© SQUID GAME TRANS TEAM.

-SQUIDDER WHO

SURGERY II HAPPENS TO RECEIVE THIS TRANS, PLEASE RESPECT US BY

REPORTING WHO LEAKED THIS TRANS TO YOU. WE ARE ALSO
MEDICAL STUDENTS LIKE YOU AND WE ARE SACRIFICING OUR
LECTURE TIME TO MAKE TRANSES. AS MUCH AS WE WOULD LIKE TO HELP
DR. VIRGILIO BONLEON III EVERYONE, WE ALSO WANT TO BE HELPED. NO TO FREE RIDERS!

[TRANS] CHAPTER 12: QUALITY, PATIENT SAFETY, ASSESSMENTS OF CARE, AND COMPLICATIONS

BACKGROUND surgeon
commits
Medicine is considered a high-risk system, with a high error state
High-risk systems, as defined by Perrow in 1984:
Have the potential to create a catastrophe loosely defined as
an event loading to loss of human or animal life, despoiling of
the environment, or some other situation that gives rise to the

Are complex in that they have large numbers of highly

interdependent subsystems with many possible combinations
that are nonlinear and poorly understood
What do you think is that? This is a 24-year-old male a motorcycle rider Are tightly coupled so that any perturbation in the system is
for food panda with vehicular accident was brought to the hospital seek in transmitted rapidly between subsystems with little attenuation
pain, Collectively, its results, not only as a huge suffering and financial
the abdomen and on physical examination he has a rigid abdomen with a burden for the patients
generalized tenderness. Eventually he was brought to the operating room for But also, its impact on the operating surgeon and sometimes to
a blunt abdominal trauma and then which is anything with surgical abdomen. related institutions
Surgery was done and it was an eventful and the patients stayed for about a
week and he was discharged. About one week in their house, started to have Kahit gaano ka kagaling na surgeon, kahit saan ka pa naggaling o
fever associated with gradual abdominal distention. He went back to the saan ka pa nag graduate. Committing a single error can destroy you
hospital again and when an x-ray of the abdomen was taken this is what they career
see. What do you think is that? This is an operative sponge or gauze. This It is well-known fact that as far as harm to the patients are concerned,
wormlike structure is the blue in string in the picture. Things like that really no surgery is routine and no surgeon is immune
happens If you are a surgeon, never say a routine surgery lang ito nothing to
worry about. Sa loob loob mo hindi ka pwede mag kumpyansa na routine
surgery lang ito because an error can happen anytime. I can say for a
fact na walang perfect na surgeon kahit magaling na nagkakaroon pa rin
ng error
Now in modern era with advent of advance technology, health care
delivery in surgery is becoming more complex and error prone
History of surgical errors and its adverse outcomes is dated back to
1795-1750 BC when it got mentioned in the ancient Mesopotamian
Code of Hammurabi

Admonition of Hippocrates, has always been a guiding principle

for the medical fraternity world over
Minsan nga ganito ang makita mo sa loob ng abdomen or worst, flexible These medical or surgical errors actually days back to the history
retractor or malleable retractor. This can happen to anybody at any time even the time of Hammurabi, if you remember my lecture on Hammurabi

Okay lang sana kung ganito

kadali, kung may maiwan sa loob
ng patient mo, ma-detect mo
agad or maconfirm mo agad na UNNECESSARY MEDICAL CARE
nandoon siya sa loob. Pero most While mistakes are inherent to human nature
of the time, patient will have It is becoming more recognized that many mistakes are preventable
fever, will have abdominal pain
before malaman something was left inside the abdomen
PATIENT SAFETY
MEDICAL CARE GONE WRONG
Absence of preventable harm to a patient during the process of
health care and reduction of risk of unnecessary harm associated
It is difficult to find any surgeon who never had an experience of one with healthcare to an acceptable minimum
or another kind of mistake An acceptable minimum refers to the collective notions of given
Committed while delivering the surgical care to the patient current knowledge, resources available and the context in which care
Whatever the reports come out through news media or other sources was delivered weighed against the risk of non-treatment or other
are just a tip of the iceberg treatment. (WHO)

