Tintinalli's Emergency Medicine - Just the Facts, 3ed.

51. COMPLICATIONS OF GENERAL SURGICAL PROCEDURES

Daniel J. Egan

images 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.

CLINICAL FEATURES

FEVER

images 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]).

images Fever in the first 24 hours is usually due to atelectasis, necrotizing fasciitis, or clostridial infections.

images In the first 72 hours, pneumonia, atelectasis, intravenous-catheter-related thrombophlebitis, and infections are the major causes of complications.

images UTIs are seen 3 to 5 days postoperatively.

images 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).

images Antibiotic-induced diarrhea (PMC) is seen 6 weeks after surgery.

RESPIRATORY COMPLICATIONS

images 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).

images 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).

GENITOURINARY COMPLICATIONS

images UTIs are more common after instrumentation of the urinary tract.

images Certain patients are at risk of urinary retention following surgical procedures (see Chapter 56).

images Decreased urine output should raise concerns for renal failure resulting from many causes (see Chapter 52).

WOUND COMPLICATIONS

images 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.

images Seromas are collections of clear fluid under the wound.

images 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.

images Necrotizing fasciitis should be considered in a patient with a rapidly expanding infection and signs of systemic toxicity (see Chapter 92).

images Wound (superficial or deep fascial) dehiscence can occur due to diabetes, poor nutrition, chronic steroid use, and inadequate or improper closure of the wound.

VASCULAR COMPLICATIONS

images Superficial thrombophlebitis, usually in the upper extremities after intravenous catheter insertion, manifests with erythema, warmth, and fullness of the affected vein.

images DVT commonly occurs in the lower extremities with swelling, pain, and sometimes erythema of the affected limb (see Chapter 27).

DRUG THERAPY COMPLICATIONS

images Many drugs are known to cause fever without any concomitant infection.

images PMC, a dreaded complication, is caused by Clostridium difficile toxin. Watery and potentially bloody diarrhea with abdominal cramping are typical features.

DIAGNOSIS AND DIFFERENTIAL

images Patients with a postoperative fever should have an evaluation focusing on the elements above.

images 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.

images Patients with oliguria or anuria should be evaluated for signs of hypovolemia or urinary retention and have laboratory testing of renal function.

images 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

images Always discuss patients and proposed treatments with the surgeon who performed the relevant procedure.

images Many patients with atelectasis may be managed as outpatients with pain control and deep breathing exercises or incentive spirometry.

images Postoperative pneumonia may be polymicrobial, and inpatient therapy with antipseudomonal and antistaphylococcal agents is often recommended (see Chapter 32).

images Nontoxic patients with UTI can be managed as outpatients with oral antibiotic therapy. Gram-positive coverage should be considered if instrumentation occurred.

images Wound hematomas may require removal of some sutures and evacuation in consultation with the surgeon. Admission is often unnecessary.

images Seromas can be confirmed and treated with needle aspiration and wound cultures. Admission may not always be necessary.

images 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.

images Emergent surgical debridement and parenteral antibiotics are indicated for necrotizing fasciitis. The emergency physicians should initiate broad-spectrum therapy rapidly.

images 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.

images Oral vancomycin and metronidazole, PO or IV, are currently available treatment modalities for drug-induced PMC.

SPECIFIC CONSIDERATIONS

COMPLICATIONS OF BREAST SURGERY

images 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

images Stimulation of the splanchnic nerves may cause dys-motility and paralytic ileus, which usually resolves within 3 days.

images Prolonged ileus should prompt investigation for non-neuronal causes. Clinical features include nausea, vomiting, obstipation, constipation, abdominal distension, and pain.

images Abdominal radiographs, complete blood count, electrolytes, blood urea nitrogen and creatinine levels, and urinalysis should be obtained.

images Treatment of adynamic ileus consists of nasogastric suction, bowel rest, and hydration.

images Mechanical obstruction is usually due to adhesions and may require surgical intervention if conservative management with nasogastric suction is ineffective.

images 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.

images 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).

images Cholecystitis and biliary colic may occur postoperative. Elderly patients are more prone to develop acalculous cholecystitis.

images Fistulas, either internal or external, may result from technical complications or direct bowel injury and require surgical consultation.

images Anastomotic leaks may occur after esophageal, gastric, or colonic surgery. Esophageal leaks cause significant morbidity and mortality.

images 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.

images 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.

images 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.

images 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.

images 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.