Management of Peri-operative Complications, An Issue of Surgical Clinics, 1e

300 Pages·2012·4.536 MB·English

by  Stanley H. Rosenbaum MD, Lewis J. Kaplan

Management of
Peri-operative Complications
Guest Editors
LEWIS J. KAPLAN, MD
STANLEY H. ROSENBAUM, MD
SURGICAL CLINICS
OF NORTH AMERICA
www.surgical.theclinics.com
Consulting Editor
RONALD F. MARTIN, MD
April 2012 • Volume 92 • Number 2
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ManagementofPeri-operativeComplications
Contributors
CONSULTING EDITOR
RONALDF.MARTIN,MD,FACS
Director,SurgicalEducation/ResidencyProgramDirector,DepartmentofSurgery,
MarshfieldClinicandSaintJoseph’sHospital,Marshfield,Wisconsin;ClinicalAssociate
Professor,UniversityofWisconsinSchoolofMedicineandPublicHealth,Madison,
Wisconsin;Colonel,MedicalCorps,UnitedStatesArmyReserve
GUEST EDITORS
LEWISJ.KAPLAN,MD,FACS,FCCM,FCCP
AssociateProfessorofSurgery,SectionofTrauma,SurgicalCriticalCareandSurgical
Emergencies,DepartmentofSurgery,YaleUniversitySchoolofMedicine,NewHaven,
Connecticut
STANLEYH.ROSENBAUM,MD
ProfessorofAnesthesiology,SurgeryandInternalMedicine,Departmentof
Anesthesiology,YaleUniversitySchoolofMedicine,NewHaven,Connecticut
AUTHORS
STEVENR.ALLEN,MD
DivisionofTraumatology,SurgicalCriticalCareandEmergencySurgery,Universityof
Pennsylvania,Philadelphia,Pennsylvania
KOENAMELOOT,MD
IntensiveCareUnit,ZiekenhuisNetwerkAntwerpen,CampusStuivenberg/Erasmus,
Antwerpen,Belgium
PHILIPS.BARIE,MD,MBA,FIDSA,FCCM,FACS
ProfessorofSurgeryandPublicHealth,DepartmentofSurgery,WeillCornellMedical
College;Chief,PrestonA.(Pep)WadeAcuteCareSurgeryService,NewYork-Presbyterian
Hospital-WeillCornellMedicalCenter,NewYork,NewYork
THOMASBUCHHEIT,MD
AssociateProfessor,DepartmentofAnesthesiology,DukeUniversityMedicalCenter,
Durham,NorthCarolina
CRAIGM.COOPERSMITH,MD
ProfessorofSurgery,AssociateDirector,EmoryCenterforCriticalCare,EmoryUniversity
SchoolofMedicineandEmoryHealthcare,Atlanta,Georgia
H.GILLCRYER,MD
ProfessorofSurgery,DivisionofGeneralSurgery,ChiefofTraumaandEmergency
Surgery,UCLAMedicalCenter,UniversityofCalifornia-LosAngeles,LosAngeles,
California
iv Contributors
KIMBERLYA.DAVIS,MD,FACS,FCCM
ProfessorofSurgery,ViceChairmanofClinicalAffairs,ChiefoftheSectionofTrauma,
SurgicalCriticalCareandSurgicalEmergencies,DepartmentofSurgery,YaleUniversity
SchoolofMedicine,NewHaven,Connecticut
NELEDESIE,MD
IntensiveCareUnit,ZiekenhuisNetwerkAntwerpen,CampusStuivenberg/Erasmus,
Antwerpen,Belgium
MICHAELG.DOORLY,MD,MS
ClinicalInstructorofSurgeryandColorectalSurgeryResearchFellow,KeckSchoolof
Medicine,UniversityofSouthernCalifornia,LosAngeles,California
JOHNFILDES,MD
Chief,DivisionofTrauma&CriticalCare,ViceChair,ProfessorofSurgery,Departmentof
Surgery,UniversityofNevadaSchoolofMedicine,LasVegas,Nevada;MedicalDirector,
AmericanCollegeofSurgeonsCommitteeonTrauma,Chicago,Illinois
LTC(Ret.)LISAM.FLYNN,MD,RVT,FACS,USAR,MC
AssistantProfessorofSurgery,DepartmentofSurgery,WayneStateUniversity,Detroit,
Michigan
HEIDIL.FRANKEL,MD,FACS
DivisionofTrauma,AcuteCareandCriticalCareSurgery,PennStateHersheyMedical
Center,Hershey,Pennsylvania;DivisionofSurgicalCriticalCare,UniversityofMaryland
RAdamsCowleyShockTraumaCenter,Baltimore,Maryland
CARLGILLEBERT,MD
IntensiveCareUnit,ZiekenhuisNetwerkAntwerpen,CampusStuivenberg/Erasmus,
Antwerpen,Belgium
SEONJONES,MD
InstructorofSurgery,DivisionofTraumaandSurgicalCriticalCare,VanderbiltUniversity
MedicalCenter,Nashville,Tennessee
LEWISJ.KAPLAN,MD,FACS,FCCM,FCCP
