Table of Contents
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
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:
Causes of post-operative fever (5 W’s)
| Category | Days post-op | Causes |
| Wind | <2 | Atelectasis, pneumonia |
| Water | 2-4 | UTI |
| Wound | 5-7 | Wound infection, infected post-operative collections |
| Walking | 8-10 | Venous thromboembolism |
| Wonder drugs | Any time | Transfusion/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
Test yourself with some questions
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. 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)
