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Surgery_Schwartz. new technologies and methods become apparent only after widespread use.Multiple surgical specialties have begun or continue to develop their experiences using robotic surgery from general surgery procedures such as inguinal hernia repairs to pancreati-coduodenectomies to complex thoracic, urologic and ear, nose, and throat procedures. When robotic surgery goes awry, how-ever, the complications can be serious. The MAUDE (Manu-facturer and User Facility Device Experience) is an open access database where mandatory and voluntary adverse events are collected. As it relates to robotic surgery, some important infor-mation has been elucidated. Device failures (electrocautery, instrument malfunctions), make up roughly half of the com-plications. A retrospective study over the past 14 years in the United States documented over 10,000 robotic device-related complications that have occurred, of which 98% were reported by the manufacturers and distributers, and 2% were voluntary reports by


Surgery_Schwartz

Surgery_Schwartz. in the United States documented over 10,000 robotic device-related complications that have occurred, of which 98% were reported by the manufacturers and distributers, and 2% were voluntary reports by hospitals and physicians. The data revealed that 1535 adverse events (14.4%) led to significant negative patient expe-riences (1391 injuries and 144 deaths). Additionally, the abso-lute number of reports increased 32 times since 2006, while in the same time period, the number of cases performed has only increased tenfold.58 Despite the large number of reports con-tained within this database, the extent to which it is a true rep-resentation of the complications associated with robotic surgery is uncertain due to the lack of comprehensive and mandatory reporting.59Despite the numbers and trends reported from this data-base, few prospective, controlled trials exist that examine the risks and benefits of robotic surgery with those of open and laparoscopic surgery. The data from 5 to 10 years


Surgery_Schwartz

Surgery_Schwartz. reported from this data-base, few prospective, controlled trials exist that examine the risks and benefits of robotic surgery with those of open and laparoscopic surgery. The data from 5 to 10 years ago may also be misleading as the approved use of robotic surgery continues to expand to additional specialties. The more recent adoption of robotic surgery by specialties such as gynecologic surgery, for example, appears to be accompanied by a disproportionately high rate of morbidity and mortality in robotically assisted pro-cedures.59 Teaching institutions are producing a newer genera-tion of robotic surgeons who will continue important advances in surgery and identify those patients who would benefit most from this type of approach. The challenge for the surgical com-munity is to develop robust and effective training programs to allow trainees and practicing surgeons to acquire the skills nec-essary to perform robotic procedures with the highest degree of safety. This need replicates


Surgery_Schwartz

Surgery_Schwartz. robust and effective training programs to allow trainees and practicing surgeons to acquire the skills nec-essary to perform robotic procedures with the highest degree of safety. This need replicates the development of skill acquisition processes that reversed the high number of bile duct injuries after the introduction of laparoscopic cholecystectomy and sug-gests that validated curricula and the use of robotic simulation applications will be crucial to achieve these goals (see Chapter 53, Skills and Simulation).Complications in Minor ProceduresWhen performing procedures such as central line insertion or arterial line insertion, one should consider the necessity of the access, the use of less invasive or lower risk alternatives such as PICC line insertion instead of central line insertion, and non-invasive cardiac monitoring instead of arterial line insertion. While these alternatives may not be reliable substitutes in all patients, considering less invasive procedures can reduce the


Surgery_Schwartz

Surgery_Schwartz. and non-invasive cardiac monitoring instead of arterial line insertion. While these alternatives may not be reliable substitutes in all patients, considering less invasive procedures can reduce the problem of avoidable harm.Central Venous Access Catheters. Complications of central venous access catheters are common. Improvements in ultra-sound technology and mass education surrounding the use and techniques in ultrasonography have led to increased employ-ment and enthusiasm for its use in central venous catheter placement. Numerous institutions have mandated the use of ultrasound for placement of all central venous lines. In addition, many subclavian catheters have been alternatively placed at the internal jugular position due to a perceived benefit of decreasing the complication of pneumothorax. This theoretical benefit may be offset by an increase in line infections as the neck is a dif-ficult site to keep clean and the dressing intact. Steps to decrease complications


Surgery_Schwartz

Surgery_Schwartz. of pneumothorax. This theoretical benefit may be offset by an increase in line infections as the neck is a dif-ficult site to keep clean and the dressing intact. Steps to decrease complications include:• Ensure that central venous access is indicated.• Experienced personnel should insert the catheter or should supervise the insertion.• Use proper positioning and sterile technique.• Ultrasound is recommended for internal jugular vein insertion.• All central venous catheters should be assessed on a daily basis and should be exchanged only for specific indications (not as a matter of routine).• All central catheters should be removed as soon as possible.Common complications of central venous access include the following.Pneumothorax Occurrence rates from both subclavian and internal jugular vein approaches are 1% to 6%. Prevention requires proper positioning of the patient and correct insertion technique. A postprocedure chest X-ray is recommended to confirm the presence or absence of a


Surgery_Schwartz

Surgery_Schwartz. vein approaches are 1% to 6%. Prevention requires proper positioning of the patient and correct insertion technique. A postprocedure chest X-ray is recommended to confirm the presence or absence of a pneumothorax, regardless Brunicardi_Ch12_p0397-p0432.indd 41520/02/19 3:57 PM 416BASIC CONSIDERATIONSPART Iof whether a pneumothorax is suspected. Recent reports have questioned whether a chest X-ray is required when the line is placed and confirmed under ultrasound guidance. Pneumotho-rax rates are higher among inexperienced providers and under-weight patients but occur with experienced operators as well. If the patient is stable, and the pneumothorax is small (<15%), close expectant observation may be adequate. If the patient is symptomatic, a thoracostomy tube should be placed. Occasion-ally, pneumothorax will occur as late as 48 to 72 hours after central venous access attempts. This usually creates sufficient compromise that a tube thoracostomy is required.Arrhythmias Arrhythmias


Surgery_Schwartz

Surgery_Schwartz. pneumothorax will occur as late as 48 to 72 hours after central venous access attempts. This usually creates sufficient compromise that a tube thoracostomy is required.Arrhythmias Arrhythmias can result from myocardial irritabil-ity secondary to guidewire placement and usually resolve when the catheter or guidewire is withdrawn from the right heart. Pre-vention requires electrocardiogram (ECG) monitoring whenever possible during catheter insertion and rapid recognition when a new arrhythmia occurs.Arterial Puncture Inadvertent puncture or laceration of an adja-cent artery with bleeding can occur, but the majority will resolve with direct pressure on or near the arterial injury site. Rarely will angiography, stent placement, or surgery be required to repair the puncture site, but close observation and a chest X-ray are indi-cated. Ultrasound-guided insertion has not mitigated this com-plication, but it may decrease the incidence of arterial puncture. Ultrasound use has also been shown


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Surgery_Schwartz. and a chest X-ray are indi-cated. Ultrasound-guided insertion has not mitigated this com-plication, but it may decrease the incidence of arterial puncture. Ultrasound use has also been shown to decrease the number of attempts and the time it takes to complete insertion.Lost Guidewire A guidewire or catheter that inadvertently migrates further into the vascular space away from the insertion site can be readily retrieved with interventional angiography techniques. A prompt chest X-ray and close monitoring of the patient until retrieval are indicated.Air Embolus Although estimated to occur in only 0.2% to 1% of patients, an air embolism can be dramatic and fatal. If an embolus is suspected, the patient should immediately be placed into a left lateral decubitus Trendelenburg position so the entrapped air can be stabilized within the right ventricle. Aus-cultation over the precordium may reveal a “crunching” sound, but a portable chest X-ray will help confirm the diagnosis. Aspi-ration via


Surgery_Schwartz

Surgery_Schwartz. air can be stabilized within the right ventricle. Aus-cultation over the precordium may reveal a “crunching” sound, but a portable chest X-ray will help confirm the diagnosis. Aspi-ration via a central venous line accessing the heart may decrease the volume of gas in the right side of the heart and minimize the amount traversing into the pulmonary circulation. Subsequent recovery of intracardiac and intrapulmonary air may require open surgical or angiographic techniques. Treatment may prove futile if the air bolus is larger than 50 mL, however.Pulmonary Artery Rupture Flow-directed, pulmonary artery (Swan-Ganz) catheters can cause pulmonary artery rupture due to excessive advancement of the catheter into the pulmonary cir-culation. There usually is a sentinel bleed with coughing noted when a pulmonary artery catheter balloon is inflated, followed by uncontrolled hemoptysis. Reinflation of the catheter balloon is the initial step in management, followed by immediate airway intubation


Surgery_Schwartz

Surgery_Schwartz. a pulmonary artery catheter balloon is inflated, followed by uncontrolled hemoptysis. Reinflation of the catheter balloon is the initial step in management, followed by immediate airway intubation with mechanical ventilation, an urgent portable chest X-ray, and notification of the OR that an emergent thoracotomy may be required. If there is no further bleeding after the bal-loon is reinflated, the X-ray shows no significant consolidation of lung fields from ongoing bleeding, and the patient is easily ventilated, then a conservative nonoperative approach may be considered. However, more typically a pulmonary angiogram with angioembolization or vascular stenting is required. Hemo-dynamically unstable patients rarely survive because of the time needed to initiate and perform interventional procedures or a thoracotomy and to identify the ruptured branch of the pulmo-nary artery.Central Venous Line Infection The CDC reports mortal-ity rates of 12% to 25% when a central venous line


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Surgery_Schwartz. procedures or a thoracotomy and to identify the ruptured branch of the pulmo-nary artery.Central Venous Line Infection The CDC reports mortal-ity rates of 12% to 25% when a central venous line infection becomes systemic, with a cost of approximately $25,000 per episode.60-62 The CDC does not recommend routine central line changes, but when the clinical suspicion of infection is high, the site of venous access must be changed. Nearly 15% of hospital-ized patients will acquire central venous line sepsis. In many instances, once an infection is recognized as central line sepsis, removing the line is adequate. Staphylococcus aureus infections, however, present a unique problem because of the potential for metastatic seeding of bacterial emboli. The required treatment is 4 to 6 weeks of tailored antibiotic therapy. Using a check-list when inserting central venous catheters has been shown to significantly decrease rates of line infections.63 Following a checklist strategy and close


Surgery_Schwartz

Surgery_Schwartz. tailored antibiotic therapy. Using a check-list when inserting central venous catheters has been shown to significantly decrease rates of line infections.63 Following a checklist strategy and close monitoring of catheters has resulted in significant reductions in infection rates for numerous institu-tions, and many are now reporting zero annual infection rates.Arterial Lines. Arterial lines are placed to facilitate arterial blood gas sampling and hemodynamic monitoring. The use of ultrasound to assist in placement of these catheters has become commonplace and markedly reduces the number of attempts and time for insertion completion.Arterial access requires a sterile Seldinger technique, and a variety of arteries are used, including the radial, femoral, bra-chial, axillary, dorsalis pedis, or superficial temporal arteries. Although complications occur less than 1% of the time, they can be catastrophic. Complications include thrombosis, bleed-ing, hematoma, arterial spasm (nonthrombotic


