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
Specific complications
General surgery
Operation
Specific complications
Gastrectomy
Dumping syndrome Malabsorption Anastomotic ulcer Peptic ulcers/gastric cancer Small intestinal bacterial overgrowth Abdominal fullness/gas bloating
Small and large bowel operations
Ileus 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
Biliary
Common bile duct injury/bile leak Common bile duct stricture Anastomotic leak Bleeding into biliary tree (jaundice) Pancreatitis
Vascular
Operation
Specific 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
Operation
Specific complications
Thyroidectomy
Airway obstruction secondary to haemorrhage – requires urgent opening of thyroidectomy wound Hypocalcaemia (damage to parathyroid glands) Recurrent laryngeal nerve damage
Parotidectomy
Facial nerve damage
Trauma and orthopaedic
Operation
Specific complications
Any orthopaedic operation
Infection of prosthesis Loss of position/failure of fixation Non-union, malunion, delayed union Neurovascular injury Compartment syndrome
Total hip arthroplasty
Sciatic nerve damage, dislocation, leg length difference, loosening, wear, need for revision surgery
Urology
Operation
Specific 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
Operation
Specific complications
Endovascular surgery
Retroperitoneal 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)
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:
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
You are asked to see a patient after a thyroidectomy, complaining of muscle spasm. The nurse noted their hand muscles spasm when the blood pressure is checked. What is this sign called? What is the cause and initial management?
Trousseau Sign = carpopedal spasm induced by inflation of blood pressure cuff
Cause is hypocalcaemia
Initial management is to check calcium, PTH, vitamin D
Initial management = replace calcium intravenously (learn more about electrolyte correction here)
An 84 year old with a neck of femur femur fracture is day one post-THR. She has palpitations and an ECG has been undertaken (link below). What is the diagnosis and initial management?
ECG shows atrial fibrillation
Initial management
Clinical examination and assessment of fluid status
Check bloods, including all electrolytes, thyroid function
Consider rate control with bisoprolol or digoxin
IV fluids if hypovolaemic, IV antibiotics if concerned about infection
Anticoagulation may need to be considered but not in the immediate post-operative period due to high bleeding risk (unless there is a concern about VTE)
