Postoperative complications are common and costly. Recent studies suggest that, on average, each avoidable surgical complication costs payers >$10,000. Their incidence, risk factors, and impact on patient outcomes are as varied as the field of surgery itself. 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. Good communication among all providers caring for surgical patients is fundamental to both the prevention and management of surgical complications. Hospitalists caring for surgical patients should, accordingly, understand what surgical procedure was performed, the indication for the procedure, and any perioperative concerns from the operating surgeon, based on the circumstances of that particular patient or procedure. This chapter will review some of the more common postoperative complications that a hospitalist needs to recognize and manage. Each section will review the risk factors of the complication, how to mitigate those risks in the perioperative period, and how the hospitalist should identify and manage such complications.
Elective procedures provide more of an opportunity to identify and mitigate risk factors before surgery, although an attempt should take place before any surgery (even urgent or emergent). A thorough history and physical examination should aim to identify risks outlined in this chapter, and optimize the risk-benefit profile of the procedure. For example, when deciding whether to hold antiplatelet or anticoagulation medications in patients with cardiac indications, the risk of cardiac complications is weighed against the risk of bleeding. This decision making should occur in concert with the surgeon, and with the patient, to ensure all parties have a common understanding of the risks and the benefits of the surgery.
Prevention of postoperative complications begins in the preoperative period.
Surgical complications are common and costly; interdisciplinary teams must work together on their prevention and management.
COMMON COMPLICATIONS WITHIN THE POST ANESTHESIA CARE UNIT (PACU)
After surgery, patients usually stay in a postanesthesia care unit (PACU) for close monitoring while they recover from the effects of anesthesia. Common problems managed in the PACU include postoperative pain, hyper- and hypotension, respiratory insufficiency, and nausea and vomiting.
Patients in this phase of care are often unable to verbalize pain due to effects of anesthesia; accordingly, pain assessments are often based on other objective assessments such as blood pressure, heart rate, respiratory rate and signs of agitation. See Chapter 48 (Perioperative Pain Management).
POSTOPERATIVE HYPER- AND HYPOTENSION
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. Certain procedures, such as carotid endarterectomy, require immediate and aggressive control of systolic blood pressure regardless of etiology to avoid catastrophic ...