AssociateProfessorofSurgery,SectionofTrauma,SurgicalCriticalCareandSurgical
Emergencies,DepartmentofSurgery,YaleUniversitySchoolofMedicine,NewHaven,
Connecticut
MANUL.N.G.MALBRAIN,MD,PhD
HeadofDepartment,IntensiveCareUnitandHighCareBurnUnit,ZiekenhuisNetwerk
Antwerpen,CampusStuivenberg/Erasmus,Antwerpen,Belgium
RONALDF.MARTIN,MD,FACS
Director,SurgicalEducation/ResidencyProgramDirector,DepartmentofSurgery,
MarshfieldClinicandSaintJoseph’sHospital,Marshfield,Wisconsin;ClinicalAssociate
ProfessorofSurgery,UniversityofWisconsinSchoolofMedicineandPublicHealth,
Madison,Wisconsin;Colonel,MedicalCorps,UnitedStatesArmyReserve
ADRIANA.MAUNG,MD,FACS
AssistantProfessorofSurgery,SectionofTrauma,SurgicalCriticalCareandSurgical
Emergencies,DepartmentofSurgery,YaleUniversitySchoolofMedicine,NewHaven,
Connecticut
Contributors v
ADDISONK.MAY,MD
ProfessorofSurgeryandAnesthesiology,DivisionofTraumaandSurgicalCriticalCare;
Director,SurgicalCriticalCareandProgramDirector,SurgicalCriticalCareandAcute
CareSurgeryFellowship,VanderbiltUniversityMedicalCenter,Nashville,Tennessee
JOHNE.MAZUSKI,MD,PhD
ProfessorofSurgery,SectionofAcuteandCriticalCareSurgery,DepartmentofSurgery,
WashingtonUniversitySchoolofMedicine,StLouis,Missouri
KEVINW.MCCONNELL,MD
AssistantProfessorofSurgery,AcuteandCriticalCareSurgery,EmoryUniversitySchool
ofMedicine,Atlanta,Georgia
LENAM.NAPOLITANO,MD,FACS,FCCP,FCCM
DivisionChief,DivisionofAcuteCareSurgery[Trauma,Burns,SurgicalCriticalCare,
EmergencySurgery];ProfessorofSurgery,Director,TraumaandSurgicalCriticalCare,
AssociateChair,DepartmentofSurgery,UniversityofMichiganHealthSystem,
AnnArbor,Michigan
AVERYB.NATHENS,MD,PhD
DivisionHeadandDirectorofTrauma,ProfessorofSurgery,St.Michael’sHospital,
UniversityofToronto,Toronto,Canada;Director,AmericanCollegeofSurgeonsTrauma
QualityImprovementProgram,Chicago,Illinois
GRETAL.PIPER,MD
AssistantProfessorofSurgery,SectionofTrauma,SurgicalCriticalCareandSurgical
Emergencies,DepartmentofSurgery,YaleUniversitySchoolofMedicine,NewHaven,
Connecticut
SRINIVASPYATI,MD
AssistantProfessor,DepartmentofAnesthesiology,DukeUniversityMedicalCenter,
Durham,NorthCarolina
JORDANM.RAYMER,MD
ResidentinGeneralSurgery,MarshfieldClinicandSaintJoseph’sHospital,Marshfield,
Wisconsin
MICHAELF.ROTONDO,MD,FACS
ProfessorandChairmanofSurgery,DepartmentofSurgery,TheBrodySchoolof
Medicine,EastCarolinaUniversity,Greenville,NorthCarolina
GAURAVSACHDEV,MD
SurgicalCriticalCareFellow,DivisionofAcuteCareSurgery[Trauma,Burns,Surgical
CriticalCare,EmergencySurgery],DepartmentofSurgery,UniversityofMichigan,
AnnArbor,Michigan
STEVENJ.SCHWULST,MD
AssistantProfessorofSurgery,DivisionofTraumaandCriticalCare,Departmentof
Surgery,NorthwesternUniversityFeinbergSchoolofMedicine,Chicago,Illinois
ANTHONYJ.SENAGORE,MD,MS,MBA,FACS,FASCRS
ProfessorandClinicalScholar,DivisionChiefofColorectalSurgery,CharlesW.and
CarolynCostelloChairforColorectalDiseases,KeckSchoolofMedicine,
UniversityofSouthernCalifornia,LosAngeles,California
vi Contributors
SAMUELA.TISHERMAN,MD,FACS,FCCM
Professor,DepartmentsofCriticalCareMedicineandSurgery,UniversityofPittsburgh,
Pittsburgh,Pennsylvania
BRETTH.WAIBEL,MD,FACS
AssistantProfessorofSurgery,DepartmentofSurgery,TheBrodySchoolofMedicine,
EastCarolinaUniversity,Greenville,NorthCarolina
ManagementofPeri-operativeComplications
Contents
Foreword:ManagementofPeri-operativeComplications xiii
RonaldF.Martin
Preface:ManagementofPeri-operativeComplications xv
