Chapter 5: Postoperative

Care &
Complications
Fever
Altered Mental States
Water and Electrolyte Imbalance
Oliguria
Chest Pain
Postoperative Hypertension
Postoperative Infection
Anxiety and Pain Management
Nausea
Constipation
Shivering
DVT
Compartment Syndrome
Hemorrhage
Septic Syndrome
Thyroid Storm
 POSTOPERATIVE COMPLICATIONS
The number of potential post-operative problems is large, with some
occurring more frequently. Those are FEVER, ALTERED MENTAL STATUS,
WATER & ELECTROLYTE DISTURBANCES, RENAL FAILURE, CHEST PAIN,
SHORTNESS OF BREATH AND HYPERTENSION (A hospitalized patient
developing cough, fever and an abnormal chest x-ray after prolonged general
anesthesia and a patient with the same fin dins following a procedure done
under local anesthesia must be viewed differently)

Fever
Temperature> 101.6 orally: Fever is the most common post-op problem. The
time of occurrence is an important clinical guide in determining the etiology.
Fever can also occur without any associated pathological conditions.

WIND (PULMONARY EMBOLISM, ATELECTASIS AND PNEUMONIA)

WATER (URINARY TRACT INFECTION)
WALKING (THROMBOPHLEBITIS- between 3-10 days postop; positive
Homan's sign)
WONDER DRUGS (DRUG FEVER- the patient is less ill than the fever
would suggest)
WOUND (SEPSIS)
WOW (BREASTS: MASTITIS) -Usually ObGyn
WOMB (ENDOMETRITIS)-Usually ObGyn
1. Fever within 24 hours (THE MOST COMMON) can be due to:
a. ATELECTASIS FROM HYPOVENTILATION
b. ASPIRATION OF ORAL OR GASTRIC CONTENTS
c. DRUG REACTIONS (IF PATIENT RECEIVED BLOOD THEN ADD TRANSFUSION
REACTIONS)

2. Fever after 24 hours following surgery can be due to:

a. ATELECTASIS & ASPIRATION
b. WOUND INFECTIONS
c. IV SITE PHLEBITIS
d. UTI
e. DVT
f. HEPATITIS
 NOTE* IF A FEVER DEVELOPS WITHIN THE FIRST 6-8 HOURS FOLLOWING
SURGERY, THE MOST LIKELY CAUSE IS AN ENDOCRINE IMBALANCE
WHICH MAY LEAD TO A TEMPORARY THYROID CRISIS OR
ADRENOCORTICOID
INSUFFICIENCY. SHOULD FEVER DEVELOP 8-10 HOURS AFTER SURGERY, A
PULMONARY MALFUNCTION SHOULD BE ENTERTAINED AS THE LIKELY
CAUSE. URINARY TRACT INFECTIONS ARE THE MOST LIKELY CAUSE OF
FEVERS AT THE SECOND OR THIRD POSTOP DAY (URGENCY, FREQUENCY,
PAIN, AND BACTERIA). BACTERIAL INFECTIONS OCCUR 3-7 DAYS POST-
OP: WITH THE EXCEPTION OF GROUP A STREP, WHICH CAN
OCCUR EARLIER. A SPIKING TEMPERATURE IS INDICATIVE OF AN INFECTION,
ALONG WITH TACHYCARDIA, CHILLS, MALAISE, LETHARGY, AND LOSS
OF APPETITE
ALL IV LINES AND HEPARIN LOCKS SHOULD BE CHANGED EVERY 2-3 DAYS
TO PREVENT INFECTION. DIABETIC FEMALES AND ELDERLY MALES ARE AT
HIGHEST RISK FOR UTI'S.

3. DO NOT TREAT THE FEVER WITH ANTIPYRETICS UNTIL THE CAUSE

IS DETERMINED (There are exceptions to this rule: patient
discomfort, delirium or convulsions and the precipitation of heart
failure

4. Risk factors:
a. Surgery over 2 hours in time
b. Transfusion
c. Pre-existing infection
d. In place prosthesis or shunt
Altered Mental States
1. Can develop In: ELDERLY PATIENTS, METABOLIC DISORDERS,
HYPONATREMIA, HYPOGLYCEMIA, HYPERGLYCEMIA (MOSTLY HYPO),
ACIDOSIS (SEPSIS, SHOCK AND DIABETIC KETOACIDOSIS), Ml,
ARRYTHMIAS, CVA'S & DRUG PROBLEMS (TOXICITY AND DRUG
INTERACTIONS)

