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ERRORS AND
COMPLICATIONS IN
VETERINARY
SURGERY
DVM MARIA ELENA MARTINEZ
BUENOS AIRES, ARGENTINA "Every failure teaches a man
something, if he will learn" Charles
Dickens
2
Necropsy
Feline with peritonitis
because of a linear foreign with a body
postoperative dehiscence of the intestinal
suture, septic peritonitis was observed
Complication:adverse event related to the surgical procedure, deviating from the desired course and may be associated with regular or bad outcomes
• worsening of signology• development of new symptoms
• new pathologies involving other organs• may appear in the pre, intra and post-surgical
stage
PhlegmonBernese mountain dog, 8 years old: with cervical pain, no motor deficit. Under treatment with corticosteroids and physical rehabilitation during a month of evolutionWith a partial response and even advancing towards a tetraparesis. Decompression surgery is decided, but begins an image of decay, hyperthermia, anorexia and fluctuating deformation in the right forelimb
Surgical drainage is performed,
sampling for cultivation/antibiogram
washed with saline solution
Penrose+ bandage drainage
daily changes+
Antibiotics
It recovers satisfactorily and
decompressive surgery is performed
cervical
Complication
WHAT’S AN
ERROR?
is the inappropriate conduct of the
professional for improbability,
recklessness or negligence that causes harm to
the patient's lifenot all
complications are caused by errors
Human error
Inadequate or incorrect
information
Correct information but
incorrect applied
methodologyCorrect
information and methodology but
execution is imperfect
8
Errors are due to:human conditionprofessional status
Detailed and
complete
medical
record
Mistakes can start as soonas you start taking the firststeps towards a diagnosis
Lack of foresight
Lack of knowledge
Lack of resources
Lack of skills
Lack of time
Poor comunication within theteam
Making themistake: demonstratesprofessionalweaknessesand involvesthe possibilityof CAUSING HARM
Confessingthe error isthe way
10
Don'tconfess from
guiltConfess fromresponsibility
TAKE AN ERROR AS A SOURCE OF POSITIVE FEEDBACK
12
error
retrospectiveplanting
careeradvancement and
improvement
change in attitude
MEASURES TO TAKE WHEN THE ERROR IS IDENTIFIED (WEARS,1999)
emphasize more in the system than
in people
non-punitive approach
determine multifactorial
nature
estimate what mistakes can be
made
develop a culture of safety
14
Hide Live with
Search for culprits
Avoiding responsibility and blaming others
Facing error
Asking for forgiveness and compensating and learning
from
• we are the only one responsible for who we want to be
• Facing one's own mistakes is the key
to never commit them again
• Acknowledging the error is an act of
• RESPONSIBILITY, not to recognize
• and hiding it is much more serious than the mistake itself
IATROGENIA
medical error
misdiagnosis
medical negligence/inappropriate procedure
error in recipe or indecipherable prescription
drug interaction/side effects or adverse effects
intra-hospital infection
It is a patient's injury caused by doctors, medication or
therapeutic treatment within the precise indication. It's always unintentional,
causing a complication in the treatment.
It depends o
n th
e case
……
IATROGENIA IS NOT MAL PRAXIS
17
LACK OF
ABILITY
IMPRUDENCE NEGLIGENCE
MAL PRAXIS FORTUITOUS
CASE
“Loose sponge"
something forgotten inside the patient
ERROR
• Had GDV surgery 8 months ago
• patient had a gastropexy
• After surgery: recurrent dilations
• Lost 10 kg of body weight: 45 kg to 35 kg
• Changed DVM: Endoscopy and indicated symptomatic treatment
• with cisapride 0.2 mg/kg every 12 hours: transient improvement
• Change of DVM internist indicated only an abdominal Rx lateral view:
• “suspicious gastric rotation”, occupying 70-80% of the abdomen
• Referred for surgical consultation
•
Once referred to the surgical office, physical examination determined:
decay, abdominal dilation, moderate abdominal pain in the epi-
mesogastric area.
Emaciated status shown by the patient when received
NO PREOP WORK UP WAS REALIZED BEFORE
To properly evaluate a gastric malposition it is necessary to obtain at
least two radiographs Right lateral and DV or VD
Sometimes a third view from the opposite side, Left lateral, may be
necessary
mechanical alteration that prevent gastric normal emptying
in the inmediate postoperative.
abnormal motility
pyloric stenosisDifferential
Diagnosis l?
