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Post-operative complications

General complications

Immediate

  • Anaesthetic complications (e.g. arrhythmia, hypo-/hypertension, hyperthermia, breathing problems, MI/stroke, allergy, teeth/lip/tongue damage)
  • Haemorrhage – often not obvious externally (monitor drains, observations, FBC/haematocrit)

Early

  • Fluid depletion
  • Electrolyte imbalances
  • Local infection (wound/surgical site) or systemic infection (chest/UTI/sepsis)
  • Fluid collections
  • Atelectasis
  • DVT/PE
  • Wound break down
  • Anastomotic break down
  • Bed sores

General surgery – complications

OperationSpecific complications
GastrectomyDumping syndrome
Malabsorption
Anastomotic ulcer
Peptic ulcers/gastric cancer
Small intestinal bacterial overgrowth
Abdominal fullness/gas bloating
Small and large bowel operationsIleus
Anastomotic leaks (typically present 5-10 days post-operatively but can be up to 21 days)
Stoma retraction
Intra-abdominal collections
Pre-sacral plexus damage
Adhesions/intestinal obstruction
Damage to other local structures, e.g. kidneys, ureters, bladder
Cholecystectomy Common bile duct injury/bile leak
BiliaryCommon bile duct injury/bile leak
Common bile duct stricture
Anastomotic leak
Bleeding into biliary tree (jaundice)
Pancreatitis

Cardiothoracic – complications

OperationSpecific complications
GastrectomyDumping syndrome
Malabsorption
Anastomotic ulcer
Peptic ulcers/gastric cancer
Small intestinal bacterial overgrowth
Abdominal fullness/gas bloating
Small and large bowel operationsIleus
Anastomotic leaks (typically present 5-10 days post-operatively but can be up to 21 days)
Stoma retraction
Intra-abdominal collections
Pre-sacral plexus damage
Adhesions/intestinal obstruction
Damage to other local structures, e.g. kidneys, ureters, bladder
Cholecystectomy Common bile duct injury/bile leak
BiliaryCommon bile duct injury/bile leak
Common bile duct stricture
Anastomotic leak
Bleeding into biliary tree (jaundice)
Pancreatitis

Vascular – complications

OperationSpecific complications
Grafts/stents/bypass procedures Failure of graft, haemorrhage/haematoma, infection, re-thrombosis, limb or organ ischaemia
Arteriovenous fistula 
Cholesterol embolism (e.g. trash foot)
Arteriopaths are at high risk of: ACS, stroke, PE
Contrast complications, e.g. anaphylaxis, renal injury

Endocrine – complications

OperationSpecific complications
ThyroidectomyAirway obstruction secondary to haemorrhage – requires urgent opening of thyroidectomy woundHypocalcaemia (damage to parathyroid glands)
Recurrent laryngeal nerve damage
ParotidectomyFacial nerve damage

Trauma and orthopaedic – complications

OperationSpecific complications
Any orthopaedic operationInfection of prosthesis
Loss of position/failure of fixation
Non-union, malunion, delayed union
Neurovascular injury
Compartment syndrome
Total hip arthroplastySciatic nerve damage, dislocation, leg length difference, loosening, wear, need for revision surgery

Urology – complications

OperationSpecific complications
Cystoscopy/transurethral resection of the prostate  High risk of UTI
Transurethral resection of the prostate syndrome (absorption of irrigation fluid causing hyponatraemia)
Impotence/retrograde ejaculation
External sphincter damage (incontinence)
Urethral stricture

Other operations – complications

OperationSpecific complications
Endovascular surgeryRetroperitoneal haemorrhage
Lymph node dissection (e.g. axillary nodes in breast cancer surgery)Lymphoedema
Neck dissection(e.g. branchial cyst excision)Cranial nerve damage (11, 12)

Assessing an unwell post-operative patient

General tips

  • Use an ABCDE approach (see notes on ABCDE management p172
  • Consider the operation, pre-operative fitness and post-operative progress
  • Think about specific risks associated with the operation 
  • Special attention should be given to operative site, newly placed drains and their contents

NB: pain, operative stress and inflammation may be confounding factors when assessing a patient with deranged physiological parameters, but it is important to exclude more serious underlying causes.

Pyrexia

  • Assess in conjunction with other physiological parameters (heart rate, blood pressure, respiratory rate) 
  • Sepsis is the most common cause but operative intervention causes an inflammatory response in itself and may result in low grade pyrexia
  • Surgical patients are at particular risk of chest infections due to suboptimal ventilation causing basal atelectasis. But consider other sources of sepsis, such as UTIs.
  • The timing of the pyrexia may give a clue to the underlying diagnosis:

Causes of post-operative fever (5 W’s)

CategoryDays post-opCauses
Wind<2Atelectasis, pneumonia
Water2-4UTI
Wound5-7Wound infection, infected post-operative collections
Walking8-10Venous thromboembolism
Wonder drugsAny timeTransfusion/drug reactions (e.g. serotonin syndrome)

Hypotension

  • There should be two aims in assessing a patient with hypotension, identifying a cause and assessing for organ dysfunction
  • Causes may include:
    • Decreased intravascular volume: long operations and evaporative fluid losses, third space fluid losses, haemorrhage and poor oral intake should all be considered
    • Pump failure (cardiogenic shock): surgical stress increases the risk of MI (typically occur 48 hours post-operatively). Fluid overload and heart failure should also be considered.
    • Sepsis and anaphylaxis
    • Sympathetic shock: patients with epidural analgesia and a high block (T5 and above) can lose sympathetic outflow causing vasodilation and cardiogenic shock – assess epidural blocks using cold sprays. Spinal anaesthetics in elderly patients may contribute to loss of sympathetic tone and hypotension. 
  • Clinical signs of poor perfusion include: delayed capillary refill time, cold peripheries, tachycardia
  • Specific evidence of organ dysfunction should be sought: ABG for lactate, assessment of urine output (should be >0.5ml/kg/hour), confusion 

Respiratory difficulties

  • Respiratory problems are common in surgical patients
    • Respiratory tract infections: post-operative patients are high-risk due to immobility, poor inspiratory effort due to pain and basal atelectasis 
    • Pulmonary embolism: both surgery and underlying pathologies such as cancers and sepsis increase VTE risk 
    • Pulmonary oedema: large fluid shifts, hypoalbuminaemia and cardiac dysfunction predispose to this
  • Assessment of respiratory difficulties should include: assessment of fluid state (clinical hydration status, JVP, urine output), assessment of calves for DVTs, investigation for infection (e.g. bloods, CXR) and ABG

Low urine output

  • An acceptable urine output as a rule is considered to be >0.5ml/kg/hour
  • Consider the causes of acute kidney injury
    • Pre-renal: most common; usually due to volume depletion but may also be caused by inadequate cardiac output 
    • Renal: may be secondary to nephrotoxic drugs (e.g. aminoglycosides, metformin)
    • Post-renal: may be due to prostatic hypertrophy or raised intra-abdominal pressures causing compression of ureters
  • An assessment of the patient with low urine output should include a fluid status assessment (with care to look at fluid losses from drains and 3rd space losses into the bowel or tissues), a medicines review, and a catheter examination/bladder scan
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