Post-Operative Complications

Post-Operative Complications

Infection

·        Usually takes 3 – 5 days

·        Wound infection:

o   Redness, induration

o   Either:

·        Abscess: red, hard mass ® needs drainage 

·        Cellulitis: red, hot, painful ® antibiotics

·        Abdominal infection:

o   Often 5 – 7 days before apparent: pain, ileus, sweats, rigours

o   Investigations (to look for abscess): Maybe US.  CT better

o   Treatment:

·        Small abscess: if deep and < 3 cm try antibiotics 

·        Large abscess: if > 4 cm then drain either surgically or under radiological guidance. Depends on depth, if its loculated or presence of overlying bowel

·        Peripheral line

·        Central line: may look innocent – but consider if no other locus found.  Can leave a central line in for 4 –       6 weeks if you look after it

·        Chest infection: 

o   Usually results from atelectasis following poor ventilation (especially immediately following extubation, especially if pain) 

o   Look for ¯saturation and fever (especially if it occurs the night following surgery) – this is initially due to inflammation – so it presents quicker than the above infections

o  Management:

§  Effective analgesia

§  Chest physio: deep breaths and cough each hour

·        Overall management:

o  Check wound, chest, iv sites, abdomen, UTI.  Check for signs of meningism, endocarditis, DVT

o  Do FBC, culture.  Consider MSU, CXR, abdo US

Decreased Blood Pressure

·        Lie flat and give O2

·        Check pulse and other vitals

·        Consider:

o  Hypovolaemia: check fluid chart, replace losses

o  Haemorrhage: review wounds

o  Cardiogenic: any heart history?

o  Sepsis

o  Anaphylaxis

Nausea/Vomiting

·        Causes: Mechanical obstruction, paralytic ileus, emetic drugs (opiates, digoxin, anaesthetics), systemic or GI illness

·        Consider AXR, NGT, antiemetic (metoclopramide or cyclizine)

 Deep Vein Thrombosis

·        If it‟s a long operation, a clot may start to form then and propagate ® inflammation ® mild fever

·        If immobile or in pain, then may form post-operatively

·        High probability of a DVT if:

o  Calf circumference > 3 cm than the other

o  Malignancy

o  Immobile

o  Local tenderness

o  Family history

·        Test using Doppler US (for flow)

·        See also Topic: Deep Vein Thrombosis (DVT)

Confused Patient

·        Ie Delirium.

·        Causes (especially if already borderline):

o  Infection

o  Hypoxia

o  Metabolic: glucose, K

o  CVA or MI

o  Drugs:

§  Too little: eg withdrawal of sleeping pills, insufficient analgesia 

§  Too much: eg morphine ® ¯respiration, pinpoint pupils. Treat with naloxone (but short T½ so may need to repeat) 

o  Delirium tremens (alcohol withdrawal)

o  Urinary retention

o  No cause found

·        Management: Quiet, gently lit area, familiar faces.  Consider midazolam or haloperidol

Decreased Urine Output

·        = < 30 ml/hour

·        Causes: 

o  Hypovolaemia: ­HR, ¯BP, peripherally shut down

o  Urinary retention: ?palpable bladder

o  Catheter blockage (especially if sudden drop off)

o  Renal failure due to hypotension, nephrotoxic drugs, transfusion

·        Management: If not overloaded then treat with fluids: normal saline unless significant blood loss.

·        Don‟t use dextrose – won‟t stay in the blood for long

Dehiscence

·        = Wound breakdown (eg of a gut anastamosis). Usually after 5 – 7 days due to ischaemic tension, infection, etc

·        Symptoms: severe pain, ¯bowel sounds

·        Investigation: CT with gastrographin contrast