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THE SCIENCE OF PATIENT SAFETY Organizations with effective safety cultures share a constant
A science that promotes the use of evidence-based medicine and local commitment to safety as a top-level priority that permeates the entire
wisdom to minimize the impact of human error on quality patient care organization
My question. Does high-risk organization mean higher error rate? Is that
always the rule? Does it also mean that high-risk organization means high- CHARACTERISTICS OF EFFECTIVE SAFETY CULTURES
reliability organization? 1. An acknowledgement of the high-risk, error-prone nature of an
o dapat yung mga tao dun alam nila na
HIGH RELIABILITY ORGANIZATION delikado ito ating trabaho kunyari surgeon ka or scrub nurse or
medical technologist ka so alam natin na dapat importante itong
trabaho natin, delikado ito and kung magkamali tayo malaking
HIGH RELIABILITY ORGANIZATION THEORY
repercussion. For example nalang yun ma switch mo ang mga
Recognizes that there are certain high-risk industries and
laboratory result diba? Or yung specimen ng ano mo yung benign na
organizations that have achieved very low accident and error rates
tumor na pagpalit mo ng malignant tumor. Can you imagine anong
compared to what would be expected given the inherent risks
repercussions nun? Magka chemotherapy ang pasyente at the same
involved in their daily operations
time yung anxiety you caused to the patient and to the family.
Itong idea ng high reliability organization nag start ito siya sa isang
2. A non-punitive environment where individuals are able to report
nuclear submarine program ng US Navy. You can just imagine nuclear errors or close calls without fear of punishment or retaliation
submarine diba naghahanap lang sila ng nuclear whatever basta may 3. An expectation of collaboration across ranks to seek solutions to
involved na something nuclear sa kanilang submarine and yet ang vulnerabilities
kanilang error rate is low so ibig sabihin kahit pala high-risk yung inyong 4. A willingness on the part of the organization to direct resources to
organization, possible pala maging low ang error rate niya or ang prone address safety concerns
niya to have errors
Traditional surgical culture stands almost in direct opposition to the
Suggests that proper oversight of people, processes, and values upheld by organizations with effective safety cultures for
technology can handle complex and hazardous activities and keep several reasons:
error rates acceptably low
Surgeons are less likely to acknowledge their propensity to make
Studies of multiple high reliability organizations show that they mistakes or to admit these mistakes to others marami daw mga
share the following common characteristics: surgeons nuon di daw mag amin nagkakamali sila diba are you
People are supportive of one another familiar na sabi nila surgeons daw are playing god? Narinig niyo
People trust one another na ba yung sabi nila?
People have friendly, open relationships emphasizing credibility Surgeons tend to minimize the effect of stress on their ability to
and attentiveness make decisions ako personally pinakamatagal na surgery na na
The work environment is resilient and emphasizes creativity and assist ko when I was a resident was 23 hours and on the same
goal achievement, providing strong feelings of credibility and week nag assist ako ng 18 hours and then 6 hours and sa private
personal trust practice ko siguro pinakamatagal ko is 8 hours na straight. Can
you imagine ang stress niyan sa katawan natin and surgeons daw
THE CONCEPTUAL MODEL they tend to sabi nila okay lang, kaya naman, hindi naman
stressful. That can lead to errors and this is a direct opposition
DONABEDIAN MODEL sa culture ng safety
Identifies three main types of improvements: The surgical culture, especially in the operating room (OR), is
1. Changes to organizational structure traditionally rife with hierarchy intimidation of other operating
2. Changes in organizational processes room personnel by surgeons was historically accepted as the
3. Changes in outcomes norm ewan ko baka may mga kwento kayo narinig before or
STRUCTURE refers to the physical and organizational, tools, may experience kayo minsan parang may mga surgeons na
equipment, and policies that improve safety structural measures mayabang. Feeling nila na talagang magaling na magaling sila
Finally, patient safety, although often viewed as important, is seldom
PROCESS is the application of these tools, equipment, and promoted from an organizational priority to an organizational value
policies/procedures to patients (good practices and evidence-based It often takes a high-profile sentinel event to motivate leads to
medicine) re the right tools, policies, and commit the necessary time and resources to improving patient safety
within their organization kailangan pa may mangyaring problema,
OUTCOME aksidente, error bago mamotivate ang leader, ang involved, or ang
in this model, structure (how care is organization to commit the necessary time and resources to
organized) plus process (what to do) influences patient outcomes improving patient safety within their organization
(the results achieved)
Developing these characteristics is an important step toward MEDICAL ERRORS
achieving a low error rate in any organization ang endpoint nito is First time in the year 2000, the serious impact of medical error and
a safety culture its magnitude were brought into the focus at international level by
SAFETY CULTURE report of the Institute of Medicine (IOM) of USA
A measure used to improve outcomes After comprehensive study on medical error and patient safety, IOM
Increasingly recognized as a metric of hospital quality pub To Err Is Human: Building a Safer Health

