Post operative Complications

Post-operative Complications
Post-operative complications either can be general or specific towards the type of surgery undertaken, and really should be managed using the patient's history in your mind. Common general post-operative complications include post-operative fever, atelectasis, wound infection, embolism and deep vein thrombosis. The greatest incidence of post-operative complications is between One and three days after the operation. However, specific complications exist in the following distinct temporal patterns: early post-operative, a few days after the operation, through the post-operative period, and in the late post-operative period.1
General post-operative complications
• Immediate:
Primary haemorrhage: either starting during surgical procedures or following post-operative increase in blood pressure level - replace hemorrhaging and may require go back to theatre to re-explore wound.
Basal atelectasis: minor lung collapse.
Shock: hemorrhaging, acute myocardial infarction, pulmonary embolism or septicaemia.
Low urine output: inadequate fluid replacement intra- and post-operatively.
• Early:
Acute confusion: exclude dehydration and sepsis
Nausea and vomiting: analgesia or anaesthetic-related; paralytic ileus
Fever
Secondary haemorrhage: frequently as a result of infection
Pneumonia
Wound or anastomosis dehiscence
Deep vein thrombosis (DVT)
Acute urinary retention
Urinary tract infection (UTI)
Post-operative wound infection
Bowel obstruction because of fibrinous adhesions
Paralytic Ileus
• Late:
Bowel obstruction due to fibrous adhesions
Incisional hernia
Persistent sinus
Recurrence of reason behind surgery, e.g. malignancy
post-urological surgery
o Blood transfusion or drug reaction
• Days 3-5:
o Bronchopneumonia
o Sepsis
o Wound infection
o Drip site infection or phlebitis
o Abscess formation, e.g. subphrenic or pelvic, with respect to the surgery involved
o DVT
• After Five days:
o Specific complications related to surgery, e.g. bowel anastomosis breakdown, fistula formation
o After the very first week
o Wound infection
o Distant sites of infection, e.g. UTI
o DVT, pulmonary embolus (PE)
Haemorrhage
• If large volumes of blood happen to be transfused, then haemorrhage may be exacerbated byconsumption coagulopathy. Can also be due to pre-operative anticoagulants or unrecognisedbleeding diathesis.
• Perform clotting screen and platelet count, ensure good intravenous access and insert central venous pressure (CVP) catheter. Give protamine if heparin has been utilized. Order cross-matched blood. If clotting screen abnormal, give fresh frozen plasma (FFP) or platelet concentrates. Consider surgical re-exploration all the time. 
• Late post-operative haemorrhage occurs several days after surgery and it is usually due to infection damaging vessels in the operation site. Treat infection and consider exploratory surgery.
Infection
• Infectious complications would be the main causes of post-operative morbidity in abdominal surgery.
• Wound infection: most typical form is superficial wound infection occurring inside the first week presenting as localised pain, redness and slight discharge usually brought on by skin staphylococci.
• Cellulitis and abscesses:
o Usually occur after bowel-related surgery
o Most present within first week but could be seen as late as third post-operative week, despite leaving hospital
o Present with pyrexia and spreading cellulitis or abscess
o Cellulitis is given antibiotics
o Abscess requires suture removal and probing of wound but deeper abscess may need surgical re-exploration. The wound remains open in both cases to heal by secondary intention
• Gas gangrene is uncommon and life-threatening.
• Wound sinus is really a late infectious complication from the deep chronic abscess that may occur after apparently normal healing. Usually needs re-exploration to get rid of non-absorbable suture or mesh, that is the underlying cause.
Disordered wound healing
Most wounds heal without complications and healing isn't impaired in the elderly unless there are particular adverse factors or complications. Factors which might affect healing rate are:
• Poor circulation.
• Excess suture tension.
• Long term steroids.
• Immunosuppressive therapy.
• Radiotherapy.
• Severe rheumatoid disease.
• Malnutrition and vitamin deficiency.
Wound dehiscence
• Affects about 2% of mid-line laparotomy wounds.
• Serious complication having a mortality of up to 30%.
• Due to failure of wound closure technique.
• Usually occurs between 7 and Ten days post-operatively.
• Often heralded by serosanguinous discharge from wound.
• Should be assumed the defect involves the whole from the wound.
• Initial management includes opiate analgesia, sterile dressing to wound, fluid resuscitation and early go back to theatre for resuture under general anaesthesia.
Incisional hernia
• Occurs in 10-15% of abdominal wounds usually appearing within newbie but can be delayed by as much as 15 years after surgery.
