L16: Surgical Complications (Ellison) Flashcards Preview

Surgery (Spring 2015) > L16: Surgical Complications (Ellison) > Flashcards

Flashcards in L16: Surgical Complications (Ellison) Deck (33):
1

infection

proliferation of micro-organisms within wound

2

dehiscence

separation of wound

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etiology of wound infection/dehiscence

-inadequate aseptic technique
-improper suturing technique
-self mutilation
-drugs and medical conditions: steroids, Cushings, chemotherapy, anemia
-surgery time-hypothermia
-anesthetic agents: propofol

4

types of wound dehiscence

Superficial separation: can be:
-uninfected (re-suture or staple)
-infected (hot soak, abx, may or may not require 2ary closure)
Herniation with Evisceration

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abx selection for dehiscence

-staphylococcus, strep: amoxicillin, clavamox, cephalosporins
-E. coli proteus: baytril
-Anaerobic bacteria: metronidazole

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Incisional swelling

-some swelling is normal in all wounds
-differentiate b/w edema vs. seroma vs. hernia with palpation, FNA, ultrasound
-if can push up into abdomen, most likely a hernia

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seroma/hematoma

-seroma: pocket of clear serous fluid that sometimes develops in the body after surgery
-hematoma: blood " "
-tx: tap (often recurs), drains (may infect), usually resolve spontaneously

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most important closure

SC closure
-if animal chews up skin sutures, prevents evisceration. If deeper sutures break, prevents hernia

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incisional hernia

-herniation with skin intact
-tx: elective sx, may have to resect herneal sac

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Tx of herniation with evisceration wound dehiscence

-emergency sx
-may have to resect and anastomose

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iatrogenic burns

clipper burns
thermal burns

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peritonitis

inflamm. of the abd. cavity
-can be:
localized (ie. sponge left in)
generalized (ie. uroabdomen/uroperitoneum)
chemical (ie. tear in bile duct w/ powerful inflamm. response)
septic (ie. leaking anastomosis)
combined

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examples of chemical peritonitis

pancreatitis
bile leakage
trauma
urine leakage
gastric perforation

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ex. of septic peritonitis

surgical contamination
sharp trauma
extension of reproductive or urinary tract infection
bowel perforation

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ex. of localized peritonitis

-local vasodilation + pain
-extravasation of plasma
-neutrophil migration
-platelet aggregation
-fibrin clots
-fibrous adhesions

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ex. of generalized peritonitis

-fluid + protein shifts
-hemoconcentration + ____
-hypovolemic shock

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consequences of bacteria + endotoxins

-neuts to abdomen
-hypoglycemia
-metabolic acidosis
-septic shock

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dx of peritonitis

-PE, Rads, BW
-U/S (including abdominocentesis, diagnostic peritoneal lavage (DPL))

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what does peritonitis look like on rad

-generalized abdominal hazinees
-loss of visceral detail
-free abdominal air*
-ileus

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Fluid sample processing

-cytology
-assess glucose, creatinine, and lactate vs. serum lvls
-if creatinine > serum --> urine leakage
-if amylase > 1000 = pancreatic inflammation

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tx of peritonitis

-medical management of hypovolemic or septic shock
-tx of infection/sepsis
-correction of the underlying cause
-providing peritoneal drainage when necessary
"dilution is a solution of pollution"

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abx therapy of peritonitis

-E. coli, Proteus sp., Staph aureus, Enterococcus, Bacteroides
-Cefoxitin, Cefazolin, Baytil, Metronidazole (gram negs), imipenum

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surgical management of peritonitis

-STOP THE CONTAMINATION
-close perforations, resection and anastamosis
-omental wrap, serosal patch, jejunal onlay graft

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Serosal patching indications

-intestinal perforations
-gastric ulcer
-FB
-gun shot wound
-buttress any hollow
-organ sx - bladder, uterus, diaphragm

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Serosal patching: technique

-usually use jejunum
-no tension or twist
-suture 3-4mm beyond margins
-3-0 polypropylene
-mucosa migrates over defect

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peritoneal drains

-silicone or latex
-sealed by fibrin and omentum in 6hrs
-don't "drain" peritoneal cavity
-effective for localized peritonitis

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drain effectiveness

gauze: 20%
penrose: 30%
penrose sump: 50-60%
triple lumen sump: 70%
triple lumen + suction: 80%
(drains don't work very well unless they have active drainage)

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intermittent peritoneal lavage (S.O.!)

-Ingress-Egress system
-Peritoneal dialysis catheter
-20ml/kg LRS, 0.9 NaCl, BID
-hypoproteinemia, hypokalemia

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Open peritoneal drainage - indications

-generalized septic peritonitis
-anaerobic bacteria
-blood components
-good support staff

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Open peritoneal drainage

-gap linea alba 1-2cm
-skin + SC antibiotic ointment
-non-adherent bandage
-sterile cotton roll
-changed 12-24hr intervals
-wound closed in 1-5d

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complications of open peritoneal drainage

-dehydration
-hypoproteinemia
-high mortality

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controversial therapes

-intraperitoneal povidone iodine
-intraperitoneal antibiotics
-intraperitoneal heparin
-peritoneal drainage

33

intraperitoneal abx:

-don't excedd parenteral levels
-don't increase survival
-may be indicated for prophylaxis