Water and Electrolyte Disturbances

1. Can develop as a result of: IMPROPER FLUID REPLACEMENT,
INCREASED BODY LOSS (Vomiting and fever), MEDICATIONS AND
STRESS

2. FLUID ADMINISTRATION OF 2000-3000 MIDDAY IS NEEDED TO

MAINTAIN A DESIRED URINE OUTPUT OF 1000-1500 ML/DAY

3. FEVER INCREASES WATER LOSS (FOR EACH DEGREE ABOVE

NORMAL WATER LOSS IS INCREASED BY 100-150 ML/DAY

4. Sodium disorders (Na):

a. HYPONATREMIA (Na<125 meq/L): Can occur post-op. Symptoms are
lethargy, confusion, coma, muscle twitch, nausea, vomiting and cardiac
problems. Treated by restricting fluids to 1000-1500 ml fluid/day. Can occur
from
i. HYPONATREMIA WITH VOLUME EXCESS
ii. HYPONATREMIA WITH VOLUME DEPLETION
iii. HYPONATREMIA WITH NORMOVOLEMIA
b. HYPERNATREMIA (Na>145 meq/L): Symptoms are confusion, stupor, coma,
muscle tremors, seizures, pulmonary and peripheral edema. Treated with
D5W slowly over 24 hours

5. Potassium disorders (HYPO OR HYPERKALEMIA): can occur post-op,

and can be life threatening
a. HYPOKALEMIA (K<2.5) occurs in the following:
i. PATIENTS GETTING DIURETICS
ii. VOMITING
iii. DIARRHEA
iv. BRITTLE DIABETES
v. ANTI-PSEUDOMONAL ANTIBIOTICS
vi. HIGH DOSES OF STEROIDS (See section Pre-op Evaluation- SMA)
b. HYPERKALEMIA (K>4.5) is seen less frequently but is far more lethal than
HYPOKALEMIA and can manifest itself with weakness, hyperactive reflexes,
and cardiac manifestations/standstill
c. Treatment of hyperkalemia must be immediate: Give Calcium Chloride,
then Sodium Bicarb or even D50 with insulin (and KAYEXELATE if necessary)

Oliguria
1. Due to:
a. BLADDER OBSTRUCTION
b. THE COMBINATION OF BEDREST/PROSTATIC HYPERTROPHY/ANALGESICS
(DEMEROL***)
c. ISCHEMIC INSULTS
d. NEPHROTOXIC DRUGS

2. To approach a patient with acute renal failure you must do the

following:
a. Measure urine volumes and medication use
b. Assess hydration and cardiovascular status
c. Bladder catheterization a possibility
d. Fresh urine analysis- with examination of the sediment
e. Labs: serum and urine sodium, creatinine, osmolality and BUN
f. Special tests: RENAL FAILURE INDEX AND FRACTIONAL EXCRETION OF
SODIUM MEASUREMENT

Chest Pain
1. Etiology:
a. MI
b. PULMONARY EMBOLUS
c. PNEUMONIA
d. ANXIETY
e. ATELECTASIS
f. ASPIRATION
g. CHF

2. Treatment:
a. Must perform EKG, chest x-ray, arterial blood gases (establishes probability
of a diagnosis)
b. May do VENTILATION PERFUSION RADIONUCLEOTIDE LUNG SCAN (A
negative study R/O P.E.)
c. If doubt remains, can do: PULMONARY ANGIOGRAPHY (Most specific and
sensitive test for P.E.)
d. A distinction should be made between ASPIRATION PNEUMONIA AND
ASPIRATION PNEUMONITIS.

NOTE* The former is caused from aspiration of sterile/acidic gastric contents and
results in a chemical pneumonitis. The latter occurs when polymicrobial oral
secretions are introduced into the pulmonary system.

Post-op Hypertension
1. Etiology:
a. Noxious stimuli (most common): Pain, excitement (emergence from
general anesthesia), shivering, and mild hypothermia
b. Drug induced: Withdrawal from beta blockers
c. Metabolic abnormalities: Pheochromocytoma, Cushing's syndrome
d. Miscellaneous: Fluid overload, distended bladder, tight cast
2. Treatment: Try to establish the etiology
a. Treat pain and anxiety first, and warming of the patient
b. If the hypertension persists, it can be treated with sublingual Procardia 20
mg, IV Furosemide (if volume overload, distended bladder), or ideally a drug
which is fast acting, titratable, rapidly reversible, efficacious, and with no side
effects that can offset the cause of the hypertension