PCV, total proteins, albumin, kidney and liver
profile plus coagulogram are repeated, all
values are found within a normal range.
ERROR
fundus
izquierda
derecha
craneal
caudal
stomachfixed to
rightabdominal
woundedge
keepingthe
rotation
theproblemwasn'tsolved
recurrence of signs
general statecommitment
the contiguity of the gastropexy to the midline can be observed.
• Incisional Gastropexy
• Exceedingly long suture line: ~15 cm
fundus
izquierdaderecha
craneal
caudal
The patient’s stomach is exposed,
left hand:
holds the fundus
right hand:
holds the pyloric antrum
the greater curvature of the stomach is found
between the two hands, identified by the
gastroepiploic vessels.
piloro
a la izquierda
fundus a la
derecha
In the previous surgery, the gastric fundus was
pexied
to the right side of the abdomen,
causing a chronic rotation of the stomach and
compromising a normal gastric emptying.
Photo taken from the right side, the blue arrow
indicates the position of the pylorus on the left
side; while the red one points the fundus, on
the right hand side.
GASTROEPIPLOIC AND SPLENIC
VESSELS
INGORGEDCONGESTED
• splenic rotation 180º
• arterial patency control
• look for vein thrombosis (string of pearls)
ERROR
• Freeing up the previous “pexy”
• Losange in right abdominal wall:
to avoid further damage to the chronically distended gastric wall
Dorita was hospitalized under fluid therapy
Continuous infusion of metoclopramide
Ranitidine 2 mg/kg every 12 hs
Sucralfate every 12 HS
Ampicillin Sulbactam 20 mg/kg every 12 hs
Tramadol 2 mg/kg every 8 hs
• Special GI diet food per os when she fully recovered from
anesthesia,
• Small amounts with a frequency of 8 times a day
• Within a week he regained 4 kg of body weight and only
presented one episode of mild gastric dilation, after a ravenous
eating on the second postoperative day
DORITA:10 DAYS AFTER SURGERY.
Incomplete physical exam and evaluation of traumatized
patient
Events linked to each
other
can involve an
implicit
deleatereal action for
the patient
• Female canine, mongrel, 5-years-old
• She fell from a height, and was nailed to the fence of her house
• The first veterinary doctor, surgically resolved the perforation of the abdominal wall
• without performing previously a complete neurological exam, or chest imaging
studies and
• spine.
• When she recovered from anesthesia, she had paraplegic hindlimbs lacking deep pain
sensation
L4 fracture
ERROR
EXTRACTION OF BONE FRAGMENTS, PAINT RESIDUES
SAMPLING FOR CULTIVATION-ANTIBIOGRAM
FIXATION-STABILIZATION
PINS AND PMMA
Postoperative:
Physical rehabilitation
Orthopedic trolley once the spine was welded
Signalment
canine/mongrel shitzu/male/ 3 years old
History:
Right chryptochid.
Five days ago he was castrated via a right-
side celiotomy.
Referred due to a severe pain and
deformation in the surgical wound area.
Clinical Findings:
hyperthermia 40ºC, pink mucous
membranes, CRT1 second, normal
hydration, auscultation within normal limits,
right superficial inguinal LN increased in
size.
abdominal palpation relates intense pain in
hypogastrium
palpable deformation in the right para-
prepucial area
ERROR
When the patient was placed in dorsal
recumbency to check the surgical wound, the
following was found:
wound showing signs of inflammation/infection
deformation under the surgical area
purulent secretion through the most caudal
suture
overlapping of the wound edges
skin area around the wound with no appropriate
trimming
Resolution:
When preparing the surgical field for
surgery, drainage of a large amount of
purulent material, (drained as much as
possible manually) was observed.
Several scrubbings with chlorhexidine
soap and final prep with chlorhexidine
solution
41
surgicalexploration
culture/sensitivitysamples
checkwound/abdomen/spermatic cord
stump
lavaged withsaline
new culture/sensitivity
sampling
final closure: drainage?
• Sutured with linen/large size (not in use anymore)
• Skin edges overlapped
• Inflammation
• Snug sutures, causing increased inflammation
• Partially opened wound
• Skin edge necrosis
apparently suture with a continuous
subcuticular pattern pretending to
leave the final knot on the outside
of the skin
• Why does the overlapping of the wound edges take
place?
