POST-OPERATIVE

COMPLICATIONS
Hadi Munib
Oral and Maxillofacial Surgery
Outline
◦ Introduction
◦ Common Complications
◦ Surgical Site Infections
◦ Wound Dehiscence, Hematomas and Seromas
◦ Gastrointestinal Complications
◦ Deep Venous Thrombosis
◦ Urinary Tract Infection
◦ References
 • Nausea and vomiting from general anesthesia
• Sore throat
• Soreness, pain, and swelling around the incision site
Discomforts • Restlessness and sleeplessness
• Thirst
• Constipation and gas (flatulence)

• Generic
Complications • Surgery Specific
Introduction
◦ Surgical site infections (SSIs) alone affect >500,000 patients annually and are
associated a 2 to 11 times increase in the risk of postoperative mortality.
◦ Patients should know about the complications before the procedure and a consent
form must be signed.
◦ The patient’s vital signs, level of consciousness, pain and hydration status are
monitored in the recovery room and supportive treatment is given.
Classification of postoperative complications
◦ Classification of postoperative complications of surgery is usually linked to time after
surgery:
◦ Immediate (within 6 h of procedure);
◦ Early (6–72 h);
◦ Late (>72 h).
◦ Clavien-Dindo: The therapy used to correct a specific complication is the basis of this
classification in order to rank a complication in an objective and reproducible manner.
Clvaien- Dindo Classification
 Postoperative Bleeding
◦ Dressings and drains should be inspected regularly in the first 24 hours after surgery.
◦ Rapid blood loss from the site of surgery can lead to shock
◦ If hemorrhage is suspected, blood samples should be taken for a full blood count,
coagulation profile and cross match.
◦ The decision about when to transfuse should be based on the individual patient
Postoperative Bleeding
◦ Indications for Transfusion include:
◦ Symptomatic Anemia (Shortness of Breath, Dizziness, Congestive Heart
Failure and Decreased Exercise Tolerance)
◦ Acute Sickle Cell Crisis
◦ Acute Blood Loss; More than 30% Blood Volume; Saline Infusion/ Plasma
Products
Postoperative Pain
◦ Unable to verbalize the pain
◦ Pain assessments are often based on other objective assessments such as blood
pressure, heart rate, respiratory rate and signs of agitation.
◦ The most commonly used intravenous opioids for postoperative pain are morphine,
hydromorphone (dilaudid), and fentanyl.
◦ Morphine is the standard choice for opiates and is widely used.
◦ Morphine has a rapid onset of action with peak effect occurring in 1 to 2 hours.
◦ Fentanyl and hydromorphone are synthetic derivatives of morphine and are more
potent, have a shorter onset of action, and shorter half-lives compared with
morphine.
Postoperative Hypertension
◦ Cardiovascular Complications are the leading cause of death after 30-days of non-
Cardiac Surgeries
◦ Pain and elevated catecholamines can contribute to hypertension and tachycardia.
◦ β-blockers should be continued in the perioperative setting for patients who took them
preoperatively.
◦ Hypertension in the PACU is most commonly caused by pain and/or a history of
hypertension.
◦ Procedures such as carotid endarterectomy, require immediate and aggressive control
of systolic blood pressure regardless of etiology to avoid catastrophic vascular,
cardiac, or neurologic complications.
Postoperative Hypertension
◦ For patients with pre-existing hypertension requiring medication, it is
generally most appropriate to gradually reintroduce the preoperative
antihypertensive regimen with the exception of diuretics in the immediate
postoperative period.
Postoperative Hypotension
◦ Usually due to:
◦ Hypovolemia
◦ Narcotic and benzodiazepine administration
◦ Epidural anesthesia; blunting sympathetic tone and decreasing vascular resistance;
Management; Fluid bolus and stop Anesthesia.
◦ Postoperative bleeding.
◦ Sepsis
◦ Arrhythmias
◦ Tension pneumothorax
◦ Pulmonary embolism
◦ Pericardial tamponade and anaphylaxis.
