para>Operative procedures can lead to severe anxiety in children aged 1 to 2 years, with lasting emotional disturbance in 20%. ‚
Geriatric Considerations
90% of patients >65 years of age experienced depression after surgery, with ADLs impaired in 50%. Increase human contact to prevent withdrawal and reduce symptoms.
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DIAGNOSIS
HISTORY
- Wound infection: history of surgery several days prior to presentation with pain, warmth, redness, or drainage at site of incision.
- Expanding mass is consistent with seroma or hematoma. Seroma more likely if interval is longer.
- Dehiscence/hernia: Patients may feel sutures "pop " ť and sense a palpable bulge. Attributed to increased abdominal pressure (e.g., coughing, Valsalva maneuver) or excessive tension on wound
- DVT: pain, swelling, and redness of leg in immobilized patient or with hypercoagulability
- Renal failure: oliguria or anuria, fatigue, electrolyte abnormalities, elevated creatinine and BUN
- Pulmonary: lack of incentive spirometry, narcotics, fluid retention, age >65 years, shortness of breath
- Cardiac: elderly, cardiothoracic surgery, cardiac dysfunction; chest pain in 27% of perioperative MI (most are pain free)
- Ileus or small bowel obstruction: progressive nausea, bilious vomiting, inability to tolerate PO intake, abdominal pain, decreased bowel function or obstipation
- Fistula or intestinal leak: severe abdominal pain (leak), fever, nausea/vomiting, drainage at skin
- Stomal complications: pain at stoma site, change in color of stoma, decreased output, increased amount of bowel above skin level (prolapsed or hernia)
- Urinary retention: inability to void, suprapubic pain
PHYSICAL EXAM
- Low fevers are not significant until 48 hours postoperatively. Wound infection is most common cause of fever after 72 hours.
- High fever, mental status changes, hypotension, and rigors are associated with severe wound complications or intestinal leak.
- Fascial dehiscence is a surgical emergency.
- Detection of intra-abdominal complications more challenging in obese patients due to body habitus
- Dolor, tumor, rubor, and calor may indicate a wound infection, fever, pus, or foul-smelling discharge.
- Necrotizing infection: dishwater-colored drainage, tenderness, firm induration of the soft tissue that extends beyond erythema, bullous lesions, and skin necrosis or ecchymosis, crepitus
- Hematoma: expanding, tender mass. Seroma: slowly expanding, nontender mass
- Dehiscence/hernia: salmon-colored drainage on postoperative days 4 to 5, evisceration, or later as ventral hernia; may see open incision or palpable fascial edge, rarely tender
- Renal failure: persistent oliguria; can have pericardial rub, bleeding/hematoma if uremic
- Pulmonary: dyspnea, cough, fever, basilar crackles or rhonchi, poor inspiratory effort, dullness to percussion at bases
- Cardiac: peripheral edema, irregularly irregular heartbeat (AFib), tachycardia
- Ileus/small bowel obstruction: "tinkling " ť or absent bowel sounds, tympanitic abdomen, distention, tenderness to palpation, occasionally guarding
- Fistula/intestinal leak: enteric or bilious contents draining from skin opening, acute/firm abdomen, fever, guarding, peritoneal signs, hypotension
- Stomal complications are evident when the ostomy appliance is removed: skin irritation, black/discolored intestinal mucosa, retracted or prolapsed ostomy
- Urinary retention: suprapubic pain, palpable bladder
- Anastomotic leak: may manifest as isolated tachycardia or patient anxiety after gastric bypass
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
- CBC with differential, blood culture and sensitivity (C/S), chemistries, BUN/creatinine, urinalysis (UA), urine C/S, ABG, chest x-ray (CXR)
- Blood cultures within 48 hours of surgery are usually unnecessary (negative most of the time) (3)[C].
- Obtain blood culture from any central venous access (central line, port, etc.).
- Elevated WBC count with wound infections, atelectasis, pneumonia, infected hematoma/seroma, bowel leak, and stomal complications
- Renal failure: BUN, creatinine, urine chemistries, FENa
- Pulmonary: ABG and CXR
- Cardiac: elevated troponins or arrhythmia; creatinine kinase (CK), CK-MB, electrocardiogram (EKG), echocardiogram
- UTI: UA, urine culture and susceptibility
- Subcutaneous gas can be seen in necrotizing infection on x-ray or CT; late finding
- CT or ultrasound can be used to diagnose hernia or fascial disruption.
- Small bowel obstruction/ileus: Abdominal series with chest one view shows air " “fluid levels, dilated small bowel
- Fistula: Fistulogram aids in diagnosis and is critical for treatment planning.
- Intestinal leak: CXR reveals free air under the diaphragm; CT shows fluid collection in abdomen.
- Bladder scan can help diagnose urinary retention if diagnosis in doubt.
