Title: general surgery for dental students by dr. ahmad k. shahwan
1GENERAL SURGERY FOR DENTAL STUDENTS
- BY
- Dr. AHMAD K. SHAHWAN
- PH.D. GENERAL SURGERY
2Approach to the Surgical Patient
- The management of surgical disorders requires not
only the application of technical skills and
training in the basic sciences to the problems of
diagnosis and treatment but also a sympathy and
indeed love for the patient. The surgeon must be
a doctor, an applied scientist, an engineer, an
artist. Because life or death often depends upon
the validity of surgical decisions, the surgeon's
judgment must be matched by courage in action and
by a high degree of technical proficiency
3Approach to the Surgical Patient
- History-
- physical Examination -
- Investigations-
- Pre-operative preparation -
- operation -
- post-operative treatment-
- management of complications.
4Approach to the Surgical Patient
- The History
- At their first contact, the surgeon must gain the
patient's confidence and convey the assurance
that help is available and will be provided. The
surgeon must demonstrate concern for the patient
as a person who needs help and not just as a
"case" to be processed. This is not always easy
to do, and there are no rules of conduct except
to be gentle and considerate.
5The History
- I- The chief complaint i.e. what the problem
that bring the patient to the doctor its
duration . - II- The present history in full detail
- 1-when the complaint start exactly ? (day ,
hour). - 2-how it starts? (slowly ,abruptly )
- 3-its course ? (increasing , the same or
decreasing ). - 4- any associated symptoms? (pain vomiting ,fever
,drowsiness ,change in vision ,..) . - 5- the provoking factors what increase the
complaint? - 6- the releasing factorswhat decrease the
complaint ? - 7- relieved by medication or not ?
- 8- constant or intermittent ,its duration for
how long ?
6The History
- e.g. The pain
- The site
- The onset gradual ,sudden or explosive
- The character burning ,colicky, vague
,heaviness,.. - The severity mild ,moderate or sever .
- constant or intermittent .
- relieved by medication or not what medication ?
- Factors increase it movement ,eating, standing
,. - Factors decrease it movement ,eating, standing
, - Radiation to other site ?
- Associated symptoms vomiting ,fever ..
7The History
- E.g. vomiting
- What did the patient vomit? Food ,fluid ,
- How much?
- How often?
- What did the color of the vomitus ? yellow
,green, brown,. - Was vomiting projectile?
- The taste of the vomitus ?acidic , bitter ,..
8The History
- III- The past history
- Any same complain before ? How it started how
ended? - Any other complain before? Related to the
complaint or not related ? - Any other diseases? hypertension. ,diabetes
mellitus , cardiac problem, - IV The drug history aspirin ,anticoagulant
,contraceptive pills ,chemotherapy . - V- The surgical history any operation before,
type of anesthesia ,any complication?
9The History
- VI- Nutritional history dehydration . Loss of
electrolyte ,protein deficiency. - VII- Menstrual history regularity ,duration ,
amount,.. - VIII-Family history known disease in the family
,same disease in the family ,hereditary diseases?
. - IX- Environmental history.
- X- Habbit history smoking, alcohol ,drug abuse
. - XI- Hypersensitivity history .
10The physical examination
- All patients are sensitive and somewhat
embarrassed at being examined . - The examining room and table should be
comfortable ,worm, closed, and drapes should be
used if the patient is required to strip for the
examination. A female nurse should be present if
the patient is female. Most patients will relax
if they are allowed to talk a bit during the
examination, which is another reason for taking
the past history while the examination is being
done.
11The physical examination
- Inspection any scar, pulsation, swelling,
redness, discharge, asymmetry, hair distribution,
ulcers, wound ,. - Palpation (superficial palpation for masses,
tenderness,.deep palpation for deep masses ) - Percation to differentiate between air solid
surfaces. - Auscultation by use stethoscope to hear normal
abnormal sounds.
12- E.g. if we find a lump (mass), we should know
- The site .
- The size .
- The shape .
- The edge (cut or rounded).
- Tenderness .
- Pulsation .
- Flactuality .
- Consistency .
- Mobility .
- The surface.
- Reducibility .
- Regional draining lymph node .
13- E.g. if we find an ulcer we should know
- The site .
- The size .
- The shape .
- The edge .
- The base (what you can feel) .
- The floor (what you can see) .
- The color .
- The secretion .
- The vascularity .
- Regional draining lymph node .
14Investigations
- I- Simple blood investigations
- C.B.C. (complete blood count) which reveals
hemoglobin, white blood cells, red blood cells,
platelets count, - Blood group Rh-factor.
- Blood sugar (fasting or random or post brandial)
. - The kidney function tests (Blood urea ,serum
creatinine) . - Electrolyte Na ,K, Ca,..
- The liver function test (ALT, AST ,Serum
bilirubin ,Serum protein albumin ) . - P.T. P.T.T.
15Investigations
- II- urine exam (general culture).
- III- Stool exam (general culture).
- IV- ultrasonography.
- V- X-ray
- 1- simple X-ray (without dye) e.g. chest X-ray
,abdominal X-ray ,K.U.B. ,skull X-ray ,panorama
X-ray, . - 2- X-ray with dye e.g. barium meal ,barium
enema, I.V.P - 3- C.T. ( computerized tomography ) scan .
- 4- M.R.I. (magnetic resonance imaging) .
- VI- E.C.G . (electro cardio graphy )
16Investigations
- Special Examinations
- such as cystoscopy, gastroscopy, esophagoscopy,
colonoscopy, angiography, and bronchoscopy are
often required in the diagnosis of certain
surgical disorders. The surgeon must be familiar
with the indications and limitations of these
procedures and be prepared to consult with
colleagues in medicine and other surgical
specialties as required.
17Pre-operative preparation
- According to the type of operation, we should do
- All the required investigations
- Prepare blood .
- Shaving the operation site.
- The patient take a bath.
- Examined by the anesthetist.
- Prepare I.C.U. if the patient need.
- Give him premedications like diazepam a night
before the operation. - Fasting 8 hours before the operation .
- The patient should enter the operation room in
the optimum condition
18Approach to the Surgical Patient
- --operation -
- --post-operative treatment-
- --management of complications.