• Risk factors include obesity, distension and poor tone of muscle, wound infection and multiple utilization of same incision site.
• Presents as bulge in abdominal wall near to previous wound. Usually asymptomatic but there might be pain, especially if strangulation occurs. Has a tendency to enlarge over time and be a nuisance.
• Management: surgical repair high is pain, strangulation or nuisance.
Surgical injury
• Unavoidable injury to nerves may occur during various kinds of surgery, e.g. facial nervedamage during total parotidectomy, impotence following prostate surgical procedures or recurrent laryngeal nerve damage during thyroidectomy.
• There is another risk of injury while being transported and handled within the theatre under general anaesthetic. Included in this are injuries due to falls from trolley, harm to diseased bones and joints during positioning, nerve palsies, and diathermy burns.
Respiratory complications
• Occur in as much as 15% of general anaesthetic and major surgery and can include:
• Atelectasis (alveolar collapse):
o Caused when airways become obstructed, usually by bronchial secretions. Many instances are mild and could go unnoticed
o Symptoms are slow recovery from operations, poor colour, mild tachypnoea, tachycardia and low-grade fever
o Prevention is as simple as pre-and post-operative physiotherapy
o In severe cases, positive pressure ventilation are usually necesary
• Pneumonia: requires antibiotics, physiotherapy.
• Aspiration pneumonitis:
o Sterile inflammation from the lungs from inhaling gastric contents
o Presents with good reputation for vomiting or regurgitation with rapid start of breathlessness and wheezing. Non-starved patient undergoing emergency surgical treatment is particularly at risk
o May assist in avoiding this by crash induction technique and employ of oral antacids or metoclopramide
o Mortality is almost 50% and requires urgent treatment with bronchial suction, positive pressure ventilation, prophylactic antibiotics and IV steroids
• Acute respiratory distress syndrome:
o Rapid, shallow breathing, severe hypoxaemia with scattered crepitations but no cough, chest pains or haemoptysis, appearing 24-48 hours after surgery
o Occurs in lots of conditions where there is direct or systemic insult towards the lung, e.g. multiple trauma with shock
o Requires intensive care with mechanical ventilation with positive-end pressure
Thrombo-embolism
• Major reason for complications and death after surgery. DVT is extremely commonly related to grade of surgery.
• Many cases are silent but present as swelling of leg, tenderness of calf muscle and increased warmth with calf pain on passive dorsiflexion of foot.
• Diagnosis is as simple as venography or Doppler ultrasound.
• Pulmonary embolism:
o Classically presents with sudden dyspnoea and cardiovascular collapse with pleuritic heart problems, pleural rub and haemoptysis. However, smaller PEs tend to be more common and present with confusion, breathlessness and heart problems
o Diagnosis is by ventilation/perfusion scanning and/or pulmonary angiography or dynamic CT
• Management: intravenous heparin or subcutaneous low molecular weight heparin for five days plus oral warfarin.
Common urinary problems
• Urinary retention: common immediate post-operative complication that may often be dealt with conservatively with adequate analgesia. If the fails may need catheterisation.
• UTI: common, especially in women, and could not present with typical symptoms. Treat with antibiotics and adequate fluid intake.
• Acute renal failure:
o May be brought on by antibiotics, obstructive jaundice and surgery towards the aorta
o Often due to episode of severe or prolonged hypotension
o Presents as low urine output with adequate hydration
o Mild cases might be treated with fluid restriction until tubular function recovers. Yet it's essential to differentiate from pre-renal failure because of hypovolaemia which requires rehydration
o In severe cases may require haemofiltration or dialysis while function gradually recovers over weeks or months
Complications of bowel surgery
• Delayed return of function:
o Temporary disruption of peristalsis: may complain of nausea, anorexia and vomiting in most cases appears with the re-introduction of fluids. Often referred to as ileus
o More prolonged extensive form with vomiting and your inability to tolerate oral intake called adynamic obstruction and requires to be distinguished from mechanical obstruction. If involves large bowel usually referred to as pseudo-obstruction. Diagnosed by instant barium enema
• Early mechanical obstruction: might be caused by twisted or trapped loop of bowel or adhesions occurring approximately 7 days after surgery. May settle with nasogastric aspiration plus IV fluids or progress and require surgery.
• Late mechanical obstruction: adhesions can organise and persist, commonly causing isolated instances of small bowel obstruction entire time after surgery. Treat for early form.