Postoperative Hypotension
◦ Postoperative hypotension can lead to end-organ dysfunction when:
◦ Decreased urine output <0.5 mL/kg/h
◦ Decreased level of consciousness
◦ Myocardial ischemia
◦ Capillary refill >2 seconds
◦ In which it needs immediate management with fluid and may require the use of
vasopressors and inotropes.
◦ Invasive monitoring with a urinary catheter, central line, or arterial line should be
utilized if a patient remains hypotensive despite initial resuscitation with crystalloid.
Shock
◦ the dangerous reduction of blood flow throughout the body.
◦ Shock is most often caused by reduced blood pressure
◦ Management:
◦ Stopping any blood loss
◦ Maintaining an open airway
◦ Keeping the patient flat
◦ Reducing heat loss with blankets
◦ Intravenous infusion of fluid or blood
◦ Oxygen therapy
◦ Medication
Arrhythmias
◦ Arrhythmias can cause hypotension, myocardial ischemia and cardiac arrest.
◦ Tachycardia (sinus or supraventricular) may occur due to anxiety, pain, myocardial
ischemia or infarction, hypovolemia, sepsis or hypoxia in the postoperative period.
◦ Consideration should be given to correction of the underlying causes and rate controlled
with β-blockers, amiodarone or cardioversion, depending on the state of the patient.
◦ Sinus bradycardia may be normal in athletes
◦ It may also be associated with hypoxia, preoperative β-blockers, digoxin and increased
intracranial pressure.
◦ Pharmacological options include glycopyrrolate or atropine intravenously.
Stroke
◦ Stroke is a recognized complication of carotid endarterectomy surgery both
early (secondary to emboli) and later (secondary to cerebral hyperperfusion
syndrome).
◦ It is also a recognized consequence of both hypotension and hypertension.
◦ Thrombolysis may be indicated but the neurology and surgical teams must
discuss together the risks and benefits of such a treatment plan.
Immediate respiratory complications
AIRWAY
◦ Upper airway obstruction is one of the commonest immediate postoperative
complications and can be due to:
◦ Laryngospasm,
◦ Persisting relaxation of airway muscles
◦ Soft tissue edema,
◦ Hematoma
◦ Vocal cord dysfunction or foreign body.
POSTOPERATIVE RESPIRATORY
INSUFFICIENCY
◦ Most patients will require some supplemental oxygen immediately after surgery.
◦ Dyspnea, tachypnea, wheezing, and signs of respiratory distress are not
normal postoperative signs and symptoms, and need to be addressed in the
PACU.
◦ All patients recovering from anesthesia require close monitoring o their
respiratory status, with personnel and equipment or reintubation readily available.
Postoperative Respiratory Insufficiency
◦ The primary factors that contribute to postoperative respiratory insufficiency
include:
◦ Use of general anesthesia
◦ Upper abdominal and thoracic surgeries
◦ Longer duration surgeries
◦ Use of endotracheal intubation
◦ Use of narcotics.
 Hypoxemia
◦ This may occur as a consequence of:
◦ Acute pulmonary edema (fluid overload, cardiac failure, postobstructive)
◦ Bronchospasm
◦ pneumothorax
◦ Aspiration
◦ Pulmonary embolism.
◦ De novo pneumonia is very unusual in the immediate postoperative period.
◦ Hypoxemia develops most quickly in patients with obstructive sleep apnea, lung disease
and obesity, who should therefore be closely observed.
Hypoxemia
◦ Patients with hypoxemia should be treated urgently.
◦ If the patient is breathing spontaneously, oxygen should be administered at 15
L/min using a non-rebreathing mask.
◦ A head tilt, chin lift or jaw thrust should relieve obstruction related to reduced
muscle tone.
◦ Suctioning of any blood or secretions and insertion of an oropharyngeal airway
may be needed.
Right Tension
Pneumothorax
Pulmonary
Artery Blood
Embolism
Early and late postoperative pulmonary
complications
◦ Significant cause of postoperative ◦ Atelectasis
morbidity and mortality (between ◦ Pneumonia
5% and 70%).