LewisJ.KaplanandStanleyH.Rosenbaum
FluidandElectrolyteManagementfortheSurgicalPatient 189
GretaL.PiperandLewisJ.Kaplan
Forsurgicalpatients,appropriateselectionandadministrationoffluidscan
mitigate against organ failure, whereas improper dosing can exacerbate
already injured systems. Fluid and electrolyte goals and deficiencies
mustbedefinedforindividualpatientstoprovidetheappropriatecombi-
nationofresuscitationandmaintenancefluids.Specificelectrolyteabnor-
malitiesshouldbeanticipated,identified,andcorrectedtooptimizeorgan
functions.Usingthestrong-ionapproachtoacid-baseassessment,deliv-
eredfluidsthatcontaincalculatedamountsofelectrolyteswillinteractwith
thepatient’splasma chargeandinfluencethepatient’spH, allowingthe
cliniciantoachieveamorepreciseendpoint.
Hypoperfusion,ShockStates,andAbdominalCompartmentSyndrome(ACS) 207
KoenAmeloot,CarlGillebert,NeleDesie,andManuL.N.G.Malbrain
Cardiovasculardysfunctionandfailurearecommonlyencounteredinpa-
tientswithintra-abdominalhypertensionorabdominalcompartmentsyn-
drome.Accurateassessmentandoptimizationofpreload,afterload,and
contractilityareessentialtorestoringend-organperfusionandmaximizing
patient survival. Application of a goal-directed resuscitation strategy, in-
cluding abdominal decompression, when indicated, improves cardiac
function, reverses end-organ failure, and minimizes intra-abdominal hy-
pertension–relatedpatientmorbidityandmortality.
MassiveTransfusionofBloodintheSurgicalPatient 221
JordanM.Raymer,LisaM.Flynn,andRonaldF.Martin
Hemorrhageremainsaleadingcauseofmorbidityanddeathinbothcivil-
ian and military trauma. Restoration of effective end-organ perfusion by
stopping hemorrhage and restoring intravascular volume in such a way
as to minimize acidosis, hypothermia, and coagulopathy, almost always
requires the use of blood and/or blood-component therapy. The best
method to manage life-threatening hemorrhage is to avoid the circum-
stancethatprompteditortomitigatebloodlossearlyintheinjurycycle;
otherwise, blood replacement must suffice. This article reviews current
understandingofmassivetransfusion,alongwithitsattendantunintended
consequences,inthemanagementofpatientswithprofoundhemorrhage.
viii Contents
PostoperativeGastrointestinalHemorrhage 235
SeonJonesandAddisonK.May
Significantgastrointestinal(GI)bleedinginthepostoperativeperiodisan
uncommon complication of surgery. The management of GI bleeding
withinthepostoperativeperiodiscomplexbecauseofalargerdifferential
forthesourceofbleedingandamorecomplexrisk/benefitanalysis.There
isminimalpublishedliteraturespecifictothemanagementofpostopera-
tive GI bleeding, and the infrequency, complexity, and variability of the
clinical setting of this complication confound simplistic consideration of
itscauseandtherapy.Thisarticleoutlinesasystematicevaluationofthe
patient,treatmentoptions,andassessmentofrisk/benefitratioforvarious
treatmentoptions.
DamageControlforIntra-AbdominalSepsis 243
BrettH.WaibelandMichaelF.Rotondo
Withthesuccessofdamage-controlsurgeryforthetreatmentofexsangui-
nating truncal trauma, it has been adapted to other surgical diseases
associated withshockstates,such asseveresecondary peritonitis. The
structuredapproachofdamagecontroliseasilyadaptedtoandcanincor-
poratethefundamentalelementsoftheSurvivingSepsisCampaign.Itis
not meant to replace tried and true surgical principles, such as source
control,butisausableframeworkinmanagingthecomplicatedcircum-
stancesseenwiththesepatients.