NOTE* Sudden decreases in blood pressure accompanying treatment of

hypertension can have catastrophic results: seizures, CVA's, acute Ml,
renal failure, and death
Postoperative Infection
1. Can occur 3-7 days postoperatively
2. Group A Strep can occur earlier
3. Symptoms
a. Increased throbbing pain
b. Swelling
4. Signs
a. Wound drainage
b. Wound dehiscence
c. Erythema
d. Fever
5. Treatment: Decide on hospital or outpatient therapy

NOTE* Admit to hospital with systemic manifestations (fever/shakes/chills,

lymphangitis, lymphadenopathy), debilitated host ( Diabetic, PVD,
alcoholic, immunosuppressive therapy, burn patients), need for IV
antibiotics, resistant organism, risk of deep space infection, deep space
necrosis or wet gangrene, suspicion of osteomyelitis, need for extensive
surgical debridement, and failure of outpatient. therapy
a. Consider ID consult/ internal medicine consult/ vascular consult prn
b. Perform local wound care/release and remove sutures/ incision and
drainage as necessary
c. Perform gram stain and aerobic/anaerobic/fungal/acid fast cultures (as
necessary) from wound site and blood cultures if indicated
d. Obtain necessary lab studies (CBC,Hb, urinalysis, chemistries)
e. Begin antibiotics as per gram stain a clinical evaluation and judgement/
reevaluate as per C & S
f. Continue appropriate antibiotic at least 10 days (especially when treating
strep, to prevent post strep glomerulonephritis. May consider IV antibiotics)

Anxiety and Pain Management

1. Pain complaints reflect not only tissue injury, but many
psychological dimensions of suffering as well.
a. A long acting local anesthetic injected at the end of the surgery will delay
postoperative pain past the initial phases.
b. The injection of a short-acting soluble steroid will help diminish painful
swelling and inflammation associated with the lag phase of healing.
c. NSAID's can many times be the sole postoperative medication because
inflammation is the hallmark of the initial and most painful postoperative
phase.
d. Opiates or opiate-like drugs can be used in combination with ASA or
acetaminophen. These drugs should be considered if NSAIDs have failed to
alleviate the pain.
e. Excessive anxiety will greatly reduce the pain threshold, therefore
sedatives can greatly help these patients.
f. Toradol® IM/IV has been found to be very effective immediately
postoperatively in eliminating pain (non-narcotic)

Note* The side effects of narcotics are: hypotension, respiratory depression,

urinary retention, nausea, and reduced peristalsis.

Nausea
1. Prolonged vomiting can lead to dehydration therefore must be
prevented or controlled.
2. Postoperative nausea responds well to:
a. Phenothiazine antiemetics (Compazine, Phenergan, Trilafon).
b. Other treatment can include the use of antihistamines (Benadryl, Atarax)
c. Tigan 100mg IM, can be of benefit
d. In children you can use Emetrol (5-10ml Q 15 minutes)

NOTE* Can prevent postoperative nausea by using a Scopolamine patch behind

the ear. This is applied preoperatively and worn perioperatively and
postoperatively. The only adverse effect is blurred vision postoperatively

Constipation
1. Can be a problem especially with elderly patients
a. Begin treatment 1st with the mildest treatment, a laxative cathartic, milk
of magnesia (watch the electrolytes)
b. If unsuccessful then try Colace 50-250mg
c. If unsuccessful then use a contact cathartic, Dulcolax

Note* All laxatives and cathartics are contraindicated in patients with cramps,
colic, nausea, vomiting and any undiagnosed abdominal pain.

Shivering
1. Can occur postoperatively and is not associated with fever or
infection, but as a reaction to general anesthesia (22-50% of cases).
The incidence seems to be increased in prolonged cases and in those
involving large amounts of blood loss, fluid administration, or both. Shivering
may also be seen after epidural anesthesia. Shivering is associated with
several undesirable physiologic effects. Oxygen consumption, carbon dioxide
production, and metabolic rate may increase as much as 500% above
baseline levels
a. Treatment is IM injection of 12.5-25mg of Demerol
b. Bear hugger forced air warmer

DVT
1. Lower extremity surgery plus the use of pneumatic tourniquets
for hemostatic control, immobilization, obesity, bedrest, and oral
contraceptives are all predisposing factors
a. Symptoms: Fever (101 °F) after 24 hours, calf tenderness
b. Signs: Swelling of the calf in the later stages
c. Diagnostic tests: Duplex scan, venogram