Surgery_Schwartz

Surgery_Schwartz. or superficial temporal arteries. Although complications occur less than 1% of the time, they can be catastrophic. Complications include thrombosis, bleed-ing, hematoma, arterial spasm (nonthrombotic pulselessness), and infection. Thrombosis or embolization of an extremity arte-rial catheter can result in the loss of a digit, hand, or foot, and the risk is nearly the same for both femoral and radial cannula-tion. Thrombosis with distal tissue ischemia is treated with anti-coagulation, but occasionally surgical intervention is required. Pseudoaneurysms and arteriovenous fistulae can also occur.Endoscopy and Bronchoscopy. The principal risk of gastro-intestinal (GI) endoscopy is perforation. Perforations occur in 1 in 10,000 patients with endoscopy alone but have a higher incidence rate when biopsies are performed (up to 10%). This increased risk is due to complications of intubating a GI diver-ticulum (either esophageal or colonic) or from the presence of weakened or inflamed tissue in


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Surgery_Schwartz. biopsies are performed (up to 10%). This increased risk is due to complications of intubating a GI diver-ticulum (either esophageal or colonic) or from the presence of weakened or inflamed tissue in the intestinal wall (e.g., diver-ticulitis, glucocorticoid use, or inflammatory bowel disease).Patients will usually complain of diffuse abdominal pain shortly after the procedure and then progress with worsen-ing abdominal discomfort and peritonitis on examination. In obtunded or elderly patients, a change in clinical status may be delayed for 24 to 48 hours. Radiologic studies to look for free intraperitoneal air, retroperitoneal air, or a pneumothorax are diagnostic. Open or laparoscopic exploration locates the perfo-ration and allows repair and local decontamination of the sur-rounding tissues.The occasional patient who may be a candidate for nonop-erative management is one in whom perforation arises during an elective, bowel-prepped endoscopy and who does not have sig-nificant pain or


Surgery_Schwartz

Surgery_Schwartz. occasional patient who may be a candidate for nonop-erative management is one in whom perforation arises during an elective, bowel-prepped endoscopy and who does not have sig-nificant pain or clinical signs of infection. These patients must be closely observed in a monitored setting and must be on strict dietary restriction and broad-spectrum antibiotics.Complications of bronchoscopy include bronchial plug-ging, hypoxemia, pneumothorax, lobar collapse, and bleeding. Brunicardi_Ch12_p0397-p0432.indd 41620/02/19 3:57 PM 417QUALITY, PATIENT SAFETY, ASSESSMENTS OF CARE, AND COMPLICATIONSCHAPTER 12When diagnosed in a timely fashion, they are rarely life-threatening. Bleeding usually resolves spontaneously and rarely requires surgery but may require repeat endoscopy for thermocoagula-tion or fibrin glue application. The presence of a pneumothorax necessitates placement of a thoracostomy tube when significant deoxygenation occurs or the pulmonary mechanics are compro-mised. Lobar


Surgery_Schwartz

Surgery_Schwartz. or fibrin glue application. The presence of a pneumothorax necessitates placement of a thoracostomy tube when significant deoxygenation occurs or the pulmonary mechanics are compro-mised. Lobar collapse or mucous plugging usually responds to aggressive pulmonary toilet but occasionally requires repeat bronchoscopy. If biopsies have been performed, the risk for these complications increases.Tracheostomy. Tracheostomy facilitates weaning from a ventilator, may decrease length of ICU or hospital stay, and improves pulmonary toilet. Tracheostomies are performed open, percutaneously, with or without bronchoscopy, and with or without Doppler guidance. The advantages of percutaneous tracheostomy include efficiency and cost containment over open tracheostomy. A recent literature review examining early (<3–7 days) vs late (>14 days) tracheostomy after endotracheal intubation demonstrates little difference in outcomes but does demonstrate greater patient comfort in those patients with


Surgery_Schwartz

Surgery_Schwartz. early (<3–7 days) vs late (>14 days) tracheostomy after endotracheal intubation demonstrates little difference in outcomes but does demonstrate greater patient comfort in those patients with tra-cheostomy than those with an endotracheal tube. Complications and outcomes between the two different methods remain largely equivalent.Recent studies do not support obtaining a routine chest X-ray after percutaneous or open tracheostomy.64,65 However, significant lobar collapse can occur from copious tracheal secre-tions or mechanical obstruction. The most dramatic complica-tion of tracheostomy is tracheoinnominate artery fistula (TIAF) (Fig. 12-8).66,67 This occurs rarely (∼0.3%) but carries a 50% to 80% mortality rate. TIAFs can occur as early as 2 days or as late as 2 months after tracheostomy. A sentinel bleed occurs in 50% of TIAF cases, followed by a large-volume bleed. Should a TIAF be suspected, the patient should be transported imme-diately to the OR for fiberoptic evaluation. If


Surgery_Schwartz

Surgery_Schwartz. A sentinel bleed occurs in 50% of TIAF cases, followed by a large-volume bleed. Should a TIAF be suspected, the patient should be transported imme-diately to the OR for fiberoptic evaluation. If needed, remove the tracheostomy and place a finger through the tracheostomy site to apply direct pressure anteriorly for compression of the innominate artery while preparation for a more definitive approach is organized.Percutaneous Endogastrostomy. A misplaced percutane-ous endogastrostomy (PEG) tube may lead to intra-abdominal sepsis with peritonitis and/or an abdominal wall abscess with necrotizing fasciitis. As in other minor procedures, the initial placement technique must be fastidious to avoid complications. Figure 12-8. This illustration depicts improper positioning of the percutaneous needle. It is possible to access the innominate artery via the trachea, thus placing the patient at risk for early tracheoin-nominate artery fistula.XEndoscopic transillumination of the abdomen from


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Surgery_Schwartz. needle. It is possible to access the innominate artery via the trachea, thus placing the patient at risk for early tracheoin-nominate artery fistula.XEndoscopic transillumination of the abdomen from within the stomach has been proposed to decrease the risk for error, but this is without supporting evidence. Inadvertent colotomies, intraperitoneal placement of the tube and subsequent leakage of tube feeds with peritonitis, and abdominal wall abscesses require surgery to correct the complications and to replace the PEG with an alternate feeding tube, usually a jejunostomy.A dislodged or prematurely removed PEG tube should be replaced as early as possible after dislodgment because the gas-trostomy site closes rapidly. A contrast X-ray (sinogram) should be performed to confirm the tube’s intragastric position before feeding. If there is uncertainty of the tube location, conversion to an open tube placement procedure is required.Tube Thoracostomy. Chest tube insertion is performed for


Surgery_Schwartz

Surgery_Schwartz. intragastric position before feeding. If there is uncertainty of the tube location, conversion to an open tube placement procedure is required.Tube Thoracostomy. Chest tube insertion is performed for pneumothorax, hemothorax, pleural effusions, or empyema. In most patients, a chest tube can be easily placed with a combina-tion of local analgesia and light conscious sedation. Common complications include inadequate analgesia or sedation, incom-plete penetration of the pleura with formation of a subcutaneous tube track, lacerations to the lung or diaphragm, intraperitoneal placement of the tube through the diaphragm, and bleeding. Additional problems include slippage of the tube out of posi-tion or mechanical problems related to the drainage system. In patients with bullous disease, there can be significant intrapleu-ral scarring, and it can be easy to mistakenly place the chest tube into bullae. All of these complications can be avoided with proper initial insertion techniques, plus a


Surgery_Schwartz

Surgery_Schwartz. be significant intrapleu-ral scarring, and it can be easy to mistakenly place the chest tube into bullae. All of these complications can be avoided with proper initial insertion techniques, plus a daily review of the drainage system and follow-up radiographs. Tube removal can create a residual pneumothorax if the patient does not maintain positive intrapleural pressure by Valsalva maneuver during tube removal and dressing application.Complications of Angiography. Intramural dissection of a cannulated artery can lead to complications such as ischemic stroke from a carotid artery dissection or occlusion, mesenteric ischemia from dissection of the superior mesenteric artery, or a more innocuous finding of “blue toe syndrome” from a dissected artery in a peripheral limb. Invasive or noninvasive imaging studies confirm the suspected problem. The severity of ischemia and extent of dissection determine if anticoagulation therapy or urgent surgical exploration is indicated.Bleeding from a


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Surgery_Schwartz. imaging studies confirm the suspected problem. The severity of ischemia and extent of dissection determine if anticoagulation therapy or urgent surgical exploration is indicated.Bleeding from a vascular access site usually is obvious, but may not be visible when the blood loss is tracking into the retroperitoneal tissue planes after femoral artery cannulation. These patients can present with hemorrhagic shock; an abdomi-nopelvic CT scan delineates the extent of bleeding along the retroperitoneum. Initial management is direct compression at the access site and resuscitation as indicated. Urgent surgical exploration may be required to control the bleeding site and evacuate larger hematomas.Renal complications of angiography occur in 1% to 2% of patients. Contrast nephropathy is a temporary and prevent-able complication of radiologic studies such as CT, angiogra-phy, and/or venography. Intravenous (IV) hydration before and after the procedure is the most efficient method for preventing


Surgery_Schwartz

Surgery_Schwartz. and prevent-able complication of radiologic studies such as CT, angiogra-phy, and/or venography. Intravenous (IV) hydration before and after the procedure is the most efficient method for preventing contrast nephropathy. Nonionic contrast also may be of benefit in higher-risk patients. Close communication between provid-ers is often required to resolve the priorities in care as well as to balance the risks versus benefits of renal protection when managing patients in need of angiographic procedures.Complications of Biopsies. Lymph node biopsies have direct and indirect complications that include bleeding, infection, Brunicardi_Ch12_p0397-p0432.indd 41720/02/19 3:57 PM 418BASIC CONSIDERATIONSPART Ilymph leakage, and seromas. Measures to prevent direct com-plications include proper surgical hemostasis, proper skin prepa-ration, and a single preoperative dose of antibiotic to cover skin flora 30 to 60 minutes before incision. Bleeding at a biopsy site usually can be controlled with


Surgery_Schwartz

Surgery_Schwartz. hemostasis, proper skin prepa-ration, and a single preoperative dose of antibiotic to cover skin flora 30 to 60 minutes before incision. Bleeding at a biopsy site usually can be controlled with direct pressure. Infection at a biopsy site will appear 5 to 10 days postoperatively and may require opening of the wound to drain the infection. Seromas or lymphatic leaks resolve with aspiration of seromas and the application of pressure dressings but may require repeated treat-ments or even placement of a vacuum drain.Organ System ComplicationsNeurologic System. Neurologic complications that occur after surgery include motor or sensory deficits and mental sta-tus changes. Peripheral motor and sensory deficits are often due to neurapraxia secondary to improper positioning and/or pad-ding during operations. Treatment is largely clinical observa-tion, and the majority of deficits resolve spontaneously within 1 to 3 months.Direct injury to nerves during a surgical intervention is a well-known