PathogenesisandClinicalandEconomicConsequencesofPostoperativeIleus 259
MichaelG.DoorlyandAnthonyJ.Senagore
Postoperative ileus is a preventable disease with surprising economic
consequences.Understandingthetriadofdysmotilityinconjunctionwith
an enhanced recovery program improves patient outcome, decreases
lengthofstayinhospital,andlowersthecost.Alvimopanandotherinves-
tigational promotility medications can help attain these goals. Surgeons
should avoid labeling all postoperative abdominal distention as ileus,
whichnotonlypreventstimelydiagnosisandtreatmentofearlypostoper-
ative small bowel obstruction or acute colonic pseudo-obstruction but
alsoincreasespatientmorbidityandmortality.
PerioperativeNutritionalSupport:Immunonutrition,Probiotics,and
AnabolicSteroids 273
AdrianA.MaungandKimberlyA.Davis
Nutritionalsupportinsurgicalpatientshasevolvedfromsimpleprovision
ofadequatecaloriestoretardlossofleanbodymasstotheprovisionof
specific nutrients in an attempt to manipulate metabolic and immune
responses.Althoughstilllimited,thecurrentunderstandingofthiscomplex
subject indicates that the type, route, amount, and composition of nu-
tritional support provided to patients can affect their outcome. Further
studiesare,however,neededtobettercharacterizetheexactnutritional
supportthatismostbeneficialforaspecificdiseasestateandaspecific
patient.
Contents ix
SurgicalProphylaxisandOtherComplicationAvoidanceCareBundles 285
StevenJ.SchwulstandJohnE.Mazuski
Individualhealthcarequalitymeasuresthathavebeenshowntoimprove
outcomecanbecombinedtogetherintowhatarecalledcarebundles,with
theexpectationthatthissetofpracticesproducesfurtherimprovementsin
outcome.Preventionofsurgicalsiteinfectionisthefocusofseveralquality
measures put forward by the Surgical Care Improvement Project; these
can collectively be considered a bundle as well. Whether these process
measures,whichincludeseveralcomponentsrelatedtotheadministration
ofantibioticprophylaxis,areeffectiveindecreasingratesofsurgicalsite
infectionhascomeunderconsiderabledebaterecently.
OrganFailureAvoidanceandMitigationStrategiesinSurgery 307
KevinW.McConnellandCraigM.Coopersmith
Postoperativeorganfailureisachallengingdiseaseprocessthatisbetter
preventedthantreated.Providersshouldusecloseobservationandclini-
caljudgment,andchecklistsofbestpracticestominimizetheriskoforgan
failureintheirpatients.Thetreatmentofmultiorgandysfunctionsyndrome
(MODS)generallyremainssupportive,outsideofrapidinitiationofsource
control(whenappropriate)andtargetedantibiotictherapy.Morespecific
treatments may be developed as the complex pathophysiology of
MODS is better understood and more homogenous patient populations
areselectedforstudy.
PostoperativePulmonaryComplications:PneumoniaandAcuteRespiratoryFailure 321
GauravSachdevandLenaM.Napolitano
Postoperative pulmonary complications (atelectasis, pneumonia, pulmo-
naryedema,acuterespiratoryfailure)arecommon,particularly afterab-
dominal and thoracic surgery, pneumonia and atelectasis being the
most common. Postoperative pneumonia is associated with increased
morbidity,lengthofhospitalstay,andcosts.Fewinstitutionshavepneu-
monia prevention programs for surgical patients, and these should be
stronglyconsidered.Acuterespiratoryfailureisalife-threateningpulmo-
nary complication that requires institution of mechanical ventilation and
admission to the intensive care unit, and is associated with increased
riskforventilator-associatedpneumonia.Thisarticlediscussesepidemiol-
ogy,riskfactors,diagnosis,treatment,andpreventionofthesepulmonary
complicationsinsurgicalpatients.
Multidrug-ResistantOrganismsandAntibioticManagement 345
PhilipS.Barie
Theincreasingprevalenceofmultidrug-resistant(MDR)infectionsinclinical
practice stems from clinical and veterinary antibiotic use, and animal
husbandry.Asresistancetoantibioticsbecomesmorecommon,avicious
circledevelopswhereinincreasinglybroad-spectrumagentsmustbepre-
scribedempiricallytoensurethatinitialantibiotictherapyisadequatetothe
task,andnew,evermorepowerfulagentsareneededforthetreatmentof