Nerve Damage Complications From Diabetes Mustnt Be Underestimated

Today's post from tudiabetes.org (see link below) is the story of a diabetes patient living with neuropathy (amongst other things) who is forced to lose a toe and it offers a salutary lesson in the consequences of certain life choices. The important thing is to avoid becoming diabetic in the first place but hey, that's easier said than done. Can't preach here but sometimes reading someone else's account of their medical history can shake you up a little and maybe persuade you to change a few things to make your health picture a little less alarming. The risk of losing parts of your feet due to neuropathic complications is all too real for some patients.

This little piggy
Roger212 Aug 3rd 2016

Diabetes Complications and other Conditions

I have never been a 'good' diabetic. Compliance with rules is just not in my nature. I was diagnosed in 1967, at the age of 18, after I had gone into hospital
for a relatively minor surgery. Two weeks after that diagnosis, I was
launched back into the world, scared and not completely sure of what
came next. The nurses had taught me all about doing injections, and I
had a shiny glass syringe and a box of one-time use needles. I also
had a diet booklet from the dietician, prescribing a 2,000 calorie
diet. Two thousand calories? Come on, I was a teenager. I ate 2,000
calories for breakfast.

Diabetes ended my plans for a military career, but I had finishing high school and getting into University to worry about, so I took my 16 units of Lente
insulin daily, avoided sweets and did pretty much what I wanted. In
those days we couldn't test for blood sugar, so we had to test for
urine sugar until the 90s. My tests always showed 4% or higher, the
highest a test could go. I saw my GPs mostly, although once in a
while they would send me to hospital for “stabilization.”

In my thirties I went through a period of heavy drinking. I don't know if it's coincidence, but it was at this time I lost the sight in my left eye. I went back
and forth between the right eye and the left eye for a few years, but
was blind in both eyes for only a week. I recovered most of my
eyesight through laser and a couple of actual eye surgeries, and a
very, very good ophthalmologist. This cost me a job, as my company
decided “your position is no longer required.” Yeah.

Skip ahead a few years, and I'm in my fifties, now equipped with human insulin and a blood glucose meter. My blood glucose management is better, but still not
good. In around 2005, I had my first foot infection. It involved my
left big toe and first toe, and they turned black. Due to the good
offices of the surgeon my GP sent me to, These toes recovered nicely,
and in six months or so looked as if they had never had a problem.

For several years I had recurring infections in toes on both feet. The usual course of events was that my toe or toes would turn black, and after antibiotics and frequent dressing changes they would slowly recover. I quickly knew
all of the staff at the wound clinic by their first names, and they
treated me wonderfully, and still do today.

So, at this point I had racked up neuropathy, nephropathy, retinopathy, cataracts, heart disease, a strange condition that gives me vertical double vision, mild liver and kidney problems, and arthritis. That last one may not
be due to diabetes, as it runs in my family. Oh! Oddly enough, I
suffer from depression, although I am medicated and able to hold it
at bay, but I don't smile much.

