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.

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.

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.

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.

Pain, hypoxia, and elevated catecholamines contribute to hypertension and tachycardia. Give beta-blockers to patients at risk for postoperative myocardial ischemia and to avoid withdrawal in patients who used them preoperatively.

There a number of factors contributing to postoperative pulmonary insufficiency: type of anesthesia, type and duration of procedure, endotracheal intubation, and respiratory depression from narcotics. Immediately after surgery most patients will require some supplemental oxygen. However, dyspnea, tachypnea, wheezing, and signs of respiratory distress need to be addressed in the PACU. Upper abdominal procedures and thoracic procedures are commonly associated with pain, impairing respiratory effort and causing hypoxia and dyspnea. Patients with a low ejection fraction or diastolic dysfunction may have difficulty managing volumes of fluid received intraoperatively, and are at risk for postoperative pulmonary edema. Evaluate with physical exam and chest X-ray. Cardiac or thoracic surgical patients will usually have a chest tube postoperatively and it is important to keep in mind that a poorly functioning chest tube or residual pneumothorax can also cause respiratory distress. This can also be detected by physical exam and confirmed with a chest X-ray. All patients who have central lines placed intraoperatively require a postoperative chest X-ray to rule out pneumothorax.

Hypotension in the PACU may be related to hypovolemia, narcotic and benzodiazepine administration, and epidural anesthesia but is most worrisome for postoperative bleeding. Markers for hypovolemia include low urine output, signs of shock, and altered mental status, which can be masked by the residual effects of anesthesia. Invasive monitoring with a urinary drainage catheter, central line, or arterial line should be utilized if a patient remains hypotensive and he or she does not improve with volume. In the case of low urine output it is usually unwise to administer diuretics in the immediate postoperative setting; pulmonary edema due to capillary leak associated with perioperative inflammation can be seen in the setting of intravascular volume depletion. The premature administration of diuretics exacerbates intravascular depletion, hypotension, and inadequate end organ perfusion, and is rarely the correct first step in volume management.

Medications and epidural anesthesia should not cause hypotension in the absence of hypovolemia. Although the instinct is to reduce the analgesia, hypotension in this case should also prompt administration of a fluid bolus to address underlying hypovolemia. Patients with hypotension require a thorough physical exam to look for sources of bleeding, and a hematocrit and coagulation panel to rule out hemorrhage and coagulopathy (see Chapter 45 Perioperative Hemostasis, Chapter 61 Perioperative Antithrombotic Management: Anticoagulants, and Chapter 62 Perioperative Management of Patients who are Receiving Antiplatelet Therapy).

The causes for nausea and vomiting are multifactorial. Prior history of PONV increases the risk of recurrence, as do long procedures, volatile anesthetics, and procedures involving the inner ear, eye, and abdominal viscera. Patients at high to moderate risk benefit from prophylactic antiemetics, motility agents, or a scopolamine patch before emersion from anesthesia.

Wound Complications

In a healthy patient wounds will take 6 weeks to heal completely and reach 80% of their previous tensile strength. Wounds closed primarily should be kept clean, dry, and covered for a minimum of 48 hours after surgery. Typically, operative dressings are removed on postoperative day 2 and thereafter patients can shower. Surgeons restrict postoperative activities to avoid stress on the wound for 4–6 weeks. Wet to dry dressing changes are used in contaminated wounds healing secondarily. The wet dressing provides a moist environment that encourages granulation. Removal of the dressing after it has dried provides mechanical debridement and keeps the wound clean. At the time of discharge, instructions include specifics relating to activity level, who and when to call should late wound complications become manifest, and instructions for follow-up.

Surgical Site Infections

Surgical site infections (SSI) account for approximately 15% of nosocomial infections and are the most common infections after surgery. They are associated with a 7-day increased length of stay and more than $3000 in additional hospital costs. In 2006, a consortium of hospital and professional groups introduced the Surgical Care Improvement Project Guidelines (see Table 46-1) with the goal of decreasing postoperative complications 25% by 2010. These include measures for reducing SSIs.