General Complications 1 Wound Complications Postoperative Parotiditis Postoperative

General Complications 1. • Wound Complications • Postoperative Parotiditis ( 省略 ) 腮腺炎 Postoperative Respiratory Complications 重點 3. Cardiac / Circulatory Complications 簡介 4. • • 重點 • Diabetes Mellitus Fat Embolism syndrome Psychiatric Complications (省略 ) • Complications of Gastrointestinal Surgery • • 油脂栓塞症候群 重點 2.

Wound Complications § § § Wound Infection Wound Hemorrhage, Hematoma, Seroma Wound Dehiscence 傷口合併症 傷口感染 ∮∮ 出血 血塊 血清凝塊 綻裂 Ø Intra-abdominal Hematoma and Abscess

傷口感染 Ø 手術傷口 ΦClean . . . Part’l contaminated. . . Conta’d wound Ø 病的因素 ΦAge, Nutrition, Immunity, BW, . . ΦDisease, Defense, Deficiency. Ø 醫療的因素 Hospital environment. ΦPersonnel: Med. , Guest or Trader, . . Φ Med. Instrument & article…. . Φ Ø 感染的因素 Φ FB, Infection, Contamination. .

Retro-gastric → Hematoma and Abscess Subhepatic ↓ Subphrenic↓ Ø and Rectal pouch, Caecal fossa. . .

Wound Incision -- Wound Complications -- Wound Dehiscence Upper median incision Para-rectal incision Mc. Burney incision

Gastrointestinal Surgery 腸胃道外科 Gastrointestinal Anastomosis ØAfter total Gastrectomy ØAfter subtotal Gastrectomy ØAfter proximal cardiectomy ØAfter antrectomy Entero-enterostomy Jejuno-colostomy Ileo-colostomy, Ceco-ileostomy Coco-colostomy Appendectomy

Complications of Gastrointestinal Surgery n Gastrointestinal Anastomosis • Total Gastrectomy • Subtotal Gastrectomy t Billroth I Gastro-duodenostomy t Billroth II Gastro-jejunostomy t Billroth III Inadvert Gastroileostomy

Total Gastrectomy

Cardiectomy x-1 Subtotal Gastrectomy Antrectomy Resection x-1 x-2 Resection x-2 x-3 Resection x-3

Complications of Gastrointestinal Surgery 腸胃道外科合併症 Postoperative Complications 手術後合併症 * Suture disrupt –duodenal stump / gastrojejunostomy. * Peritonitis; ileus. 腹膜炎; 腸阻塞 * Retrogastric hematoma / abscess. 胃後血腫/膿瘍 * Subphrenic / subhepatic abscess. 膈下/肝下膿瘍 * Intra- or extraluminal bleeding. 腸道外/內出血 * Pancreatitis, pancreatic necrosis. 胰臟炎/胰臟壞死

Retro-gastric → Hematoma and Abscess Subhepatic ↓ Subphrenic↓ Ø and Rectal pouch, Caecal fossa. . .

Complications of Gastrointestinal Surgery n Vascular Complications Hemorrhage Gangrene 血管合併症 出血 壞疽

Complications of Gastrointestinal Surgery Mechanical Problem a. Stoma Obstruction 胃腸造口開口阻 塞 b. Afferent ( Blind ) Loop Syndrome 傳入盲圈症候群 c. Intestinal Obstruction 腸阻塞 d. Inadvert Gastroileostomy 胃迴腸造口吻合 術 Anastomotic Leakage 吻合部的滲漏

Complications of Gastrointestinal Surgery External Fistula and Stoma Complications 腸道瘻管和開口端合併症 n Fistula 瘻管 n External Stoma Complications 胃腸造口開口端合併症

General Complications 術後呼吸系統合併症 Postoperative Respiratory Complications n Atelectasis 無氣肺/肺塌陷 n Respiratory Failure 呼吸衰竭 n Pulmonary edema 肺水腫 ( Pulmonary congestion )

General Complications Atelectasis Lobar Atelectasis Segmental Atelectasis Plate like Atelectasis ØReduced Alveolar Surface Tension ØBronchial Secretion Obstruction Fever, Rapid RR / HR, Collapse / Purification

