Post operative Complications & Their Prevention

About


Post operative complications can range from minor, self limiting problems to major life threatening ones depending on the nature of the surgery and the organ operated upon. Complication can be due to anesthesia or surgery or a reaction to the stress of surgery itself. Some complications are general and apply to all procedures and some are specific that apply to only that procedure.

Common complications include fever, chest infection, pneumonia, wound infection, bleeding or deep vein thrombosis. Most of the complications manifests after the first few days of surgery – usually 1 to 3 days.

Immediate or delayed complication: Some of the complications may be evident soon after the operation while some may take a couple of days to show up, they may be called ‘immediate’ or ‘delayed’ according to the time of manifestation. There are also complications that may manifest only after the patient has been discharged from the hospital.

Associate Conditions that may Increase morbidity of Surgery: By and large it can be said that a healthy young individual undergoing a minor surgery for conditions such as piles or squint surgery will have a smooth recovery, devoid of any complications in the post-operative period. Whereas a person with other medical problems like high blood pressure, diabetes, asthma or heart or kidney disease runs a greater risk of experiencing post-op complications due to the illness he suffers from. The possibility of having complications is increased if the above illnesses are untreated or not under control. Thus it is very important to inform the surgeon as well as the anesthetist of the existence of any illness or allergy and so on. Previous instances of specific complications or problems during any surgery in the past will also guide the doctors in preventing and being prepared to tackle any complications.

Avoiding Complication: Recent statistics indicate that worldwide almost 234 million major surgical procedures are performed each year. This translates into 1 for every 25 people in the world. Majority of the patients who undergo the procedure get well and go home however major complications ranges from 3% to 16%, and rates of permanent disability or death range from 0.4% to 0.8%.

Co-operation from patients can help in preventing some of the complications. If planning prolonged surgery under general anaesthesia of the lungs or the upper abdomen, it is always wise to ask the patient to learn and practise breathing exercises for a few days prior to surgery. This not only helps to open up areas that maybe functioning sub-optimally but most importantly helps the patient resume normal breathing during the post-operative period and also helps overcome some of the sedative effects of anesthesia on the lungs. In most studies patients who undertook breathing exercises prior to surgery had less chances of lung infection and post-operative fever and had better surgical outcomes.

Similarly people who smoke should give up smoking at least a month prior to surgery.

Auto-transfusion: Patients who may require blood transfusion for an elective surgery should think of donating one unit of their own blood to prevent blood transfusion relate problems. This kind of donation has to be done a week or ten days prior to surgery.

Sometimes despite all the precautions a patient may develop a complication like deep vein thrombosis after surgery. However this is rare, if all necessary precautions are taken. The best way to avoid complications is to anticipate them.

Types of post-operative complications


Post- operative complications generally fall in one or more of the three broad categories –

1. Anesthesia related complications

2. Complications common to any procedure

3. Complications common to specific procedure

Depending on the severity of the complications they can again be broadly categorized as Major or Minor.

Minor Complications -Dryness of the mouth and throat, sore throat, drowsiness, shivering, vomiting, dizziness, and giddiness are common side effects of the medicines used during anesthesia. They are self-limiting and do not persist beyond an hour or two.

Fatigue, feeling weak, headache are also common and could be attributed to the fasting that is often required before and after a surgery. Under normal circumstances these symptoms vanish in a day or two.

Some people also experience bloated feeling, constipation and urine retention following an operation and these resolve spontaneously.

Fever can occur as a reaction to the intravenous fluid transfused during an operation.

Major Complications - These complications can be serious and sometimes even life-threatening. They prolong the recovery period and stay in the hospital. The complications may happen during surgery or in the post-operative period. Some of these include -

1.Pulmonary thromboembolism - Clots formed in the deep veins of the legs or thigh can get detached from the leg veins and travel to the lungs and get stuck in the major artery supplying the lungs causing a fatal collapse. These clots are formed in the leg veins when a patient is in prolonged immobilization following a surgery.

