Surgical Complications

Surgical Complications - Setting the Stage

• Definition: Deviation from ideal post-op course.
• Timing:
  • Immediate: <24 hrs (e.g., hemorrhage, anesthetic reaction).
  • Early: 1-30 days (e.g., SSI, DVT, atelectasis).
  • Late: >30 days (e.g., hernia, adhesions, pain).
• Severity Grading: Clavien-Dindo Classification (I-V).
  • I: Minor deviation; no specific treatment.
  • II: Pharmacological Rx (incl. transfusion, TPN).
  • III: Surgical, endoscopic, or radiological intervention.
    • IIIa: Intervention w/o GA.
    • IIIb: Intervention w/ GA.
  • IV: Life-threatening; ICU care.
    • IVa: Single organ dysfunction.
    • IVb: Multi-organ dysfunction.
  • V: Death.
  • Suffix 'd': Disability at discharge.

⭐ Clavien-Dindo Grade IIIb requires surgical, endoscopic, or radiological intervention, typically under general anesthesia.

Surgical Complications - Wound Woes

• Hematoma: Collection of blood.
  • Risk: Inadequate hemostasis, anticoagulants.
  • Mx: Small - observe; Large/expanding - evacuate.
• Seroma: Collection of serous fluid.
  • Mx: Aspiration (sterile), pressure dressing; recurrent - sclerosant/drain.
• Surgical Site Infection (SSI): Infection at/near surgical incision within 30 days (or 1 year if implant).
  • Types: Superficial, Deep incisional, Organ/space.
  • Mx: Antibiotics, drainage, debridement.

  ⭐ Staphylococcus aureus is the most common pathogen in SSIs.

• Wound Dehiscence: Partial/complete separation of wound layers.
  • Risk factors: ↑intra-abdominal pressure, poor nutrition, infection.
• Evisceration: Protrusion of viscera through dehisced wound (surgical emergency!).
  • Mx: Sterile saline-soaked gauze, immediate OR.
• Fistula: Abnormal communication between two epithelial surfaces.
• Incisional Hernia: Protrusion of abdominal contents through previous incision site.

Surgical Complications - Systemic Storms

⭐ The "5 W's" (Wind, Water, Wound, Walking, Wonder drugs/What did we do?) is a classic mnemonic for causes of post-operative fever based on timing.

• Post-Op Fever (📌 5 W's):
  • Wind (Atelectasis, Pneumonia): POD 1-3.
  • Water (UTI): POD 3-5.
  • Wound (Infection): POD 5-7.
  • Walking (DVT/PE): POD 7+.
  • Wonder Drugs (Drug fever): Anytime.
• Key Systemic Issues:
  • Respiratory: Atelectasis (commonest early fever), Pneumonia, PE (DVT prophylaxis).
  • Cardiovascular: DVT (Wells, Doppler), MI (peri-op stress).
  • GI: Ileus (prolonged >3-5 days), Anastomotic leak (fever, ↑HR).
  • GU: UTI (CAUTI), AKI (monitor UO).
• SIRS/Sepsis:
  • SIRS: ≥2 (T >38°C/<36°C, HR >90, RR >20 or $P_aCO_2 < \textbf{32}$ mmHg, WBC >12k/<4k/>10% bands).
  • Sepsis: SIRS + infection → MODS.

Surgical Complications - Critical Crises

• Shock: Acute circulatory failure.
  • Hypovolemic: ↓Volume (hemorrhage). Treat: Fluids, blood, stop loss.
  • Septic: Infection + dysregulated host response. Treat: Fluids, antibiotics, vasopressors.
  • Cardiogenic: Pump failure (e.g., MI). Treat: Inotropes, address cause.
  • Neurogenic: Sympathetic tone loss (spinal injury). Treat: Vasopressors, atropine.
• SIRS, Sepsis, Septic Shock:
  • SIRS: ≥2: Temp >38°C/<36°C; HR >90/min; RR >20/min or PaCO₂ <32mmHg; WBC >12,000/mm³/<4,000/mm³ or >10% bands.
  • Sepsis: SIRS + suspected/confirmed infection.
  • Septic Shock: Sepsis + hypotension despite fluids, requiring vasopressors & lactate >2 mmol/L.

⭐ Key components of qSOFA score (≥2 points suggests higher risk of poor outcome with sepsis): Respiratory Rate ≥22/min, Altered Mentation (GCS <15), Systolic Blood Pressure ≤100 mmHg.

High‑Yield Points - ⚡ Biggest Takeaways

• Staphylococcus aureus is the most common cause of Surgical Site Infections (SSI).
• Post-op fever causes (5 W's): Atelectasis (Day 1-2), UTI (Day 3-5), SSI (Day 5-7), DVT/PE (Day 7+), Drug fever.
• Wound dehiscence is fascial separation; evisceration involves visceral protrusion.
• DVT prophylaxis is critical in major surgeries to prevent pulmonary embolism.
• Anastomotic leaks in GI surgery present with sepsis and require prompt management.
• Malignant hyperthermia, triggered by anesthetics, is treated with dantrolene.