – OR

•  Stop bleeding •  Evacuate hematoma •  Damage control

Questions?

Postoperative complications

Thank You…..

ward&emergencies& when&things&go&wrong:&& … · pneumonia subarachnoid...

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