General Complications Treatment of Atelectasis Patent Air Way Enforced Respiration Ventilator Support Return to Normal Surfactant Clear the Bronchial Passage ØWarm & Moist Inhalation ØComplete Respiratory Care ØFluid supply & Antibiotics

General Complications Respiratory Failure 呼吸衰竭 Definition üPa. O 2 < Predicted normal üPa. CO 2 > 50 mm. Hg metabolic alkalosis Pathophysiology ØHypoventilation ØDiffusion defect ØAbnormal V/Q ratio ØShunting ØReduction in Cardiac Output ØHb/Dissociation Curve Alteration

General Complications Pulmonary Edema ( Pulmonary Congestion ) Ventilation Fi. O 2 ↓，Airway ，Alveolar Tension ↓ O 2 carrier ↓ ( Massive Bleeding / Mete-Hb ) Diffusion Interstitial Membrane Resistance↑ Vascular Osmotic Pressure ↓/ Electrolyte Perfusion Pumping Failure，AV Shunt etc. , Shock ， Vascular Stagnation Peripheral Resistance ↑ / Requirement ↑ 以『供需失調』的概念，去瞭解Pulmonary Congestion

General Complications Treatment of Pulmonary Edema Ventilation Fi. O 2 Diffusion ，Patent Airway，Keep Alveolar Tension Fresh Blood Transfusion Steroid ： Reduce Interstitial Fibrosis Diuretics ，Albumin/Plasma/Colloid Perfusion Cardiotonics ， Diuretics ，Colloid Prevent & Treat Shock Requirement ↓ ， Peripheral Resistance ↓ 調整『供需失序』，去治療Pulmonary Edema

General Complications Respiratory Failure 呼吸衰竭 Indication for Respiratory Support • F i. O 2 Close monitoring Intubation Tracheostomy RR 12 -25 25 -35 >35 VC, ml/kg 70 -30 30 -45 <15 • VD/VT F. inspiratory 100 -50 50 -25 <25 A – a. DO 2 50 -200 200 -350 >350 • PEEP Pa. O 2 100 -75 200 -70 <70 Air Mask O 2 Inhalation • Qs/Qt • A-a. DO 2 • CPAP • IPPB VD/VT 0. 3 -0. 4 -0. 6 >0. 6 • IMV Pa. CO 2 35 -45 45 -60 >60+

General Complications Following Respiratory Support Endotracheal Intubation /Tracheostomy Airway Aphonia Wound Bleeding/Infection Cuff Pressure - Erosion/Bleeding /Stricture/ Granuloma Mechanical Ventilator PEEP – Pneumothorax Prolonged Ventilator Use / Oxygen Intoxication Lung Edema / Weaning Failure

General Complications Cardiac Complications 心臟的合併症 a. Arrhythmias 心律不整 b. Myocardial Infarction 肌梗塞 心

General Complications Cardiac Complications -- Arrhythmias Old age > 60 y , Arteriorsclerosis, Heart Diseas, Hypertension Anesthesia ( Halothane ) → AV Dissociation, Electrolyte Paroxysmal Supraventricular Tachycardia Chest Surgery Paroxysmal ventricular Tachycardia Myocardial Infarction Atrial Flutter, Sinus Tachycardia Positive Breathing AV Nodal Rhythm , Perioperative Cardiac Arrhythmias AV Block Sinus Bradycardia, Premature Contraction

General Complications Cardiac Complications -- Myocardial Infarction Coronary Artery Thrombosis Myocardial Infarction Anoxia, Hypotension, Hemorrhage, Dehydration, Fluid & Electrolyte Disturbance, Arrhythmias ECG, SGOT, CPK-MB, BGA, Isotope Scan Digitalization, Diuretics, Vasopressor & Shock Treatment, Adequate Ventilation, Treat Anemia, Relief Pain, Sedation, ICU Swan Ganz Catheter Monitor

Arterial system Circulatory Complications Coronary Artery Embolism Carotid Artery Embolism Mesenteric Artery Embolism Embolectomy / Anti-coagulant Venous system Mesenteric Venous Thrombo-phlebitis of the Limbs Thrombectomy / Facioyomy Gangrene Lymphatic system

Preoperative Evaluation n n n Lung Heart Liver Kidney GI Others O. R. Anesthesia ØPre medication ØNPO ØFluid e+ ØOthers I&O