This report shocked the world when it highlighted death between

CREATING A CULTURE OF SAFETY
44,000 and 98,000 and over 1 million injuries occurred each year
Culture is to an organization what personality is to the individual iba
in American hospitals due to medical error
ibang organization meron kanya-kanyang culture, meron kanya-kanyang
pag-uugali

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This drew much needed attention of international community towards gi-MRM siya pagkatapos biglang ng edema, parang nag swell ang
this serious issue as medical error itself was found to be one among kanyang or
the top ten leading causes of death 2, is that negligence? That is a complication of the surgery but most
Defined as:
An unintended act (either of omission or commission) or one ang standard of care okay?
that does not achieve its intended outcome NEAR MISS
The failure of a planned action to be completed as intended (an An error that does not result in patient harm
error of execution) Analysis of near misses provides the opportunity to identify and
The use of a wrong plan to achieve an aim (an error of planning) remedy system failures before the occurrence of harm so example,
A deviation from the process of care, which may or may not patient A admitted sa ward because of diarrhea, patient B naman
cause harm to the patient admitted in the same ward because of anemia. Habang andun sila
Medical error can occur at the individual provider level or at the magkatabi sila, patient A, patient B, patient A may diarrhea, patient B
system level may anemia, dumating ang nurse may dalang blood bag. Dumating
The role of error may be complex sa tabi ng patient A na may diarrhea kasi ita-transfuse niya yung bag,
Error can sometimes tragically end the life of a thriving person with yung blood dun kay patient B then may dumating isang nurse sabi
a long life expectancy, or it can also accelerate an imminent death
TYPES OF MEDICAL ERRORS
Adverse event
Negligence SENTINEL EVENT
Near miss An unexpected occurrence involving death or serious physical or
Sentinel event psychological injury
ADVERSE EVENT The injury involves loss of limb or function
This type of event requires immediate investigation and response
Injury caused by medical management rather than the underlying
Examples:
condition of the patient example a patient went to the hospital or
came to the hospital for diarrhea, on assessment may severe Hemolytic transfusion reaction example niyan nabigay yung
dehydration siya so anong dapat gawin? Kailangan mong ihydrate. type B na dugo sa type A na patient
The patient was given IV fluid for hydration. What happens is that Wrong-site, wrong-procedure, or wrong-patient surgery
after a few hours, si patient biglang hirap mag hinga, the patient nag A medication error or other treatment-related error resulting in
difficulty in breathing and then pag auscultate mo yun pala na death may nabigay na gamut tapos namatay yung pasyente so
overhydrate pala siya. Ano yung kanyang underyling condition? -investigate
Diarrhea diba? Pero bakit siya nagkaron ng problema o bakit siya Unintentional retention of a foreign body in a patient after surgery
nagkaron ng morbidity kasi na overhydrate siya which is actually part
of the medical management. Do you understand my example? CASE 12-1: SYSTEMS CHANGE RESULTING FROM MEDICAL ERROR
