Post-operative complications

Acutely Unwell Patients > Managing other emergencies

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.

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 (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)

Link to ECG here

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