Daniel J. Egan
Common postoperative disorders seen in the ED include fever, respiratory complications, genitourinary complaints, wound infections, vascular problems, and complications of drug therapy. Specific problems not discussed elsewhere in this book are mentioned here.
The causes of postoperative fever are listed as the five Ws: Wind (respiratory), Water (urinary tract infection [UTI]), Wound, Walking (deep venous thrombosis [DVT]), and Wonder drugs (pseudomembranous colitis [PMC]).
Fever in the first 24 hours is usually due to atelectasis, necrotizing fasciitis, or clostridial infections.
In the first 72 hours, pneumonia, atelectasis, intravenous-catheter-related thrombophlebitis, and infections are the major causes of complications.
UTIs are seen 3 to 5 days postoperatively.
DVT does not typically occur until 5 days after a procedure, and wound infections generally appear 7 to 10 days after surgery (see Chapter 27).
Antibiotic-induced diarrhea (PMC) is seen 6 weeks after surgery.
Atelectasis develops from postoperative pain, splinting, and inadequate clearance of secretions. Fever, tachypnea, tachycardia, and mild hypoxia may be seen. Pneumonia may develop 24 to 96 hours later (see Chapter 32).
The diagnosis of pulmonary embolism should be entertained at any point postoperatively. Findings include hypoxia, tachycardia, chest pain, and shortness of breath (see Chapter 27).
UTIs are more common after instrumentation of the urinary tract.
Certain patients are at risk of urinary retention following surgical procedures (see Chapter 56).
Decreased urine output should raise concerns for renal failure resulting from many causes (see Chapter 52).
Hematomas result from inadequate hemostasis and lead to pain and swelling at the surgical site. Careful evaluation and sometimes exploration to rule out infections must be undertaken.
Seromas are collections of clear fluid under the wound.
Wound infections present with pain, swelling, erythema, drainage, and tenderness. Extremes of age, diabetes, poor nutrition, necrotic tissue, poor perfusion, foreign bodies, and wound hematomas contribute to the development of wound infections.
Necrotizing fasciitis should be considered in a patient with a rapidly expanding infection and signs of systemic toxicity (see Chapter 92).
Wound (superficial or deep fascial) dehiscence can occur due to diabetes, poor nutrition, chronic steroid use, and inadequate or improper closure of the wound.
Superficial thrombophlebitis, usually in the upper extremities after intravenous catheter insertion, manifests with erythema, warmth, and fullness of the affected vein.
DVT commonly occurs in the lower extremities with swelling, pain, and sometimes erythema of the affected limb (see Chapter 27).
DRUG THERAPY COMPLICATIONS
Many drugs are known to cause fever without any concomitant infection.
PMC, a dreaded complication, is caused by Clostridium difficile toxin. Watery and potentially bloody diarrhea with abdominal cramping are typical features.
DIAGNOSIS AND DIFFERENTIAL
Patients with a postoperative fever should have an evaluation focusing on the elements above.
Patient with suspected respiratory complications should have chest radiographs, which may reveal atelectasis, pneumonia, or pneumothorax. Advanced imaging with CT may be required for the evaluation of infection, effusions, or pulmonary embolism.
Patients with oliguria or anuria should be evaluated for signs of hypovolemia or urinary retention and have laboratory testing of renal function.
Diagnosis of PMC is established by demonstrating C. difficile cytotoxin in the stool. However, the assay is negative in up to 27% of cases.
EMERGENCY DEPARTMENT CARE AND DISPOSITION
Always discuss patients and proposed treatments with the surgeon who performed the relevant procedure.
Many patients with atelectasis may be managed as outpatients with pain control and deep breathing exercises or incentive spirometry.
Postoperative pneumonia may be polymicrobial, and inpatient therapy with antipseudomonal and antistaphylococcal agents is often recommended (see Chapter 32).
Nontoxic patients with UTI can be managed as outpatients with oral antibiotic therapy. Gram-positive coverage should be considered if instrumentation occurred.
Wound hematomas may require removal of some sutures and evacuation in consultation with the surgeon. Admission is often unnecessary.
Seromas can be confirmed and treated with needle aspiration and wound cultures. Admission may not always be necessary.
Most wound infections can be treated with oral antibiotics unless there is systemic toxicity or significant comorbidities. Perineal infections usually require admission and parenteral antibiotics due to their polymicrobial nature.
Emergent surgical debridement and parenteral antibiotics are indicated for necrotizing fasciitis. The emergency physicians should initiate broad-spectrum therapy rapidly.
Most patients with superficial thrombophlebitis can be treated with local heat, NSAIDs, and elevation of the affected area if there is no evidence of cellulitis or lymphangitis. Suppurative thrombophlebitis requires excision of the affected vein.
Oral vancomycin and metronidazole, PO or IV, are currently available treatment modalities for drug-induced PMC.
COMPLICATIONS OF BREAST SURGERY
Wound infections, hematomas, pneumothorax, necrosis of the skin flaps, and lymphedema of the arms after mastectomy are common problems seen after breast surgery.
COMPLICATIONS OF GASTROINTESTINAL SURGERY
Stimulation of the splanchnic nerves may cause dys-motility and paralytic ileus, which usually resolves within 3 days.
Prolonged ileus should prompt investigation for non-neuronal causes. Clinical features include nausea, vomiting, obstipation, constipation, abdominal distension, and pain.
Abdominal radiographs, complete blood count, electrolytes, blood urea nitrogen and creatinine levels, and urinalysis should be obtained.
Treatment of adynamic ileus consists of nasogastric suction, bowel rest, and hydration.
Mechanical obstruction is usually due to adhesions and may require surgical intervention if conservative management with nasogastric suction is ineffective.
Intra-abdominal abscesses are caused by preoperative contamination or postoperative anastomotic leaks. Diagnosis can be confirmed by computed tomography (CT) scan or ultrasonography. Percutaneous drainage or surgical exploration, evacuation, and parenteral antibiotics will be required.
Pancreatitis may occur after direct manipulation of the pancreatic duct. Patients typically have nausea, vomiting, abdominal pain, and leukocytosis. Serum amylase and lipase levels are usually elevated (although amylase is nonspecific).
Cholecystitis and biliary colic may occur postoperative. Elderly patients are more prone to develop acalculous cholecystitis.
Fistulas, either internal or external, may result from technical complications or direct bowel injury and require surgical consultation.
Anastomotic leaks may occur after esophageal, gastric, or colonic surgery. Esophageal leaks cause significant morbidity and mortality.
Bariatric surgery procedures are at risk for leak and bleeding. Dumping syndrome can be seen after gastric bypass. Patients are also at risk for mechanical obstruction, ulcers, reflux, and vitamin deficiencies.
Complications of percutaneous endoscopic gastrostomy (PEG) tubes include infections, hemorrhage, peritonitis, aspiration, wound dehiscence, sepsis, and obstruction of the tube. Tubes may also be dislodged requiring replacement either permanently or temporarily with a Foley catheter.
Complications arising from stomas are due to technical errors or from underlying disease such as Crohn’s disease and cancer. Ischemia, necrosis, bleeding, hernia, and prolapse are sometimes seen.
The most common colonoscopy complications are hemorrhage (after biopsy procedures) and perforation. Symptoms may be delayed by several hours. Abdominal and upright chest radiographs are necessary to evaluate for free air; however, their limited sensitivity warrants CT imaging if highly suspicious.
Rectal surgery complications include urinary retention, constipation, prolapse, bleeding, and infections.
For further reading in Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed., see Chapter 90, “Complications of General Surgical Procedures,” by Edmond A. Hooker.