• Due to take more tissue on one side of the suture line
compared to the opposite.
• Why a line of necrosis can be observed in one of the
wound’s edges?
• Rough handling of the tissues, associated with excessive
suture tension disturbs the blood supply to the incised skin.
• Inflammation is minimized through delicate tissue handling, strict
aseptic handling,and appropriate instrumentation for each
procedure.
• Pain:
• If the patient feels uncomfortable and want to lick his wound, pay
attention! something could be wrong
• Infection:
• It is not recomended to use of prophylactic antibiotic therapy in
clean surgeries like this that is described here is not indicated.
• infection in this case was caused by incorrect handling of the
aseptic technique.
•
Respect for the patient is
our most precious treasure;
we must take care of it and
should not cause any
further damage when trying
to solve a problem
surgically
• Resolution:
• Repeated sampling for growing-antibiogram (1)
upon entering the abdomen and before closing
(2).
• Extendedd the wound cranially to check the
abdomen and perform a copious washing with
warm saline solution.
• Penrose drain was placed in the subcutaneous
layer, fixed with two separate simple points.
• Wound closure was made in 4 layers (muscular,
subcutaneous, subcuticular and skin) with 3-0
non-absorbable monofilament Nylon, simple
interrupted pattern:
• the edges of the muscle layer were
debrided
• The result of the antibiogram culture 1:
Staph. aureus and E. fecalis. Sensitive to
ceftriaxone, resistant to other antibiotics.
• Patient was treated at a dose of 30 mg/kg
every 12 hours for one week.
• The drain is removed at 72 hours.
• The wound evolved favorably withdrawing
the skin stitches after 7 days.
This case and highlights the
importance of following Halsted’s
principles, of utmost importance to
the success in the surgical treatment
of tissues with minimal damage.
- Soft handling of the tissues:
- Meticulous hemostasis:.
- Preservation of the blood source:
- Strict aseptic technique:
- Minimum tension in the fabrics:
- Precise apposition:
- Avoid leaving death space
Kika meningioma corpus calloso
Transfrontoparietal craniotomy
Fluctuating deformation 10 days
postoperative: Fistula LCR?
Surgical review
CSF fistula resolution
Moon
Operated about a week from a femur fracture, without pre-surgical studies
Arrived with hyperthermia 40.5ºC, decay, hyporexia.
Severe pain and deformation in more in the area of surgery, bleeding over
the proximal region of the wound
Blood count presenting severe anemia, and neutrophilia with high desviousness to the left
Hto 19 High neutrophilia: infection?
Thepatient isadmitted
Startanalgesic
infusion IV
Fluid therapy
antibiotics
Planning Surgicalexploration
and bloodtransfusion
culture: Proteus sensitive to Imipenem
she repeat from clinical signs
And go on deterioration of her status
We decided the amputation of the limb
amputation of the limb
she recovered very well
ERROR
58
actitudes
DON'T RUN AWAY AFTER THE
SURGERY END!
IF YOU HAVE ANOTHER
COMMITMENT, LEARN TO SET THE
AGENDA
AGREE TO BE ABLE TO DO EVERY
JOB CORRECTLY
IF A SURGEON,
DOESN'T KNOW WHAT
HAPPENED TO THAT PATIENT
AFTER THE SURGERY.
BECAUSE HE DOES NOT
FOLLOW ACCORDINGLY:
Peter Douglas
THE ANESTESIC PROCESS
DOESN'T CONCLUDE WHEN
WE CLOSE THE ANESTHESIC
VAPORIZER NO CONCLUYO EL
TRATAMIENTO QUIRURGICO
01.NO SURGICAL PROCEDURE IS SIMPLE
02.How a surgeon works in the face of
complications difference
a "great surgeon" of an ”operator"
03.we should operate with the delicacy and
responsibility we would like,
if we were the patient
04. "I can lie to you all,
less myself”
I must be honest with me..
05. The well-being of our patient is our goul
We should not hesitate to ask for help or wait
until we're ready to deal with a difficult case
06.Each case is unique and distinct
We've never seen everything/never
know everything
07.Analyze complications until getting a
conclusion, up to the source.
If we do not understand why they happened,
we are not going to prevent them