Another example, patient came in because of a cough tapos pag LIBBY ZION
tingin sa kanya meron siyang pneumonia that be managed by oral Libby Zion was an 18-year-old woman who died after being admitted
medication so binigyan siya ng antibiotic. Ang problema one of the to the New York Hospital with fever and agitation on the evening of
side effect of that antibiotic magkaroon ka ng soft stools so nag October 4, 1984
diarrhea ang pasyente. Grabe ang diarrhea niya nag dehydrated siya Her father, Sidney Zion, a lawyer and columnist for the N.Y. Daily
so kailangan niya ma-admit sa hospital para mahydrate. What is the
underlying condition of the patient? Yung kanyang pneumonia pero inadequate staffing and overworked physicians at the hospital and
na-admit siya because of the diarrhea brought about by the antibiotic was determined to bring about changes to prevent other patients
or the medication that was given. Those are adverse events from suffering as a result of the teaching hospital system
Prolongs hospitalization, produces a disability at discharge Due to his efforts to publicize the circumstances surrounding his
Classified as preventable or unpreventable
NEGLIGENCE agreed to let a grand jury consider murder charges
Care that falls below a recognized standard of care ano ibig sabihin Although the hospital was not indicted, in May 1986, a grand jury
non? For example, a patient came in meron siyang bukol sa breast.
May bukol siya sa breast, PE niya uy matigas yung bukol, hard, fixed,
nontender, may family history ng cancer. Sabi ng surgeon, tara! As a result, New York State Health Commissioner David Axelrod
Operahan kita tanggalin natin yung breast mo so a mastectomy was convened a panel of experts headed by Bertrand M. Bell, a primary
done, modified radical mastectomy. Then pag labas ng biopsy, care physician at Albert Einstein College of Medicine who had long
fibroadenoma na siya, a benign condition so is that negligence? Yes been critical of the lack of supervision of physicians-in-training, to
po doc. Why? Ano ba dapat ang standard of care dun? The doctors evaluate the training and supervision of doctors in New York State
should have confirmed that its fibroadenoma doc and not proceed The Bell Commission recommended that residents work no more
without autopsy. How do you do that? Proper PE po doc and history than 8 hours per week and no more than 24 consecutive hours per
of patient po. Yun nga ang kanyang proper PE, matigas, fixed. Biopsy shift, and that a senior physician needed to be physically present in
po doc. Yes ang standard of care dapat nag biopsy muna siya. the hospital at all times
Pwedeng core needle biopsy, or pwedeng incision biopsy to confirm These recommendations were adopted by New York State in 1989.
na cancer talaga yun diba? A care was given pero it fell below the In 2003, the Accreditation Council on Graduate Medical Education
standard of care followed by mandating that all residency training programs adhere to
Standard of care is considered to be care a reasonable physician of the reduced work hour schedule
similar knowledge, training, and experience would use in similar Libby Zion went to the hospital who was taking antidepressant before
circumstances pero kunwari na biopsy siya, breast cancer, tapos and was given a medication that has potentiating or synergistic effect to
her medication. She develops serotonin syndrome leading to her demise