◦ Pleural effusion
◦ Complications include:
◦ Pneumothorax
◦ Fever (due to microatelectasis)
◦ Respiratory failure.
◦ Cough
◦ Dyspnea
◦ Bronchospasm
◦ Hypercapnoea
Early and late postoperative pulmonary
complications
◦ Thoracic or abdominal surgery carries the highest risk.
◦ Risk Factors include
◦ Obese
◦ Smokers
◦ Chronic lung disease
◦ Obstructive sleep apnea
◦ Poor nutritional status.
◦ Can be identified preoperatively, facilitating the development of strategies that will reduce
the impact of surgery on the individual patient.
Right upper lobe
atelectasis
Classical
Staphylococcus
Aureus Pneumonia
 Low Urine Output
◦ Intravascular volume depletion may occur concurrently with pulmonary edema due to
increased vascular permeability associated with perioperative inflammation
◦ Administration of diuretics or postoperative pulmonary edema can exacerbate
intravascular depletion, hypotension, and inadequate end-organ perfusion.
◦ Postoperative oliguria (less than the equivalent of 0.5 cc/kg/h) requires urgent
evaluation.
Postoperative Nausea and Vomiting
◦ Common.
◦ The causes are multifactorial.
◦ Prior history is the most significant risk factor
◦ Other risk actors include longer duration procedures, use of volatile anesthetics
(such as isoflurane), and procedures involving the inner ear, eye, and abdominal
viscera.
◦ Patients at moderate to high risk benefit from prophylactic antiemetics, motility
agents, or a scopolamine patch before emerging from anesthesia
 Postoperative Fever
◦ About 40% of patients develop pyrexia after major surgery
◦ Low-grade fevers in the first 48 hours after surgery are a normal sequelae of inflammation,
atelectasis, or hematoma absorption following surgery, and usually not from an infectious
process.
◦ In the absence of any localizing signs or symptoms, self-limited fever within the first 48
hours postoperatively usually does not need infectious work-up.
◦ After 48 hours, temperatures greater than 38.5°C should prompt a complete fever workup.
◦ In the postoperative patient, the surgical wound and site of venous access are potential
sources of infection and need to be carefully examined.
SURGICAL SITE INFECTION
◦ Account for approximately 30% of nosocomial infections and are the most
common infections after surgery.
◦ Associated with a 7-Day increased length of stay.
◦ Classified as
◦ Superficial; Infections involving the skin and subcutaneous tissues.
◦ Deep; Involve the Fascia or the Muscles below
◦ Organ space infections; Involve organs below the muscular and cutaneous
layers
 Surgical Site Infections
◦ Wound infections
◦ Despite the most rigorous aseptic technique, all wounds are contaminated to some
degree and have some risk of infection.
◦ Even “clean” wounds have a 1.5% risk of infection.
◦ Wound infections commonly occur between 5 and 10 days after an operation.
◦ Antibiotics are not necessary for simple wounds that have been drained.
◦ Deep space infections usually require drainage; antibiotics alone are insufficient.
Surgical Site Infections
◦ Risk factors for wound infection are patient and operation dependent.
◦ Patient related risk actors include:
◦ Large body habitus
◦ Diabetes
◦ Disability
◦ Immunosuppression
◦ Malnutrition
◦ Smoking
Surgical Site Infections
◦ Operative Risk Factors include:
◦ Certain operations, such as those involving the colon or small bowel, are higher
risk than others.
◦ Operating room conditions
◦ Surgical technique (eg, laparoscopic or open)
◦ Administration of antibiotic prophylaxis
◦ Hypoxia or hypotension during the procedure.
Surgical Site Infections
◦ Prophylactic antibiotics are very effective at reducing the risk of SSIs
◦ They should be administered within 1 hour of incision and continued for no more than
24 hours after surgery.
◦ In the event of significant contamination in the OR, wounds may be left open and
managed with delayed primary closure or wet to dry dressings.