- (according to the type of the operation.)
19Postoperative Care
- The recovery from surgery can be divided into
three phases - (1) an immediate, or post-anesthetic phase
- (2) an intermediate phase, ( the hospitalization
period) - (3) a convalescent phase.
- During the first two phases, care is principally
directed at maintenance of homeostasis, treatment
of pain, and prevention and early detection of
complications. The convalescent phase is a
transition period from the time of hospital
discharge to full recovery. - The trend toward earlier postoperative discharge
after major surgery make the 3rd phase more
important.
201-The Immediate Postoperative Period
- The major causes of early complications and death
following major surgery are acute pulmonary,
cardiovascular, and fluid derangements. The
post-anesthesia care unit (PACU) is staffed by
specially trained personnel and provided with
equipment for early detection and treatment of
these problems. All patients should be monitored
in this specialized unit initially following
major procedures .
211-The Immediate Postoperative Period
- The patient can be discharged from the recovery
room when cardiovascular, pulmonary, and
neurologic function have returned to baseline,
which usually occurs 13 hours following
operation. - Patients who require continuing ventilatory or
circulatory support or who have other conditions
that require frequent monitoring are transferred
to an intensive care unit (I.C.U.) . In this
setting, nursing personnel specially trained in
the management of respiratory and cardiovascular
emergencies are available. - Monitoring equipment is available to enable
early detection of cardio-respiratory
derangements.
22Postoperative Orders in The Immediate
Postoperative Period
- The nursing team must be advised of the nature of
the operation and the patient's condition. - Postoperative orders should cover the following
- 1- Monitoring the following
- A- Vital Signs Blood pressure, pulse, and
respiration should be recorded frequently until
stable and then regularly until the patient is
discharged from the recovery room. The frequency
of vital sign measurements thereafter depends
upon the nature of the operation and the course
in the PACU. Continuous electrocardiographic
monitoring is indicated for most patients in the
PACU. Any major changes in vital signs should be
communicated to the anesthesiologist and surgeon
immediately.
23- B-Central Venous Pressure
- Central venous pressure should be recorded
periodically in the early postoperative period if
the operation has entailed large blood losses or
fluid shifts, and invasive monitoring is
available. A Swan-Ganz catheter for measurement
of pulmonary artery wedge pressure is indicated
under these conditions if the patient has
borderline cardiac or respiratory function.
24- C- Fluid Balance
- The anesthetic record includes all fluid
administered as well as blood loss and urine
output during the operation. This record should
be continued in the postoperative period and
should also include fluid losses from drains and
stomas. This aids in assessing hydration and
helps to guide intravenous fluid replacement. A
bladder catheter can be placed for frequent
measurement of urine output. In the absence of a
bladder catheter, the surgeon should be notified
if the patient is unable to void within 68 hours
after operation.
25- D- Other Types of Monitoring
- Depending on the nature of the operation and the
patient's pre-existing conditions, other types of
monitoring may be necessary. Examples include
measurement of intracranial pressure and level of
consciousness following cranial surgery and
monitoring of distal pulses following vascular
surgery or in patients with casts.
26- 2- Respiratory Care
- In the early postoperative period, the patient
may remain mechanically ventilated or treated
with supplemental oxygen by mask or nasal prongs.
These orders should be specified. For intubated
patients, tracheal suctioning or other forms of
respiratory therapy must be specified as
required. Patients who are not intubated should
do deep breathing exercises frequently to prevent
atelectasis.
27- 3- Position in Bed and Mobilization
- The postoperative orders should describe any
required special positioning of the patient.
Unless doing so is contraindicated, the patient
should be turned from side to side every 30
minutes until conscious and then hourly for the
first 812 hours to minimize atelectasis. - Early ambulation is encouraged to reduce venous
stasis the upright position helps to increase
diaphragmatic function. - Venous stasis may also be minimized by
intermittent compression of the calf by pneumatic
stockings.
28- 4- Diet
- Patients at risk for emesis and pulmonary
aspiration should have nothing by mouth until
some gastrointestinal function has returned
(usually within 4 days). Most patients can
tolerate liquids by mouth shortly after return to
full consciousness. - 5- Administration of Fluid and Electrolytes
- Orders for postoperative intravenous fluids
should be based on maintenance needs and the
replacement of gastrointestinal losses from
drains, fistulas, or stomas.
29- 6- Drainage Tubes
- Drain care should be included in the
postoperative orders. Details such as type and
pressure of suction, irrigation fluid and
frequency, and skin exit site care should be
specified. The surgeon should examine drains
frequently, since the character or quantity of
drain output may herald the development of
postoperative complications such as bleeding or
fistulas. - 7- Medications
- Orders should be written for antibiotics,
analgesics, gastric acid suppression, deep vein
thrombosis prophylaxis, and sedatives. If
appropriate, preoperative medications should be
reinstituted. Careful attention should be paid to
replacement of corticosteroids in patients at
risk, since postoperative adrenal insufficiency
may be life-threatening. Other medications such
as antipyretics, laxatives, and stool softeners
should be used selectively as indicated.
30- 8- Laboratory Examinations and Imaging
- The use of postoperative laboratory and
radiographic examinations should be to detect
specific abnormalities in high-risk groups. The
routine use of daily chest radiographs, blood
counts, electrolytes, and renal or liver function
panels is not useful.
31The Intermediate Postoperative Period
- The intermediate phase starts with complete
recovery from anesthesia and lasts for the rest
of the hospital stay. During this time, the
patient recovers most basic functions and becomes
self-sufficient and able to continue
convalescence at home.
32- 1- Care of the Wound
- Within hours after a wound is closed, the wound
space fills with an inflammatory exudate.
Epidermal cells at the edges of the wound begin
to divide and migrate across the wound surface.
By 48 hours after closure, deeper structures are
completely sealed off from the external
environment. Sterile dressings applied in the
operating room provide protection during this
period. Dressings over closed wounds should be
removed on the third or fourth postoperative day.
If the wound is dry, dressings need not be
reapplied this simplifies periodic inspection.
