By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
As mentioned in a previous post on routine postoperative care, the following 7 Ps are postoperative complications I explicitly look for when routinely assessing all postoperative patients because they are common and seriously affect patient quality of life and length of hospitalization:
Here I will go over what to do to assess for the specific and common postoperative complications of atelectasis, infections, DVT, and fluid and electrolyte imbalances. I used UpToDate to inform my general approaches to each issue.
I assess for atelectasis (i.e., collapsed lung) by asking the postoperative patient if they are experiencing dyspnea, and I also auscultate the lungs to listen for decreased breath sounds and review vital signs to look for evidence of respiratory compromise on examination. Although dyspnea, decreased breath sounds, and decreased oxygen saturation have differential diagnoses and are not specific findings for atelectasis, atelectasis is a common reason for these symptoms/signs in the postoperative period. The impairment from atelectasis tends to peak approximately 2 days postoperatively, but it may be ongoing for up to a week postoperatively. Postoperative deep breathing exercises (ex: incentive spirometry) help to prevent this complication.
The approach to treating this complication depends on whether the patient is producing respiratory secretions or not. In the former, a trial of CPAP can be attempted, with close monitoring to intervene with intubation if respiratory status is significantly compromised. On the other hand, if there are significant respiratory secretions, frequent suctioning and chest physiotherapy is first-line.
Infection may be signified by localised pain or other symptoms associated with a particular site of infection, or it may be signified by systemic features (ex: fever/chills, altered level of consciousness, leukocytosis). Note that postoperative fever in the immediate postoperative period is not uncommon and by itself is not highly specific for infection, but it is also to do ones due diligence to at least clinically assess and continue to monitor for infection until there are no longer any symptoms or signs that could suggest an ongoing infection. Common postoperative infections include those of the surgical site, pneumonia, urinary tract infection, and intravascular catheter infection.
If any source of infection is suspected, starting patients on broad spectrum antibiotics to cover suspected sources of infection is indicated. In the setting of postoperative infection, it is particularly important to start broad spectrum antimicrobials prior to obtaining the results of cultures & sensitivities, as hospital-acquired infections are more likely to be from antimicrobial-resistant pathogens, and that being said, it is best to refer your local institutions antibiogram to select antibiotics taking into account local resistance patterns. If a patient has an invasive line and is febrile, it is best to remove this possible source of contamination if not absolutely necessary.
A painful or swollen extremity in a postoperative patient raises the possibility of deep vein thrombosis (DVT). Risk of DVT is usually categorised as low, medium, or high, based on a clinician's gestalt of the individual's patient risk but often also by employing the Well's Criteria as a validated tool for estimating likelihood of DVT in a given patient. Postoperative patients with extremity pain or swelling are automatically high risk per the Well's Criteria, and as such they pretty well always warrant investigation by compression ultrasonography with Doppler.
If a patient is indeed found to have a DVT, initiating therapeutic anticoagulation is standard of care unless the individual has a seriously high risk of hemorrhage that may outweigh anticoagulation therapy (in this setting, consider referral to a specialist for alternative therapies such as clot retrieval). While I won't get into the nuances of selecting a specific anticoagulant agent and determining for how long to prescribe it in this blog post, preferred postoperative choices include factor Xa and thrombin inhibitors, depending on patient factors. Anticoagulation therapy is needed for at least 3 months no matter the suspected precipitating factor(s) or lack thereof. Actual duration of anticoagulation past 3 months will be highly dependent on multiple patient factors that I also won't go into here, but the duration can for as brief as 3 months (if the DVT is deemed to be entirely circumstantial) to a prolonged 6 months, 12 months, or indefinitely depending on risk factors for recurrence.
Fluid and electrolyte imbalances
Depending on a patient's fluid and electrolyte status preoperatively, perioperatively, and in the immediate postoperative period, patients may require rehydration or maintenance fluid therapy. Evidence of dehydration clinically or based on laboratory investigations warrants replacement with small boluses of normal saline (or blood transfusion if indicated) until hypovolemia is corrected. If a patient has ongoing fluid losses without sufficient fluid intake, then a patient also needs to be maintained on maintenance fluid (ex: 20 mEq/L of KCl in D51/2NS, with a rate approximated by the 4:2:1 rule). Any patient receiving intravenous fluids requires monitoring of electrolytes (and some patients who are not receiving IV fluid but who have risk factors for electrolyte disturbance also require daily electrolyte monitoring while in hospital). Correcting for electrolyte abnormalities is important in the postoperative period to avoid complications secondary to electrolyte disturbances (ex: ileum, arrhythmia, seizure). There are a number of different ways to correct for electrolyte derangements depending on the particular electrolyte disturbance(s), and choice will again depend on individual patient factors.