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There are many postoperative complications related to particular procedures that are beyond the scope of this text. Hospitalists caring for surgical patients should have an understanding of what surgical procedure was performed, the indication for that operation, and what perioperative concerns the operating surgeon has based on the circumstances of that particular patient or procedure. This should be part of the communication between the surgical and hospitalist staff. Here we will consider complications that are commonly associated with all surgical procedures.
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The prevention of postoperative complications should begin in the preoperative period. A thorough history and physical examination should identify conditions that increase the risk for bleeding, infection, and cardiopulmonary compromise. Elective surgery provides an opportunity to uncover and modify risk factors. Aspirin, antiplatelet agents, NSAIDS, and anticoagulant therapy are routinely held pre-operatively to decrease bleeding risk.
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Low-grade postoperative fever occurs in as many as one-third of postoperative patients and is usually caused by postoperative inflammation, atelectasis, or hematoma absorption rather than infection. Fever from inflammation occurs earlier than fever from infection; 1.6 vs. 2.7 days in 1 series. Evaluation should include physical exam and a white blood cell count, and should otherwise be targeted toward specific signs and symptoms in the first 48 hours. After 48 hours, temperatures greater than 38.5°C without a clear source should prompt a complete fever workup including chest X-ray, blood, sputum, and urine cultures, and a white blood cell count. Pay particular attention to the surgical wound and sites of venous access as potential sources.
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After surgery, the patient will stay in the Post Anesthesia Care Unit (PACU) for close monitoring, to regain consciousness, and for physiologic recovery. Typical problems managed in the PACU include postoperative pain, hypertension, respiratory insufficiency, and postoperative nausea and vomiting (PONV). Patients with altered consciousness after general anesthesia may be unable to verbalize their pain, leaving caregivers to rely on physical signs such as hypertension, tachycardia, agitation, and tachypnea for diagnosis.
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Pain, hypoxia, and elevated catecholamines contribute to hypertension and tachycardia. Give beta-blockers to patients at risk ...