Dressings should be removed earlier if they are
wet, because soaked dressings increase bacterial
contamination of the wound.
331- Care of the Wound
- Dressings should also be removed if the patient
has manifestations of infection (such as fever or
increasing wound pain). The wound should then be
inspected and the adjacent area gently
compressed. Any drainage from the wound should be
examined by culture and Gram-stained smear.
Removal of the dressing and handling of the wound
during the first 24 hours should be done with
aseptic technique. Medical personnel should wash
their hands before and after caring for any
surgical wound. Gloves should always be used when
there is contact with open wounds or fresh
wounds.
341- Care of the Wound
- Generally, skin sutures or skin staples may be
removed by the fifth postoperative day and
replaced by tapes. Sutures should be left in
longer (eg, for 2 weeks) in incisions that - 1- cross creases (eg, groin, popliteal area)
- 2-for incisions closed under tension
- 3-for some incisions in the extremities (eg, the
hand) - 4-with incisions of any kind in debilitated
patients. - Sutures should be removed if suture tracts show
signs of infection. If the incision is healing
normally, the patient may be allowed to shower or
bathe by the seventh postoperative day.
351- Care of the Wound
- Fibroblasts proliferate in the wound space
quickly, and by the end of the first
postoperative week, new collagen is abundant in
the wound. On palpation of the wound, connective
tissue can be felt as a prominence (the healing
ridge) and is evidence that healing is normal.
Tensile strength is minimal for the first 5 days.
It increases rapidly between the fifth and
twentieth postoperative days and more slowly
thereafter. Wounds continue to gain tensile
strength slowly for about 2 years. In otherwise
healthy patients, the wound should be subjected
to only minor stress for 68 weeks. When wound
healing is expected to be slower than normal
(e.g., in elderly or debilitated patients or
those taking corticosteroids), activity should be
delayed even further
361- Care of the Wound
- When a wound has been contaminated with bacteria
during surgery, it is often best to leave the
skin and subcutaneous tissues open and either to
perform delayed primary closure or allow
secondary closure to occur. The wound is loosely
packed with fine-mesh gauze in the operating room
and is left undisturbed for 45 days the packing
is then removed. If at this time the wound
contains only serous fluid or a small amount of
exudate, the skin edges can be approximated with
tapes. If drainage is considerable or infection
is present, the wound should be allowed to close
by secondary intention. In this case, the wound
should be packed with moist-to-dry dressings,
which are changed once or twice daily. The
patient can usually learn how to care for the
wound and should be discharged as soon as his or
her general condition permits. Most patients do
not require visiting nurses to assist with wound
care at home.
371- Care of the Wound
- Wound healing is faster if the state of nutrition
is normal and there are no specific nutritional
deficits. For example, vitamin C deficiency
interferes with collagen synthesis and vitamin A
deficiency decreases the rate of
epithelialization. Deficiencies of copper,
magnesium, and other trace metals decrease the
rate of scar formation. Supplemental vitamins and
minerals should be given postoperatively when
deficiencies are suspected, but wound healing
cannot be accelerated beyond the normal rate by
nutritional supplements. - Wound problems should be anticipated in patients
taking corticosteroids, which inhibit the
inflammatory response, fibroblast proliferation,
and protein synthesis in the wound. Maturation of
the scar and gain of tensile strength occur more
slowly. Extra precautions include using
non-absorbable suture materials for fascial
closure, delaying removal of skin stitches, and
avoiding stress in the wound for 36 months.
382-Management of Drains
- Drains are used either to prevent or to treat an
unwanted accumulation of fluid such as pus,
blood, or serum. Drains are also used to evacuate
air from the pleural cavity so that the lungs can
reexpand. When used prophylactically, drains are
usually placed in a sterile location. Strict
precautions must be taken to prevent bacteria
from entering the body through the drainage tract
in these situations. The external portion of the
drain must be handled with aseptic technique, and
the drain must be removed as soon as it is no
longer useful. When drains have been placed in an
infected area, there is a smaller risk of
retrograde infection of the peritoneal cavity,
since the infected area is usually walled off.
Drains should usually be brought out through a
separate incision, because drains through the
operative wound increase the risk of wound
infection.
392-Management of Drains
- Closed drains connected to suction devices are
preferable to open drains (such as Penrose) that
predispose to wound contamination. The quantity
and quality of drainage should be recorded, and
contamination minimized. When drains are no
longer needed, they may be withdrawn entirely at
one time if there has been little or no drainage
or may be progressively withdrawn over a period
of a few days. -
402-Management of Drains
- Sump drains (such as Davol drains) have an
airflow system that keeps the lumen of the drain
open when fluid is not passing through it, and
they must be attached to a suction device. Sump
drains are especially useful when the amount of
drainage is large or when drainage is likely to
plug other kinds of drains. Some sump drains have
an extra lumen through which saline solution can
be infused to aid in keeping the tube clear.
After infection has been controlled and the
discharge is no longer purulent, the large-bore
catheter is progressively replaced with smaller
catheters, and the cavity eventually closes.
413-Postoperative Pulmonary Care
- The changes in pulmonary function observed
following anesthesia and surgery are principally
the result of decreased vital capacity,
functional residual capacity (FRC), and pulmonary
edema. These changes are accentuated in patients
who are - obese,
- who smoke heavily, or
- who have preexisting lung disease.
- Elderly patients are particularly vulnerable
because they have decreased compliance, increased
closing volume, increased residual volume, and
increased dead space, all of which enhance the
risk of postoperative atelectasis.
423-Postoperative Pulmonary Care
- Pain is thought to be one of the main causes of
shallow breathing postoperatively. Complete
abolition of pain, however, does not completely
restore pulmonary function . The principal means
of minimizing atelectasis is deep inspiration.
Early mobilization, encouragement to take deep
breaths (especially when standing), and good
coaching by the nursing staff suffice for most
patients.