Surgery_Schwartz

Surgery_Schwartz. operations. Treatment is largely clinical observa-tion, and the majority of deficits resolve spontaneously within 1 to 3 months.Direct injury to nerves during a surgical intervention is a well-known complication of several specific operations, includ-ing superficial parotidectomy (facial nerve), carotid endarterec-tomy (hypoglossal nerve), thyroidectomy (recurrent laryngeal nerve), prostatectomy (nervi erigentes), inguinal herniorrhaphy (ilioinguinal nerve), and mastectomy (long thoracic and thora-codorsal nerves). The nerve injury may be a stretch injury or an unintentionally severed nerve. In addition to loss of function, severed nerves can result in a painful neuroma that may require subsequent surgery.Mental status changes in the postoperative patient can have numerous causes (Table 12-12). Mental status changes must be continually assessed. A noncontrast CT scan should be used early to detect new or evolving intracranial causes.Atherosclerotic disease increases the risk for


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Surgery_Schwartz. 12-12). Mental status changes must be continually assessed. A noncontrast CT scan should be used early to detect new or evolving intracranial causes.Atherosclerotic disease increases the risk for intraoperative and postoperative stroke (cerebrovascular accident). Postopera-tively, hypotension and hypoxemia are the most likely causes of a cerebrovascular accident. Neurologic consultation should be obtained immediately to confirm the diagnosis. Management is largely supportive and includes adequate intravascular volume replacement plus optimal oxygen delivery. Advents in inter-ventional radiology by radiologists and vascular and neurologic Table 12-12Common causes of mental status changesELECTROLYTE IMBALANCETOXINSTRAUMAMETABOLICMEDICATIONSSodiumEthanolClosed head injuryThyrotoxicosisAspirinMagnesiumMethanolPainAdrenal insufficiencyβ-BlockersCalciumVenoms and poisonsShockHypoxemiaNarcoticsInflammationEthylene glycolPsychiatricAcidosisAntiemeticsSepsisCarbon monoxideDementiaSevere


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Surgery_Schwartz. insufficiencyβ-BlockersCalciumVenoms and poisonsShockHypoxemiaNarcoticsInflammationEthylene glycolPsychiatricAcidosisAntiemeticsSepsisCarbon monoxideDementiaSevere anemiaMAOIsAIDS DepressionHyperammonemiaTCAsCerebral abscess ICU psychosisPoor glycemic controlAmphetaminesMeningitis SchizophreniaHypothermiaAntiarrhythmicsFever/hyperpyrexia HyperthermiaCorticosteroids, anabolic steroidsAIDS = acquired immunodeficiency syndrome; ICU = intensive care unit; MAOI = monoamine oxidase inhibitor; TCA = tricyclic antidepressant.surgeons have proven successful alternatives in patients requir-ing diagnostic and therapeutic care in the immediate and acute postoperative period. Catheter-directed therapy with anticoagu-lants such as the kinases and tissue plasminogen activator (tPA) has potential benefit in postoperative thrombosis where reopera-tion carries significant risk. In addition, endoluminal stents with drug-eluting stents (DESs) or non-DESs have been used with some degree of success. DESs


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Surgery_Schwartz. in postoperative thrombosis where reopera-tion carries significant risk. In addition, endoluminal stents with drug-eluting stents (DESs) or non-DESs have been used with some degree of success. DESs do require systemic antiplatelet therapy due to the alternative coagulation pathway. Duration of antiplatelet therapy of 1 year is routine.Eyes, Ears, and Nose. Corneal abrasions are unusual, but are due to inadequate protection of the eyes during anesthe-sia. Overlooked contact lenses in patients occasionally cause conjunctivitis.Persistent epistaxis can occur after nasogastric tube place-ment or removal, and nasal packing is the best treatment option if prolonged persistent direct pressure on the external nares fails. Anterior and posterior nasal gauze packing with balloon tam-ponade, angioembolization, and fibrin glue placement may be required in refractory cases. The use of antibiotics for posterior packing is controversial.External otitis and otitis media occasionally occur


Surgery_Schwartz

Surgery_Schwartz. angioembolization, and fibrin glue placement may be required in refractory cases. The use of antibiotics for posterior packing is controversial.External otitis and otitis media occasionally occur post-operatively. Patients complain of ear pain or decreased hearing, and treatment includes topical antibiotics and nasal deconges-tion for symptomatic improvement.Ototoxicity due to aminoglycoside administration occurs in up to 10% of patients and is often irreversible. Vancomycin-related ototoxicity occurs about 3% of the time when used alone, and as often as 6% when used with other ototoxic agents.68Vascular Problems of the Neck. Complications of carotid endarterectomy include central or regional neurologic defi-cits or bleeding with an expanding neck hematoma. An acute change in mental status or the presence of localized neurologic deficit requires an immediate return to the OR. An expanding hematoma may warrant emergent airway intubation and subse-quent transfer to the OR for control of


Surgery_Schwartz

Surgery_Schwartz. or the presence of localized neurologic deficit requires an immediate return to the OR. An expanding hematoma may warrant emergent airway intubation and subse-quent transfer to the OR for control of hemorrhage. Intraopera-tive anticoagulation with heparin during carotid surgery makes bleeding a postoperative risk. Other complications include arte-riovenous fistulae, pseudoaneurysms, and infection, all of which are treated surgically.Brunicardi_Ch12_p0397-p0432.indd 41820/02/19 3:57 PM 419QUALITY, PATIENT SAFETY, ASSESSMENTS OF CARE, AND COMPLICATIONSCHAPTER 12Intraoperative hypotension during manipulation of the carotid bifurcation can occur and is related to increased tone from baroreceptors that reflexively cause bradycardia. Should hypotension occur when manipulating the carotid bifurcation, an injection of 1% lidocaine solution around this structure should attenuate this reflexive response.The most common delayed complication following carotid endarterectomy remains myocardial


Surgery_Schwartz

Surgery_Schwartz. an injection of 1% lidocaine solution around this structure should attenuate this reflexive response.The most common delayed complication following carotid endarterectomy remains myocardial infarction. The possibility of a postoperative myocardial infarction should be considered as a cause of labile blood pressure and arrhythmias in high-risk patients.Thyroid and Parathyroid Glands. Surgery of the thyroid and parathyroid glands can result in hypocalcemia in the immedi-ate postoperative period. Manifestations include ECG changes (shortened P-R interval), muscle spasm (tetany, Chvostek’s sign, and Trousseau’s sign), paresthesias, and laryngospasm. Treatment includes calcium gluconate infusion and, if tetany ensues, chemical paralysis with intubation. Maintenance treat-ment is thyroid hormone replacement (after thyroidectomy) in addition to calcium carbonate and vitamin D.Recurrent laryngeal nerve (RLN) injury occurs in less than 5% of patients. Of those with injury, approximately 10%


Surgery_Schwartz

Surgery_Schwartz. replacement (after thyroidectomy) in addition to calcium carbonate and vitamin D.Recurrent laryngeal nerve (RLN) injury occurs in less than 5% of patients. Of those with injury, approximately 10% are permanent. Dissection near the inferior thyroid artery is a com-mon area for RLN injury. At the conclusion of the operation, if there is suspicion of an RLN injury, direct laryngoscopy is diag-nostic. The cord on the affected side will be in the paramedian position. With bilateral RLN injury, the chance of a successful extubation is poor. If paralysis of the cords is not permanent, function may return 1 to 2 months after injury. Permanent RLN injury can be treated by various techniques to stent the cords in a position of function.Superior laryngeal nerve injury is less debilitating, as the common symptom is loss of projection of the voice. The glottic aperture is asymmetrical on direct laryngoscopy, and manage-ment is limited to clinical observation.Respiratory System. Surgical


Surgery_Schwartz

Surgery_Schwartz. as the common symptom is loss of projection of the voice. The glottic aperture is asymmetrical on direct laryngoscopy, and manage-ment is limited to clinical observation.Respiratory System. Surgical complications that put the respiratory system in jeopardy are not confined to techni-cal errors. Malnutrition, inadequate pain control, inadequate mechanical ventilation, inadequate pulmonary toilet, and aspi-ration can cause serious pulmonary problems.Pneumothorax can occur from central line insertion during anesthesia or from a diaphragmatic injury during an abdomi-nal procedure. Hypotension, hypoxemia, and tracheal deviation away from the affected side may be present. A tension pneumo-thorax can cause complete cardiovascular collapse. Treatment is by needle thoracostomy, followed by tube thoracostomy. The chest tube is inserted at the fifth intercostal space in the anterior axillary line. The anterior chest wall is up to 1 cm thicker than the lateral chest wall, so needle decompression


Surgery_Schwartz

Surgery_Schwartz. The chest tube is inserted at the fifth intercostal space in the anterior axillary line. The anterior chest wall is up to 1 cm thicker than the lateral chest wall, so needle decompression is more effec-tive in the lateral position. Attempted prehospital needle decom-pression in the traditional anterior position results in only 50% needle entry into the thoracic cavity.Hemothoraces should be evacuated completely. Delay in evacuation of a hemothorax leaves the patient at risk for empy-ema and entrapped lung. If evacuation is incomplete with tube thoracostomy, video-assisted thoracoscopy or open evacuation and pleurodesis may be required.Pulmonary atelectasis results in a loss of functional resid-ual capacity (FRC) of the lung and can predispose to pneumo-nia. Poor pain control in the postoperative period contributes to poor inspiratory effort and collapse of the lower lobes in particular. The prevention of atelectasis is facilitated by sit-ting the patient up as much as possible, early


Surgery_Schwartz

Surgery_Schwartz. period contributes to poor inspiratory effort and collapse of the lower lobes in particular. The prevention of atelectasis is facilitated by sit-ting the patient up as much as possible, early ambulation, and adequate pain control. An increase in FRC by 700 mL or more can be accomplished by sitting patients up to greater than 45°. For mechanically ventilated patients, simply placing the head of the bed at 30° to 45° elevation and delivering adequate tidal volumes (8–10 mL/kg) improves pulmonary outcomes.69Patients with inadequate pulmonary toilet are at increased risk for bronchial plugging and lobar collapse. Patients with copious and tenacious secretions develop these plugs most often, but foreign bodies in the bronchus can be the cause of lobar collapse as well. The diagnosis of bronchial plugging is based on chest X-ray and clinical suspicion with acute pulmo-nary decompensation with increased work of breathing and hypoxemia. Fiberoptic bronchoscopy can be useful to clear mucous