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COMMUNICATION TOOLS Recently, in 2011, it has been again revised and updated and
SIGN OUTS now consists of 29 events grouped into seven categories:
The term sign out can refer to either the verbal or written communication Surgical
of patient information to familiarize oncoming physicians about patients Product or device
who will be under their care Patient protection
Care management
Performed well, sign outs help to ensure the transfer of pertinent Radiologic
information Criminal
Common categories of communication failure during sign outs include errors in medical care that are clearly identifiable,
content omissions, such as failure to mention active medical problems, preventable and serious in their consequences for patients, and that
and failures in the actual communication process, such as leaving indicate a real problem in the safety and credibility of a health care
illegible or unclear notes facility
These failures lead to confusion and uncertainty by the covering - NQF
physician during patient care decisions, resulting in the delivery of
inefficient and suboptimal care Never events are errors in medical care that are clearly identifiable,
preventable, and serious in their consequences for patients and that
CASE 12-3: INADEQUATE SIGN OUT LEADING TO MEDICAL ERROR indicate a real problem in the safety and credibility of a healthcare
JOSIE KING facility
Josie King was an 18-month-old child who was admitted to Johns
Hopkins Hospital in January of 2001 for first- and second-degree
burns Unambiguous clear, no other interpretation. If the surgeon
She spent 10 days in the pediatric intensive care unit and was well committed an error, then it is an ERROR
on her way to recovery Preventable
She was transferred to an intermediate care floor with the Serious, resulting in death or loss of a body part, disability, or more
expectation that she would be sent home in a few days than transient loss of a body function
The following week, her central line was removed, but nurses would And any ONE of the following:
not allow Josie to drink anything by mouth Adverse, and/or
Around 1 pm the next day, a nurse came to ,
syringe of methadone and/or
Important for public credibility or public accountability
narcotics, the nurse insisted that the orders had been changed and
administered the drug
Surgery performed on the wrong body part
She was moved to the pediatric intensive care unit and placed on life
support Surgery performed on the wrong patient
Wrong surgical procedure performed on a patient
Two days later, on February 22, 2001, she died from severe
dehydration Unintended retention of a foreign object in a patient after surgery or
other procedure
to work with leaders at Johns Hopkins to ensure that no other family Intraoperative or immediately postoperative death in an ASA Class 1
would have to endure the death of a child due to medical error patient
They later funded the Josie King Patient Safety Program and an Class 1 is the normal patient (benign patient)
academic scholarship in the field of safety
CASE 12-
OPERATING ROOM DEBRIEFINGS MIKE HUREWITZ
Local journalist in NY who donated a part of his liver to his brother,
Five-point operating room briefing he was healthy, but he died after the donation. It was later found out the
What are the names and roles of the team members? cause of death was due to an inadequate post op care and because of
Is the correct patient/procedure confirmed? (The Joint Commission these the transplant program for that hospital was temporarily stop
Universal Protocol [TIME-OUT])
Have antibiotics been given? (if appropriate)
What are the critical steps of the procedure?
What are the potential problems for the case?

MEASURING QUALITY IN SURGERY

NATIONAL QUALITY FORUM

NEVER EVENTS
First coined in 2001 by Ken Kizer, MD of the National Quality
Forum (NQF)
Initially, in 2002, the NQF identified 27 events, which was
updated in 2006 with additional of one new event

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Four patient events that advanced the modern field of patient safety
PATIENT INSTITUTION YEAR EVENT ROOT CAUSE OUTCOME
Libby Zion New York Hospital, New York, 1984 Missed allergy to Demerol Physician fatigue Bell commission shortened resident
NY work hours
Betsy Lehman Dana-Farber Cancer Institute, 1994 Chemotherapy overdose Lack of medication Fired doctor, three pharmacists, 15
Boston, MA checks and triggers nurses; overhauled safety program
Josie King Johns Hopkins Hospital, 2001 Severe dehydration Poor communication Increased safety research funding
Baltimore, MD
Mike Hurewitz Mit. Sinai Hospital, New York, 2002 Inadequate postoperative Inadequate Transplant program shutdown until
NY care supervision better patient safety safeguards
implemented
The table above are cases where sentinel events occur and investigations was done resulting to changes or improvements