434-Postoperative Fluid Electrolyte Management
- Postoperative fluid replacement should be based
on the following considerations - (1) maintenance requirements,
- (2) extra needs resulting from systemic factors
(e.g., fever, burns), - (3) losses from drains, and
- (4) requirements resulting from tissue edema and
ileus (third space losses). - Daily maintenance requirements for sensible and
insensible loss in the adult are about 15002500
mL depending on the patient's age, gender,
weight, and body surface area. A rough estimate
can be obtained by multiplying the patient's
weight in kilograms times 30 (e.g., 1800 mL/24 h
in a 60-kg patient). Maintenance requirements are
increased by fever, hyperventilation, and
conditions that increase the catabolic rate.
444-Postoperative Fluid Electrolyte Management
- For patients requiring intravenous fluid
replacement for a short period (most
postoperative patients), it is not necessary to
measure serum electrolytes at any time during the
postoperative period, but measurement is
indicated in more complicated patients (those
with extra fluid losses, sepsis, preexisting
electrolyte abnormalities, or other factors).
Assessment of the status of fluid balance
requires accurate records of fluid intake and
output and is aided by weighing the patient
daily. - As a rule, 20002500 mL of 5 dextrose /or
normal saline / or lactated Ringer's solution
is given daily. Potassium should usually not be
added during the first 24 hours after surgery,
because increased amounts of potassium enter the
circulation during this time as a result of
operative trauma and increased aldosterone
activity.
45(No Transcript)
464-Postoperative Fluid Electrolyte Management
- In most patients, fluid loss through a
nasogastric tube is less than 500 mL/d and can be
replaced by increasing the infusion used for
maintenance by a similar amount. About 20 meq of
potassium should be added to every liter of fluid
used to replace these losses. However, with the
exception of urine, body fluids are isosmolar and
if large volumes of gastric or intestinal juice
are replaced with normal saline solution,
electrolyte imbalance will eventually result.
Whenever external losses from any site amount to
1500 mL/d or more, electrolyte concentrations in
the fluid should be measured periodically, and
the amount of replacement fluids should be
adjusted to equal the amount lost.
475-Postoperative Care of the Gastrointestinal
Tract
- In the immediate postoperative period, the
stomach may be decompressed with a nasogastric
tube. Nasogastric intubation was once used in
almost all patients undergoing laparotomy to
avoid gastric distention and vomiting, The
nasogastric tube should be connected to low
intermittent suction and irrigated frequently to
ensure patency. The tube should be left in place
for 23 days or until there is evidence that
normal peristalsis has returned (e.g., return of
appetite, audible peristalsis, or passage of
flatus).
485-Postoperative Care of the Gastrointestinal Tract
- Once the nasogastric tube has been withdrawn,
fasting is usually continued for another 24
hours, and the patient is then started on a
liquid diet. Opioids may interfere with gastric
motility and should be stopped in patients who
have evidence of gastro-paresis beyond the first
postoperative week. After most operations in
areas other than the peritoneal cavity, the
patient may be allowed to resume a regular diet
as soon as the effects of anesthesia have
completely worn off.
496-Postoperative Pain
- Severe pain is a common sequela of intrathoracic,
intra-abdominal, and major bone or joint
procedures. About 60 of such patients perceive
their pain to be severe, 25 moderate, and 15
mild. In contrast, following superficial
operations on the head and neck, limbs, or
abdominal wall, less than 15 of patients
characterize their pain as severe. The factors
responsible for these differences include
duration of surgery, degree of operative trauma,
type of incision, and magnitude of intraoperative
retraction. Gentle handling of tissues, expedient
operations, and good muscle relaxation help
lessen the severity of postoperative pain.
506-Postoperative Pain
- While factors related to the nature of the
operation influence postoperative pain, it is
also true that the same operation produces
different amounts of pain in different patients.
This varies according to individual physical,
emotional, and cultural characteristics. Much of
the emotional aspect of pain can be traced to
anxiety. Feelings such as helplessness, fear, and
uncertainty contribute to anxiety and may
heighten the patient's perception of pain.
517-Physician-Patient Communication
- Close attention to the patient's needs, frequent
reassurance, and genuine concern help minimize
postoperative pain. Spending a few minutes with
the patient every day in frank discussions of
progress and any complications does more to
relieve pain than many physicians realize.
528-Parenteral Opioids
- Opioids are the mainstay of therapy for
postoperative pain. Their analgesic effect is via
two mechanisms - (1) a direct effect on opioid receptors and
- (2) stimulation of a descending brain stem
system that contributes to pain inhibition.
Morphine ,pethidine tramal are the most widely
used opioid for treatment of postoperative pain.
Morphine may be administered intravenously,
either intermittently or continuously
53Nonopioid Parenteral Analgesics
- They are non-steroidal anti-inflammatory drugs
(NSAID) with potent analgesic and moderate
anti-inflammatory activities. It is available in
injectable form suitable for postoperative use . - E.g. aspirin (acetyl salicylic acid ),diclofen
sodium ,piroxicam,. -
54Oral Analgesics
- Within several days following most surgical
procedures, the severity of pain decreases to a
point where oral analgesics suffice. Aspirin
should be avoided as an analgesic
postoperatively, since it interferes with
platelet function, prolongs bleeding time, and
interferes with the effects of anticoagulants.
For most patients, a combination of acetaminophen
with codeine (e.g., Tylenol) or with propoxyphene
(analgan) suffices. - As with all opioids, tolerance develops with
long-term use. - Continuous Epidural Analgesia
- Intercostal Block
55Postoperative Complications
- Postoperative complications may result from 1-
the primary disease, - 2- the operation, or
- 3-unrelated factors.
- Occasionally, one complication results from
another previous one (eg, myocardial infarction
following massive postoperative bleeding). The
clinical signs of disease are often blurred in
the postoperative period. Early detection of
postoperative complications requires repeated
evaluation of the patient by the operating
surgeon and other team members .
56Postoperative Complications
- Prevention of complications starts in the
preoperative period with evaluation of the
patient's disease and risk factors. Improving the
health of the patient before surgery is one goal
of the preoperative evaluation. For example,
cessation of smoking for 6 weeks before surgery
decreases the incidence of postoperative
pulmonary complications from 50 to 10.
