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GS12 General Surgery and Thoracic Surgery Surgical Complications Toronto Notes 2019 RESPIRATORY FAILURE
Clinical Features
• dyspnea,cyanosis,andevidenceofobstructivelungdisease
• earliest manifestations – tachypnea and hypoxemia (RR >25, pO2 <60) • pulmonaryedema,andunexplaineddecreaseinSaO2
Treatment
• ABCs,O2,±positivepressureventilation,andintubation
• bronchodilators,anddiureticstotreatCHF
• adequatebloodpressuretomaintainpulmonaryperfusion
• if these measures fail to keep PaO2 >60, consider ARDS (see Respirology, R26)
Cardiac Complications
• abnormalECGscommoninpost-operativeperiod(comparetopre-operativeECG)
• commonarrhythmias:supraventriculartachycardia,atrialfibrillation(secondarytofluidoverload,PE,
and MI)
MYOCARDIAL INFARCTION
• seeCardiologyandCardiacSurgery,C27 • surgeryincreasesriskofMI
• incidence
■ 0.5% in previously asymptomatic men >50 yr old
■ 40-fold increase in men >50 yr old with previous MI
Risk Factors
• pre-operativeHTN,CHF
• previousMI(highestrisk≤6mo,butriskneverreturnstobaseline) • increasedage
• intra-operativehypotension
• operations>3h
• angina
Clinical Features
• majorityofcasesondayofoperationorPOD#3-4(shiftingofthirdspacefluidbackintointravascular compartment)
• oftensilentwithoutchestpain,mayonlypresentwithnew-onsetCHF(dyspnea),arrhythmias,and hypotension
Intra-Abdominal Abscess
Definition
• collectionofpuswalled-offfromrestofperitonealcavitybyinflammatoryadhesionsandviscera
Etiology
• usuallypolymicrobial:Gram-negativebacteria,andanaerobes ■ consider Gram-positives if coexisting cellulitis
Risk Factors
• emergencysurgery,andcontaminatedOR
• GIsurgerywithanastomoses
• poorhealingriskfactors(DM,poornutrition,etc.)
• mayoccurPOD#3afterlaparotomywhenthirdspacefluidre-distributionoccurs
Clinical Features
• persistentspikingfever,dullpain,andweightloss
• massdifficulttopalpate
• peritonealsignsifabscessperforationandsecondaryperitonitis
• leukocytosisorleukopenia(immunocompromised,andelderly)
• co-existingeffusion(pleuraleffusionwithsubphrenicabscess)
• commonsites:pelvis,Morrison’spouch(spacebetweenkidneyandliver),subphrenic,paracolicgutters,
lesser sac, peri-appendiceal, post-surgical anastomosis, diverticular, and psoas
Investigations
• CBC,bloodculturesx2
• CT±IVandwater-solublecontrast • DRE(pelvicabscess)