Surgery_Schwartz

Surgery_Schwartz. plugging is based on chest X-ray and clinical suspicion with acute pulmo-nary decompensation with increased work of breathing and hypoxemia. Fiberoptic bronchoscopy can be useful to clear mucous plugs and secretions.Aspiration complications include pneumonitis and pneu-monia. The treatment of pneumonitis is similar to that for acute respiratory distress syndrome (see later in this section) and includes oxygenation with general supportive care. Antibiotics are not indicated. Hospitalized patients who develop aspiration pneumonitis have a mortality rate as high as 70% to 80%. Early, aggressive, and repeated bronchoscopy for suctioning of aspi-rated material from the tracheobronchial tree will help mini-mize the inflammatory reaction of pneumonitis and facilitate improved pulmonary toilet. Forced diuresis to overcome ana-sarca and over-resuscitation remains controversial and unsub-stantiated. Complications of forced diuresis include electrolyte disturbances, replacement of those


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Surgery_Schwartz. Forced diuresis to overcome ana-sarca and over-resuscitation remains controversial and unsub-stantiated. Complications of forced diuresis include electrolyte disturbances, replacement of those electrolytes, metabolic alka-losis, hypotension, and acute kidney injury.Pneumonia is the second most common nosocomial infec-tion and is the most common infection in ventilated patients. Ventilator-associated pneumonia (VAP) occurs in 15% to 40% of ventilated ICU patients, with a probability rate of 5% per day, up to 70% at 30 days. The 30-day mortality rate of nosocomial pneumonia can be as high as 40% and depends on the micro-organisms involved and the timeliness of initiating appropri-ate antimicrobials. Protocol-driven approaches for prevention and treatment of VAP are recognized as beneficial in managing these difficult infectious complications.Once the diagnosis of pneumonia is suspected (an abnormal chest X-ray, fever, productive cough with purulent sputum, and no other obvious fever


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Surgery_Schwartz. in managing these difficult infectious complications.Once the diagnosis of pneumonia is suspected (an abnormal chest X-ray, fever, productive cough with purulent sputum, and no other obvious fever sources), it is invariably necessary to ini-tially begin treatment with broad-spectrum antibiotics until proper identification, colony count (≥100,000 colony-forming units [CFU]), and sensitivity of the microorganisms are determined. The spectrum of antibiotic coverage should be narrowed as soon as the culture sensitivities are determined. Double-coverage anti-biotic strategy for the two pathogens, Pseudomonas and Acineto-bacter spp., may be appropriate if the local prevalence of these particularly virulent organisms is high. One of the most helpful tools in treating pneumonia and other infections is the tracking of a medical center’s antibiogram every 6 to 12 months.70Epidural analgesia decreases the risk of perioperative pneumonia. This method of pain control improves pulmonary toilet and


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Surgery_Schwartz. is the tracking of a medical center’s antibiogram every 6 to 12 months.70Epidural analgesia decreases the risk of perioperative pneumonia. This method of pain control improves pulmonary toilet and the early return of bowel function; both have a sig-nificant impact on the potential for aspiration and for acquir-ing pneumonia. The routine use of epidural analgesia results in a lower incidence of pneumonia than patient-controlled analgesia.71Acute lung injury (ALI) was a diagnosis applied to patients with similar findings to those with acute respiratory distress Brunicardi_Ch12_p0397-p0432.indd 41920/02/19 3:57 PM 420BASIC CONSIDERATIONSPART Isyndrome (ARDS). The Berlin definition of ARDS developed by the American-European Consensus Conference of 2012 not only simplifies the definition of ARDS but also eliminates the term ALI from critical care vernacular. ARDS is now classified by partial pressure of oxygen in arterial blood (Pao2)/fraction of inspired oxygen (Fio2) ratios as mild


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Surgery_Schwartz. of ARDS but also eliminates the term ALI from critical care vernacular. ARDS is now classified by partial pressure of oxygen in arterial blood (Pao2)/fraction of inspired oxygen (Fio2) ratios as mild (300–201 mmHg), moder-ate (200–101 mmHg), and severe (<100 mmHg). Elements of modification of the definition include the following: <7 days of onset; removal of pulmonary artery occlusion pressure; and clinical judgment for characterizing hydrostatic pulmonary edema is acceptable, unless risk factors for ARDS have been eliminated, in which case objective analysis is necessary.72-75The definition of ARDS traditionally included five crite-ria (Table 12-13). The multicenter ARDS Research Network (ARDSnet) research trial demonstrated improved clinical out-comes for ARDS patients ventilated at tidal volumes of only 5 to 7 mL/kg.76 This strategy is no longer prescribed solely for patients with ARDS but is also recommended for patients with normal pulmonary physiology who are intubated for


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Surgery_Schwartz. tidal volumes of only 5 to 7 mL/kg.76 This strategy is no longer prescribed solely for patients with ARDS but is also recommended for patients with normal pulmonary physiology who are intubated for reasons other than acute respiratory failure. The beneficial effects of positive end-expiratory pressure (PEEP) for ARDS were con-firmed in this study as well. The maintenance of PEEP during ventilatory support is determined based on blood gas analysis, pulmonary mechanics, and requirements for supplemental oxy-gen. As gas exchange improves with resolving ARDS, the initial step in decreasing ventilatory support should be to decrease the levels of supplemental oxygen first, and then to slowly bring the PEEP levels back down to minimal levels.77 This is done to minimize the potential for recurrent alveolar collapse and a worsening gas exchange.Not all patients can be weaned easily from mechanical ventilation. When the respiratory muscle energy demands are not balanced or there is an ongoing


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Surgery_Schwartz. alveolar collapse and a worsening gas exchange.Not all patients can be weaned easily from mechanical ventilation. When the respiratory muscle energy demands are not balanced or there is an ongoing active disease state external to the lungs, patients may require prolonged ventilatory sup-port. Protocol-driven ventilator weaning strategies are success-ful and have become part of the standard of care. The use of a weaning protocol for patients on mechanical ventilation greater than 48 hours reduces the incidence of VAP and the overall length of time on mechanical ventilation. Unfortunately, there is still no reliable way of predicting which patient will be suc-cessfully extubated after a weaning program, and the decision for extubation is based on a combination of clinical parameters and measured pulmonary mechanics.78 The Tobin Index (fre-quency [breaths per minute]/tidal volume [L]), also known as the rapid shallow breathing index, is perhaps the best negative predictive instrument.79


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Surgery_Schwartz. pulmonary mechanics.78 The Tobin Index (fre-quency [breaths per minute]/tidal volume [L]), also known as the rapid shallow breathing index, is perhaps the best negative predictive instrument.79 If the result equals less than 105, then Table 12-13Inclusion criteria for the acute respiratory distress syndromeAcute onsetPredisposing conditionPao2:Fio2 <200 (regardless of positive end-expiratory pressure)Bilateral infiltratesPulmonary artery occlusion pressure <18 mmHgNo clinical evidence of right heart failureFio2 = fraction of inspired oxygen; Pao2 = partial pressure of arterial oxygen.there is nearly a 70% chance the patient will pass extubation. If the score is greater than 105, the patient has an approximately 80% chance of failing extubation. Other parameters such as the negative inspiratory force, minute ventilation, and respiratory rate are used, but individually these have no better predictive value than the rapid shallow breathing index.80Malnutrition and poor nutritional


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Surgery_Schwartz. inspiratory force, minute ventilation, and respiratory rate are used, but individually these have no better predictive value than the rapid shallow breathing index.80Malnutrition and poor nutritional support may adversely affect the respiratory system. The respiratory quotient (RQ), or respiratory exchange ratio, is the ratio of the rate of carbon dioxide (CO2) produced to the rate of oxygen uptake (RQ = Vco2/V.O2). Lipids, carbohydrates, and protein have differing effects on CO2 production. Patients consuming a diet of mostly carbohydrates have an RQ of 1 or greater. The RQ for a diet of mostly lipids is closer to 0.7, and that for a diet of mostly protein is closer to 0.8. Ideally, an RQ of 0.75 to 0.85 suggests adequate balance and composition of nutrient intake. An excess of car-bohydrate may negatively affect ventilator weaning because of the abnormal RQ due to higher CO2 production and altered pul-monary gas exchange.Although not without risk, tracheostomy decreases the


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Surgery_Schwartz. may negatively affect ventilator weaning because of the abnormal RQ due to higher CO2 production and altered pul-monary gas exchange.Although not without risk, tracheostomy decreases the pulmonary dead space and provides for improved pulmonary toilet. When performed before the tenth day of ventilatory sup-port, tracheostomy may decrease the incidence of VAP, the overall length of ventilator time, and the number of ICU patient days.The occurrence of PE is probably underdiagnosed. Its eti-ology is thought to stem from DVT. This concept, however, has recently been questioned by Spaniolas et al.81 The diagno-sis of PE is made when a high degree of clinical suspicion for PE leads to imaging techniques such as ventilation–perfusion nuclear scans or CT pulmonary angiogram. Clinical findings include elevated central venous pressure, hypoxemia, shortness of breath, hypocarbia secondary to tachypnea, and right heart strain on ECG. Ventilation–perfusion nuclear scans are often indeterminate in


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Surgery_Schwartz. elevated central venous pressure, hypoxemia, shortness of breath, hypocarbia secondary to tachypnea, and right heart strain on ECG. Ventilation–perfusion nuclear scans are often indeterminate in patients who have an abnormal chest X-ray and are less sensitive than a CT angiogram or pulmonary angio-gram for diagnosing PE. The pulmonary angiogram remains the gold standard for diagnosing PE, but spiral CT angiogram has become an alternative method because of its relative ease of use and reasonable rates of diagnostic accuracy. For cases without clinical contraindications to therapeutic anticoagula-tion, patients should be empirically started on heparin infusion until the imaging studies are completed if the suspicion of a PE is high.Sequential compression devices on the lower extremities and low-dose subcutaneous heparin or low molecular weight heparinoid administration are routinely used to prevent DVT and, by inference, the risk of PE. Neurosurgical and orthopedic patients have higher


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Surgery_Schwartz. low-dose subcutaneous heparin or low molecular weight heparinoid administration are routinely used to prevent DVT and, by inference, the risk of PE. Neurosurgical and orthopedic patients have higher rates of PE, as do obese patients and those at prolonged bed rest.When anticoagulation is contraindicated, or when a known clot exists in the inferior vena cava (IVC), decreasing the risk for PE includes insertion of an IVC filter. The Greenfield filter has been most widely studied, and it has a failure rate of less than 4%. Newer devices include those with nitinol wire that expands with body temperature and retrievable filters. Retrievable filters, however, must be considered as permanent. In most studies, the actual retrievable rate only reached about 20%. Some studies recognize the benefit of automated reminders and diligence of outlying patient follow-up, where higher retrieval rates have been achieved.82 Patients with spinal cord injury and multiple long-bone or pelvic fractures