2. Aspiration of stomach contents into the lung - This can happen during the initiation of anesthesia if a patient has eaten a meal before the surgery. The food and acidic contents of the stomach can be inhaled into the lungs setting up a severe near-fatal pneumonia of the lung.

3. Anaphylaxis - is a severe allergic reaction to either the anesthetic agents or antibiotics or certain substances used during the operation (e.g-cement used during a joint replacement surgery)

4. Cardiac arrest - is possible as an end result of any of the above events. Prompt cardio-pulmonary resuscitation can help revive the person.

Other possible complications may occur and be related to pre-existing medical illness

A person who suffers from ischemic heart disease, diabetes, high blood pressure, asthma, kidney disease, liver disease, epilepsy, psychosis can expect an exacerbation of these problems in the post-operative period.

Therefore such a patient may develop a heart attack, stroke, high blood sugar, severe asthma, liver or kidney failure following the surgery. The likelihood of these eventualities is more if any of the above mentioned conditions are not under control and the patient is not under regular medication.

A thorough pre-operative evaluation of the risk factors is essential when dealing with patients who have these co-morbid condition. Diabetes and hypertension is not uncommon in the middle and older age group patients. Control of sugar and cardiac evaluation prior to surgery is mandatory in such situations.

Steps to Avoid Complications


Pre-operative Steps to Avoid Complications

Before a patient is subjected to any surgery it is essential that a thorough check up is done and a risk evaluation is undertaken. If there are certain unavoidable risks and the operation is mandatory these risks should be explained to the relatives. A proper informed consent is essential before proceeding for surgery.

Certain surgeries like heart surgery have the inherent problem of blood loss hence enough blood should be cross-matched and kept ready. Similarly in some situations the chances of infections are high and this can lead to sepsis – in this situation prophylactic antibiotic should be used.

General guidelines to avoid complications include -

1. History- certain problems like allergy can be avoided if prior knowledge of these complications is informed to the anesthetists and surgeons.

2. Proper medication-Regular treatment of illnesses like diabetes, high blood pressure should be undertaken

3. Follow instructions regarding fasting, discontinuing some medications as advised faithfully to prevent complications

4. Prevent contamination of wound (operated site) by maintaining general hygiene and asepsis while changing dressings

Remain calm- A relaxed mind will go a long way in making the ordeal of surgery a pleasant experience

Surgcial Checklists for Hospitals To Avoid Complications /post-op-complications-surgical-checklist


Over half and sometimes almost 100% of the surgical complications can be prevented by following simple rules. The release of ‘ WHO Surgical Safety Checklist’ has for the first time provided universally applicable surgical safety standards and aims to improve surgical safety, especially in underserved areas.

To provide high standrard of surgical care audit of 1000 patients from 8 pilot sites were undertaken. It was concluded that by using the checklist the chances of surgical complications can be halved.

Margaret Chan, MD, director-general of WHO, said in a news release -. ‘Preventable surgical injuries and deaths are now a growing concern and using the Checklist is the best way to reduce surgical errors and improve patient safety."

The checklist covers 3 phases of a surgical procedure:

Before anesthesia is induced or "Sign In"

Before skin incision or "Time Out"

Before the patient leaves the operating room or “Sign Out".

Before anesthesia - use mnemonic "Sign In"

Check to see if the patient has -

(1) Any known allergy e.g. antibiotics - If so, document it

(2) If anticipating an anatomically difficult airway to intubate or aspiration risk get additional equipment and assistance should be available.

(3) If there is a risk of losing more than more than 500-mL of blood in adults or 7 mL/kg in children – ensure that there is adequate intravenous access and fluids or reserve blood .

Before induction of anesthesia, key components of the checklist or "Sign In," are as follows:

1. Patient’s identity - Check that the patient has confirmed their identity, the surgical site, and the procedure to be done and that the patient has given informed consent.