Risk factors for retained surgical sponges

RETAINED SURGICAL ITEMS Emergency surgery
A retained surgical item refers to any surgical items found to be inside Unplanned changes in procedure
a patient after he or she left the OR Patient with higher body mass index
Requires a second operation to remove the item Multiple surgeons involved in same operation
Estimates of retained foreign bodies in surgical procedures range from Multiple procedures performed on same patient
one case per 8000 to 18,000 operations, corresponding to one case or Involvement of multiple operating room nurses/staff members
more each year for a typical large hospital or approximately 1500 cases
per year in the United States
SURGICAL SPONGE most common retained surgical item SURGICAL COUNTS
The benefit of performing surgical counts to prevent the occurrence of
That is why because of that retained surgical items is controversial
they place the blue part (which is The increased risk of a retained surgical item during emergency surgery
sensitive to the x-rays) in the in the study by Gawande and colleagues appeared to be related to
sponge bypassing the surgical count in many of these cases

performed and declared correct when it is actually incorrect, occurred in

21% to 100% of cases in which a retained surgical item was found
This type of count was the most common circumstance encountered in
all retained surgical item cases, which suggests that performing a
surgical count in and of itself does not prevent this error from taking
place
A retained surgical item can occur even in the presence of a known
incorrect count
This event is usually a result of poor communication in which a surgeon
will dismiss the incorrect count and/or fail to obtain a radiograph before
the patient leaves the OR
Others: Stronger institutional policies in place in case of an incorrect count (such
Surgical instruments as requiring a mandatory radiograph while the patient is still in the OR)
Needles can avoid conflict among caregivers and mitigate the likelihood of a
Current recommendations: retained surgical item occurring as a result of a known incorrect count
Use of standard counting procedures
Performing a thorough wound exploration before closing a WRONG-SITE SURGERY
surgical site Wrong-site surgery is any surgical procedure performed on:
Using only x-ray-detectable items in the surgical wound Wrong patient
The arrow in the x-ray is Wrong body part
pointing to the blue part of the Wrong side of the body
sponge. It was left inside the Wrong level of a correctly identified anatomic site
The Washington University School of Medicine suggests a rate of one in
17,000 operations, which adds up to approximately 4000 wrong-site
surgeries in the United States each year
If these numbers are correct, wrong-site surgery is the third most
frequent life-threatening medical error in the United States

The risk of performing wrong-site surgery increases when there are:

Multiple surgeons involved in the same operation
Multiple procedures are performed on the same patient,
especially if the procedures are schedule or performed on
different areas of the body
Time pressure
Emergency surgery

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Abnormal patient anatomy THE JOINT COMMISSION UNIVERSAL PROTOCOL TO ENSURE

Morbid obesity CORRECT SURGERY
Communication errors are the root cause in more than 70% of the According to The Joint Commission, communication breakdown is one
wrong-site surgeons of the top three root causes of sentinel events such as wrong-site
- The Joint Commission surgery
Other risk factors include: Poor communication contributed to over 60% of sentinel events reported
Receiving an incomplete preoperative assessment to the Joint Commission in 2011
Having inadequate procedures in place to verify the correct Good communication is an essential component of teamwork and is
surgical site especially important in the operating room
Having an organizational culture that lacks teamwork The importance of good communication in preventing medical errors is
Reveres the surgeon as someone whose judgment should never undeniable; however, it is difficult to achieve
be questioned
The traditional surgical hierarchy can prevent OR personnel from sharing
The specialties most commonly involved in reporting wrong-site important patient data and expressing safety concerns
surgeries according to The Joint Commission are:
One perioperative field study showed a 30% rate of communication
Orthopedic surgery (41%)
failure in the OR, with 36% of these breakdowns having a substantial
General surgery (20%)
Neurosurgery (14%) impact on patient safety
Maxillofacial, cardiovascular, otolaryngology, and ophthalmology Best practices for operating room safety
(14%)
-
Urology (11%)
prevent wrong-site surgery
Most errors involved symmetric anatomic structures: Perform an operating room briefing (checklist) to identify and
1. Lower extremities (30%) mitigate hazards early
2. Head/neck (24%) Promote a culture of speaking up about safety concerns
3. Genital/urinary/pelvic/groin (21%) Use a screening X-ray to detect foreign bodies in high-risk cases
Although orthopedic surgery is the most frequently involved, this Begin patient sign-outs with the most likely immediate safety hazard
may be due to the higher volume of cases performed as well as the
increased opportunity for lateralization errors inherent in the
COMPLICATIONS
speciality
COMPLICATIONS IN MINOR PROCEDURES