My last toe problem occurred in 2013 on a trip, at Heathrow airport. I was travelling with my daughter who was on a business trip to Paris and London. She noticed blood on the floor when I came out of the bathroom in the
morning. My right big toenail had become detached, and we dealt with
it with some bandaids my daughter had, and bought some supplies when
we got to Paris. I limped through the rest of the trip, and got back
to the wound clinic, where the doctor saved me again.
I continued to go to the wound clinic monthly for medical pedicures. They handed that job off to a podiatrist who shares office space with the clinic. At one of these pedicures, in March this year, the podiatrist discovered a
sore on the end of my middle right toe.

So now it was back to the wound clinic for antibiotics and dressing changes. After two months, I brought up the possibility of an amputation, as we seemed to be getting nowhere with the toe. Furthermore, I was having considerable
pain from the toe. The doctor wanted to wait awhile, but in June
X-rays revealed that the bones in the toe were fully infected. So we
agreed on an amputation, and set the following Wednesday, June 22, as
the date.

I had thought the process of amputation would require some fanfare – a hospital stay, hospital food, pretty nurses, all that. However, it was done in the
clinic, on the same cot I lie on for dressing changes or pedicures.
The doctor took off the dressing, wiped the toe down and gave me some
local anaesthetic. Then, while we chatted back and forth, he
cheerfully removed the toe. No pain, no fuss. I saw the toe go into a
specimen jar, and called out, “Wait, wait! I've changed my mind!”

The doctor said, “Ya want me to put it back? Too late!” and we all had a laugh. They are used to me at the clinic. In a matter of minutes the wound was
bandaged, and I walked out of the clinic with a note to come back at
7:30 the following morning. I had walked into the clinic at 7:25, and
walked out at 7:50, less one toe, but the pain from the toe was gone,
and stayed gone.

Along with my family and friends we came up with a bunch of jokes about only being able to count to 19, having difficulty playing “This little piggy.” After
all, do you drop the one that had roast beef, or the one that had
none, or go to the fourth toe and say “This little piggy had tofu,”
because then the next little piggy wouldn't want any, and could go
“Wee, wee...” oh, never mind!

All jokes aside, it isn't easy to give up a toe. It seems like a small thing, and I recognized the necessity, but when it got down to the crunch, I felt saddened. I
have known for fifty years that something like this could happen.
Thank God that I have made it this far without going blind, as has
happened to people I know. I also know people who have lost legs.
Some of those have subsequently lost their lives, so I know it could
be worse, and could get worse. But as I mentioned, I suffer from
depression, and am beginning to do a lot of sitting around with time
to think.

The wound appears to be healing well, and it seems by mid August it will be healed. This
should allow me to return to my activities such as woodwork,
swimming, walking and maybe even riding my bicycle, but two weeks ago
the doctor showed me X-rays that show the second toe is infected in
the bone, and therefore must go, too. So, the piggy that stayed at
home is to be evicted.

This did not improve my mood. It puts my recovery off until late September, and cancels any thoughts I may have had of doing much this summer. I spent a week with my daughter recently, and had to do my own dressing changes,
which is something I am unwilling to repeat. I should be able to
dance at my daughter's wedding on October 1 if nothing else goes
awry. I thought at one time that removing the toe would be the end of
the problem for now, but of course that is not true. I now have to
deal with the possibility of losing half a foot, and after that, half
my lower leg.

I try not to sit around dwelling on the problem or its infinite possibilities. There are things I can do, and I do them. I am trying to be careful about my
bgs, and waiting for the day when the doctor says, “There, Roger!
You're all healed. You don't have to come back here any more.” That
will be the best present I could have.

I said at the outset that I have not been a 'good' diabetic, but I'm still here after 50 years.

I know I have done things wrong during the course of this whole
thing, and I don't need to hear about it. The thing a diabetic
doesn't need to hear when faced with complications is, “You could
have prevented this if....” This is just my experience of losing a
toe. Whether you see it as inspiration or cautionary tale is up to
you. I hope you have gained something from it.

LATE BREAKING NEWS!

Just before submitting this, I saw the doctor at the clinic, and he thinks my second toe may get better, so we are holding off removing it until it gets a chance to improve. So, the second piggy has a stay of execution. We'll wait
and see.
Roger N. Tulk (Roger212)
 
http://www.tudiabetes.org/forum/t/this-little-piggy/55179