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Surgery_Schwartz. of automated reminders and diligence of outlying patient follow-up, where higher retrieval rates have been achieved.82 Patients with spinal cord injury and multiple long-bone or pelvic fractures frequently receive IVC filters, and Brunicardi_Ch12_p0397-p0432.indd 42020/02/19 3:57 PM 421QUALITY, PATIENT SAFETY, ASSESSMENTS OF CARE, AND COMPLICATIONSCHAPTER 12there appears to be a low, but not insignificant, long-term com-plication rate with their use. However, IVC filters do not prevent PEs that originate from DVTs of the upper extremities.Cardiac System. Arrhythmias are often seen preoperatively in elderly patients but may occur postoperatively in any age group. Atrial fibrillation is the most common arrhythmia83 and occurs between postoperative days 3 to 5 in high-risk patients. This is typically when patients begin to mobilize their intersti-tial fluid into the vascular fluid space. Contemporary evidence suggests that rate control is more important than rhythm con-trol for


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Surgery_Schwartz. This is typically when patients begin to mobilize their intersti-tial fluid into the vascular fluid space. Contemporary evidence suggests that rate control is more important than rhythm con-trol for atrial fibrillation.84,85 The first-line treatment includes β-blockade and/or calcium channel blockade. β-Blockade must be used judiciously because hypotension, as well as withdrawal from β-blockade with rebound hypertension, is possible. Cal-cium channel blockers are an option if β-blockers are not toler-ated by the patient, but caution must be exercised in those with a history of congestive heart failure. Although digoxin is still a standby medication, it has limitations due to the need for opti-mal dosing levels. Cardioversion may be required if patients become hemodynamically unstable and the rhythm cannot be controlled.Ventricular arrhythmias and other tachyarrhythmias may occur in surgical patients as well. Similar to atrial rhythm prob-lems, these are best controlled with


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Surgery_Schwartz. and the rhythm cannot be controlled.Ventricular arrhythmias and other tachyarrhythmias may occur in surgical patients as well. Similar to atrial rhythm prob-lems, these are best controlled with β-blockade, but the use of other antiarrhythmics or cardioversion may be required if patients become hemodynamically unstable.Cardiac ischemia is a cause of postoperative mortality. Acute myocardial infarction (AMI) can present insidiously, or it can be more dramatic with the classic presentation of short-ness of breath, severe angina, and sudden cardiogenic shock. The workup to rule out an AMI includes an ECG and cardiac enzyme measurements. The patient should be transferred to a monitored (telemetry) floor. Morphine, supplemental oxygen, nitroglycerine, and aspirin (MONA) are the initial therapeutic maneuvers for those being investigated for AMI.Gastrointestinal System. Surgery of the esophagus is poten-tially complicated because of its anatomic location and blood supply. Nutritional support


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Surgery_Schwartz. maneuvers for those being investigated for AMI.Gastrointestinal System. Surgery of the esophagus is poten-tially complicated because of its anatomic location and blood supply. Nutritional support strategies should be considered for esophageal resection patients to maximize the potential for sur-vival. The two primary types of esophageal resection performed are the transhiatal resection and the transthoracic (Ivor-Lewis) resection.86 The transhiatal resection has the advantage that a formal thoracotomy incision is avoided. However, dissection of the esophagus is blind, and anastomotic leaks occur more than with other resections. However, when a leak does occur, simple opening of the cervical incision and draining the leak is all that is usually required.The transthoracic Ivor-Lewis resection includes an esoph-ageal anastomosis performed in the chest near the level of the azygos vein. These have lower leak rates, but the leaks that do occur result in mediastinitis and can be difficult


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Surgery_Schwartz. includes an esoph-ageal anastomosis performed in the chest near the level of the azygos vein. These have lower leak rates, but the leaks that do occur result in mediastinitis and can be difficult to control. The reported mortality is about 50% with an anastomotic leak, and the overall mortality of the procedure is about 5%, which is similar to transhiatal resection.Postoperative ileus is related to dysfunction of the neural reflex axis of the intestine. Excessive narcotic use may delay return of bowel function. Epidural anesthesia results in better pain control, and there is an earlier return of bowel function and a shorter length of hospital stay. The limited use of naso-gastric tubes and the initiation of early postoperative feeding are associated with an earlier return of bowel function.87 The use of chewing gum and other oral stimulants to minimize ileus remains controversial.Pharmacologic agents commonly used to stimulate bowel function include metoclopramide and erythromycin.


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Surgery_Schwartz. The use of chewing gum and other oral stimulants to minimize ileus remains controversial.Pharmacologic agents commonly used to stimulate bowel function include metoclopramide and erythromycin. Metoclo-pramide’s action is limited to the stomach and duodenum, and it may help primarily with gastroparesis. Erythromycin is a motilin agonist that works throughout the stomach and bowel. Several studies demonstrate significant benefit from the administration of erythromycin in those suffering from an ileus.88 Alvimopan, a newer agent and a µ-opioid receptor antagonist, has shown some promise in many studies for earlier return of gut function and subsequent reduction in length of stay.89,90 Neostigmine has been used in refractory pan-ileus patients (Ogilvie’s syndrome) with some degree of success. It is recommended for patients receiving this type of therapy to be in a monitored unit.91Small bowel obstruction occurs in less than 1% of early postoperative patients. When it does occur, adhesions


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Surgery_Schwartz. It is recommended for patients receiving this type of therapy to be in a monitored unit.91Small bowel obstruction occurs in less than 1% of early postoperative patients. When it does occur, adhesions are usu-ally the cause. Internal and external hernias, technical errors, and infections or abscesses are also causative. Hyaluronidase is a mucolytic enzyme that degrades connective tissue, and the use of a methylcellulose form of hyaluronidase, Seprafilm®, has been shown to result in a 50% decrease in adhesion formation in some patients.92,93 This may translate into a lower occurrence of postoperative bowel obstruction, but has yet to be proven.Fistulae are the abnormal communication of one structure to an adjacent structure or compartment and are associated with extensive morbidity and mortality. Common causes for fistula formation are summarized in the mnemonic FRIENDS (Foreign body, Radiation, Ischemia/Inflammation/Infection, Epitheli-alization of a tract, Neoplasia, Distal


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Surgery_Schwartz. and mortality. Common causes for fistula formation are summarized in the mnemonic FRIENDS (Foreign body, Radiation, Ischemia/Inflammation/Infection, Epitheli-alization of a tract, Neoplasia, Distal obstruction, and Steroid use). Postoperatively, they are most often caused by infection or obstruction leading to an anastomotic leak. The cause of the fis-tula must be recognized early, and treatment may include non-operative management with observation and nutritional support, or a delayed operative management strategy that also includes nutritional support and wound care.Gastrointestinal (GI) bleeding can occur perioperatively (Table 12-14). Technical errors such as a poorly tied suture, a nonhemostatic staple line, or a missed injury can all lead to Table 12-14Common causes of upper and lower gastrointestinal (GI) hemorrhageUPPER GI BLEEDLOWER GI BLEEDErosive esophagitisAngiodysplasiaGastric varicesRadiation proctitisEsophageal varicesHemangiomaDieulafoy’s


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Surgery_Schwartz. causes of upper and lower gastrointestinal (GI) hemorrhageUPPER GI BLEEDLOWER GI BLEEDErosive esophagitisAngiodysplasiaGastric varicesRadiation proctitisEsophageal varicesHemangiomaDieulafoy’s lesionDiverticulosisAortoduodenal fistulaNeoplastic diseasesMallory-Weiss tearTraumaPeptic ulcer diseaseVasculitisTraumaHemorrhoidsNeoplastic diseaseAortoenteric fistulaIntussusceptionIschemic colitisInflammatory bowel diseasePostprocedure bleedingBrunicardi_Ch12_p0397-p0432.indd 42120/02/19 3:57 PM 422BASIC CONSIDERATIONSPART Ipostoperative intestinal bleeding.94,95 The source of bleeding is in the upper GI tract about 85% of the time and is usually detected and treated endoscopically. Surgical control of intesti-nal bleeding is required in up to 40% of patients.96When patients in the ICU have a major bleed from stress gastritis, the mortality risk is as high as 50%. It is important to keep the gastric pH greater than 4 to decrease the overall risk for stress gastritis in patients


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Surgery_Schwartz. ICU have a major bleed from stress gastritis, the mortality risk is as high as 50%. It is important to keep the gastric pH greater than 4 to decrease the overall risk for stress gastritis in patients mechanically ventilated for 48 hours or greater and patients who are coagulopathic.97 Proton pump inhibitors, H2-receptor antagonists, and intragastric antacid installation are all effective measures. However, patients who are not mechanically ventilated or who do not have a history of gastritis or peptic ulcer disease should not be placed on gastritis prophylaxis postoperatively because it carries a higher risk of causing pneumonia.Hepatobiliary-Pancreatic System. Complications involv-ing the hepatobiliary system are usually due to technical errors. Laparoscopic cholecystectomy has become the standard of care for cholecystectomy, but common bile duct injury remains a nemesis of this approach. Intraoperative cholangiography has not been shown to decrease the incidence of common bile duct


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Surgery_Schwartz. standard of care for cholecystectomy, but common bile duct injury remains a nemesis of this approach. Intraoperative cholangiography has not been shown to decrease the incidence of common bile duct injuries because the injury to the bile duct usually occurs before the cholangiogram.98,99 Early recognition and immediate repair of an injury are important because delayed bile duct leaks often require a more complex repair.Ischemic injury due to devascularization of the common bile duct has a delayed presentation days to weeks after an operation. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrates a stenotic, smooth common bile duct, and liver function studies are elevated. The recommended treatment is a Roux-en-Y hepaticojejunostomy.A bile leak due to an unrecognized injury to the ducts may present after cholecystectomy as a biloma. These patients may present with abdominal pain and hyperbilirubinemia. The diag-nosis of a biliary leak can be confirmed by CT scan, ERCP, or


Surgery_Schwartz

Surgery_Schwartz. the ducts may present after cholecystectomy as a biloma. These patients may present with abdominal pain and hyperbilirubinemia. The diag-nosis of a biliary leak can be confirmed by CT scan, ERCP, or radionuclide scan. Once a leak is confirmed, a retrograde biliary stent and external drainage are the treatment of choice.Hyperbilirubinemia in the surgical patient can be a com-plex problem. Cholestasis makes up the majority of causes for hyperbilirubinemia, but other mechanisms of hyperbiliru-binemia include reabsorption of blood (e.g., hematoma from trauma), decreased bile excretion (e.g., sepsis), increased unconjugated bilirubin due to hemolysis, hyperthyroidism, and impaired excretion due to congenital abnormalities or acquired disease. Errors in surgery that cause hyperbilirubinemia largely involve missed or iatrogenic injuries.The presence of cirrhosis predisposes to postoperative complications. Abdominal or hepatobiliary surgery is problem-atic in the cirrhotic patient. Ascites