Correction of gross obesity decreases
intra-abdominal pressure and the risk of wound
and respiratory complications and improves
ventilation postoperatively. - The surgeon should explain the operation and the
expected postoperative course to the patient and
family. The preoperative hospital stay, if one is
necessary, should be as short as possible both to
reduce costs and to minimize exposure to
antibiotic-resistant microorganisms. Adequate
training in respiratory exercises planned for the
postoperative period substantially decreases the
incidence of postoperative pulmonary
complications.
57Postoperative Complications
- Early mobilization, proper respiratory care, and
careful attention to fluid and electrolyte needs
are important. On the evening after surgery the
patient should be encouraged to sit up, cough,
breathe deeply, and walk, if possible. The
upright position permits expansion of basilar
lung segments, and walking increases the
circulation of the lower extremities and lessens
the danger of venous thromboembolism. - In severely ill patients, continuous monitoring
of systemic blood pressure and cardiac
performance enables identification and correction
of mild derangements before they become severe.
58I- Wound Complications
- 2- Seroma
- A seroma is a fluid collection in the wound other
than pus or blood. Seromas often follow
operations that involve elevation of skin flaps
and transection of numerous lymphatic channels
(eg, mastectomy, operations in the groin).
Seromas delay healing and increase the risk of
wound infection. Those located under skin flaps
can usually be evacuated by needle aspiration.
Compression dressings should then be applied to
seal lymphatic leaks and prevent reaccumulation.
Small seromas that recur may be treated by
repeated evacuation. Seromas of the groin, which
are common after vascular operations, are best
left to resorb without aspiration, since the
risks of introducing a needle (infection,
disruption of vascular structures, etc) are
greater than the risk associated with the seroma
itself. If seromas persistor if they start
leaking through the woundthe wound should be
explored in the operating room and the lymphatics
ligated.
59I- Wound Complications
- 1- Hematoma
- Wound hematoma, a collection of blood and clot in
the wound, is one of the most common wound
complications and is almost always caused by
imperfect hemostasis. Patients receiving aspirin
or low-dose heparin have a slightly higher risk
of developing this complication. The risk is much
higher in patients who have been given
systemically effective doses of anticoagulants
and those with preexisting coagulopathies.
Vigorous coughing or marked arterial hypertension
immediately after surgery may contribute to the
formation of a wound hematoma. - Hematomas produce elevation and discoloration of
the wound edges, discomfort, and swelling. Blood
sometimes leaks through skin sutures. Neck
hematomas following operations on the thyroid,
parathyroid, or carotid artery are particularly
dangerous, because they may expand rapidly and
compromise the airway. Small hematomas may
resorb, but they increase the incidence of wound
infection. Treatment in most cases consists of
evacuation of the clot under sterile conditions,
ligation of bleeding vessels, and reclosure of
the wound.
60I- Wound Complications
- 3- Wound Dehiscence
- Wound dehiscence is partial or total disruption
of any or all layers of the operative wound.
Rupture of all layers of the abdominal wall and
extrusion of abdominal viscera is evisceration.
Wound dehiscence occurs in 13 of abdominal
surgical procedures. Systemic and local factors
contribute to the development of this
complication. - 3-1-- Systemic Risk Factors
- Dehiscence is rare in patients under age 30 but
affects about 5 of patients over age 60 having
laparotomy. It is more common in patients with
diabetes mellitus, uremia, immunosuppression,
jaundice, sepsis, hypoalbuminemia, and cancer in
obese patients and in those receiving
corticosteroids.
61- 3-2- Local Risk Factors
- The three most important local factors
predisposing to wound dehiscence are inadequate
closure, increased intra-abdominal pressure, and
deficient wound healing. Dehiscence often results
from a combination of these factors rather than
from a single one. The type of incision
(transverse, midline, etc) does not influence the
incidence of dehiscence. - E.g. Adequacy of Closure
- This is the single most important factor. The
fascial layers give strength to a closure, and
when fascia disrupts, the wound separates.
Accurate approximation of anatomic layers is
essential for adequate wound closure. Most wounds
that dehisce do so because the sutures tear
through the fascia. Prevention of this problem
includes performing a neat incision, avoiding
devitalization of the fascial edges by careful
handling of tissues during the operation, placing
and tying sutures correctly, and selecting the
proper suture material. Sutures must be placed
23 cm from the wound edge and about 1 cm apart.
Dehiscence is often the result of using too few
stitches and placing them too close to the edge
of the fascia. Ostomies and drains should be
brought out through separate incisions to reduce
the rate of wound infection and disruption.
62II- Respiratory Complications
- Respiratory complications are the most common
single cause of morbidity after major surgical
procedures and the second most common cause of
postoperative deaths in patients older than 60
years. - Patients undergoing chest and upper abdominal
operations are particularly prone to pulmonary
complications. The incidence is lower after
pelvic surgery and even lower after extremity or
head and neck procedures. - Pulmonary complications are more common after
emergency operations. - Special hazards are posed by preexisting chronic
obstructive pulmonary disease (chronic
bronchitis, emphysema, asthma, pulmonary
fibrosis). Elderly patients are at much higher
risk because they have decreased compliance,
increased residual volumes, and increased dead
space, all of which predispose to atelectasis.
63II- Respiratory Complications
- 1- Atelectasis
- Atelectasis, the most common pulmonary
complication, affects 25 of patients who have
abdominal surgery. It is more common in patients
who are elderly or overweight and in those who
smoke or have symptoms of respiratory disease. It
appears most frequently in the first 48 hours
after operation and is responsible for over 90
of febrile episodes during that period. In most
cases, the course is self-limited and recovery
uneventful.
64- Atelectasis is usually manifested by fever
(pathogenesis unknown), tachypnea, and
tachycardia. Physical examination may show
elevation of the diaphragm and decreased breath
sounds. - Postoperative atelectasis can be largely
prevented by early mobilization, frequent changes
in position, encouragement to cough, and
physiotherapy. Preoperative teaching of
respiratory exercises and postoperative execution
of these exercises prevents atelectasis in
patients without preexisting lung disease. - Treatment consists of clearing the airway by
chest percussion, coughing, or nasotracheal
suction. Bronchodilators and mucolytic agents
given by nebulizer may help in patients with
severe chronic obstructive pulmonary disease.
