Transcript Laparoscopic Cholecystectomy and the Dyspeptic Patient: A

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?
Hyaluronidase
 Peroxidase
 Acethycholinesterase
 Crotalase

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 Complications










Surgical Wound Complications
Complications of Thermal Regulation
Pulmonary Complications
Cardiac Complications
Renal and Urinary Tract Complications
Endocrine Complications
Gastrointestinal Complications
Hepatobiliary Complications
Neurologic Complications
Ear, Nose, and Throat Complications
Approach
Page
 Elevator thoughts
 Quick Bedside Look
 ABC
 Selective H+P
 Management

Case
85 yo elderly male
 POD #3 Laparoscopic Colectomy
 Painful R cheek while eating


What are your thoughts?


Diagnosis
How do you want to proceed??

Treatment
Parotitis

Decrease 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
Parotitis
Potentially serious
 Elderly
 Poor oral hygiene
 Poor nutritional state
 Dehydration

Post operative Parotitis

Results in inflammation, accumulation of cells
that obstruct large and medium-sized ducts,
and, eventually, formation of multiple small
abscesses
 These 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?
Diagnosis

Clinical
Pain or tenderness at the angle of the jaw
 Swelling and redness in the parotid area
 High fever and leukocytosis develop


Investigations

Ultrasound
Treatment
Clindamycin/Vancomycin should be
started while the results of cultures are
awaited
 Warm moist packs and mouth irrigations
may be helpful
 Rehydrate

Case
68 yo male
 POD #1 Lap APR
 Desaturated to 85%


What are your thoughts?
Case

Approach
ABC
 Hx and Px
 Investigations

Bloodwork
 CEA


Consultation
Thromboembolisms

Mechanisms:
Alterations in normal blood flow
 Injuries to vascular endothelium
 Alterations in the constitution of blood

Symptoms and Signs of Pulmonary
Embolism


Pleuritic chest pain[*]
Sudden Dyspnea[*]
 Tachypnea
 Hemoptysis[*]
 Tachycardia[*]
 Leg swelling[*]
 Pain on palpation of the leg[*]
 Acute right ventricular dysfunction
 Hypoxia
 Fourth heart sound[*]
 Loud second pulmonary sound[*]
 Inspiratory crackles[*]
Investigations
CXR, ECG, ABG
 D-dimer
 CT scan
 V/Q scan
 Duplex U/S
 Pulmonary Angiogram
 Echo

Treatment
Depends on hemodynamic stability
 Unstable

Get help
 Thrombolytics?


Stable
Anticoagulate
 intrinsic fibrinolysis restores pulmonary
blood flow

Heparin

Complications
BLEEDING
 osteoporosis
 HIT

No increased risk of bleed
 INCREASED risk of Thrombosis



BOTH ARTERIAL AND VENOUS
Increased for a period of 1 month
Heparin
Prevents formation of new thrombi and
stops propagation of thrombi
 Enhances antithrombotic activity of
antithrombin III
 Contraindications

Consider IVC filter
 Overt bleeding

HIT
can occur with LMWH as well
 Usually after 5-10 days

HIT

Treatment
Get help – Hematology
 Discontinue Heparin
 Other anticouagulants

Argatroban
 Danaparoid

IVC Filter placement

Indications
Recurrent PE despite adequate
anticoagulation
 Contraindications to anticoagulation

DVT
Investigations
 presentations
 management
 medical

Cardiac
Mortality
 no h/o MI 1-1.2%
 6 or more months 6%
 3 months 16-37%
 age more than 70
 AS
 medical conditions
 emergency operations




Intraoperative
hypotension
Preoperative CHF
Preoperative
Hypotension
Angina
Cardiac Pearls

Inpatient HR 101
Intravascular volume depletion till proven
otherwise
 Pain
 Fever

Case
67 yo female
 POD #3, Ivor Lewis Esophagectomy
 HR= 168


BP= 80/60

What to do next?

Approach
ABC
 ACLS protocol
 Call for help!!

Catch!

Cardiac Arrythmias

Underlying cause
Extracardiac – sepsis
 Anastomotic leak

Pulmonary


Smoking
Obesity
Age
Home oxygen
Unable to walk 1 flight of stairs w/o respiratory
compromise
Major lung resection

Screen with PFTs, CXR




PFT’s
Studies demonstrate that any patient
with an FEV1 greater than 2 L will
probably not have serious pulmonary
problems
 Conversely, patients with an FEV1 less
than 50% of the predicted value will
probably have exertional dyspnea.

Ventilator

Criteria for Weaning From the Ventilator
Respiratory rate<25 breaths/min
 Pao2 >70 mm Hg (Fio2 of 40%)
 PaCo2 <45 mm Hg
 Minute ventilation 8-9 L/min
 Tidal volume 5-6 mL/kg
 Negative inspiratory force- 25 cm H2O

Case
POD #4, Whipple’s
 Temp, fever
 CXR shows collapse consolidation of
RLL consistent with pneumonia


Treat?

Community-acquired pneumonia (CAP)
infection that begins outside of the hospital
 is 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 Therapy

HAP
Cefotaxime+ gentamycin
 Tazocin


CAP

Fluoroquinolones


Levofloxacin
Macrolides

azithromax
Postop Fever

Courtesy of Diagnosaurus
Wind: pneumonia, atelectasis
 Water: urinary tract infection
 Wound: wound infection


Superficial vs deep
Walking: deep vein thrombosis (DVT) from
immobilization
 Wonderdrugs: drug fever
 Wanes: CVL, peripheral lines

Postop Fever

Tubes: N/G

sinusitis
Surgery: anastomosis
 Spinal: epidural abscess
 Cardiac – Endocarditis
 Colorectal: perianal abscess
 HPB – acalalculous cholecystitis

Acute Renal Failure
Defined as urine output <25cc/hr,
increasing Cr, increasing BUN
 Associated mortality, >50%
 Differential dx

Prerenal
 Renal
 Post renal

Thyroid Storm

Thyrotoxic crisis
Acute life threatening exacerbation of
thyrotoxicosis
 Usually in patient with discontinued
antithyroid medication or more commonly
undiagnosed hyperthyroidism

Thyroid Storm

Clinical
Acute onset hyperpyrexia (temp>40 ‘C)
 Diaphoretic
 Marked tachycardia (Afib)
 Nausea, vomiting
 Agitation
 Delirium
 Tremulousness

Thyroid Storm

Precipitants:
Surgery
 DKA
 Sepsis
 MI
 Trauma
 Drugs
 Iodinated contrast

Thyroid Storm

Diagnosis
Serum T4, T3, free T4, free T3 elevated
 TSH suppressed

Thyroid Storm

Treatment
ABC
 Get help – Endocrinology/Medicine, ICU
 Treat the underlying cause
 Specific

Propanalol
 Propylthiouracil
 Methimazole
 KI
 Steroids?

Take Home Messages
Clinical:
 Have a good approach to common
clinical scenarios
 Acknowledge your limitations
 Do not hesitate to access
multidisciplinary approach

Take Home Messages

Examination
DO NOT READ SCHWARTZ from
beginning to end
 Old exams

QUESTIONS?