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Postoperative management

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Postoperative complications

Postoperative fever

  • Overview
    • Definition: Temperature 38.0°C (100.4°F) post-op.
    • Key Concept: Postoperative Day (POD) dictates the differential diagnosis and management strategy.
  • Etiology Timeline (The 5 W’s)
    • POD 0–2: Wind
      • Physiologic SIRS: Tissue trauma, cytokine release. Most common cause POD 0–1. Tx: Observation, antipyretics.
      • Malignant Hyperthermia (MH): Occurs intra-op or PACU. Triggered by inhaled anesthetics/succinylcholine. Signs: Masseter rigidity, , hyperthermia, rhabdomyolysis. Tx: Dantrolene, 100% , cooling.
      • Aspiration Pneumonia: Hypoxia, fever, infiltrate on CXR. Tx: Empiric Abx.
    • POD 3–5: Water
      • Urinary Tract Infection (UTI): Associated w/ indwelling Foley catheter > 48–72 hrs. Dx: UA ( WBC, (+) nitrites/leukocyte esterase) + UCx. Tx: Remove catheter, empiric Abx.
    • POD 5–7: Wound
      • Superficial Surgical Site Infection (SSI): Incisional erythema, warmth, purulent drainage. Most common org: S. aureus. Tx: Open/drain wound; add Abx if systemic signs/cellulitis present.
    • POD 7–10+: Walking
      • DVT / PE: Unilateral leg swelling or acute dyspnea, hypoxia, pleuritic chest pain. Dx: Duplex US (DVT) or CTPA (PE). Tx: Anticoagulation (Heparin/LMWH).
    • POD > 10 / Delayed: Wonder Drugs & Deep Infections
      • Intra-abdominal Abscess: Persistent fever + leukocytosis 1–2 weeks post-op. Dx: CT A/P w/ IV contrast. Tx: Percutaneous drainage + IV Abx.
      • Drug Fever: Diagnosis of exclusion. Fever 7–14 days post-new drug (e.g., Abx, heparin), eosinophilia, maculopapular rash. Tx: Stop offending agent.
      • C. difficile: Post-Abx watery diarrhea, leukocytosis. Dx: Stool PCR/toxin. Tx: Oral Vancomycin or Fidaxomicin.
  • Workup & Management Strategy
    • Hemodynamically Unstable: ABCs, IVF bolus, Blood cultures x2, STAT CXR/UA, empiric broad-spectrum Abx (e.g., Zosyn + Vancomycin).
    • Hemodynamically Stable:
      • POD 0–2: Observation, incentive spirometry, CXR only if hypoxemic.
      • POD 3–5: UA + UCx, catheter removal.
      • POD 5–7: Inspect incision, unroof/drain if purulent.
      • POD > 7: CT A/P w/ contrast (if abdominal surgery) or Duplex US/CTPA.
  • High-Yield Step 2 CK Pearls
    • Isolated POD 1 fever in a stable patient: Normal stress response. Do not perform extensive workup; reevaluate patient.
    • Earliest indicator of MH: (refractory to hyperventilation), NOT temperature rise (temperature is a late sign).
    • Persistent fever + normal CXR/UA 1 week post-laparotomy: Suspect intra-abdominal abscess Order CT A/P w/ contrast Perform percutaneous drainage.

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.
  • Postoperative pneumonia
    • Management
      • Prevention (Most Important):
        • Incentive spirometry, deep breathing exercises. c
        • Early mobilization.
        • Adequate post-op pain control (epidural/regional blocks preferred over high-dose opioids to prevent hypoventilation).
      • First-line (Empiric Antibiotics): Must target Gram-negatives (including Pseudomonas) and Gram-positives (including MRSA) based on local antibiogram.
        • Pseudomonas coverage (choose 1): Piperacillin-tazobactam (Zosyn), Cefepime, or Meropenem.
        • MRSA coverage (choose 1): Vancomycin or Linezolid.
      • Second-line / De-escalation: Narrow Abx spectrum based on sputum/blood culture results after 48-72 hours. Duration: Typically 7 days for uncomplicated HAP.
      • Supportive: Supplemental (maintain ), chest physiotherapy, aggressive pulmonary toilet.

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.

Surgical site infection

  • Definition & Timing:
    • Infection within 30 days of surgery (90 days if implant/prosthesis placed).
  • Risk factor
    • Patient Risk Factors: Uncontrolled DM (perioperative hyperglycemia), smoking, obesity, malnutrition, chronic steroid use, active infection at distant site. c
    • Surgical Risk Factors: Shaving hair with razors (use clippers instead), dirty/contaminated surgical wound class, prolonged operative time (> 75th percentile), hypothermia, inadequate pre-op Abx prophylaxis.
  • High-Yield Microbiology:
    • Most common overall: S. aureus (MSSA/MRSA), S. epidermidis (implants/prosthetics).
    • GI / Colorectal: Gram-negative rods (E. coli, Klebsiella) + anaerobes (B. fragilis).
    • Early post-op (< 24–48 hrs): S. pyogenes (GAS) or C. perfringens (severe pain, bronze fluid, gas).
  • Prevention:
    • Prophylactic Abx: Cefazolin IV within 60 mins prior to incision (Vancomycin if severe PCN allergy). Indicated for surgeries with entrance into GI, GU, or respiratory tract
    • Hair Removal: Use clippers only (never razors).
  • Management:
    • Superficial Incisional:
      • 1st Line: Incision & Drainage (I&D) + suture removal + packing.
      • Systemic Abx: NOT indicated for uncomplicated superficial SSI. Add oral Abx (e.g., Cephalexin or TMP-SMX) only if spreading cellulitis (>2 cm), systemic signs (fever/leukocytosis), or immunocompromised.
    • Deep Incisional / Organ-Space:
      • Percutaneous Drainage (CT/US-guided) for intra-abdominal fluid collections > 3 cm.
      • Empiric IV Abx: Broad-spectrum (e.g., Vancomycin + Zosyn or Cefepime + Metronidazole).
  • Key Complications:
    • Evisceration: Cover with warm, moist sterile saline dressings → urgent surgical repair.
    • Necrotizing Fasciitis: Severe pain out of proportion, crepitus, bullae → emergent surgical debridement.

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