Atelectasis from obstruction of a major airway
may require intrabronchial suction through an
endoscope, a procedure that can usually be
performed at the bedside with mild sedation
65- 2- Pulmonary Aspiration
- Aspiration of oropharyngeal and gastric contents
is normally prevented by the gastroesophageal and
pharyngoesophageal sphincters. Insertion of
nasogastric and endotracheal tubes and depression
of the central nervous system by drugs interfere
with these defenses and predispose to aspiration.
Other factors, such as gastroesophageal reflux,
food in the stomach, or position of the patient,
may play a role. Trauma victims are particularly
likely to aspirate regurgitated gastric contents
when consciousness is depressed. Patients with
intestinal obstruction and pregnant womenwho
have increased intra-abdominal pressure and
decreased gastric motilityare also at high risk
of aspiration. Two-thirds of cases of aspiration
follow thoracic or abdominal surgery, and of
these, one-half result in pneumonia. The death
rate for grossly evident aspiration and
subsequent pneumonia is about 50.
66- The magnitude of pulmonary injury produced by
aspiration of fluid, usually from gastric
contents, is determined by the volume aspirated,
its pH, and the frequency of the event. If the
aspirate has a pH of 2.5 or less, it causes
immediate chemical pneumonitis, which results in
local edema and inflammation, changes that
increase the risk of secondary infection. - Aspiration of solid matter can produce airway
obstruction. Obstruction of distal bronchi,
though well tolerated initially, can lead to
atelectasis and pulmonary abscess formation. The
basal segments are affected most often.
Tachypnea, fever, and hypoxia are usually present
within hours less frequently, cyanosis,
wheezing, and apnea may appear. In patients with
massive aspiration, hypovolemia caused by
excessive fluid and colloid loss into the injured
lung may lead to hypotension and shock.
67- Aspiration can be prevented by preoperative
fasting, proper positioning of the patient, and
careful intubation. A single dose of cimetidine
before induction of anesthesia may be of value in
situations where the risk of aspiration is high. - Treatment of aspiration involves reestablishing
patency of the airway and preventing further
damage to the lung. Endotracheal suction should
be performed immediately, as this procedure
confirms the diagnosis and stimulates coughing,
which helps to clear the airway. Bronchoscopy may
be required to remove solid matter. Fluid
resuscitation should be undertaken concomitantly.
Antibiotics are used initially when the aspirate
is heavily contaminated they are used later to
treat pneumonia.
683- Postoperative Pneumonia
- Pneumonia is the most common pulmonary
complication among patients who die after
surgery. It is directly responsible for death in
more than half of these patients. Patients whos
requiring prolonged ventilatory support are at
highest risk for developing postoperative
pneumonia. - Atelectasis, aspiration, and copious secretions
are important predisposing factors. - The clinical manifestations of postoperative
pneumonia are fever, tachypnea, increased
secretions, and physical changes suggestive of
pulmonary consolidation. A chest x-ray usually
shows localized parenchymal consolidation.
693- Postoperative Pneumonia
- Maintaining the airway clear of secretions is of
paramount concern in the prevention of
postoperative pneumonia. Respiratory exercises,
deep breathing, and coughing help prevent
atelectasis, which is a precursor of pneumonia. - Treatment consists of measures to aid the
clearing of secretions and administration of
antibiotics. Sputum obtained directly from the
trachea, usually by endotracheal suctioning, is
required for specific identification of the
infecting organism.
70III-Fat Embolism
- Fat embolism is relatively common but only rarely
causes symptoms. Fat particles can be found in
the pulmonary vascular bed in 90 of patients who
have had fractures of long bones or joint
replacements. Fat embolism can also be caused by
exogenous sources of fat, such as blood
transfusions, intravenous fat emulsion, or bone
marrow transplantation. Fat embolism symptoms
consist of neurologic dysfunction, respiratory
insufficiency, and petechiae of the axillae,
chest, and proximal arms. - Fat embolism characteristically begins 1272
hours after injury but may be delayed for several
days. The diagnosis is clinical. The finding of
fat droplets in sputum and urine is common after
trauma.
71IV- Cardiac Complications
- Cardiac complications following surgery may be
life-threatening. Their incidence is reduced by
appropriate preoperative preparation. - Dysrhythmias, unstable angina, heart failure, or
severe hypertension should be corrected before
surgery whenever possible. Valvular
diseaseespecially aortic stenosislimits the
ability of the heart to respond to increased
demand during operation or in the immediate
postoperative period. When aortic stenosis is
recognized preoperatively , the incidence of
major perioperative complications is small. Thus,
patients with preexisting heart disease should be
evaluated by a cardiologist preoperatively.
72IV- Cardiac Complications
- General anesthesia depresses the myocardium, and
some anesthetic agents predispose to
dysrhythmias. - Monitoring of cardiac activity and blood pressure
during the operation detects dysrhythmias and
hypotension early. - In patients with a high cardiac risk, regional
anesthesia may be safer than general anesthesia
for procedures below the umbilicus. - Non-cardiac complications may affect the
development of cardiac complications by
increasing cardiac demands in patients with a
limited reserve. E.g. Postoperative sepsis and
hypoxemia. Fluid overload can produce acute left
ventricular failure. - Patients with coronary artery disease,
dysrhythmias, or low cardiac output should be
monitored postoperatively in an intensive care
unit.
73V- Complications of Intravenous Therapy
Hemodynamic Monitoring
- 1- Air Embolism
- Air embolism may occur during or after insertion
of a venous catheter or as a result of accidental
introduction of air into the line. Intravenous
air lodges in the right atrium, preventing
adequate filling of the right heart. This is
manifested by hypotension, jugular venous
distention, and tachycardia. - This complication can be avoided by placing the
patient in the Trendelenburg position when a
central venous line is inserted. - Emergency treatment consists of aspiration of
the air with a syringe. If this is unsuccessful,
the patient should be positioned right side up
and head down, which will help dislodge the air
from the right atrium and return circulatory
dynamics to normal.