2. Surgical site should be marked, if applicable.

3. Do Anesthesia Safety Checks should be completed.

4. Place a Pulse oximeter on the patient and ensure it is functioning.

Before Incision or the checklist use the mnemonic "Time Out"

Introduction, familiarity with roles during surgery and anticipating critical events are the key components:

1. Ensure all team members have introduced themselves both by name and by their role on the surgical team.

2. The surgeon, anesthesia professional, and nurse should verbally confirm the patient's identity, surgical site, and procedure to be performed.

3. Anticipated critical events to be reviewed by the surgeon are any critical or unexpected steps, estimated operative duration, and anticipated blood loss.

4. Anticipated critical events to be reviewed by the anesthesia team are whether there are any patient-specific concerns.

5. Anticipated critical events to be reviewed by the nursing team are confirmation of sterility of the tools, supplies, and field (including indicator results);

a. documentation and discussion of any equipment issues or concerns;

b. whether antibiotic prophylaxis has been given within the last 60 minutes - if applicable

c. and whether essential imaging is displayed - if applicable.

Before Patient Leaves Operating Room uses the mnemonic "Sign Out"

Check for the following components --

1. The nurse verbally confirms with the team the name of the procedure to be recorded

2. The nurse verifies instrument, sponge, and needle counts - if applicable

3. Labeling for the surgical specimen, including patient name

4. Whether there are any equipment problems to be addressed

5. The surgeon, anesthesia professional and nurse should review the key concerns regarding recovery and management of the specific patient.

"Surgical care has been an essential component of health systems worldwide for more than a century," says checklist co-author Atul Gawande, MD, MPH, a surgeon and professor at Harvard Medical School in Boston, Massachusetts. "Although there have been major improvements over the last few decades, the quality and safety of surgical care has been dismayingly variable in every part of the world. The Safe Surgery Saves Lives initiative aims to change this by raising the standards that patients anywhere can expect."

Published in Lancet online - June 25, 2008.

FAQs


1. Which doctor looks after the post-operative complications if they occur?

The doctor who operates on you will look after you during this period. Sometimes if the complication is considered to be major or life-threatening you maybe shifted to the surgical intensive care unit.

2. Is it true that one may never wake up after anesthesia?

This misconception is rampant thanks to the media. A healthy individual, whose anesthesia passés off smoothly will wake up after the anesthetic effect wears off. Those instances where a person goes into a coma or does not wake up after anesthesia is due to some life-threatening event, which possibly affected the oxygen, supply to the brain. In such a situation, the person may have a delayed return to consciousness depending on the extent of the insult suffered.

3. Low back pain is a complication of spinal anesthesia-please clarify

Back pain following a spinal anesthesia is often attributed to spinal anesthesia, though it is not proven to be a cause for backache. There are some types of backache, which are themselves treated by a spinal epidural injection. The occurrence of low back pain following spinal is only co-incidental, as there are many causes like posture, strain and so on which can lead to backache.

3. Are diabetics prone for wound infection?

Yes, Diabetics are prone for wound infection. Strict control of blood sugar will flavor faster healing. Also, one should take care to keep the wound free from contamination and apply proper dressing as per the doctor’s advice

Glossary


Post-op/ post operative - following an operation.

Urine retention - accumulation of urine in the urinary bladder.

Incision - area of the skin and underlying tissue which has been cut open in order to perform the surgery

Dehiscence - break down or open and gaping

Suture - stitches

Thrombophlebitis - inflammation of the vein due to a clot within

Ileus - lack of normal bowel movement of the small intestine

Thromboembolism - a clot traveling along the vessel to reach the heart or brain or any other organ

Aspiration - inhaling or choking on food or drink

Anaphylaxis - a kind of severe allergic reaction which could even cause shock

Reference


1. World Health Organization.
Implementation Manual WHO Surgical Safety Checklist (First Edition).
Available at: http://www.who.int/patientsafety.





Compiled by: Dr.Gayatri

Reviewed by: Dr. S. Shroff

Uploaded by: Mani

    

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