Outpatient surgical procedures are common, and with increasing pressure for cost containment, admitted patients are being discharged earlier in their postoperative course. As a result, more patients are coming to the ED with postoperative fever, respiratory complications, GU complaints, wound infections, vascular problems, and complications of drug therapy (Table 87-1). This chapter reviews the complications common to all surgical procedures and those specific to a single procedure.

The operating surgeon should be called when one of his or her patients appears in the ED with a surgical complication. This is not just a courtesy, but provides continuity of care important for the patient’s well-being.

Fever is a common presenting complaint (Table 87-2). A mnemonic for the common causes of postoperative fever is the “five Ws”: wind (atelectasis or pneumonia), water (urinary tract infection), wound, walking (deep vein thrombosis), and wonder drugs (drug fever or pseudomembranous colitis).¹ Respiratory complications, such as atelectasis, and IV catheter–related problems, such as thrombophlebitis, are the predominant causes of fever in the first 72 hours. Necrotizing streptococcal and clostridial infections also occur in surgical wounds early in the postoperative course.

Urinary tract infections become evident 1 to 5 days postoperatively. Seven to 10 days postoperatively, clinical manifestations of wound infections develop. Deep venous thrombosis can result in fever any time but usually not until the fifth postoperative day. Antibiotic-induced pseudomembranous colitis occurs up to 6 weeks postoperatively. An approach for evaluating and managing fever in postoperative patients is presented in Table 87-3.

ATELECTASIS

Atelectasis, the collapse of pulmonary alveoli, is very common. Contributing factors include inadequate clearance of secretions after general anesthesia, decreased intra-alveolar pressure, and postoperative pain, which results in hypoventilation. Although atelectasis can occur after any procedure, it frequently occurs after upper abdominal and thoracic surgery. The presentation varies from an isolated fever to tachypnea, dyspnea, and tachycardia.

Evaluation includes chest radiography, pulse oximetry, and a CBC. Chest radiographs may show normal findings or exhibit platelike linear densities, triangular densities, or lobar consolidation. Mild hypoxemia from ventilation and perfusion mismatch is common, but hypercarbia is uncommon. Patients with mild atelectasis and no evidence of hypoxemia may be managed as outpatients with pain control and increased deep breathing. Admission is indicated for aggressive pulmonary toilet and supplemental oxygenation in debilitated patients, patients with underlying lung disease, patients with hypoxemia, or those in whom the diagnosis is in question.

PNEUMONIA

Pneumonia usually becomes evident between 24 and 96 hours postoperatively. Predisposing factors include prolonged ventilatory support and atelectasis. Presenting symptoms can include dyspnea, chest pain, productive cough, fever, and tachypnea. Postoperative pneumonia is likely to be polymicrobial. After specimens of sputum and blood are obtained for culture, parenteral antimicrobial therapy is given. There are many options for polymicrobial coverage. One option is levofloxacin, 750 milligrams IV once daily, and vancomycin, 1 gram IV twice daily. Admission to the hospital is generally indicated.

PNEUMOTHORAX

Pneumothorax can occur as a complication of thoracic wall surgery, breast biopsy, laparoscopic abdominal surgery, abdominal paracentesis, nasogastric and feeding tube insertion, thoracic surgery, central venous catheter insertion, endoscopic procedures, shoulder arthroscopy, and tracheostomy. For further discussion, see chapter 68, “Pneumothorax.”

PULMONARY EMBOLUS

Pulmonary embolism may present any time during the postoperative period. For further discussion of signs, symptoms, and treatment, see chapter 56, “Venous Thromboembolism.”

URINARY TRACT INFECTION

Urinary tract infections can occur after any surgical procedure, but the incidence increases in patients who have undergone instrumentation of the GU tract or bladder catheterization. The cause is direct contamination of the urinary bladder, most commonly with Escherichia coli. Other organisms isolated include Staphylococcus aureus, Staphylococcus epidermidis, Proteus mirabilis, Klebsiella, Pseudomonas, and enterococci. Oral antibiotics (ciprofloxacin, 500 milligrams PO twice daily, or levofloxacin, 750 milligrams PO once daily) are appropriate for most infections, and choice of antibiotic should be based on local susceptibility patterns. Elderly or debilitated patients and those with sepsis require admission for parenteral administration of antibiotics (usually levofloxacin, 750 milligrams IV once daily).

URINARY RETENTION

Postoperative acute urinary retention is a common problem for surgical patients.² Urinary retention occurs as the result of catecholamine stimulation of α-adrenergic receptors in the bladder neck and urethral smooth muscle. Increased incidence of urinary retention is likely to occur in elderly men, patients receiving excessive fluid administration during surgery, those undergoing anorectal surgery, patients undergoing longer procedures (>2 hours), and those for whom spinal or epidural anesthesia was used.^3,4

Patients with urinary retention present with lower abdominal discomfort, urinary urgency, and inability to void. The diagnosis is confirmed by use of a bladder scanner or placement of a Foley catheter. The bladder can be safely drained quickly, and there appears to be no foundation for the fears of hematuria, postobstructive diuresis, and hypotension. For patients with normal renal function and no anatomic obstruction, continued catheter drainage is not necessary. For patients with retention after GU procedures, a urologist should be consulted. Antibiotics can be given if the GU tract has been instrumented, if retention is prolonged, or if the patient is at risk for infection (see “Urinary Tract Infection” section above).

ACUTE RENAL FAILURE

Acute renal failure is classified according to the primary cause: prerenal, intrinsic, or postrenal. Volume depletion is the most common prerenal cause. The patient should be examined for signs of hypovolemia and a urinary catheter placed. Indwelling urinary catheters should be irrigated or replaced. A fluid bolus should be given. Intrinsic causes include acute tubular necrosis and drug nephrotoxicity. Obstructive uropathy is a common cause of postrenal failure. In patients with urinary outlet obstruction, placement of a urinary catheter is diagnostic and therapeutic. Renal US is needed to identify hydronephrosis or hydroureter.

Inform the operative surgeon about all postoperative wound complications.

HEMATOMAS

Wound hematomas result from unrecognized inadequate hemostasis. Patients have pain, pressure, and swelling within the wound. Patients with wound hematomas may be febrile and have sanguineous or serous wound drainage. Differentiating between hematoma and wound infection can be difficult. A few sutures should be removed to allow the hematoma to drain, and culture of wound specimens should be performed. If there is no evidence of infection and hemostasis can be maintained, the patient can be discharged. In patients who have a hematoma of the neck or who have undergone vascular surgery, extreme caution and consultation are appropriate.

SEROMAS

A seroma, a collection of serous fluid, is usually the result of inadequate control of lymphatics during dissection but can occur under split-thickness skin grafts and in areas with large dead spaces (e.g., axilla, groin, neck, or pelvis). Patients have painless swelling below the wound or graft, and needle aspiration yields a serous fluid. Aspiration confirms the diagnosis and alleviates the problem, although aspiration may have to be repeated later.

INFECTION

Systemic factors (e.g., extremes of age, poor nutrition, or diabetes) contribute to wound infections. However, local factors (e.g., necrotic tissue, poor perfusion, foreign bodies, and hematomas) are of greatest significance. In nontraumatic, uninfected operative wounds in which the respiratory, alimentary, and GU tracts were not entered, infection rates are low. In such cases, the infecting organism is usually from the skin but can originate from remote infected sources (e.g., urinary tract infection). If there is a remote infected source, the organism is probably the same in both infections. Wounds associated with entering the respiratory, alimentary, or GU tract or wounds secondary to trauma have a higher risk of infection.