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Management of the acutely unwell surgical patient should be approached in the same ABCDE way as any other acutely unwell patient
bearing in mind specific risks associated with each operation. Bleeding, infection and damage to local structures are a useful starting point
when determining risks. Consideration should be given when assessing a patient to the procedure undertaken, pre-operative fitness and
post-operative progress. Special attention should be made to assess to operative site, operatively placed drains and their contents.
Although complications can be divided into those related to the procedure, those related to specific patient groups and general
complications, they are interconnected with different procedures and patients affecting the post operative frequency of general
complications. Pain, operative stress and inflammation may be confounding factors when assessing a patient with deranged physiological
parameters, but it is important to exclude more serious underlying causes first and recognition of the acutely unwell surgical patient is the
most important skill to acquire.
Although we have listed some of the common post-operative complications by timing and by procedure at the end of this page, it
is more useful to consider common presentations that you will be called to assess as junior doctors on the ward. It is important to note
how many of these presentations are interconnected.
Pyrexia
Pyrexia results from circulating inflammatory mediators, it should be used in conjunction with other physiological parameters (heart rate,
white cell count, respiratory rate) to diagnose Systemic Inflammatory Response Syndrome (SIRS). Sepsis is the most likely cause of SIRS in a
surgical patient but operative intervention causes an inflammatory response itself and may result in low grade pyrexia.
Considering the timing pyrexia will give a clue to the underlying diagnosis, infected post operative collections take 5-7 days to
develop and anastamotic leaks in general surgical patients tend to present at a similar time. Surgical patients are at particular risk of chest
infections due to suboptimal ventilation causing basal atelectasis but other septic sources such as UTIs should be screened for.
Hypotension
There should be two aims in assessing a patient with hypotension, identifying a cause and assessing organ dysfunction. Causes may
include:
Decreased intravascular volume: long operations and evaporative fluid losses, third space fluid losses, haemorrhage, poor oral
intake should all be considered.
Pump failure (cardiogenic shock): surgical stress increases the risk of a myocardial infarction. These typically occur 48hrs post op.
Fluid overload and heart failure should also be considered and evidence of LVF or CCF sought.
Sepsis and anaphylaxis: both cause hypotension, the mechanism is more complex than simple vasodilation as increased capillary
permeability and cardiac dysfunction contribute. Early identification and treatment of the underlying cause is essential.
Sympathetic shock: patients with epidural analgesia and a high block (T5 and above) can lose sympathetic outflow causing
vasodilation and cardiogenic shock, assess epidural blocks using cold sprays. Spinal anaesthetics in elderly patients may
contribute to loss of sympathetic tone and hypotension.
Inadequate tissue Mean Arterial Pressure (MAP) causes organ hypoperfusion. Clinical signs of poor perfusion are raised capillary refill
time, cold peripheries, reflex tachycardia. Specific evidence of organ dysfunction should be sought - an ABG for lactate, assessment of urine
output (0.5ml per Kg per hr) and confusion.
Respiratory difficulties
Respiratory problems are common in surgical patients:
They are at high risk of respiratory tract infections due to immobility, poor inspiratory effort due to inadequate pain control and
basal atelectasis and co-morbid states.
Both surgery and underlying pathologies such as cancers and sepsis increase the risk of Pulmonary Embolisms.
Large fluid shifts, hypoalbuminaemia and cardiac dysfunction may lead to pulmonary oedema.
Assessment of respiratory difficulties should therefore include investigation for infection (bloods), assessment of fluid state (urine
output, JVP, clinical hydration status), assessment of calves for DVTs along with a CXR and ABG.
2013 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students finals OSCE revision
General Complications
Immediate
Anaesthetic complications (e.g. arrhythmia, hypo/hypertension, hyperthermia, breathing problems, MI/stroke, death, allergy,
teeth/lip/tongue damage)
Haemorrhage - often not obvious externally
Early
Fluid depletion
Electrolyte imbalances
Local infection (wound/ surgical site)
Systemic infection (chest/ UTI/ sepsis)
Fluid collections Chest problems are very common post-op
Atelectasis and a common cause of tachycardia and
fever. Listen to the lungs, get physio, sit the
DVT/PE patient up, give oxygen and saline nebs, and
Wound break down prescribe antibiotics if indicated
Anastamotic break down
Bed sores
Cardiothoracic
CABG/ stenting Reperfusion arrhythmias
Post operative MIs
Often need inotropes post operatively that may reduce organ perfusion elsewhere
Vascular
Grafts/ stents/ bypass procedures Failure of graft: haemorrhage, infection, re-thrombosis, limb or organ inschaemia
Areteriopaths are at high risk of: MI, CVA, PE
Endocrine
Thyroidectomy Airway obstruction secondary to haemorrhage - requires urgent opening of thyroidectomy wound
Hypocalcaemia (damage to parathyroid glands)
Recurrent laryngeal nerve damage
Parotidectomy Facial nerve damage
2013 Dr Christopher Mansbridge at www.OSCEstop.com, a source of free OSCE exam notes for medical students finals OSCE revision