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Toronto Notes 2019 Surgical Complications General Surgery and Thoracic Surgery GS11
Treatment
• pre-operativeprophylaxis
■ smoking cessation (best if >8 wk pre-operative)
• post-operativeprophylaxis
■ incentive spirometry, deep breathing exercise, chest physiotherapy, and intermittent positive-
pressure breathing
■ selective NGT decompression after abdominal surgery
■ short-acting neuromuscular blocking agents
■ minimize use of respiratory depressive drugs, appropriate pain control, and early ambulation
PNEUMONIA/PNEUMONITIS
• maybesecondarytoaspirationofgastriccontentsduringanestheticinductionorextubation,causinga chemical pneumonitis
Risk Factors
• aspiration:generalanesthetic,decreasedLOC,GERD,fullstomach,bowel/gastricoutletobstruction+ non-functioning NGT, pregnancy, and seizure disorder
• non-aspiration:atelectasis,immobility,andpre-existingrespiratorydisease
Clinical Features
• productivecough,andfever
• tachycardia,cyanosis,respiratoryfailure,anddecreasedLOC • CXR:pulmonaryinfiltrate
Treatment
• prophylaxis:seeatelectasisprophylaxis,pre-operativeNPO/NGT,andrapidsequenceanesthetic induction
• immediateremovalofdebrisandfluidfromairway
• considerendotrachealintubationandflexiblebronchoscopicaspiration
• empiricIVantibioticstocoveroralnosocomialaerobesandanaerobes(e.g.piperacillin-tazobactam,
cefepimemetronidazole)
PULMONARY EMBOLUS
Clinical Features
• unilaterallegswellingandpain(DVTasasourceofPE),suddenonsetdyspnea,pleuriticchestpain, tachycardia, and fever
• mostcommonlyPOD#8-10,butcanoccuranytimepost-operatively,evenafterdischarge
• diagnosismadebyChestCTscanusually
Treatment
• initialtreatment:IVheparinorsubcutaneousLMWH,bridgingtotherapeuticanticoagulationis required for a minimum of 3 mo; for patients with cancer, or other risk factors for hypercoagulability, the duration of anticoagulation may be longer
• Greenfield(IVC)filterifcontraindicationstoanticoagulation
• prophylaxis:subcutaneousheparin(5,000Ubid)orLMWH,compressionstockings(TEDTMHose),and
sequential compression devices
PULMONARY EDEMA
Etiology
• cardiogenicvs.noncardiogenic
• circulatoryoverload:excessvolumereplacement,LVfailure,shiftoffluidfromperipheraltopulmonary
vascular bed, negative airway pressure, and alveolar injury due to toxins (e.g. ARDS) ■ more common with pre-existing cardiac disease
• negativepressurepulmonaryedemaduetoinspiratoryeffortsagainstaclosedglottisuponawakening from general anesthesia
Clinical Features
• shortnessofbreath,cracklesatlungbases,andCXRabnormal
Treatment (LMNOP)
• Lasix
• Morphine(decreasessymptomsofdyspnea,venodilator,andafterloadreduction) • Nitrates(venodilator)
• Oxygen+non-invasiveventilation
• Position(sitpatientup)
New onset “asthma” and wheezing in the elderly is cardiogenic until proven otherwise