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POSTOPERATIVE COMPLICATIONS. Samaad Malik, MD, MSc, FRCSC Clinical Fellow, CMAS McMaster University August 20, 2008. Objectives. Case Based Clinical Approach Examination Preparation. POS Question sample. 1. What enzyme facilitates access of snake venom into the human lymphatics? - PowerPoint PPT Presentation

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  • POSTOPERATIVE COMPLICATIONS Samaad Malik, MD, MSc, FRCSCClinical Fellow, CMASMcMaster UniversityAugust 20, 2008

  • ObjectivesCase BasedClinical ApproachExamination Preparation

  • POS Question sample1. What enzyme facilitates access of snake venom into the human lymphatics?HyaluronidasePeroxidaseAcethycholinesteraseCrotalase

  • We shall not cease from exploration And the end of all our exploring Will be to arrive where we started And know the place for the first time.T.S. Eliot

  • Surgical ComplicationsSurgical Wound ComplicationsComplications of Thermal RegulationPulmonary ComplicationsCardiac ComplicationsRenal and Urinary Tract ComplicationsEndocrine ComplicationsGastrointestinal ComplicationsHepatobiliary ComplicationsNeurologic ComplicationsEar, Nose, and Throat Complications

  • Approach PageElevator thoughtsQuick Bedside LookABCSelective H+PManagement

  • Case85 yo elderly malePOD #3 Laparoscopic Colectomy Painful R cheek while eating

  • What are your thoughts?DiagnosisHow do you want to proceed??Treatment

  • ParotitisDecrease in the secretory activity of the gland with inspissation of parotid secretions that become infected by staphylococci or gram-negative bacteria from the oral cavity

  • ParotitisPotentially seriousElderlyPoor oral hygienePoor nutritional stateDehydration

  • Post operative ParotitisResults in inflammation, accumulation of cells that obstruct large and medium-sized ducts, and, eventually, formation of multiple small abscessesThese lobular abscesses, separated by fibrous bands, may dissect through the capsule and spread to the periglandular tissues to involve the auditory canal, the superficial skin, and the neck If the disease is not treated at this stage, it may produce acute respiratory failure from tracheal obstruction

  • ORAL HYGIENE?

  • DiagnosisClinicalPain or tenderness at the angle of the jawSwelling and redness in the parotid areaHigh fever and leukocytosis develop

    InvestigationsUltrasound

  • TreatmentClindamycin/Vancomycin should be started while the results of cultures are awaitedWarm moist packs and mouth irrigations may be helpfulRehydrate

  • Case 68 yo malePOD #1 Lap APRDesaturated to 85%

    What are your thoughts?

  • CaseApproachABCHx and PxInvestigationsBloodworkCEAConsultation

  • ThromboembolismsMechanisms:Alterations in normal blood flowInjuries to vascular endotheliumAlterations in the constitution of blood

  • Symptoms and Signs of Pulmonary EmbolismPleuritic chest pain[*]Sudden Dyspnea[*]TachypneaHemoptysis[*]Tachycardia[*]Leg swelling[*]Pain on palpation of the leg[*]Acute right ventricular dysfunctionHypoxiaFourth heart sound[*]Loud second pulmonary sound[*]Inspiratory crackles[*]

  • InvestigationsCXR, ECG, ABGD-dimerCT scanV/Q scanDuplex U/SPulmonary AngiogramEcho

  • TreatmentDepends on hemodynamic stabilityUnstableGet helpThrombolytics?StableAnticoagulateintrinsic fibrinolysis restores pulmonary blood flow

  • HeparinComplicationsBLEEDINGosteoporosisHITNo increased risk of bleedINCREASED risk of ThrombosisBOTH ARTERIAL AND VENOUSIncreased for a period of 1 month

  • HeparinPrevents formation of new thrombi and stops propagation of thrombiEnhances antithrombotic activity of antithrombin III ContraindicationsConsider IVC filterOvert bleeding

  • HITcan occur with LMWH as wellUsually after 5-10 days

  • HITTreatmentGet help HematologyDiscontinue HeparinOther anticouagulantsArgatrobanDanaparoid

  • IVC Filter placementIndicationsRecurrent PE despite adequate anticoagulationContraindications to anticoagulation

  • DVTInvestigationspresentationsmanagementmedical

  • CardiacMortality no h/o MI 1-1.2%6 or more months 6%3 months 16-37%age more than 70ASmedical conditionsemergency operations

    Intraoperative hypotensionPreoperative CHFPreoperative HypotensionAngina

  • Cardiac PearlsInpatient HR 101

    Intravascular volume depletion till proven otherwisePainFever

  • Case67 yo femalePOD #3, Ivor Lewis EsophagectomyHR= 168

    BP= 80/60

    What to do next?

  • ApproachABCACLS protocolCall for help!!

  • Catch!Cardiac ArrythmiasUnderlying causeExtracardiac sepsisAnastomotic leak

  • PulmonarySmokingObesity AgeHome oxygenUnable to walk 1 flight of stairs w/o respiratory compromiseMajor lung resection

    Screen with PFTs, CXR

  • PFTsStudies demonstrate that any patient with an FEV1 greater than 2 L will probably not have serious pulmonary problemsConversely, patients with an FEV1 less than 50% of the predicted value will probably have exertional dyspnea.

  • VentilatorCriteria for Weaning From the VentilatorRespiratory rate70 mm Hg (Fio2 of 40%)PaCo2
  • CasePOD #4, WhipplesTemp, feverCXR shows collapse consolidation of RLL consistent with pneumonia

    Treat?

  • Community-acquired pneumonia (CAP) infection that begins outside of the hospitalis diagnosed within 48 h after admission to the hospital in a patient who has not resided in a long-term facility for 14 days or more before the onset of symptoms

  • Hospital-acquired pneumonia (HAP)infection of lung parenchyma occurring more than 48 h after admission to a hospital

  • Empiric TherapyHAPCefotaxime+ gentamycinTazocinCAPFluoroquinolonesLevofloxacinMacrolidesazithromax

  • Postop FeverCourtesy of DiagnosaurusWind: pneumonia, atelectasis Water: urinary tract infection Wound: wound infection Superficial vs deepWalking: deep vein thrombosis (DVT) from immobilization Wonderdrugs: drug feverWanes: CVL, peripheral lines

  • Postop FeverTubes: N/GsinusitisSurgery: anastomosisSpinal: epidural abscessCardiac EndocarditisColorectal: perianal abscessHPB acalalculous cholecystitis

  • Acute Renal FailureDefined as urine output 50%Differential dxPrerenalRenalPost renal

  • Thyroid StormThyrotoxic crisisAcute life threatening exacerbation of thyrotoxicosisUsually in patient with discontinued antithyroid medication or more commonly undiagnosed hyperthyroidism

  • Thyroid StormClinicalAcute onset hyperpyrexia (temp>40 C)DiaphoreticMarked tachycardia (Afib)Nausea, vomitingAgitationDeliriumTremulousness

  • Thyroid StormPrecipitants:SurgeryDKASepsisMITraumaDrugsIodinated contrast

  • Thyroid StormDiagnosisSerum T4, T3, free T4, free T3 elevatedTSH suppressed

  • Thyroid StormTreatmentABCGet help Endocrinology/Medicine, ICUTreat the underlying causeSpecificPropanalolPropylthiouracilMethimazoleKISteroids?

  • Take Home MessagesClinical:Have a good approach to common clinical scenariosAcknowledge your limitationsDo not hesitate to access multidisciplinary approach

  • Take Home MessagesExaminationDO NOT READ SCHWARTZ from beginning to endOld exams

  • QUESTIONS?