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Surgery_Schwartz. involve missed or iatrogenic injuries.The presence of cirrhosis predisposes to postoperative complications. Abdominal or hepatobiliary surgery is problem-atic in the cirrhotic patient. Ascites leak in the postoperative period can be an issue when any abdominal operation has been performed. Maintaining proper intravascular oncotic pressure in the immediate postoperative period can be difficult, and resus-citation should be maintained with crystalloid solutions. Pre-vention of renal failure and the management of the hepatorenal syndrome can be difficult, as the demands of fluid resuscitation and altered glomerular filtration become competitive. Spirono-lactone with other diuretic agents may be helpful in the post-operative care. These patients often have a labile course, and bleeding complications due to coagulopathy are common. The operative mortality in cirrhotic patients is 10% for Child class A, 30% for Child class B, and 82% for Child class C patients.100Pyogenic liver abscess


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Surgery_Schwartz. due to coagulopathy are common. The operative mortality in cirrhotic patients is 10% for Child class A, 30% for Child class B, and 82% for Child class C patients.100Pyogenic liver abscess occurs in less than 0.5% of adult admissions, due to retained necrotic liver tissue, occult intesti-nal perforations, benign or malignant hepatobiliary obstruction, sepsis, and hepatic arterial occlusion. The treatment is long-term antibiotics with percutaneous drainage of large abscesses.Pancreatitis can occur following injection of contrast dur-ing cholangiography and after endoscopic cholangiopancreatog-raphy (ERCP). These episodes range from a mild elevation in amylase and lipase with abdominal pain, to a fulminant course of pancreatitis with necrosis requiring surgical debridement. The incidence of post-ERCP pancreatitis has been shown to be reduced by the administration of rectal indomethacin.101 Stud-ies are underway to determine whether the prophylactic use of pancreatic duct stenting in


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Surgery_Schwartz. of post-ERCP pancreatitis has been shown to be reduced by the administration of rectal indomethacin.101 Stud-ies are underway to determine whether the prophylactic use of pancreatic duct stenting in patients at high risk for post-ERCP pancreatitis can be avoided with the use of rectal indomethacin.Traumatic injuries to the pancreas can occur during surgi-cal procedures on the kidneys, GI tract, and spleen most com-monly. Treatment involves serial CT scans and percutaneous drainage to manage infected fluid and abscess collections; ster-ile collections should not be drained because drain placement can introduce infection. A pancreatic fistula may respond to antisecretory therapy with a somatostatin analogue. Manage-ment of these fistulae initially includes ERCP with or without pancreatic stenting, percutaneous drainage of any fistula fluid collections, total parenteral nutrition (TPN) with bowel rest, and repeated CT scans. The majority of pancreatic fistulae will eventually heal


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Surgery_Schwartz. stenting, percutaneous drainage of any fistula fluid collections, total parenteral nutrition (TPN) with bowel rest, and repeated CT scans. The majority of pancreatic fistulae will eventually heal spontaneously.Renal System. Renal failure can be classified as prerenal failure, intrinsic renal failure, and postrenal failure. Postrenal failure, or obstructive renal failure, should always be consid-ered when low urine output (oliguria) or anuria occurs. The most common cause is a misplaced or clogged urinary catheter. Other, less common causes to consider are unintentional ligation or transection of ureters during a difficult surgical dissection (e.g., colon resection for diverticular disease) or a large retro-peritoneal hematoma (e.g., ruptured aortic aneurysm).Oliguria is initially evaluated by flushing the urinary cath-eter using sterile technique. Urine electrolytes should also be measured (Table 12-15). A hemoglobin and hematocrit level should be checked immediately. Patients in


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Surgery_Schwartz. by flushing the urinary cath-eter using sterile technique. Urine electrolytes should also be measured (Table 12-15). A hemoglobin and hematocrit level should be checked immediately. Patients in compensated shock from acute blood loss may manifest anemia and end-organ mal-perfusion as oliguria.Acute tubular necrosis (ATN) carries a mortality risk of 25% to 50% due to the many complications that can cause, or result from, this insult. When ATN is due to poor inflow (prer-enal failure), the remedy begins with IV administration of crys-talloid or colloid fluids as needed. If cardiac insufficiency is the problem, the optimization of vascular volume is achieved first, followed by inotropic agents, as needed. Intrinsic renal failure Table 12-15Urinary electrolytes associated with acute renal failure and their possible etiologies FENaOSMOLARITYURNaETIOLOGYPrerenal<1>500<20CHF, cirrhosisIntrinsic failure>1<350>40Sepsis, shockCHF = congestive heart failure; FENa = fractional excretion of


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Surgery_Schwartz. failure and their possible etiologies FENaOSMOLARITYURNaETIOLOGYPrerenal<1>500<20CHF, cirrhosisIntrinsic failure>1<350>40Sepsis, shockCHF = congestive heart failure; FENa = fractional excretion of sodium; URNa = urinary excretion of sodium.Brunicardi_Ch12_p0397-p0432.indd 42220/02/19 3:57 PM 423QUALITY, PATIENT SAFETY, ASSESSMENTS OF CARE, AND COMPLICATIONSCHAPTER 12and subsequent ATN are often the result of direct renal toxins. Aminoglycosides, vancomycin, and furosemide, among other commonly used agents, contribute directly to nephrotoxicity. Contrast-induced nephropathy usually leads to a subtle or tran-sient rise in creatinine. In patients who are volume depleted or have poor cardiac function, contrast nephropathy may perma-nently impair renal function.102-105The treatment of renal failure due to myoglobinuria has shifted away from the use of sodium bicarbonate for alkalinizing the urine, to merely maintaining brisk urine output of 100 mL per hour with crystalloid fluid


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Surgery_Schwartz. renal failure due to myoglobinuria has shifted away from the use of sodium bicarbonate for alkalinizing the urine, to merely maintaining brisk urine output of 100 mL per hour with crystalloid fluid infusion. Mannitol and furosemide are not recommended. Patients who do not respond to resusci-tation are at risk for needing renal replacement therapy. Fortu-nately, most of these patients eventually recover from their renal dysfunction.Musculoskeletal System. A compartment syndrome can develop in any compartment of the body. Compartment syn-drome of the extremities generally occurs after a closed fracture. The injury alone may predispose the patient to compartment syndrome, but aggressive fluid resuscitation can exacerbate the problem. Pain with passive motion is the hallmark of com-partment syndrome, and the anterior compartment of the leg is usually the first compartment to be involved. Confirmation of the diagnosis is obtained by direct pressure measurement of the individual


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Surgery_Schwartz. syndrome, and the anterior compartment of the leg is usually the first compartment to be involved. Confirmation of the diagnosis is obtained by direct pressure measurement of the individual compartments. If the pressures are greater than 20 to 25 mmHg in any of the compartments, then a four-compartment fasciotomy is considered. Compartment syndrome can be due to ischemia-reperfusion injury, after an ischemic time of 4 to 6 hours. Renal failure (due to myoglobinuria), tissue loss, and a permanent loss of function are possible results of untreated compartment syndrome.Decubitus ulcers are preventable complications of pro-longed bed rest due to traumatic paralysis, dementia, chemi-cal paralysis, or coma. Unfortunately, they are still occurring despite extensive research and clinical initiatives that demon-strate successful prevention strategies. Ischemic changes in the microcirculation of the skin can be significant after 2 hours of sustained pressure. Routine skin care and turning of


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Surgery_Schwartz. that demon-strate successful prevention strategies. Ischemic changes in the microcirculation of the skin can be significant after 2 hours of sustained pressure. Routine skin care and turning of the patient help ensure a reduction in skin ulceration. This can be labor intensive, and special mattresses and beds are available to help. The treatment of a decubitus ulcer in the noncoagulopathic patient is surgical debridement. Once the wound bed has a via-ble granulation base without an excess of fibrinous debris, a vacuum-assisted closure dressing can be applied. Wet to moist dressings with frequent dressing changes is the alternative and is labor intensive. Expensive topical enzyme preparations are also available. If the wounds fail to respond to these measures, soft tissue coverage by flap is considered.Contractures are the result of muscle disuse. Whether from trauma, amputation, or vascular insufficiency, contractures can be prevented by physical therapy and splinting. If not attended


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Surgery_Schwartz. considered.Contractures are the result of muscle disuse. Whether from trauma, amputation, or vascular insufficiency, contractures can be prevented by physical therapy and splinting. If not attended to early, contractures will prolong rehabilitation and may lead to further wounds and wound healing issues. Depending on the functional status of the patient, contracture releases may be required for long-term care.Hematologic System. The traditional transfusion guideline of maintaining the hematocrit level in all patients at greater than 30% is no longer valid. Only patients with symptomatic anemia, who have significant cardiac disease, or who are critically ill and require increased oxygen-carrying capacity to adequately perfuse end organs require higher levels of hemoglobin. Other than these select patients, the decision to transfuse should gener-ally not occur until the hemoglobin level falls to 7 mg/dL or the hematocrit reaches 21%.Transfusion reactions are common complications of


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Surgery_Schwartz. select patients, the decision to transfuse should gener-ally not occur until the hemoglobin level falls to 7 mg/dL or the hematocrit reaches 21%.Transfusion reactions are common complications of blood transfusion. These can be attenuated with a leukocyte filter, but not completely prevented. The manifestations of a transfusion reaction include simple fever, pruritus, chills, muscle rigidity, and renal failure due to myoglobinuria secondary to hemolysis. Discontinuing the transfusion and returning the blood products to the blood bank is an important first step, but administration of antihistamine and possibly steroids may be required to control the reaction symptoms. Severe transfusion reactions are rare but can be fatal.Infectious complications in blood transfusion range from cytomegalovirus transmission, which is benign in the nontrans-plant patient, to human immunodeficiency virus (HIV) infec-tion, to passage of the hepatitis viruses (Table 12-16).Patients on warfarin (Coumadin) who


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Surgery_Schwartz. transmission, which is benign in the nontrans-plant patient, to human immunodeficiency virus (HIV) infec-tion, to passage of the hepatitis viruses (Table 12-16).Patients on warfarin (Coumadin) who require surgery can have anticoagulation reversal by administration of fresh frozen plasma. Each unit of fresh frozen plasma contains 200 to 250 mL of plasma and includes one unit of coagulation factor per milliliter of plasma.Thrombocytopenia may require platelet transfusion for a platelet count less than 20,000/mL when invasive procedures are performed, or when platelet counts are low and ongoing bleed-ing from raw surface areas persists. One unit of platelets will increase the platelet count by 5000 to 7500 per mL in adults. It is important to delineate the cause of the low platelet count. Usually there is a self-limiting or reversible condition such as sepsis. Rarely, it is due to heparin-induced thrombocytopenia I and II. Complications of heparin-induced thrombocytopenia II can be