- DVT: duplex ultrasound; image iliac veins if possible
- Pulmonary: CXR, CT pulmonary angiography more sensitive test for suspected pulmonary embolism
Diagnostic Procedures/Other
- Exploratory laparotomy/laparoscopy if extremely ill/septic and diagnosis is unknown.
- Immediate debridement for necrotizing or concerning wound infections
- Intra-abdominal abscesses frequently can be drained percutaneously.
- Cardiac: EKG shows signs of ischemia or dysrhythmia.
TREATMENT
MEDICATION
- Opiates and NSAIDs for pain control
- VTE prophylaxis as appropriate
- Broad-spectrum antibiotics for sepsis or severe infection
- Simple wound infections and stomal complications: 1st- or 2nd-generation cephalosporins, trimethoprim/sulfamethoxazole, or clindamycin
- Intestinal leak: gram-negative, anaerobic, and gram-positive coverage
- Pneumonia should be treated empirically with antibiotics appropriate for health care " “associated pneumonia and ventilator-associated pneumonia.
SURGERY/OTHER PROCEDURES
- Wound infections may need surgical debridement.
- Necrotizing wound infections need emergent debridement.
- Hematomas may need reexploration and hemostasis.
- Dehiscence/hernia should be repaired. Evisceration is a surgical emergency.
- Small bowel obstruction that fails to resolve or improve with nasogastric decompression in 48 hours should be explored.
- Intestinal leak is a surgical emergency for immediate exploration and repair. Fistulas may need surgical intervention to resolve.
- Some stomal complications (necrosis, retraction, parastomal hernia) need surgical revision.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
Hemodynamic instability, respiratory distress, need for IV fluids/antibiotics, or nasogastric decompression ‚
- Fluid resuscitation as needed
- Broad-spectrum antibiotics, if the patient is septic
- IV antibiotics for infections
Discharge Criteria
Able to tolerate PO intake, voiding, return of bowel function, afebrile, good wound healing, and pain controlled ‚
Nursing
- Teaching for drain maintenance and wound care/dressing change prior to discharge
- Close follow-up (1 to 2 weeks)
- NPO with tube feeds or TPN for patients with fistula upon discharge
REFERENCES
11 Becher ‚ RD, Hoth ‚ JJ, Miller ‚ PR, et al. A critical assessment of outcomes in emergency versus nonemergency general surgery using the American College of Surgeons National Surgical Quality Improvement Program database. Am Surg. 2011;77(7):951 " “959.22 Ghaferi ‚ AA, Birkmeyer ‚ JD, Dimick ‚ JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009;361(14):1368 " “1375.33 Pile ‚ JC. Evaluating postoperative fever: a focused approach. Cleve Clin J Med. 2006;73(Suppl 1):S62 " “S66.44 Fischer ‚ JP, Wink ‚ JD, Nelson ‚ JA, et al. Among 1,706 cases of abdominal wall reconstruction, what factors influence occurrence of major operative complications? Surgery. 2014;155(2):311 " “319.55 Hawn ‚ MT, Houston ‚ TK, Campagna ‚ EJ, et al. The attributable risk of smoking on surgical complications. Ann Surg. 2011;254(6):914 " “920.66 Robinson ‚ TN, Wu ‚ DS, Pointer ‚ L, et al. Simple frailty score predicts postoperative complications across surgical specialties. Am J Surg. 2013;206(4):544 " “550.
CODES
ICD10
- R50.82 Postprocedural fever
- T81.4XXA Infection following a procedure, initial encounter
- T81.31XA Disruption of external operation (surgical) wound, not elsewhere classified, initial encounter
- T88.8XXA Oth complications of surgical and medical care, NEC, init
- J95.89 Oth postproc complications and disorders of resp sys, NEC
- I97.89 Oth postproc comp and disorders of the circ sys, NEC
ICD9
- 780.62 Postprocedural fever
- 998.59 Other postoperative infection
- 998.32 Disruption of external operation (surgical) wound
- 998.11 Hemorrhage complicating a procedure
- 997.2 Peripheral vascular complications, not elsewhere classified
- 997.39 Other respiratory complications
SNOMED
- Postoperative fever (finding)
- Postoperative infection (disorder)
- dehiscence of surgical wound (disorder)
- hemorrhage AND/OR hematoma complicating procedure (disorder)
- Complication of surgical procedure (disorder)
- Postoperative pulmonary embolus
CLINICAL PEARLS
- Smoking is associated with increased risk for general morbidity, wound complications, general infections, pulmonary complications, neurologic complications, and admission to the intensive care unit.
- Smoking cessation at any interval prior to surgery decreases postoperative complications.
- Treatment of some complications related to hospitalization will no longer be reimbursed by payers, including wrong-site surgery and central venous catheter infections.
- Respiratory complications are the most costly surgical complications related to surgical episode of care (4)[C].
- AFib and other arrhythmias are much more common after cardiothoracic surgery.