NOTE* A painful swollen leg and a positive duplex scan are criteria to initiate
treatment for a DVT. However, a swollen/painful leg plus a questionable
scan requires a venogram for adequate criteria to initiate treatment
d. Treatment: After drawing blood for a coagulation profile, treat with Heparin
IV
NOTE* Fever may be the only initial warning but also occurs with other
postoperative problems, therefore, must work up the patient
completely prior to initiating treatment
5000-10,OOOU followed by a constant infusion of 1000-1500U/HR. The PTT is
kept at 2 times the baseline and the PT is kept at 1 and 1/2 the baseline.
Coumadin is also utilized (to help prevent pulmonary emboli) and should be
started upon admission, to the hospital as it takes 3-5 days to start working.
The patient can eventually be discharged on p.o. Coumadin

Compartment Syndrome

Two criteria must be fulfilled for this diagnosis to be made:

a. a space that is limited by fascia, skin, or bone must be present
b. increased compartment pressure caused by a decrease in compartment
size or an increase in the size of the contents within that compartment
must be present

Usually diagnosed in the arm and leg, also occurs in the foot, and can follow
several types of injuries, most commonly multiple fractures or crushing
injuries. This entity should be considered in the differential diagnosis in
patients presenting with a painful swollen foot post trauma

1. Definition: Increased compartmental pressure resulting in decreased

perfusion and ultimate ischemic changes to the tissues on the compartment.
This can eventually result in contractures and poorly functioning limbs.
a. Physiology: At rest the intramuscular pressure is approximately 5 mm Hg.
During a muscular contracture the pressure can increase up to 150 mm Hg or
more. At relaxation, the compartment pressure rapidly drops, and within 5-10
minutes, has returned to baseline. With a compartment syndrome, there is
no drop of pressure

2. Types of compartment syndrome:

a. Acute: Occurs when the resting pressure in the compartment exceeds the
available perfusion pressure. This is usually the result of trauma with
hemorrhage or gross muscular edema causing the increased compartmental
pressure. If untreated tissue necrosis is inevitable
b. Chronic: Occurs when the resting pressure is higher than the normal
resting pressure but not so high as to cause hyperprofusion. Following
excercise, the time for pressure to return to baseline is protracted. This
results in a relative prolongation of the ischemic time resulting in symptoms
during or following exercise. Actual muscle necrosis is unusual

3. Diagnosis: Measurement of an increased intramuscular pressure in the

compartment via a wicks catheter (usually greater than 30mmHg)

NOTE * Heppenstal demonstrated that the key element of an alteration in

aerobic metabolism was the difference between the Mean Arterial Pressure
(MAP) and the Intramuscular Pressure (P). He determined this difference as
"p. The lowest "p to maintain normal metabolism was 30mm Hg in normal
and 40 mm Hg is traumatized muscle. The formula used to determine ^p is
as follows:

MAP = Diastolic + 1/3 pulse pressure MAP

P = Compartment pressure -P
^P
Case 1: A 30 year old female suffered a crushing injury to her foot. Her blood
pressure was 140/80. The patient was essentially stable, but had a painful
and swollen foot. X-ray examination was normal.

With these findings a compartment syndrome is suspected. A Wicks catheter

measured pressure in the central compartment at 50 mmHg. Therefore,
does a compartment syndrome exist?

According to the above Heppenstal's formula a compartment syndrome does

not exist in this case. Using the above formula, the ^p in this case= 45. This
value is greater than 40 and therefore the patient does not have a
compartment syndrome.

Therefore, the most accurate way of determining the presence of a

compartment syndrome would be to measure the compartment pressure
and then use Heppenstal's formula.

4. Clinical Findings:
a. Pain out of proportion to the clinical findings
b. Paresthesias
c. Pulselessness
d. Or none of the above

Note* The patient might present with a pulse because the vascular collapse
occurs first at the arteriolar level

5. Associated complications:
a. Comminuted fractures
b. Severe soft tissue injuries
c. Post-ischemia swelling
d. Intramuscular hematomas associated with bleeding diathesis
e. Crush injuries

6. Compartments of the foot: 4

a. Medial compartment: Its borders are the medial and lateral intermuscular
septum, the medial portion of the plantar aponeurosis, the tarsus
(proximally) and shaft of the first metatarsal (distally). It contains the
abductor hallucis flexor hallucis brevis, and the FDL tendon
b. Central compartment: Its borders are the medial and lateral intermuscular
septum, the central portion of the plantar aponeurosis, the tarsus
(proximally) and interosseous fascia (distally). It contains the flexor digitorum
brevis, FDL tendon with lumbricals, quadratus plantae, adductor hallucis, PT
and peroneal tendons
c. Lateral compartment: Its borders are the lateral intermuscular septum,
lateral portion of the plantar aponeurosis, and the associated osseous
components. It contains the abductor digiti minimi, flexor digiti minimi, and
opponens digiti
d. Interosseous compartment: Its borders are the metatarsals and the
interossei fascia. It contains the interossei

