Harvey's Garden

Postoperative management

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Postoperative complications

Cardiovascular & Pulmonary Complications

  • Postoperative MI
    • Usually POD 2-3. Often silent (no chest pain) due to analgesia/anesthesia. c
    • Risk Factors: Pre-existing CAD, CHF, CKD, diabetes mellitus, advanced age (> 65), and high-risk surgical procedures (e.g., vascular, prolonged open abdominal/thoracic surgeries).
    • Pathophysiology: Usually due to surgical stress (↑ catecholamines causing ↑ myocardial oxygen demand/tachycardia) superimposed on baseline CAD (demand ischemia/Type 2 MI), or plaque rupture (Type 1 MI) secondary to hypercoagulability/inflammation.
    • Presentation: Hypotension, arrhythmias, dyspnea, new-onset HF.
    • Dx: ECG, Troponins.
    • Tx: PCI or medical management (Aspirin, statin, beta-blocker if hemodynamically stable).
  • ARDS (Acute Respiratory Distress Syndrome)
    • Post-trauma, massive transfusion, or sepsis.
    • Dx: Bilateral opacities on CXR, PaO2/FiO2 < 300.
    • Tx: Mechanical ventilation with low tidal volumes (6 mL/kg) & PEEP.
  • Postoperative atelectasis

    • Most common after thoracic or upper abdominal surgeries.

    • PE: ↓ breath sounds, dullness to percussion, basilar crackles.

    • Management

      1. First-line / Prevention: Incentive spirometry (NBS & best preventive measure), early ambulation. c
      2. Second-line: Optimize pain control (e.g., epidural/PCA to allow deep breaths).
      3. Refractory: CPAP/BiPAP for persistent hypoxemia.

Acute Postoperative Mediastinitis

  • Epidemiology & Risk Factors
    • < 14 days post-median sternotomy (CABG/valves).
    • Orgs: S. aureus, S. epidermidis.
    • Risks: DM, obesity, smoking, reoperation.
  • Clinical Features
    • Fever, tachycardia, purulent wound drainage.
    • Buzzword: Sternal instability (“clicking” or “rocking” w/ breathing).
  • Diagnosis
    • Initial: Blood & wound cx, CBC (↑ WBC).
    • Imaging: CT Chest w/ contrast (mediastinal fluid/gas). Note: Small amt of pneumomediastinum on CXR is normal < 14 days post-op; worsening gas is pathologic.
    • Confirmatory: Surgical exploration w/ positive cx.
  • Differential Diagnostics
    • Superficial Skin Infection: Intact sternum (no clicking), no systemic toxicity.
    • Postpericardiotomy Syndrome: Autoimmune, weeks-months later. Pleuritic pain, friction rub. Tx: NSAIDs.
    • Non-infectious Dehiscence: Sternal clicking without fever or purulence (mechanical failure).
  • Management
    1. Surgical (Immediate): Urgent exploration, debridement, & sternal fixation (muscle flaps). c
    2. Medical: Empiric IV Abx (Vanco + Cefepime) targeting MRSA/Gram-negatives.
    3. Ongoing: 4-6 wks IV Abx tailored to cx.
  • Complications
    • Sepsis / Septic shock (high mortality).
    • Sternal osteomyelitis.

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