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Surgery_Schwartz. Usually there is a self-limiting or reversible condition such as sepsis. Rarely, it is due to heparin-induced thrombocytopenia I and II. Complications of heparin-induced thrombocytopenia II can be serious because of the diffuse thrombogenic nature of the disorder. Simple precautions to limit this hypercoagulable state include saline solution flushes instead of heparin solutions and limiting the use of heparin-coated catheters. The treatment is anticoagulation with synthetic agents such as argatroban.For patients with uncontrollable bleeding due to dissemi-nated intravascular coagulopathy (DIC), a potentially useful drug is factor VIIa, but its use should be judicious.106-109 Origi-nally used in hepatic trauma and obstetric emergencies, this agent was lifesaving in some circumstances. The CONTROL Trial,109 however, has largely decreased overuse of this agent because investigators demonstrated no benefit over simple fac-tor replacement in severely coagulopathic patients. Factor VIIa use


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Surgery_Schwartz. Trial,109 however, has largely decreased overuse of this agent because investigators demonstrated no benefit over simple fac-tor replacement in severely coagulopathic patients. Factor VIIa use may also be limited due to its potential thrombotic com-plications. For some situations, the combination of ongoing, Table 12-16Rate of viral transmission in blood product transfusionsaHIV1:1.9 millionHBVb1:137,000HCV1:1 millionaPost-nucleic acid amplification technology (1999). Earlier rates were erroneously reported higher due to lack of contemporary technology.bHBV is reported with prenucleic acid amplification technology. Statistical information is unavailable with postnucleic acid amplification technology at this writing.Note that bacterial transmission is 50 to 250 times higher than viral transmission per transfusion.HBV = hepatitis B virus; HCV = hepatitis C virus.Brunicardi_Ch12_p0397-p0432.indd 42320/02/19 3:57 PM 424BASIC CONSIDERATIONSPART Inonsurgical bleeding and renal failure


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Surgery_Schwartz. per transfusion.HBV = hepatitis B virus; HCV = hepatitis C virus.Brunicardi_Ch12_p0397-p0432.indd 42320/02/19 3:57 PM 424BASIC CONSIDERATIONSPART Inonsurgical bleeding and renal failure can occasionally be suc-cessfully treated with desmopressin.In addition to classic hemophilia, other inherited coagula-tion factor deficiencies can be difficult to manage in surgery. When required, transfusion of appropriate replacement products is coordinated with the regional blood bank center before sur-gery. Other blood dyscrasias seen by surgeons include hyper-coagulopathic patients. Those who carry congenital anomalies such as the most common factor V Leiden deficiency, as well as protein C and S deficiencies, are likely to form thromboses if inadequately anticoagulated, and these patients should be man-aged in consultation with a hematologist.Abdominal Compartment Syndrome. Multisystem trauma, thermal burns, retroperitoneal injuries, and surgery related to the retroperitoneum are the major


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Surgery_Schwartz. be man-aged in consultation with a hematologist.Abdominal Compartment Syndrome. Multisystem trauma, thermal burns, retroperitoneal injuries, and surgery related to the retroperitoneum are the major initial causative factors that may lead to abdominal compartment syndrome (ACS). Ruptured AAA, major pancreatic injury and resection, or multiple intes-tinal injuries are also examples of clinical situations in which a large volume of IV fluid resuscitation puts these patients at risk for intra-abdominal hypertension. Manifestations of ACS typically include progressive abdominal distention followed by increased peak airway ventilator pressures, oliguria followed by anuria, and an insidious development of intracranial hyperten-sion.110 These findings are related to elevation of the diaphragm and inadequate venous return from the vena cava or renal veins secondary to the transmitted pressure on the venous system.Measurement of abdominal pressures is easily accom-plished by transducing bladder


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Surgery_Schwartz. inadequate venous return from the vena cava or renal veins secondary to the transmitted pressure on the venous system.Measurement of abdominal pressures is easily accom-plished by transducing bladder pressures from the urinary catheter after instilling 100 mL of sterile saline into the urinary bladder.111 A pressure greater than 20 mmHg constitutes intra-abdominal hypertension, but the diagnosis of ACS requires intra-abdominal pressure greater than 25 to 30 mmHg, with at least one of the following: compromised respiratory mechan-ics and ventilation, oliguria or anuria, or increasing intracranial pressures.112-114The treatment of ACS is to open any recent abdominal incision to release the abdominal fascia or to open the fascia directly if no abdominal incision is present. Immediate improve-ment in mechanical ventilation pressures, intracranial pressures, and urine output is usually noted. When expectant management for ACS is considered in the OR, the abdominal fascia should be left


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Surgery_Schwartz. in mechanical ventilation pressures, intracranial pressures, and urine output is usually noted. When expectant management for ACS is considered in the OR, the abdominal fascia should be left open and covered under sterile conditions (e.g., a vac-uum-assisted open abdominal wound closure system) with plans made for a second-look operation and delayed fascial closure. Patients with intra-abdominal hypertension should be monitored closely with repeated examinations and measurements of blad-der pressure, so that any further deterioration is detected and operative management can be initiated. Left untreated, ACS may lead to multiple system end-organ dysfunction or failure and has a high mortality.Abdominal wall closure should be attempted every 48 to 72 hours until the fascia can be reapproximated. If the abdo-men cannot be closed within 5 to 7 days following release of the abdominal fascia, a large incisional hernia is the net result. A variety of surgical options have evolved for


Surgery_Schwartz

Surgery_Schwartz. If the abdo-men cannot be closed within 5 to 7 days following release of the abdominal fascia, a large incisional hernia is the net result. A variety of surgical options have evolved for prevention and closure of the resultant hernias, but no standard approach has yet evolved.Wounds, Drains, and InfectionWound (Surgical Site) Infection. No prospective, random-ized, double-blind, controlled studies exist that demonstrate antibiotics used beyond 24 hours in the perioperative period prevent infections. Prophylactic use of antibiotics should sim-ply not be continued beyond this time. Irrigation of the operative field and the surgical wound with saline solution has shown benefit in controlling wound inoculum.115 Irrigation with an antibiotic-based solution has not demonstrated significant ben-efit in controlling postoperative infection.Antibacterial-impregnated polyvinyl placed over the oper-ative wound area for the duration of the surgical procedure has not been shown to decrease the rate


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Surgery_Schwartz. in controlling postoperative infection.Antibacterial-impregnated polyvinyl placed over the oper-ative wound area for the duration of the surgical procedure has not been shown to decrease the rate of wound infection.116-120 Although skin preparation with 70% isopropyl alcohol has the best bactericidal effect, it is flammable and could be hazard-ous when electrocautery is used. The contemporary formulas of chlorhexidine gluconate with isopropyl alcohol remain more advantageous.121-123There is a difference between wound colonization and infection. Overtreating colonization is just as injurious as under-treating infection. The strict definition of wound (soft tissue) infection is more than 105 CFU per gram of tissue. This warrants expeditious and proper antibiotic/antifungal treatment.124 Often, however, clinical signs raise enough suspicion that the patient is treated before a confirmatory culture is undertaken. The clinical signs of wound infection include rubor, tumor, calor, and dolor


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Surgery_Schwartz. however, clinical signs raise enough suspicion that the patient is treated before a confirmatory culture is undertaken. The clinical signs of wound infection include rubor, tumor, calor, and dolor (redness, swelling, heat, and pain). Once the diagnosis of wound infection has been established, the most definitive treatment remains open drainage of the wound. The use of antibiotics for wound infection treatment should be limited.125-128One type of wound dressing/drainage system that has gained popularity is the vacuum-assisted closure dressing. The principle of the system is to decrease local wound edema and to promote healing through the application of a sterile dressing that is then covered and placed under controlled suction for a period of 2 to 4 days at a time. Although costly, the benefits are frequently dramatic and may offset the costs of nursing care, frequent dressing changes, and operative wound debridement.Drain Management. The four indications for applying a surgi-cal drain


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Surgery_Schwartz. are frequently dramatic and may offset the costs of nursing care, frequent dressing changes, and operative wound debridement.Drain Management. The four indications for applying a surgi-cal drain are:• To collapse surgical dead space in areas of redundant tissue (e.g., neck and axilla)• To provide focused drainage of an abscess or grossly infected surgical site• To provide early warning notice of a surgical leak (either bowel contents, secretions, urine, air, or blood)—the so-called sentinel drain• To control an established fistula leakOpen drains are often used for large contaminated wounds such as perirectal or perianal fistulas and subcutaneous abscess cavities. They prevent premature closure of an abscess cavity in a contaminated wound. More commonly, surgical sites are drained by closed suction drainage systems, but data do not sup-port closed suction drainage to “protect an anastomosis” or to “control a leak” when placed at the time of surgery. Closed suc-tion devices can exert a


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Surgery_Schwartz. suction drainage systems, but data do not sup-port closed suction drainage to “protect an anastomosis” or to “control a leak” when placed at the time of surgery. Closed suc-tion devices can exert a negative pressure of 70 to 170 mmHg at the level of the drain; therefore, the presence of this excess suction may call into question whether an anastomosis breaks down on its own or whether the drain creates a suction injury that promotes leakage (Fig. 12-9).129On the other hand, CTor ultrasound-guided placement of percutaneous drains is now the standard of care for abscesses, loculated infections, and other isolated fluid collections such Brunicardi_Ch12_p0397-p0432.indd 42420/02/19 3:57 PM 425QUALITY, PATIENT SAFETY, ASSESSMENTS OF CARE, AND COMPLICATIONSCHAPTER 12ABFigure 12-9 This illustration demonstrates typical intraoperative placement of closed suction devices in pancreatic or small bowel surgery, where there may be an anastomosis. At negative pressures of 70 to 170 mmHg, these


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Surgery_Schwartz. demonstrates typical intraoperative placement of closed suction devices in pancreatic or small bowel surgery, where there may be an anastomosis. At negative pressures of 70 to 170 mmHg, these devices may actually encourage anas-tomotic leaks and not prevent them or become clogged by them.as pancreatic leaks. The risk of surgery is far greater than the placement of an image-guided drain.The use of antibiotics when drains are in place is often unnecessary as the drain provides direct source control. Twenty-four to 48 hours of antibiotic use after drain placement is pro-phylactic, and after this period, only specific treatment of positive cultures should be performed to avoid increased drug resistance and superinfection.Urinary Catheters. Several complications of urinary cath-eters can occur that lead to an increased length of hospital stay and morbidity. In general, use of urinary catheters should be minimized and every opportunity to expeditiously remove them should be encouraged. If