7. Treatment:
a. Fasciotomy
1. Double dorsal technique

NOTE* Midfoot and forefoot: 2 dorsal longitudinal incisions, one over the 2nd
metatarsal and the other over the 4th (deepened down to the metatarsal
shaft) where a hemostat is passed into each adjacent interosseous space,
where the interosseous muscle is stripped from its corresponding
metatarsal. The wound is closed secondarily in 5 days. If closure cannot be
completed, then skin grafting is employed

ii. Extensile medial incision

iii. Combined approach
Hemorrhage
The incidence of major hemorrhage is low considering the total number of
surgeries done in the U.S. The use of blood products is an important decision
that any surgeon must make considering the impact of AIDS seen in
transfusion medicine today.
1. Physiology of anemia:
a. Sufficient amounts of Hb and cardiac output must be present to supply
tissue demands
b. A 20-30% volume loss leads to hypotension and shock, the end result is
tissue hypoxia
c. As the hemoglobin decreases the cardiac output increases (cardiac output
is increased as stroke volume increases)
d. The hematocrit level requiring transfusion is still under debate. However, it
is considered advisable to consider transfusion when the Hb is 7 Gm/dl or
less. Some will transfuse if Hb is under 10 Gm/dl, which is an HCT of 30%

2. Types of transfusion (see chapter, Fluid Replacement)

a. Autologous blood:
i. Preoperative donation: must be done 1 week prior to surgery
ii. Euvolemic hemodilution: removal of the RBC mass at the time of surgery
and replacement with either colloid or crystalloid to maintain intravascular
volume
iii. Cell salvage: blood is collected by automated cell washing devices ( it is
contraindicated in cases where infection is present and where cancer cells
may be encountered). The automatic cell washers contain clear plasma and
platelets, and there is no clotting function transfused with the product
b. Homologous blood: Blood bank blood

3. Complications:
a. WBC-mediated allergic type reaction, or immune reaction to minor group
factors
b. Human error causing major cell lysis, mistyping, and hemolytic transfusion
reactions
c. Disease transmission
i. Hepatitis B and C are greatest risks
ii. AIDS (1-50,000 transfusions reported)

NOTE* See chapter 11 Fluid Management, section Blood Bank

Septic Syndrome
In patients who have had recent major surgery, prompt and accurate
diagnosis of sepsis often is difficult. Many of the features commonly
attributed to sepsis (fever, leukocytosis) are normal phenomena in the
postoperative period 1. Criteria: The most important criteria is evidence of
an infection based upon a high index of clinical suspicion using the following
a. Fever > 101 °F or hypothermia < 96°F
b. Heart rate > 90 beats per minute
c. Respiratory rate > 20 breaths per minute
d. Evidence of organ dysfunction
e. A PaO2 < 75 mmHg
f. Elevated plasma lactic acid levels
g. Altered mentation

NOTE* Among the most devastating complications seen in bacteremic shock

is the development of adult respiratory distress syndrome (ARDS)

2. Treatment:
a. Empiric broad spectrum antibiotics in maximum doses

Thyroid Storm
This represents the extreme state of decompensated
thyrotoxicosis. Thyrotoxic patients inadequately prepared are at great risk for
developing thyroid storm from the stress of surgery
1. Signs and symptoms:
a. Tachycardia
b. Fever
c. Arrhythmias
d. Agitation, psychosis, coma (CNS always affected)
e. GI symptoms (abdominal pain, jaundice vomiting
f. Dyspnea
2. Treatment:
a. Propranolol 1-2 mg IV with continuous cardiac monitoring. Repeat every 5
minutes until the pulse rate drops to 90-110
b. PTU 300 mg PO q6h (antithyroid drug: propylthiouracil)
c. Saturated solution of potassium iodide 10 drops PO q8h
d. Hydrocortisone 200 mg IV q8h
e. General supportive therapy with acetaminophen, IV's and peripheral
cooling

3. Prevention:
a. Good history
b. Appropriate lab tests (T3, T4, TSH, serum cholesterol)
c. Endocrinology consult to determine if thyroid disease is primary or
secondary and to monitor treatment