Postoperative Complications

Postoperative Complications - Feverish Frights

Postoperative fever (>38°C or 100.4°F) is a common concern, prompting systematic evaluation.

📌 5 W's of Post-Op Fever:

• Wind (Pulmonary: Atelectasis - common in first 48 hrs; Pneumonia): POD 1-2.
• Water (UTI - esp. catheterized; pyelonephritis): POD 3-5.
• Wound (SSI: Staph aureus/Strep; erythema, warmth, discharge. Deep infections later): POD 5-7.
• Walking (VTE: DVT/PE; assess risk - Virchow's, Wells score): POD >5-7.
• Wonder drugs / What did we do? (Drug fever - exclusion; transfusion rxns, line sepsis): Anytime.

⭐ Most common causes of fever by postoperative day:

• Day 1-2: Atelectasis
• Day 3-5: UTI
• Day 5-7: Wound Infection
• Day >7: DVT/PE, Abscesses

Postoperative Complications - Respiratory Riddles

• Atelectasis:
  • Most common, 24-48h post-op. Fever, ↓breath sounds.
  • Prevention: Incentive spirometry, deep breathing exercises, early mobilization.

⭐ Atelectasis is the most common overall postoperative complication.

• Pneumonia (HAP/VAP):
  • Hospital-Acquired (HAP): >48h post-admission.
  • Ventilator-Associated (VAP): >48h post-intubation.
  • Symptoms: Fever, cough, purulent sputum, leukocytosis.
  • Risk factors: Aspiration, prolonged ventilation, immunosuppression.
• Pulmonary Embolism (PE):
  • Symptoms: Sudden dyspnea, pleuritic chest pain, tachycardia, hemoptysis.
  • 📌 Virchow's Triad: Stasis, Hypercoagulability, Endothelial injury.
  • Diagnosis: Wells/Geneva score, D-dimer, CT Pulmonary Angiography (CTPA - gold standard).
  • Management: Anticoagulation. Prophylaxis is key (LMWH, UFH).
• ARDS (Acute Respiratory Distress Syndrome):
  • Acute onset hypoxemia with bilateral pulmonary infiltrates not fully explained by cardiac failure.
  • Key diagnostic criterion: $PaO_2/FiO_2$ ratio ≤300 mmHg.
  • Berlin Criteria for severity (based on $PaO_2/FiO_2$ with PEEP ≥5 cmH2O):
    • Mild: 201-300 mmHg
    • Moderate: 101-200 mmHg
    • Severe: ≤100 mmHg

Postoperative Complications - Cardiac & Clot Catastrophes

• Postoperative Myocardial Infarction (MI)
  • Risk Factors: RCRI: IHD, CHF, CVA, Insulin DM, Cr >2 mg/dL, High-risk surgery.
  • Diagnosis: Serial ECGs, ↑Troponins. Management: Aspirin, β-blockers, statins; consider revascularization.

  ⭐ Peak incidence: postoperative MI 24-72 hours.

• Venous Thromboembolism (VTE: DVT/PE)
  • 📌 Virchow's Triad: Stasis, Hypercoagulability, Endothelial injury.
  • Prophylaxis: Risk-stratify (Caprini). Early ambulation. Pharm: LMWH (e.g., Enoxaparin 40mg OD/30mg BID), UFH. Mech: IPC, GCS.
  • Diagnosis: Wells score, D-dimer. US Doppler (DVT); CTPA (PE).
• Postoperative Arrhythmias
  • Atrial Fibrillation (AFib): Most common.
  • Triggers: Hypoxia, electrolytes (K⁺↓, Mg²⁺↓), pain, sepsis, cardiac surgery.
  • Management: Rate/rhythm control; anticoagulation if persistent/high CHADS₂-VASc.

Postoperative Complications - Gut & Gash Griefs

• Surgical Site Infection (SSI):
  • Types: Superficial, Deep, Organ/Space.
  • Onset: 5-7 days. Prophylaxis: antibiotics, asepsis.

  ⭐ Staphylococcus aureus is the most common cause of SSIs.

• Hematoma/Seroma:
  • Blood/fluid collection.
  • Risk: Anticoagulants.
  • Manage: Observe or Drain.
• Wound Dehiscence & Evisceration:
  • Dehiscence: Fascial separation. Evisceration: Viscera protrudes (emergency!).
  • Risks: ↑IAP, infection.
• Postoperative Ileus:
  • Impaired GI motility; prolonged if >3-5 days.
  • Causes: Opioids, bowel handling.
  • Manage: NPO, NG, ambulate.
• Anastomotic Leak:
  • Grave; 5-7 days post-op.
  • Signs: Fever, tachycardia, pain, peritonitis, drain changes.
  • 📌 LEAK: Low BP, Elevated WBC, Abdominal pain, Kindling (fever).

High‑Yield Points - ⚡ Biggest Takeaways

• Atelectasis: Most common cause of post-op fever within 48 hours ("Wind").
• UTI: Common fever source after day 3 ("Water"), especially with catheters.
• Surgical Site Infection (SSI): Presents after day 5 ("Wound"); S. aureus is the usual culprit.
• DVT/PE: Major risks; prophylaxis (e.g., LMWH, SCDs) is crucial.
• Malignant Hyperthermia: Immediate, life-threatening reaction to succinylcholine/halothane.
• Postoperative Ileus: Common after abdominal surgery; rule out obstruction if prolonged.
• Wound Dehiscence/Evisceration: Requires immediate surgical intervention.