Surgery_Schwartz

Surgery_Schwartz. that lead to an increased length of hospital stay and morbidity. In general, use of urinary catheters should be minimized and every opportunity to expeditiously remove them should be encouraged. If needed, it is recommended that the catheter be inserted its full length up to the hub and that urine flow is established before the balloon is inflated because mis-placement of the catheter in the urethra with premature inflation of the balloon can lead to tears and disruption of the urethra.Enlarged prostatic tissue can make catheter insertion dif-ficult, and a catheter coudé may be required. If this attempt is also unsuccessful, then a urologic consultation for endoscopic placement of the catheter may be required to prevent harm to the urethra. For patients with urethral strictures, filiform-tipped catheters and followers may be used, but these can potentially cause bladder injury. If endoscopic attempts fail, the patient may require a percutaneously placed suprapubic catheter to obtain


Surgery_Schwartz

Surgery_Schwartz. catheters and followers may be used, but these can potentially cause bladder injury. If endoscopic attempts fail, the patient may require a percutaneously placed suprapubic catheter to obtain decompression of the bladder. Follow-up investigations of these patients are recommended so definitive care of the ure-thral abnormalities can be pursued.The most frequent nosocomial infection is urinary tract infection (UTI). These infections are classified into compli-cated and uncomplicated forms. The uncomplicated type is a UTI that can be treated with outpatient antibiotic therapy. The complicated UTI usually involves a hospitalized patient with an indwelling catheter whose UTI is diagnosed as part of a fever workup. The interpretation of urine culture results of less than 100,000 CFU/mL is controversial. Before treating such a patient, one should change the catheter and then repeat the cul-ture to see if the catheter was simply colonized with organisms. Cultures with more than 100,000


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Surgery_Schwartz. controversial. Before treating such a patient, one should change the catheter and then repeat the cul-ture to see if the catheter was simply colonized with organisms. Cultures with more than 100,000 CFU/mL should be treated with the appropriate antibiotics and the catheter changed or removed as soon as possible. Undertreatment or misdiagnosis of a UTI can lead to urosepsis and septic shock.Recommendations are mixed on the proper way to treat Candida albicans fungal bladder infections. Continuous blad-der washings with fungicidal solution for 72 hours have been recommended, but this is not always effective. Replacement of the urinary catheter and a course of fluconazole are appropriate treatments, but some infectious disease specialists claim that C. albicans in the urine may serve as an indication of fungal infection elsewhere in the body. If this is the case, then screen-ing cultures for other sources of fungal infection should be per-formed whenever a fungal UTI is


Surgery_Schwartz

Surgery_Schwartz. may serve as an indication of fungal infection elsewhere in the body. If this is the case, then screen-ing cultures for other sources of fungal infection should be per-formed whenever a fungal UTI is found.Empyema. One of the most debilitating infections is an empyema, or infection of the pleural space. Frequently, an overwhelming pneumonia is the source of an empyema, but a retained hemothorax, systemic sepsis, esophageal perforation from any cause, and infections with a predilection for the lung (e.g., tuberculosis) are potential etiologies as well. The diag-nosis is confirmed by chest X-ray or CT scan, followed by aspiration of pleural fluid for bacteriologic analysis. Gram’s stain, lactate dehydrogenase, protein, pH, and cell count are obtained, and broad-spectrum antibiotics are initiated while the laboratory studies are performed. Once the specific organisms are confirmed, anti-infective agents are tailored appropriately. Placement of a thoracostomy tube is needed to evacuate


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Surgery_Schwartz. while the laboratory studies are performed. Once the specific organisms are confirmed, anti-infective agents are tailored appropriately. Placement of a thoracostomy tube is needed to evacuate and drain the infected pleural fluid, but depending on the specific nidus of infection, video-assisted thoracoscopy may also be Brunicardi_Ch12_p0397-p0432.indd 42520/02/19 3:57 PM 426BASIC CONSIDERATIONSPART Ihelpful for irrigation and drainage of the infection. Refractory empyemas require specialized surgical approaches.Abdominal Abscesses. Postsurgical intra-abdominal abscesses can present with vague complaints of intermittent abdominal pain, fever, leukocytosis, and a change in bowel habits. Depending on the type and timing of the original pro-cedure, the clinical assessment of these complaints is some-times difficult, and a CT scan is usually required. When a fluid collection within the peritoneal cavity is found on CT scan, antibiotics and percutaneous drainage of the collection is the


Surgery_Schwartz

Surgery_Schwartz. is some-times difficult, and a CT scan is usually required. When a fluid collection within the peritoneal cavity is found on CT scan, antibiotics and percutaneous drainage of the collection is the treatment of choice. Initial antibiotic treatment is usually with broad-spectrum antibiotics such as piperacillin-tazobactam or imipenem. Should the patient exhibit signs of peritonitis and/or have free air on X-ray or CT scan, then re-exploration should be considered.For patients who present primarily (i.e., not postopera-tively) with the clinical and radiologic findings of an abscess but are clinically stable, the etiology of the abscess must be determined. A plan for drainage of the abscess and decisions about further diagnostic studies with consideration of the tim-ing of any definitive surgery all need to be balanced. This can be a complex set of decisions, depending on the etiology (e.g., appendicitis or diverticulitis), but if the patient exhibits signs of peritonitis, urgent surgical


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Surgery_Schwartz. all need to be balanced. This can be a complex set of decisions, depending on the etiology (e.g., appendicitis or diverticulitis), but if the patient exhibits signs of peritonitis, urgent surgical exploration should be performed.Necrotizing Fasciitis. Postoperative infections that progress to the fulminant soft tissue infection known as necrotizing fas-ciitis are uncommon. Group A streptococcal (M types 1, 3, 12, and 28) soft tissue infections, as well as infections with Clos-tridium perfringens and C. septicum, carry a mortality of 30% to 70%. Septic shock can be present, and patients can become hypotensive less than 6 hours following inoculation. Manifesta-tions of a group A Streptococcus pyogenes infection in its most severe form include hypotension, renal insufficiency, coagu-lopathy, hepatic insufficiency, ARDS, tissue necrosis, and ery-thematous rash.These findings constitute a surgical emergency, and the mainstay of treatment remains wide debridement of the necrotic tissue to


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Surgery_Schwartz. hepatic insufficiency, ARDS, tissue necrosis, and ery-thematous rash.These findings constitute a surgical emergency, and the mainstay of treatment remains wide debridement of the necrotic tissue to the level of bleeding, viable tissue. A gray serous fluid at the level of the necrotic tissue is usually noted, and as the infection spreads, thrombosed blood vessels are noted along the tissue planes involved with the infection. Typically, the patient requires serial trips to the OR for wide debridement until the infection is under control. Antibiotics are an important adjunct to surgical debridement, and broad-spectrum coverage should be used because these infections may be polymicrobial (i.e., so-called mixed-synergistic infections). Streptococcus pyogenes is eradicated with penicillin, and it should still be used as the initial drug of choice.Systemic Inflammatory Response Syndrome, Sepsis, and Multiple-Organ Dysfunction Syndrome. The systemic inflammatory response syndrome (SIRS) and


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Surgery_Schwartz. it should still be used as the initial drug of choice.Systemic Inflammatory Response Syndrome, Sepsis, and Multiple-Organ Dysfunction Syndrome. The systemic inflammatory response syndrome (SIRS) and the multiple-organ dysfunction syndrome (MODS) carry significant mortal-ity risks (Table 12-17). Specific criteria have been established for the diagnosis of SIRS (Table 12-18), but two criteria are not required for the diagnosis of SIRS: lowered blood pressure and blood cultures positive for infection. SIRS is the result of proin-flammatory cytokines related to tissue malperfusion or injury. The dominant cytokines implicated in this process include interleukin (IL)-1, IL-6, and tissue necrosis factor (TNF). Other mediators include nitric oxide, inducible macrophage-type nitric oxide synthase, and prostaglandin I2.Table 12-17Mortality associated with patients exhibiting two or more criteria for systemic inflammatory response syndrome (SIRS)PROGNOSISMORTALITY (%)2 SIRS criteria53 SIRS


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Surgery_Schwartz. and prostaglandin I2.Table 12-17Mortality associated with patients exhibiting two or more criteria for systemic inflammatory response syndrome (SIRS)PROGNOSISMORTALITY (%)2 SIRS criteria53 SIRS criteria104 SIRS criteria15–20Table 12-18Inclusion criteria for the systemic inflammatory response syndromeTemperature >38°C or <36°C (>100.4°F or <96.8°F)Heart rate >90 beats/minRespiratory rate >20 breaths/min or Paco2 <32 mmHgWhite blood cell count <4000 or >12,000 cells/mm3 or >10% immature formsPaco2 = partial pressure of arterial carbon dioxide.Sepsis is categorized as sepsis, severe sepsis, and septic shock. Sepsis is SIRS plus infection. Severe sepsis is sepsis plus signs of cellular hypoperfusion or end-organ dysfunction. Septic shock is sepsis plus hypotension after adequate fluid resuscitation.MODS is the culmination of septic shock and multiple end-organ failure.130 Usually there is an inciting event (e.g., perforated sigmoid diverticulitis), and as the patient undergoes


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Surgery_Schwartz. resuscitation.MODS is the culmination of septic shock and multiple end-organ failure.130 Usually there is an inciting event (e.g., perforated sigmoid diverticulitis), and as the patient undergoes resuscitation, he or she develops cardiac hypokinesis and oli-guric or anuric renal failure, followed by the development of ARDS and eventually septic shock with death.The international Surviving Sepsis Campaign (www.sccm.org/Documents/SSC-Guidelines.pdf) continues to dem-onstrate the importance of early recognition and initiation of specific treatment guidelines for optimal management of sep-sis. Management of SIRS/MODS includes aggressive global resuscitation and support of end-organ perfusion, correction of the inciting etiology, control of infectious complications, and management of iatrogenic complications.131-133 Drotrecogin-α, or recombinant activated protein C, appears to specifically counteract the cytokine cascade of SIRS/MODS, but its use is still limited.134,135 Other adjuncts for


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Surgery_Schwartz. complications.131-133 Drotrecogin-α, or recombinant activated protein C, appears to specifically counteract the cytokine cascade of SIRS/MODS, but its use is still limited.134,135 Other adjuncts for supportive therapy include tight glucose control, low tidal volumes in ARDS, vasopressin in septic shock, and steroid replacement therapy.Nutritional and Metabolic Support ComplicationsNutrition-Related Complications. A basic principle is to use enteral feeding whenever possible, but complications can inter-vene such as aspiration, ileus, and to a lesser extent, sinusitis. There is no difference in aspiration rates when a small-caliber feeding tube is placed postpyloric or if it remains in the stom-ach. Patients who are fed via nasogastric tubes are at risk for aspiration pneumonia because these large-bore tubes stent open the gastroesophageal junction, creating the possibility of gas-tric reflux. The use of enteric and gastric feeding tubes obviates Brunicardi_Ch12_p0397-p0432.indd