PostOp Complications (for non-surgeons)

Post Op Fever

The mnemonic to help remember causes of post op fever, the 5 W’s:  Wind, Water, Wound, Walking, Wound, and Wonder drugs. I add one more, alcohol Withdraw.

First 24hrs: can be NORMAL, then “waves” for EKG changes like STEMI or MI, also transfusion reaction, thyroid storm, Addisonian Crisis, malignant hypothermia

• Wind aka pneumonia. post op day(POD) 1 – 2
• Water aka UTI. POD 3 – 5
• Walking aka DVT or PE. POD 4 – 8
• Wound aka surgical infection. POD 5 – 7
• Wonder drugs aka drug fever. POD 0 – 14
• alcohol Withdraw. POD 1 – 4. Not everyone admits to daily drinking and if they never admitted it, required surgery and hospital stay and therefore not had a drink in 2-3 days- they could be going through withdraw- which can cause fever.

So to summarize post op fevers for non surgeons, we don’t immediately need to call the surgeon. While it is courtsey to inform them of  their complications, do a little checking first. Look for PNAs, UTIs, look at the wound, and yes that does mean don’t be scared and TAKE OFF THE BANDAGE. There isn’t anything special or magical about that bandage as long as you replace it with another one. Think about if your parents warrants a CT for a PE or deep abscess. Should you have a conversation about alcohol use? Then contact the surgeon with the problem already solved – which they will appreciate because at least a little investigation was already done. 

Seromas

Seroma is “serous” or clear yellow fluid (made of blood plasma + inflammatory fluid) that accumulates in space created by surgery

• The greater the surgery the more likely a seroma formation becomes, most common after breast surgeries and abd surgeries.
• JP drains are thought help prevent seroma formation but this has recently fallen out of favor since drains doubles your infection risk of infection.
• go away on their own at different rates, weeks-years but some are permanent.
• like to form in the incision site and can cause some pain and redness at the incision site, especially if the person is obese or if the surgeon didn’t put in enough deep sutures.
• Aspiration is not common because it refills

Dehiscence

surgical incision coming open after it has been closed

• infection is MCC of dehiscense.
• Risk factors for a non infected dehiscence: trauma after surgery (heavy lifting & over exercise), morbid obesity, uncontrolled diabetes, smoking (nicotine), previous scar tissue in the area, coughing, steroid use, poor surgical technique (some intern didn’t put in enough or the right kind of sutures), and noncompliance of patient after surgery. 
• If internal organs or tissues come through the incision site, but the skin itself is still closed, this is called a hernia- not dehiscence. Simple hernias are not emergencies. Dehiscense can be.

Constipation

Constipation after any surgery is some combination of anesthesia meds, rerouting of blood and use of opiate pain medications. It happens in every surgery and can cause hard stools for weeks post op. Use stool softeners with any opiate medications. Often laxatives like miralax or mag citrate are needed and remember your secret weapon of glycerin suppositories, which help soften the stools already formed. Enemas can do this as well.

Ileus

lack of peristalsis of intestine, your intestine literally quits moving and digesting. 

• This is why surgeons want to know if you’ve farted after surgery.
• the importance and obsession of surgeons after surgery with flatulence. The intestine is more likely to do this if it has been touched during surgery, opioids don’t help. An Ileus is almost a guarantee after abd surgery which is why surgeons don’t let people go home until they have farted.
• Bloating and absent bowel sounds are common signs, but the biggest is lack of BM or flatus.
• When it resolves folks get watery diarrhea the first few times they go to bathroom.
• One of the best ways to encourage bowels to start working again, besides minimizing opiates, is moving around early after surgery.
• The recovery order of ileus is: small intestine first, then stomach (being hungry), then large intestine.
  —–  In some cases, it can go on too long and become a paralytic ileus. this happens if something foreign is touching the bowel (feces, blood, foreign body, large abscess).

Adhesions

• scar tissue that forms threads or lines in the abdomen, which the intestines can accidentally wrap themselves around and cause a small bowel obstruction
• Signs of a SBO to know are vomiting, especially brown fecal material, abd pain, and lack of BMs.
• Tx is often non surgical: NG tube and waiting will resolve on own but ususualy need to be admitted to hospital for IV fluids and monitoring.

Bleeding

Although this seems obvious can be subtle and internal. Post op bleeding can be tricky because it all depends on where the surgery was that depends on weather it is a concern or not. For example, some bleeding is expected after a D&C on the uterus, but over 1L is considered massive and a big deal. Some large bruising is expected when a cardiologist does an angiogram for a heart cath, the femoral vessels bleed and cause what looks like a large bruise afterward but that is considered normal even as it pools in the heels due to gravity but obviously there is a point to which there is too much immediate bleeding and symptoms of severe anemia develop. This is an art, and the best advice I can give is use your logic, order a hg and compare to the last one. Is one point drop in Hg of an ortho hip repair really unexpected? Probably not, whereas 3 points and orthostatic vitals might be. When in doubt have surgeon evaluate or call for help with a more experienced practioner. 

SITE SPECIFICS

The second section of this are complications to be aware of in Body Area specific surgeries. I highly recommend you check out the PDF for specifics.

• Brain & spine surgery- paralysis, personality change, CVA

• Eye surgery – endophthalmitis

• ENT – post op tonsillectomy bleed & sentinel trach bleed

• Thyroid – accidental removal of Parathyroid (low CA) & bleeding

• Heart surgery – depression, a fib, watershed infarcts of organs

• Abd surgery – adhesions & SBO, dumping syndrome

• OB & rectal – fistulas, retained products, 

• Ortho surgery – fat embolism, compartment syndrome

• Vascular surgery – clots, infarcts