CENTRAL VENOUS ACCESS CATHETERS

The Safety Attitudes Questionnaire (SAQ) is a validated survery
Pneumothorax
instrument that can be used to measure culture in a healthcare
Arrythmias
setting adapted from two safety tools used in aviation, the Flight
Arterial puncture
Management Attitudes Questionnaire and its predecessor, the
Lost guidewire
Cockpit Management Attitudes Questionnaire
The SAQ consists of a series of questions measuring six domains:
Teamwork climate
Safety climate
Job satisfaction
Perception of management
Stress recognition
Working conditions
Efforts to foster culture change within an organization with regard to
patient safety have been limited in the past by the inability to measure
the impact of any given intervention. However, studies have shown
that employee attitudes about culture are associated with error
reduction behaviors in aviation and with patient outcomes in ICUs
The Safety Attitudes Questionnaire (SAQ) is a validated survey
instrument that can be used to measure culture in a healthcare
The safety climate scale portion of the questionnaire consists of the
following seven items: Pneumothorax
I am encouraged by my colleagues to report any patient safety Subclavian and internal jugular vein
concerns I may have Symptomatic: thoracostomy tube should be placed
The culture in this clinical area makes it easy to learn from the Occurs at 48-72 hrs tube thoracostomy is required
mistakes of others Arrythmias
Medical errors are handled appropriately in this clinical area Result from myocardial irritability secondary to guidewire placement
I know the proper channels to direct questions regarding patient Usually resolve when catheter or guidewire is withdrawn from right
safety in this clinical area heart
I receive appropriate feedback about my performance PREVENTION: EKG monitoring during insertion
I would feel safe being treated here as a patient Arterial Puncture
In this clinical area, it is not difficult to discuss mistakes Puncture or laceration of adjacent artery w/ bleeding can occur
Resolve with direct pressure on or near the arterial injury site

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Rarely: angiography, stent replacement, surgery required to repair Bronchoscopy