Surgical Site Infections
◦ The hallmarks of a wound infection are
◦ FEVER
◦ PAIN/ TENDERNESS
◦ PURULENT DRAINAGE
◦ The typical presentation is between 5 and 10 days postoperatively.
◦ Clostridial necrotizing wound infection should be suspected when a patient has a
very high fever in the immediate postoperative period; immediate surgical
evaluation and drainage.
Surgical Site Infections
◦ Deep space infections occur in enclosed spaces with some degree of isolation from
blood supply, making them relatively impervious to antibiotics.
◦ Such infections usually require drainage either percutaneously or in the operating
room.
◦ Anastomotic leaks typically occur between postoperative days 5 and 7 and should
be suspected in surgical patients with tachycardia, abdominal pain, fever, and
elevated white count.
◦ These leaks can often be managed with percutaneous drainage, but inability to
control the infection may require operative drainage
Wound Dehiscence, Hematomas and
Seromas
◦ Wounds typically heal to a maximum of 80% of the tensile strength within 6 weeks
among healthy, well-nourished patients.
◦ Most surgeons restrict postoperative activities to avoid stress on the wound for 4 to 6
weeks.
◦ Wounds that have been closed primarily should be kept clean, dry and well covered for
48 hours post-surgery.
◦ Dry, sterile wound dressing should be kept for the second post-operative day;
Showering.
 Wound Dehiscence
◦ It is the disruption of any layer of the surgical wound.
◦ This rare complication results from increased pressure on the wound and can arise due to
a variety of reasons.
◦ May need a return into the operation room
◦ Poor wound healing often leads to dehiscence.
◦ Malnutrition, liver disease, diabetes, immunosuppression, and chronic steroid use
inhibit normal wound healing and are risk factors.
◦ Most common layers involved; Skin and Fascia
◦ Sudden release of serosanguinous fluid of the wound is usually the first sign of
Dehiscence
 Wound Dehiscence
◦ Management depends on: Size, location and patient’s condition
◦ Fascial dehiscence; separation of the deepest layer of the abdominal wall;
typically requires urgent closure in the operating room.
◦ In the most severe cases, dehiscence leads to extrusion of intra-abdominal
contents (eg, evisceration).
◦ Evisceration is a surgical emergency that requires immediate return to operating
room.
 Hematomas
◦ More common
◦ Can be caused either by inadequate hemostasis during surgery or disruption of
hemostasis Postoperatively
◦ Risk factors include bleeding disorders and anticoagulant use.
◦ Can result in; wound elevation, pressure, pain, dehiscence, and infection.
◦ Management; depending on the size and location;
◦ Watchful waiting to re-exploration in the OR.
◦ Hematomas following neck exploration may rapidly compromise the airway in the
postoperative period.
Hematomas
◦ Precipitating factors include:
◦ Abrupt increases in intrathoracic pressure from coughing
◦ Emesis; Vomiting
◦ Valsalva maneuvers; moderately forceful attempted exhalation against a
closed airway, usually done by closing one's mouth, pinching one's nose shut
while expelling air out as if blowing up a balloon
◦ Treatment; emergent evacuation of the hematoma prior to reintubation.
Seromas
◦ Collections of serous fluid that form after procedures involving disrupted
lymphatic flow and raised skin flaps.
◦ Generally the result of a normal physiologic response to anatomic dead space.
◦ Their incidence is dependent on the anatomic location of the wound
◦ Procedures associated; inguinal hernia repair, groin exploration, and
mastectomy.
◦ Suction drains may be left in place at the end of the procedure to increase
tissue apposition and remove fluid.
Seromas
◦ Compression dressings can also reduce the risk of seroma formation.
◦ Seromas may increase the risk for wound disruption and infection but are
usually nothing more than a nuisance.
◦ Management may be expectant or include serial aspirations.
◦ Rarely, return to the OR is indicated to ligate contributing lymphatics.
Deep Venous Thrombosis and Pulmonary Embolus
◦ Venous thromboembolism (VTE) is a leading cause of preventable death in the
postoperative setting.
