Post-operative Complications

Post-operative Complications
Post-operative complications either can be general or specific towards the type of surgery undertaken, and really should be managed using the patient's history in your mind. Common general post-operative complications include post-operative fever, atelectasis, wound infection, embolism and deep vein thrombosis. The greatest incidence of post-operative complications is between One and three days after the operation. However, specific complications exist in the following distinct temporal patterns: early post-operative, a few days after the operation, through the post-operative period, and in the late post-operative period.1
General post-operative complications
• Immediate:
Primary haemorrhage: either starting during surgical procedures or following post-operative increase in blood pressure level - replace hemorrhaging and may require go back to theatre to re-explore wound.
Basal atelectasis: minor lung collapse.
Shock: hemorrhaging, acute myocardial infarction, pulmonary embolism or septicaemia.
Low urine output: inadequate fluid replacement intra- and post-operatively.
• Early:
Acute confusion: exclude dehydration and sepsis
Nausea and vomiting: analgesia or anaesthetic-related; paralytic ileus
Fever
Secondary haemorrhage: frequently as a result of infection
Pneumonia
Wound or anastomosis dehiscence
Deep vein thrombosis (DVT)
Acute urinary retention
Urinary tract infection (UTI)
Post-operative wound infection
Bowel obstruction because of fibrinous adhesions
Paralytic Ileus
• Late:
Bowel obstruction due to fibrous adhesions
Incisional hernia
Persistent sinus
Recurrence of reason behind surgery, e.g. malignancy
post-urological surgery
o Blood transfusion or drug reaction
• Days 3-5:
o Bronchopneumonia
o Sepsis
o Wound infection
o Drip site infection or phlebitis
o Abscess formation, e.g. subphrenic or pelvic, with respect to the surgery involved
o DVT
• After Five days:
o Specific complications related to surgery, e.g. bowel anastomosis breakdown, fistula formation
o After the very first week
o Wound infection
o Distant sites of infection, e.g. UTI
o DVT, pulmonary embolus (PE)
Haemorrhage
• If large volumes of blood happen to be transfused, then haemorrhage may be exacerbated byconsumption coagulopathy. Can also be due to pre-operative anticoagulants or unrecognisedbleeding diathesis.
• Perform clotting screen and platelet count, ensure good intravenous access and insert central venous pressure (CVP) catheter. Give protamine if heparin has been utilized. Order cross-matched blood. If clotting screen abnormal, give fresh frozen plasma (FFP) or platelet concentrates. Consider surgical re-exploration all the time. 
• Late post-operative haemorrhage occurs several days after surgery and it is usually due to infection damaging vessels in the operation site. Treat infection and consider exploratory surgery.
Infection
• Infectious complications would be the main causes of post-operative morbidity in abdominal surgery.
• Wound infection: most typical form is superficial wound infection occurring inside the first week presenting as localised pain, redness and slight discharge usually brought on by skin staphylococci.
• Cellulitis and abscesses:
o Usually occur after bowel-related surgery
o Most present within first week but could be seen as late as third post-operative week, despite leaving hospital
o Present with pyrexia and spreading cellulitis or abscess
o Cellulitis is given antibiotics
o Abscess requires suture removal and probing of wound but deeper abscess may need surgical re-exploration. The wound remains open in both cases to heal by secondary intention
• Gas gangrene is uncommon and life-threatening.
• Wound sinus is really a late infectious complication from the deep chronic abscess that may occur after apparently normal healing. Usually needs re-exploration to get rid of non-absorbable suture or mesh, that is the underlying cause.
Disordered wound healing
Most wounds heal without complications and healing isn't impaired in the elderly unless there are particular adverse factors or complications. Factors which might affect healing rate are:
• Poor circulation.
• Excess suture tension.
• Long term steroids.
• Immunosuppressive therapy.
• Radiotherapy.
• Severe rheumatoid disease.
• Malnutrition and vitamin deficiency.
Wound dehiscence
• Affects about 2% of mid-line laparotomy wounds.
• Serious complication having a mortality of up to 30%.
• Due to failure of wound closure technique.
• Usually occurs between 7 and Ten days post-operatively.
• Often heralded by serosanguinous discharge from wound.
• Should be assumed the defect involves the whole from the wound.
• Initial management includes opiate analgesia, sterile dressing to wound, fluid resuscitation and early go back to theatre for resuture under general anaesthesia.
Incisional hernia
• Occurs in 10-15% of abdominal wounds usually appearing within newbie but can be delayed by as much as 15 years after surgery.
