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Post-operative surgical care and complications

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Post Operative Pyrexia

Cause	Comments
Atelectasis	Fever, reduced oxygen saturation, Get patient sitting out, ensure adequate analgesia to get breathing freely, encourage coughing. Those post abdominal or thoracic surgery vulnerable, smokers, chest physiotherapy to help expectoration. Hydration
Wound infections	Wounds need inspection for inflammation and infection. May be due to poor wound closure. Swab if there is frank pus. Start antibiotics
Hospital acquired Pneumonia	Cough, sputum, fever, consolidation on CXR
DVT and PE	Swelling of leg needs duplex. Consider starting treatment dose LMWH if delay and suspicion high
Deep abdominal infections	Post abdominal surgery. Needs CT
UTI/Urosepsis/Catheter related	Check urine, send culture, change catheter, Consider antibiotics. Remove catheter if possible.

Complications

Complication	Comments
Primary haemorrhage	Inspect the wound, use pressure to control bleeding. Continuation of bleeding from surgery and a failure to achieve adequate initial haemostasis. It requires aggressive management and may necessitate return. Insert cannula, consider cross match and transfusion. to theatre.
Reactive haemorrhage	Inspect the wound, Use pressure to control bleeding. Bleeding from small vessels which begin to bleed as the BP rises postoperatively. Transfusion may be needed. Severe cases may need to return to theatre. Watch Hb. Senior review. Insert cannula, consider cross match and transfusion.
Deep vein thrombosis/Pulmonary embolism	High-risk patients should receive prophylaxis. Consider starting treatment dose LMWH if delay and suspicion high
Wound breakdown	Anastomotic leaks, fistulas, adhesions, wound dehiscence, bleeding.
Nausea/Vomiting	Side effects of anaesthetics and opioids or may be associated with constipation and ileus.
Hypotension	It May be due to hypovolaemia due to dehydration or losses even bleeding, diarrhoea or vasodilation and sepsis or low BP due to spinal anaesthesia. Often oliguria and tachycardia. See haemorrhage above. Watch Hb, U&E. Consider IV fluids.
Vascular events	Myocardial Infarction, Stroke, Post op arrhythmias e.g. AF
Delirium post op	due to hypoxia, metabolic disturbance, infection, drugs, or withdrawal syndromes.
Acute Kidney Injury	Anuria and oliguria and may be due to pre-existing renal disease +/- hypotension, dehydration and most commonly prerenal worsened by nephrotoxic drugs e.g. aminoglycosides, NSAIDs. Once hypovolaemia has been corrected any remaining renal impairment requires specialist renal support.
A low-grade pyrexia	is normal in the immediate postoperative period but may also arise due to infection, collections or DVT
Infections	include pneumonia secondary to pooling of secretions, urinary tract infections and cannula site infections.
Surgical site complications	include paralytic ileus, anastomotic leaks, surgical site infections (with secondary haemorrhage as a result of the infection), fistula formation and wound dehiscence (total wound breakdown). Intestinal fistulae may be managed conservatively with skin protection, replacement of fluid and electrolytes and parenteral nutrition. If such conservative therapy fails the fistula may be closed surgically.
Post op pneumonia	Due to atelectasis and pre-existing lung disease
Postoperative hypoxia	is almost always initially due to perioperative atelectasis unless a respiratory infection was present preoperatively. Prophylaxis and treatment involves adequate analgesia, physiotherapy and humidification of administered gases. Respiratory failure may occur secondary to airway obstruction. Laryngeal spasm/oedema may occur in epiglottis or following traumatic intubation. Tracheal compression may complicate operations in the head and neck. In the absence of obstruction hypoxia may result from drugs causing respiratory depression, infection, pulmonary embolism or exacerbation of pre-existing respiratory disease. Respiratory support may be necessary.
Prolonged immobility	increases the risk of pressure sores especially in patients with diabetes or vascular insufficiency. Skincare, hygiene, turning of the patient and the use of specialised mattresses should prevent pressure sores. Treatment involves debridement, treatment of any infection, application of zinc paste and in severe cases, plastic surgery.
Late postoperative complications	which may occur weeks or years after surgery, include adhesions, strictures and incisional hernias.

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