◦ Surgical patients are at high risk for VTE due to the surgical procedure itself as well as
induction of general anesthesia, which results in prolonged immobility,
hypercoagulability, and endothelial damage.
◦ Patients with known hyper- coaguable states, prior VTE, and malignancy are at
especially high risk.
◦ High-risk surgical procedures include orthopedic surgery, trauma, and neurosurgical
treatment of head injury and brain tumors.
◦ Prophylaxis starts with the application of pneumatic compression devices and
subcutaneous heparin 2 hours prior to anesthetic induction.
Deep Venous Thrombosis and Pulmonary Embolus
◦ Unless there are clear contraindications, such as increased bleeding risk, patients
should receive pharmacologic prophylaxis and pneumatic boots throughout and
perioperative period.
◦ Pulmonary embolus (PE) still causes considerable mortality in hospitalized patients.
◦ PE should be suspected in all surgical patients presenting with symptoms of dyspnea,
tachycardia, and hypoxemia.
◦ The decision to start anticoagulation should be made with the operating surgeon, while
pending further diagnostic testing.
Urinary Tract Infections
◦ Most common after vaginal or urologic surgery and any surgery with the use of
indwelling catheters.
◦ Women and obese patients are at highest risk.
◦ The most common pathogens are Escherichia coli, Staphylococcus saprophyticus,
and Proteus mirabilis.
◦ Hospitalized and immunosuppressed patients are also susceptible to Klebsiella,
Proteus vulgaris, Candida albicans, and Pseudomonas.
◦ The standard for prevention is the removal of indwelling catheters within 48 hours
of insertion.
Urinary Tract Infections
◦ The need for continued urinary catheterization should be assessed at least daily
to prevent needless prolongation of catheter placement and increased risk of
catheter-associated UTI.
Post-Operative Urinary Retention
◦ Postoperative is common but rarely prolonged.
◦ Common risk factors include; male sex, prostatic enlargement, epidural/spinal/prolonged
anesthesia, use of antihistamines or narcotics, and pelvic/perineal procedures.
◦ An overdistended bladder (>500 mL) and disruption of the neural pathways that control
voiding impairs urinary contraction and micturition.
◦ Prophylactic catheterization in the operating room is recommended or any procedure
lasting more than 3 hours
◦ Also when interruption of the sacral plexus is anticipated (eg, abdominoperineal
resection).
Post-Operative Urinary Retention
◦ Patients should be encouraged to void soon after the procedure.
◦ If the patient has not voided for more than 6 hours, it is appropriate to evaluate
retention with a bedside ultrasound; or an in-out catheter may be used to determine the
extent of retention.
◦ The treatment for bladder distention is intermittent catheterization along with
mitigation of any contributing factors.
◦ Some patients may have prolonged urinary retention in the postoperative period (>48
hours).
◦ Appropriate pharmacologic treatment should be initiated and an indwelling Foley
catheter should be placed.
◦ Some may require subsequent outpatient urologic follow-up or a void trial after
discharge
Acute Kidney Injury
◦ According to national guidance (National Institute for Health and Care Excellence,
NICE) based on several definitions, acute kidney injury can be detected by the
following criteria:
◦ A rise in serum creatinine of 26 μmol/L or greater within 48 hours;
◦ a ≥50% rise in serum creatinine known or presumed to have occurred within the
past 7 days;
◦ A fall in urine output to less than 0.5 mL/kg/h for more than 6 hours in adults and
more than 8 hours in children and young people;
◦ A ≥25% fall in estimated glomerular filtration rate in children and young people
within the past 7 days.
Management
◦ Specific treatment for any post-surgical complication(s) will be based on:
◦ Age, overall health, and medical history
◦ Extent of the disease
◦ Type of surgery performed
◦ Tolerance for specific medications, procedures, or therapies
◦ Patient’s opinion or preference
 References
◦ Principles and Practice of Hospital Medicine; Chapter 45: Postoperative Complications
◦ Bailey and Love Short Practice of Surgery; Chapter 20: Postoperative Care
THANK YOU