• M/65, Hep B carrier, 60kg
• 6cm tumour in R lobe liver, cirrhosis
• R hepatic lobectomy: blood loss 600ml, no blood transfusion, operation duration 6hr
• Post-op ICU care: nutritional support, chest physio, oxygen therapy
• Home on post-op day 7
• Wt loss 7 kg

• F/18, crush inj by care
• Shock
• Laparotomy: massive haemoperitoneum, multiple episodes of hT, lacerated R lobe liver + spleen, successful R hepatectomy + splenectomy, blood transfusion 40 units
• Post-op ICU care
• Remained febrile and tachcardiac
• Day 2 - renal failure req haemodialysis
• Day 5 - bronchopneumonia
• Day 7 - severe jaundice and paralytic ileus (SI + LI dilated, no peristalsis)
• Day 9 - hT (heart failure)
• Day 10 - died from multi-organ failure (heart, liver, lung, kidney)

• Pt 1: why does a relatively healthy person having smooth recovery from major operation lose wt? Is debility after a major operation inevitable?
• Answer: nutritional support never enough, lobectomy is a major operation (increased tissue trauma), debility can be decreased during flow phase)
• Pt 2: why does an apparently successful operation lead to multi-organ failure mortality?
• Answer: massive trauma, lots of blood loss, hypotension leading to hypoperfusion of organs, SIRS (increased cytokines causing tissue trauma)

• Laparotomy wound - tissue trauma
• Exposure of viscera to air - loss of fluid and heat
• Intestinal anastomosis to restore continuity of SI
• Room temp + humidity too low - heat + fluid loss from Pt
• Operating light - no heat but causes desiccation of exposed viscera
• Bleeding (massive in hepatectomy, aortic aneurysm, cardiac surgery) - blood loss needs to be replaced

1. Skin incision + tissue trauma - inflammatory response -> wound healing
2. Bleeding - hypotension -> hypoperfusion of vital organs (heart, kidney liver, lung, brain) -> blood transfusion (immunosuppression)
3. Hypothermia - VC, decreased CO, coagulopathy
4. Bacterial contamination - infection
5. Exposure of viscera to air - fluid loss, desiccation of wound -> infection

• Heal wound
• Attenuate consequences of stress + achieve homeostasis

• Ab wound -> evisceration (SI + LI come out through ab wall)
• Anastomosis (1) Bowel contents leak -> peritonitis -> bacterial proliferate and spread in abdomen and blood -> septicaemia -> mortality (2) BV -> bleeding, loss of organ function

1. Increased A + glucagon -> increased blood glucose, increased lactate, increased FFA
2. Decreased CO -> organ hypoxia + ischaemia + decreased oxygen consumption
3. Hypothermia -> decreased oxygen consumption

• Succumb from lack of oxygen + nutrient supply to major organs
• Survive if prompt resuscitation is given (stop bleeding, anaesthetist restore BV)

• Metabolic response to heal wound + restore function
• Results in wt loss

• Inflammatory reaction
• Removal of debris, bacteria by macrophages
• Formation of new BV, collagen + epithelium

1. Immed after trauma: fibrin + platelet in wound area, stop bleeding, monocyte converts to macrophage, BV dilated to prepare for neutrophil entry
2. Early stage: neutrophil removes bacteria + debris, increased BF so wound heals, clot dries, epithelium grows across layer, cytokines (from macrophage) produced and act locally (eg. VD, increased BF, increased leakage of fluid from caps), migration of neutrophils across BV wall into site of injury
3. Intermediate stage - epithelial bridge, macrophage number increases within wound (remove necrotic debris)
4. Late stage: fibroblasts deposit collagen, new (1) BV (2) Collagen (3) Epithelium - all for wound healing

• Nutrients: aa, glucose, FA (needed for actively dividing cells)
• Oxygen

• Glycogen in m + liver (depleted in 12-24 hr)
• Mobilisation of aa from m + FA from fat
• These leads to wt loss

• Malaise, m weakness
• Predisposition to bronchopneumonia (skeletal m's like costal m and diaphragm affected - less clearance of secretions in aw)
• Mortality from infection (eg. Bronchopneumonia, UTI) b/c not enough nutrients for actively dividing WBC -> increased infection

• Increased catecholamine, glucagon, cortisol, CO, BF
• Clinically: increased heart rate/ pulse, RR, fever (inevitable mild fever after major surgery)
• Purpose: increase BF to wound + vital organs

• IL1, IL6, TNF from macrophages locally - accumulate in wound
• For local inflam response + promotion of wound healing
• SIRS (Systemic Inflammatory Response Syndrome) due to spillage of cytokines into systemic circulation, perpetuation of hypermetab, multi-organ failure

• Beneficial for recovery
• Cost may be substantial

Ebb Flow

• Recovery
• Loss of retained fluid
• Restoration of lean body mass, BW, fat store, well-being

• Prompt fluid + blood replacement to maintain BP
• Adequate O2 supply + ventilation
• CV support by inotropes (heart and BV stimulants, can manipulate BV diameter, eg. NA, dopamine, dobutamine)
• ABX
• Avoid hypothermia (cover non-operational site with warm air current blankets)

• Parenteral Nutritional Support - GIT not functioning therefore cannot eat immediately after op
• Note: need food in gut to stimulate epithelium - or else atrophic epithelium can allow blood to enter portal blood (1) Enterotoxaemia (2) Septicaemia
• Warm room temp
• Mobilisation, chest physio (all Pt's, clear sputum and icnrease resp function)
• Haemodialysis for renal failure
• Timely re-operation for surg complciation (eg. Leakage of anastomosis in SI, may occur 2-3d post-op; accumulation of blood in peritoneal cavity may clot and cause infection leading to bacteriaemia/ septicaemi - therefore surgery to remove clot)