• Risk factors include obesity, distension and poor tone of muscle, wound infection and multiple utilization of same incision site.
• Presents as bulge in abdominal wall near to previous wound. Usually asymptomatic but there might be pain, especially if strangulation occurs. Has a tendency to enlarge over time and be a nuisance.
• Management: surgical repair high is pain, strangulation or nuisance.
Surgical injury
• Unavoidable injury to nerves may occur during various kinds of surgery, e.g. facial nervedamage during total parotidectomy, impotence following prostate surgical procedures or recurrent laryngeal nerve damage during thyroidectomy.
• There is another risk of injury while being transported and handled within the theatre under general anaesthetic. Included in this are injuries due to falls from trolley, harm to diseased bones and joints during positioning, nerve palsies, and diathermy burns.
Respiratory complications
• Occur in as much as 15% of general anaesthetic and major surgery and can include:
• Atelectasis (alveolar collapse):
o Caused when airways become obstructed, usually by bronchial secretions. Many instances are mild and could go unnoticed
o Symptoms are slow recovery from operations, poor colour, mild tachypnoea, tachycardia and low-grade fever
o Prevention is as simple as pre-and post-operative physiotherapy
o In severe cases, positive pressure ventilation are usually necesary
• Pneumonia: requires antibiotics, physiotherapy.
• Aspiration pneumonitis:
o Sterile inflammation from the lungs from inhaling gastric contents
o Presents with good reputation for vomiting or regurgitation with rapid start of breathlessness and wheezing. Non-starved patient undergoing emergency surgical treatment is particularly at risk
o May assist in avoiding this by crash induction technique and employ of oral antacids or metoclopramide
o Mortality is almost 50% and requires urgent treatment with bronchial suction, positive pressure ventilation, prophylactic antibiotics and IV steroids
• Acute respiratory distress syndrome:
o Rapid, shallow breathing, severe hypoxaemia with scattered crepitations but no cough, chest pains or haemoptysis, appearing 24-48 hours after surgery
o Occurs in lots of conditions where there is direct or systemic insult towards the lung, e.g. multiple trauma with shock
o Requires intensive care with mechanical ventilation with positive-end pressure
Thrombo-embolism
• Major reason for complications and death after surgery. DVT is extremely commonly related to grade of surgery.
• Many cases are silent but present as swelling of leg, tenderness of calf muscle and increased warmth with calf pain on passive dorsiflexion of foot.
• Diagnosis is as simple as venography or Doppler ultrasound.
• Pulmonary embolism:
o Classically presents with sudden dyspnoea and cardiovascular collapse with pleuritic heart problems, pleural rub and haemoptysis. However, smaller PEs tend to be more common and present with confusion, breathlessness and heart problems
o Diagnosis is by ventilation/perfusion scanning and/or pulmonary angiography or dynamic CT
• Management: intravenous heparin or subcutaneous low molecular weight heparin for five days plus oral warfarin.
Common urinary problems
• Urinary retention: common immediate post-operative complication that may often be dealt with conservatively with adequate analgesia. If the fails may need catheterisation.
• UTI: common, especially in women, and could not present with typical symptoms. Treat with antibiotics and adequate fluid intake.
• Acute renal failure:
o May be brought on by antibiotics, obstructive jaundice and surgery towards the aorta
o Often due to episode of severe or prolonged hypotension
o Presents as low urine output with adequate hydration
o Mild cases might be treated with fluid restriction until tubular function recovers. Yet it's essential to differentiate from pre-renal failure because of hypovolaemia which requires rehydration
o In severe cases may require haemofiltration or dialysis while function gradually recovers over weeks or months
Complications of bowel surgery
• Delayed return of function:
o Temporary disruption of peristalsis: may complain of nausea, anorexia and vomiting in most cases appears with the re-introduction of fluids. Often referred to as ileus
o More prolonged extensive form with vomiting and your inability to tolerate oral intake called adynamic obstruction and requires to be distinguished from mechanical obstruction. If involves large bowel usually referred to as pseudo-obstruction. Diagnosed by instant barium enema
• Early mechanical obstruction: might be caused by twisted or trapped loop of bowel or adhesions occurring approximately 7 days after surgery. May settle with nasogastric aspiration plus IV fluids or progress and require surgery.
• Late mechanical obstruction: adhesions can organise and persist, commonly causing isolated instances of small bowel obstruction entire time after surgery. Treat for early form.