74V- Complications of Intravenous Therapy
Hemodynamic Monitoring
- 2- Phlebitis
- A needle or a catheter inserted into a vein and
left in place will in time cause inflammation at
the entry site. When this process involves the
vein, it is called phlebitis. Factors determining
the degree of inflammation are the nature of the
cannula, the solution infused, bacterial
infection, and venous thrombosis. Phlebitis is
one of the most common causes of fever after the
third postoperative day. The symptomatic triad of
induration, edema, and tenderness is
characteristic. Prevention of phlebitis is best
accomplished by observance of aseptic techniques
during insertion of venous catheters, frequent
change of tubing (ie, every 4872 hours),
75VI-Postoperative Fever
- Fever occurs in about 40 of patients after major
surgery. In most patients the temperature
elevation resolves without specific treatment.
However, postoperative fever may herald a serious
infection, and it is therefore important to
evaluate the patient clinically. - Normal body tempreture is 36.737.3c
- Fever within 48 hours after surgery is usually
caused by - 1- atelectasis Re-expansion of the lung causes
body temperature to return to normal. - 2- reactions to drugs ,anesthesia ,blood
transfusion , absorption of haematoma ,
76VI-Postoperative Fever
- fever appears in the third postoperative day,
atelectasis is a less likely explanation. The
differential diagnosis of fever at this time
includes catheter-related phlebitis, pneumonia,
and urinary tract infection. A directed history
and physical examination complemented by focused
laboratory and radiologic studies usually
determine the cause. - Patients without infection are rarely febrile
after the fifth postoperative day. - Fever in the fifth postoperative day suggests
wound infection or, less often, anastomotic
breakdown and intra-abdominal abscesses.
77VI-Postoperative Fever
- Fever after the 7th postoperative day (in the
2nd week ) suggests deep venous thrombosis in the
calf muscles .
78Special Medical Problems in Surgical Patients
- Diabetes Mellitus
- Diabetic patients undergo more surgical
procedures than do non-diabetics, and management
of the diabetic patient before, during, and after
surgery is an important responsibility of the
surgeon. Fortunately, because close control of
fluids, electrolytes, glucose, and insulin is now
possible in the operating room, control of blood
glucose levels during the peri-operative period
is usually relatively simple. Marked
hyperglycemia should be avoided during surgery
the greater danger, however, is from severe
unrecognized hypoglycemia.
79Diabetes Mellitus
- Preoperative Workup
- Blood glucose concentrations may be elevated in
diabetic patients during the preoperative period.
Physical trauma, if present, combined with the
emotional and physiologic stress of the illness
may cause epinephrine and cortisol levels to
rise, in each case resulting in increased blood
glucose levels.
80Diabetes Mellitus
- The preoperative workup of patients with diabetes
mellitus includes - A thorough physical examination, with special
care to discover occult infections - An ECG to rule out myocardial infarction
- A chest x-ray to identify hidden pneumonia or
pulmonary edema. - A complete urinalysis can rule out urinary tract
infection and proteinuria, the earliest signs of
diabetic renal disease. - Serum potassium levels are measured to check for
hypokalemia or hyperkalemia . - Serum creatinine levels are used to assess renal
function. - The serum glucose concentration should ideally
be between 100 and 200 mg/dL,
81Preoperative Intraoperative Management of
Diabetic Patients
- Type 2 (Non-Insulin-Dependent) Diabetes Mellitus
- Approximately 85 of diabetics over age 50 years
have only a moderately decreased ability to
produce and secrete insulin, and when at home
they can usually be controlled by diet or by oral
hypoglycemic drugs. If the serum glucose level is
below 200 mg/dL on the morning of surgery, oral
hypoglycemic drugs should be withheld and 5
glucose solution should be administered
intravenously at a rate of about 100 mL/h. This
means that over a 10-hour period, only 50 g of
glucose would be given by contrast, during an
average day, a diabetic on a normal diet would
consume four to five times as much carbohydrate
(ie, 200250 g).
82- If the operation is lengthy, blood glucose levels
should be measured every 34 hours during surgery
to ensure adequate glucose control. The goal is
to maintain glucose levels between 100 and 200
mg/dL, -
- Type 1 (Insulin-Dependent) Diabetes Mellitus
- Type 1 patients require insulin during surgery.
It can be administered by any of the following
methods - (1) subcutaneous administration of short-acting
insulin - (2) constant infusion of a mixture of glucose
and insulin or - (3) separate infusions of glucose and insulin.
- blood glucose levels should be monitored at
least every 2 hours during the procedure to avoid
hypoglycemia below 60 mg/dL and hyperglycemia
above 200 mg/dL. - Blood glucose levels can be measured rapidly
during surgery with a portable electronic glucose
analyzer.
83Postoperative Care
- Hypoglycemia, the most common postoperative
complication, most often follows the use of
long-acting insulin given subcutaneously before
surgery. Although hypoglycemia may also occur if
the intravenous insulin infusion is excessive in
relation to that of the glucose, an infusion of
1.5 units or less of insulin per hour, when given
with 5 glucose, rarely results in hypoglycemia.
Blood glucose levels should be measured every 24
hours and the patient monitored for signs and
symptoms of hypoglycemia (eg, anxiety,
tremulousness, profuse sweating without fever).
When hypoglycemia is detected, the amount of
glucose infused should be promptly increased and
the insulin decreased.
84Postoperative Care
- In the intermediate phase we do blood sugar
every 6 hours give soluble insulin
subcutaneously according to the following table
85- This is continue till the patient can drink /0r
eat then the patient return to his old medical
treatment do blood sugar twice daily to be sure
that its level below 180 mg/dl. - A marked increase in glucose and insulin
requirements postoperatively suggests the
presence of occult infection (eg, wound
infection, cellulitis at the intravenous site,
urinary tract infection, or unrecognized
aspiration pneumonia). - Adjustments in the rate of glucose or insulin
administration must be based on blood glucose
levels.
86Hypertension
- Patients with uncomplicated and controlled
hypertension usually tolerate surgery well. The
patient advised to took his medication till the
day of surgery at the morning of surgery
continue after the surgery if possible or replace
it with parentral drugs. - The patient should stop aspirin a week before
surgery an internist should consulted before
the operation.
