Post operative complications

Question 1

List some post operative complications?

Answer 1

Post op fever
Post op pain
post op ileus
anastomotic leak
post op haemorrhage

Question 2

Causes of post op fever?

Answer 2

Early on should consider physiological response to surgery
should always consider sepsis
should always consider infections of any lines

5Ws

Wind - lung causes e.g. atelectasis or pneumonia
Water- UTI from prolonged catheterisation
Walking- DVT/ PE
Wound - surgical site/ wound infection
Wonder about drugs - serotonergic or dopaminergic drugs

Question 3

Approach to patient with post op fever?

Answer 3

HPC:
What operation did you have and how many days post op?
How are you feeling apart from the fever?
Do you feel breathless or struggling to breathe?
Any cough? Haemoptysis or coughing up sputum?
Have you still got your catheter in does it feel uncomfortable? If not any dysuria, frequency, urgency, loin pain, haematuria, rigors?
Any swelling or pain in your leg?
Any chest pain?
Any pain in the wound? How does it look?
What medications are you still taking?
Are you in pain from the surgery?
Any blood transfusions?

PMH
Relevant for determining risk

Medications
Look over HEPMA, what has been prescribed, could any of these be causing post operative fever?

Question 4

Examination of a patient with post op fever?

Answer 4

ABCDE approach
Chest expansion, percussion and auscultation important in assessing for atelectasis or pneumonia
Examining any catheters and lines for signs of infection
Abdominal examination
Examine the wounds
Examine the calves for signs of DVT

Question 5

Investigations for a patient with post op fever?

Answer 5

Bloods – cultures, FBC, U+Es, LFTs, CRP, clotting
Urine – for dipstick and MSU for culture
Swabs- consider throat swab if signs of respiratory infection, consider wound swab
Imaging- CXR can be helpful in diagnosing atelectasis or pneumonia (atelectasis will see volume loss on cxr whereas pneumonia will not see volume loss)

D dimers will likely be raised post operatively so if suspect VTE go straight for CTPA or doppler

Question 6

Initial management of a patient with post op fever?

Answer 6

Manage any initial findings on ABCDE e.g. fluids if dry/ hypotensive, oxygen if hypoxic, antibiotics and sepsis 6 if suspect sepsis

Question 7

Explain and describe lung causes of post op fever?

Answer 7

refers to respiratory causes – first cause to consider is atelectasis which is when there is areas of alveoli collapse decreasing gas exchange in the lungs. Most common cause is post-surgery due to anaesthesia although it can be caused by obstructions such as tumours, foreign bodies or mucus plugs. This will present days 1-3 usually. If rule atelectasis out should also consider a post surgical pneumonia.

Question 8

What days does UTI usually cause post op fever?

Answer 8

days 3-5

Question 9

What days does PE/ DVT usually cause post op fever?

Answer 9

4-6

Question 10

What days does wound infection cause post op fever?

Answer 10

days 5-7

Question 11

What days does drugs typically cause post op fever?

Answer 11

day 7

Question 12

Explain what a post op ileus is and risk factors?

Answer 12

This is a common complication after bowel surgery, there is reduced peristalsis which leads to a pseudo obstruction
It is more common in surgeries that involve a lot of handling of the bowel
Medications that reduce peristalsis used for anaesthetic and pain relief also increase risk
Electrolyte abnormalities can also contribute

Question 13

Presentation of post op ileus?

Answer 13

Abdominal distension and bloating
Abdominal pain
Nausea and vomiting
Total constipation: stool and wind

Question 14

Investigations for post op ileus?

Answer 14

• Bloods – FBC, U and Es, Ca, Mg and phosphate
• CT abdo and pelvis to rule out more serious pathology

Question 15

Initial management of post op ileus?

Answer 15

• Usually conservative
• Check fluids and electrolyte status as this can contribute to ileus
• Have them nil by mouth
• Put in a NG tube if vomiting
• Reduce opioids and encourage mobilisation as tolerated

Question 16

Explain what an anastomotic leak is?

Answer 16

An anastomotic leak can be defined as “a leak of luminal contents from a surgical join”
This can result in significant peritonitis, sepsis and death if not recognised early
Any patient who is not progressing as expected or who deteriorates after surgery should be considered as having an anastomotic leak until proven otherwise

Question 17

Patient features of anastomotic leak?

Answer 17

• Usually develops post op days 3-5 but can happen earlier
• Worsening abdominal pain and features of sepsis
• Some patients will present more subtly and anyone who is not progressing as expected should be investigated for anastomotic leak

Question 18

Initial investigations of an anastomotic leak?

Answer 18

• FBC, CRP, coag, ABG
• Urgent CT scan with contrast

Question 19

Initial management of an anastomotic leak?

Answer 19

• Nil by mouth
• Start sepsis 6
• Definitive management will be decided by surgeons, may be conservative or back into theatre

Question 20

Presentation and management of post op haemorrhage?

Answer 20

• Can occur at any day post op – as get primary and secondary causes of bleeding
• Patient will present shocked
• A-E approach
• Major haemorrhage protocol as appropriate
• Urgent senior review