puncture site Bronchial plugging, hypoxemia, pneumothorax, lobar collapse,
Indicated: close observation and CXR bleeding
Prevention: careful attention to insertion technique When diagnosed early, rarely life threatening
Lost Guidewire Bleeding usually resolves; rarely requires surgery
Guidewire or catheter that migrates into the vascular space May require repeat endoscopy for thermocoagulation or fibrin glue
completely can be readily retrieved with interventional angiography application
techniques Presence of pneumothorax = requires placement of thoracostomy
Prompt CXR and close monitoring of the patient until retrieval is tube
indicated Lobar collapse or mucous plugging respond to > aggressive
Air Embolus pulmonary toilet, occasionally requires repeat bronchoscopy
Occur 0.2 to 1% of patients; dramatic and fatal TRACHEOSTOMY
Treatment futile if air bolus larger than 50 ml Facilitates weaning from a ventilator
Auscultation = over the precordium reveal crunching noise Decreases length of ICU/hospital stay
Portable CXR required for dx Improve pulmonary toilet
If embolus suspected = pt immediately placed into left lateral Performed open, percutaneously
decubitus Trendelenburg position > entrapped air stabilized in right With or without bronchoscopy
ventricle With or without Doppler guidance
Aspiration (via central venous line) accessing heart > decrease Complications still arise
volume of gas on the right side of heart > minimize amt. traversing The most dramatic complication is tracheoinnominate artery fistula
into the pulmonary circulation (TIAF)
Recovery of intracardiac and intrapulmonary air require: open TUBE THORACOSTOMY
surgical or angiographic techniques Performed d/t following conditions
PREVENTION: careful attention to technique Pneumothorax
Pulmonary Artery Rupture Hemothorax
Flow-directed pulmonary artery ( Swan-Ganz ) catheters cause Pleural effusions
pulmonary artery rupture d/t excessive advancement of catheter into Empyema
pulmonary circulation Tube can be placed easily with combination of local analgesia and
There is usually sentinel bleed when catheter is inflated > pt begins light conscious sedation
to have uncontrolled hemoptysis Common complications:
Reinflation of balloon > initial step in mgt > ff by immediate airway Inadequate analgesia of sedation
intubation w/ mechanical ventilation, urgent portable CXR, and Incomplete penetration of pleura with formation of subcutaneous
emergent thoracotomy track for tube
Bleeding stops > conservative nonoperative approach > observation Laceration of the lung or diaphragm
alone or pulmonary angiogram w/ angioembolization or vascular Intraperitoneal placement of tube through the diaphragm
stenting required Bleeding related to various laceration or injury to pleural
Hemodynamically unstable pts = rarely survive adhesions
Measures taken: Additional problems
Ensure that central venous access is indicated Slippage of the tube out of position
Experienced personnel should insert the catheter or should Mechanical problems related to the drainage system
supervise the insertion All these complications can be avoided with proper initial insertion
Use proper positioning and sterile technique techniques, plus a daily review of the drainage system and follow-up
Ultrasound is recommended for internal jugular vein insertion radiographs
All central venous catheters should be assessed on a daily basis Tube removal create a residual pneumothorax if pt does not
All central catheters should be removed as soon as possible maintain positive intrapleural pressure by Valsalva s maneuver
during tube removal and dressing application
ENDOSCOPY AND BRONCHOSCOPY Inadequate analgesia or sedation
Perforation = principal risk of GI endoscopy Incomplete penetration of the pleura with formation of a
Increased risk d/t complications of intubating a GI diverticulum, or subcutaneous track for the tube
from presence of weakened or inflamed tissue in intestinal wall Lacerations to the lung or diaphragm
Pts usually complain diffuse abdominal pain after procedure = Intraperitoneal placement of the tube through the diaphragm
progress w/ worsening abdominal discomfort Bleeding related to these various lacerations or injury to pleural
Obtunded for elderly pts = change in clinical status take several hrs, adhesions
as long as 24 to 48 hrs to manifest Additional problems include: slippage of the tube out of position or
Diagnostic: radiologic studies > look for free intraperitoneal air, mechanical problems related to the drainage system
retroperitoneal air, or pneumothorax
En or laparoscopic exploration > locates perforation; allows repair ORGAN SYSTEM COMPLICATIONS
and local decontamination
Pt closely observed: in a monitored setting, strict dietary restriction, HEPATOBILIARY-PANCREATIC SYSTEM/SURGERY
and broad spectrum antibiotics Usually due to technical errors:
Endoscopy Laparoscopic cholecystectomy
Perforation Standard care for cholecystectomy
Common bile duct injury remains a nemesis of this approach

½ SURG TEAM 7
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 [SURGERY 2] CHAPTER 12: QUALITY, PATIENT SAFETY, ASSESSMENTS OF CARE, AND COMPLICATIONS

Bile leak; due to unrecognized injury to ducts may present after

cholecystectomy as biloma
Pt may present w/ abdominal pain & hyperbilirubinemia
Dx is confirmed by CT scan, ECRP, or radionuclide scan
Once leak is confirmed, tx of choice:
Retrograde biliary stent
External drainage

CRITICAL VIEW OF SAFETY

How to achieve the CVS
Three criteria are required to achieve the CVS:
1. The hepatocystic triangle is cleared of fat and fibrous tissue. The
hepatocystic triangle is defined as the triangle formed by the
cystic duct, the common hepatic duct, and inferior edge of the
liver. The common bile duct and common heaptic duct do not
have to be exposed
2. The lower one third of the gallbladder is separated from the liver
to expose the cystic plate. The cystic plate is also known as liver
bed of the gallbladder and lies in the gallbladder fossa
3. Two and only two structures should be seen entering the
gallbladder

½ SURG TEAM 8
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