87Respiratory Disease
- Acute Upper Respiratory Tract Infections
- Both anesthesia and surgery provide opportunities
for the spread of infection because respiratory
defense mechanisms are compromised and
instrumentation of the airway may be required.
Therefore, the presence of a cold, pharyngitis,
or tonsillitis is a relative contraindication to
elective surgery, since viral infections decrease
defense mechanisms against bacterial infections. - If surgery is necessary, the appropriate
antibiotic should be administered and
manipulation of the infected area avoided when
possible. - Acute Lower Respiratory Tract Infections
(Tracheitis, Bronchitis, Pneumonia) - These infections are absolute contraindications
to elective surgery. For emergency surgery,
therapy includes humidification of inhaled gases,
removal of lung secretions, and continued
administration of bronchodilators and antibiotics.
88- Bronchial Asthma
- patients with bronchial asthma who are undergoing
surgery are at increased risk of pulmonary
complications. Preoperative management includes
adjustment of bronchodilator medication,
cessation of smoking, and treatment of infection.
- Intraoperative bronchoconstriction from
mechanical stimulation of the airway must be
prevented so that appropriate anesthetics can be
given in adequate concentrations. Since
intraoperative use of bronchodilators may be
necessary, adverse interactions between
anesthetic agents and bronchodilators must be
avoided. Many patients with bronchial asthma have
been treated with corticosteroids and require
corticosteroid therapy in the perioperative period
89aneamia
- Surgical patients with anemia should undergo a
thorough workup to identify and treat the
underlying cause before elective procedures are
undertaken. A detailed history should be obtained
to identify any symptoms of blood loss from the
genitourinary and gastrointestinal tracts. A
history of renal, hepatic, hematologic, or
endocrinologic disorders and a medication history
should be elicited. A history suggestive of
hemolytic episodes or a family history of anemia
may offer clues to the diagnosis. Signs of
pallor, jaundice, lymphadenopathy, and
organomegaly should be sought on physical
examination. - A complete laboratory evaluation including CBC,
reticulocyte count, peripheral smear, and stool
test for occult blood should be done. - Correctable causes of anemia, like
deficiencies of iron, folate, and vitamin B12 ,
should be treated. - Preoperative red blood cell (RBC) transfusions
are not routinely recommended, and the decision
to transfuse should be based on the need to
improve tissue oxygenation.
90pregnancy
- The Pregnancy may alter or mask the signs and
symptoms of the particular presentation or course
of disease, so that diagnosis is made more
difficult. Furthermore, the fetus and changes in
maternal physiology and anatomy must be
considered in the use of diagnostic tests,
medical therapy, and the planning of surgical
procedures. - Any major operation represents a risk not only
to the mother but to the fetus as well. An
increase in both preterm delivery and growth
restriction in infants that resulted from
pregnancies that involved a surgical procedure. - Although there is no evidence that congenital
anomalies are induced in the developing fetus by
anesthesia, semielective procedures should be
deferred until the second trimester of pregnancy,
exercising the greatest precautions to prevent
hypoxia and hypotension. - Emergent surgical procedures should proceed as
necessary however, changes in maternal
physiologyparticularly in cardiac output and
maternal blood volumeas well as of the size of
the gravid uterus must be considered.
91Normal values
92Fluid Electrolyte Management
- Fluid intake (input ) is derived from two
sources - (1) exogenous and
- (2) endogenous.
- Exogenous water is either drunk or ingested in
solid food. The quantities vary within wide
limits, but average 23 litres per 24 hours, of
which nearly half is contained in solid food. - The water requirements of infants and children
are relatively greater than those of adults
because of - (1) the larger surface area per unit of body
weight - (2) the greater metabolic activity due to
growth (3) the comparatively poor
concentrating ability of the immature kidney. - Endogenous water is released during the
oxidation of ingested food the amount is
normally less than 500 ml / 24 hours. However,
during starvation, this amount is supplemented by
water released from the breakdown of body
tissues.
93- Fluid output
- Water is lost from the body by four routes.
- 1 By the lungs. About 400 ml of water is lost
in expired air each 24 hours. In a dry
atmosphere, and when the respiratory rate is
increased, the loss is correspondingly greater . - 2By the skin. When the body becomes overheated,
there is visible perspiration, but throughout
life invisible perspiration is always occurring.
The cutaneous fluid loss varies with the
atmospheric temperature and humidity, muscular
activity and body temperature. In a temperate
climate the average loss is between 600 and 1000
ml / 24 hours. - 3 Faeces. Between 60 and 150 ml of water are
lost by this route daily. In diarrhoea this
amount is greatly multiplied. - 4 Urine. The output of urine is under the
control of multiple influences, such as blood
volume, hormonal and nervous influences, among
which the antidiuretic hormone acts by
stimulating the reabsorption of water from the
renal tubules. The normal urinary output is
approximately 1500 ml / 24 hours, and provided
that the kidneys are healthy, the specific
gravity of the urine bears a direct relationship
to the volume. A minimum urinary output of
approximately 400 ml / 24 hours is required to
excrete the end products of protein metabolism.
94- Water depletion
- Pure water depletion is usually due to diminished
intake. This may be due to lack of availability,
difficulty or inability to swallow because of
painful conditions of the mouth and pharynx, or
obstruction in the oesophagus. Pure water
depletion may also follow the increased loss from
the lungs after tracheostomy. This loss may be as
much as 500 ml in excess of the normal insensible
loss. After tracheostomy, humidification of the
inspired air is an important preventive measure. - Clinical features
- The main symptoms are weakness and intense
thirst. The urinary output is diminished and its
specific gravity increased. - Treatment by drinking water /or give 5glucose
water solution.
95- Water intoxication
- This can occur when excessive amounts of water,
low sodium or hypotonic solutions are taken or
given by any route. The commonest cause on
surgical wards is the over-prescribing of
intravenous 5 glucose solutions to postoperative
patients. - Similarly, water intoxication can occur if the
body retains water in excess to plasma solutes.
This can be seen in the syndrome of inappropriate
antidiuretic hormone (SIADH) secretion which is
most commonly associated with lung conditions
such as lobar pneum