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Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

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Page 1: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Surgical Complications

John Cosgrove, MD FACSChairman and Residency Program DirectorBronx Lebanon Hospital Center

Page 2: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Primum no nocere

Think before you act.

Page 3: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Complications can be deadly…

Logarithmic increase in bile duct injuries after the introduction of laparoscopic cholecystectomy.

Page 4: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

SCIP

Antibiotics Normothermia VTE Prophylaxis

Page 5: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Morbidity and Mortality Conference

Mainstay quality program of general surgery residency programs.

Page 6: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Mortalities

Page 7: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Morbidities

Cardiorespiratory Wound Urinary tract

Page 8: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Wound

Seroma Hematoma Dehiscence Evisceration

Page 9: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Wound

Superficial Deep Organ space

Page 10: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Pathogens

Staphylococcus(coagulase neg) 25% Enterococcus(D) 11.5% Staph aureus 8.7% E. coli 6.5%

Page 11: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Wound classification

Clean Clean contaminated Contaminated Dirty

Page 12: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Temperature regulation

Issues of hypothermia

Page 13: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Malignant hyperthermia

1 in 30,000 cases Mortality less than 10% Autosomal dominant with variable

penetrance Altered calcium metabolism Halothane, isoflurane, succinylcholine Cause rise myoplasmic calcium

Page 14: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

MH

Tachycardia Arrhythmia Raised temperature Acidosis Muscle rigidity Tachypnea Flushing (inability to open mouth)

Page 15: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Treatment

Discontinue triggering anesthetic Hyperventilate with 100% oxygen Terminate surgery Dantrolene 2.5mg/kg as bolus and repeat every 5

minutes Monitoring Sodium bicarbonate Beta blockers Lidocaine Lasix

Page 16: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Pulmonary complications

Atelectasis Pneumonia Pulmonary embolism Aspiration Pulmonary edema ARDS

Page 17: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Weaning criteria

RR <25 breaths/min Pa02 >70mmHg(Fi02 of 40%) PaC02<45 mm Hg MV 8-9L/m TV 5-6mL/kg NIF -25cm H20

Page 18: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Cardiac

Greatest risk in first 48 hours Non-Q wave, non ST segment elevation

Page 19: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Prevention

Major predictors of risk Unstable chest pain, CHF, sympotomatic

arrhythmias, severe valvular disease

Page 20: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Management

Cardiology consult Tachyarrhythmia Unstable-cardioversion SVT-Beta blocker, esmolol, amiodarone PSVT-vagal stimulation, adenosine, amiodarone MAT-B blocker or amiodarone VTach-lidocaine or amiodarone Brady-atropine Heart block-high grade second or third degree-

insertion of permanent pacemaker

Page 21: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Amiodarone

Phosphodiesterase inhibitor Inhibits breakdown of camp Increase cardiac output and decreases

preload and after load without increasing myocardial oxygen demand

May cause vasodilitation and GI problems and thrombocytopenia

Page 22: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Adrenal

Chronic use of steroids causes suppression of the HPA axis

Potentially life threatening Give 250ug cosyntropin intravenousl

Page 23: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Hemodialysis indications

Serum potassium >5.5 BUN>80-90 Persistent metabolic acidosis Acute fluid overload Uremic symptoms(pericarditis, encephalopathy,

anorexia) Removal of toxins Platelet dysfunction Hyperphosphatemia with hypercalcemia

Page 24: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

SIADH

Common cause of chronic normovolemic hyponatremia

Serum sodium<135 Treat underlying disease process Fluid restriction Rapid correction may result in seizures

Page 25: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Gastrointestinal

Ileus Early SBO Compartment syndrome GI bleeding Stomal complications C. difficile colitis

Page 26: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Anastomotic leak

Strategies for prevention Low anterior resection

Page 27: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Enterocutaneous fistula

Low output <200 cc/24h Moderate 200-500 cc/24 h High >500 cc/24 h

Page 28: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

“The Checklist”

Provonost Gawande

Page 29: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Airline Industry

Crew resource management Communication No hierarchy Checklist, checklist, checklist Debriefing

Page 30: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Universal Protocol

Preprocedure Verification Presurgical “timeout” Post procedure “debriefing”

Page 31: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Prospective Case Conference

Dr. Judson Randolph 1988-Childrens Hospital Center, Washington,

DC A priori discussion of all upcoming pediatric

surgery cases involving multiple disciplines

Page 32: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

Interdisciplinary teamwork

GI/bleeds/biliary Radiology/bleeds/abscess Medicine/evaluation/cardiac Anesthesia/PST/surgical readiness

Page 33: Surgical Complications John Cosgrove, MD FACS Chairman and Residency Program Director Bronx Lebanon Hospital Center

“Never events”

CMS