Post-operative complications

Common and important post-operative problems

Cardiorespiratory

Atelectasis

Pneumonia

Congestive failure

Arrhythmias

Infection

Chest

Operative site and wound

Urinary

Catheters and other lines

Venous thromboembolism

Deep vein thrombosis

Pulmonary embolism

Categorisation of potential post-operative complications

1. Those related to the procedure:

   • e.g. laparoscopy: air embolism

   • pancreatic leak after pancreaticoduodenectomy

   • sympathetic ophthalmia after eye surgery (very rare)

2. Those related to specific patients:

   • e.g. increased risk of infection in the immunocompromised individual

   • consequence of infection in a patient with a synthetic heart valve

   • bleeding in a patient with a coagulation disorder

3. General problems:

   • e.g. cardiorespiratory

   • venous thromboembolism

   • infection

This chapter will take the former approach, but obviously it is sensible that in managing any patient with a post-operative problem, the doctor considers:

• the procedure

• the general state of health of the patient before the illness/operation

• progress since the procedure.

Thus, the questions to be asked should include:

• what procedure was done, when was it done and why was it done

• is there any coexisting illness (i.e. is there a past medical history of note [e.g. chronic respiratory disease])

• is the patient on any medication

• what has now happened to the patient to demand your attention

• what investigations have been done (both pre- and post-procedure)?

These will then be followed by:

• is the cause of the problem clear-cut

• if yes, how should I proceed with management

• if no, what will I need to do to make a clear diagnosis?

This chapter contains a number of examples of postoperative complications. A model answer is provided for each scenario. As a learning exercise, cover each model answer (in italics) and provide your own answer. Put yourself in the position of the intern.

Confusion

A 67-year-old man becomes confused 2 days after a laparotomy for a perforated peptic ulcer. The operation was uneventful and 2 litres of gastric contents were evacuated from the peritoneal cavity. Lavage was performed and the perforation closed. What critical piece of information would help you determine the cause of the confusion? How would you approach the problem?

Hypoxia is the most important and common cause of confusion. If this patient has a chest infection, you may have the quick explanation for his confusion.

To approach the problem, gain all the information you can about the patient's pre-operative state of health, the details of the procedure and progress since the operation. From the case notes you will hopefully glean information on the patient's past medical history, medications, examination findings and general fitness. From the past history, look for evidence of chronic respiratory disease and sustained alcohol consumption. Various investigations may have been undertaken (e.g. blood biochemistry) that may give clues as to the current problem. Any problems associated with the operation (the procedure itself or the anaesthetic) should be noted. The case records and the nursing observations since the procedure may help determine the cause of the current problem. Note any investigations that have been performed since the procedure.

Take a history from the patient, if his state of confusion allows. Examine the patient, looking particularly for evidence of hypoxia. A chest infection may explain the confusion. There may be other causes of hypoxia to consider (e.g. opiate toxicity, cardiac failure). If the patient is not obviously hypoxic, he may be septic, have a fluid and electrolyte disturbance, be suffering a drug complication or be in alcohol withdrawal.

To test some of these hypotheses, several investigations may be required. These may include arterial blood gas analysis, serum biochemistry, blood culture, an electrocardiogram (ECG) and a chest X-ray.

Before you start the investigations, some simple measures can be adopted. Ensure that the patient is given supplemental oxygen through a face mask and that intravenous fluids are being given. If sepsis is likely, you may want to start the patient on a broad-spectrum antibiotic. Ideally, you would like pulse oximetry performed and may even want to consider further management on a high-dependency unit.

You have excluded hypoxia as a cause for the confusion and the patient does not appear to be septic. There is no apparent electrolyte disturbance and you are reasonably confident that the patient is suffering alcohol withdrawal symptoms (delerium tremens). Describe your plan of management.

Move the patient to a quiet, well-lit room. Arrange continuous nursing care, preferably with a nurse familiar to the patient. Institute an alcohol withdrawal program. The protocol for this program will stipulate regular observations of the patient's symptoms, allocating a score to various symptom grouping and correlating the amount of sedation (if any) that needs to be given according to the score. Symptoms to be scored include nausea, anxiety, visual disturbances and agitation. The preferred sedative is oral diazepam.