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- Any negative outcome either by surgeon or patient; no consensus on definition
- Multiple classification systems exist based on severity.
Incidence varies with type of operation, operative time, hospital, surgeon, and patient characteristics:
- Mortality rate in general and vascular surgery is 3.5–6.9% (1).
- Overall complication rate in general and vascular surgery is 24.6–26.9% (1).
- Postoperative fever is very common. Incidence ranges (14–91%) (2).
- 2008: 3 venous thromboembolic events/1,000 surgical discharges in the US (3)
- Emergent cases associated with more postop complications vs. nonemergent cases (22.8% vs. 14.2%) and have higher mortality rate (6.5% vs. 1.4%) (4)
- Complications after bariatric surgery: Anastamotic leak (0–5.6%), internal hernia (3–4.5%), marginal ulcer (1–16%), GI bleeding (0.6–4%), acute distention of distal stomach.
- Surgical infection incidence varies with type of operation:
- 1–2% clean operative site (e.g., hernia repair)
- 5–15% clean contaminated site (e.g., cholecystectomy)
- 10–20% contaminated site (e.g., colectomy)
- 50% dirty operative site
- People at increased operative risk include those with:
- Poorly controlled diabetes/obesity
- Heart disease (especially myocardial infarction [MI] and heart failure)
- Bleeding disorders
- Renal failure
- Liver and pulmonary disease
- Other risk factors:
- Prolonged surgery
- Immobility following surgery
- Emergency surgery
- Malignant hyperthermia:
- Incidence: 1/50–100,000; treated with dantrolene
- Pseudocholinesterase deficiency:
- Inherited enzyme deficiency resulting in abnormally slow degradation of choline ester drugs
- Causes prolonged respiratory paralysis following administration of standard doses of succinylcholine
- Incidence: <0.01% of the general population; may have personal or family history of prolonged postanesthesia wake-up time
- Bleeding disorders, including hemophilia
Preventive measures span entire perioperative period:
- Smoking cessation (5)[A]
- Appropriate fluid/blood resuscitation
- Assessment of underlying risk factors
- Preoperative antibiotics, when appropriate
- Sterile technique
- Warming during surgery
- Clip hair instead of shaving preoperatively (6)[B]
- Fever caused by pyrogens (mediated by interleukin-1): Bacteria, viruses, antigen-antibody complexes
- Wound dehiscence: Poor wound healing (malnutrition) or increased abdominal pressure
- Deep vein thrombosis: Blood clot formation attributed to 1 of Virchow triad:
- Hemodynamic changes (stasis, turbulence)
- Endothelial injury/dysfunction
- Renal failure:
- Drug toxicity (commonly antibiotics)
- Inadequate resuscitation leading to poor perfusion (catecholamine release during surgery and activation of renin-angiotensin-aldosterone system) results in ATN.
- Decreased vital capacity leads to atelectasis, pneumonitis, and acute respiratory distress syndrome (ARDS).
- Aspiration can occur at any time. Stomach acid/particulate matter cause an inflammatory reaction, leading to cyanosis or death.
- Pulmonary edema due to fluid transudation to alveolus from fluid overload or heart failure
- Pulmonary mechanics are compromised postoperatively. Precipitating factors include pain and altered mental status.
- Postoperative MI occurs within 3 days of surgery; caused by anesthetics and blood loss (loss of as little as 500 mL can cause shock).
- Arrhythmia is due to destabilization of cardiac membranes or prolongation of conduction.
- Small bowel obstruction: Intra-abdominal adhesive bands can form and constrict the bowel, even decades after surgery.
- Urinary retention: Men more frequently than women, impaired coordination between α-receptors in the bladder neck and parasympathetic stimulation to the bladder
- Fever in the first 24 hours is usually due to atelectasis. Consider the 5 Ws:
- Wind—atelectasis, PNA, aspiration
- Walking—deep venous thrombosis (DVT)
- Wound—surgical site infection
- Wonder drugs—drug fever
- Fever >102°F in the first 48 hours is concerning for necrotizing wound infection.
- Staphylococcus aureus is the most common cause of wound infection. Others include Pseudomonas, Proteus, and Klebsiella.
- Hematoma: Inadequate hemostasis/bleeding
- Seroma: Disruption of lymphatics
- UTI: Related to indwelling catheter
- Dehiscence: Increased abdominal pressure, inadequate fascial closure, malnutrition, contamination, and chemotherapy
- Renal failure: Hypovolemia, drug toxicity (commonly due to antibiotics or IV contrast)
- Respiratory: Volume overload, aspiration, and decreased vital capacity lead to decreased diffusion capacity. Pulmonary embolism formation is another possible postoperative etiology.
- Pulmonary embolism: Generally due to thromboembolism from the deep veins of the legs; more rarely from air, fat, or amniotic fluid.
- Cardiac: Arrhythmia occurs due to electrolyte abnormalities, catecholamine release (from pain), hypercapnia, and digitalis.
- Small bowel obstruction: Adhesive bands form intra-abdominally and can constrict the bowel; occurs remotely after abdominal surgery.
- Fistula/Intestinal leak: Generally occurs at the site of bowel anastomosis due to suture line breakdown
- Stomal complications:
- More common in obese patients
- Include fibrosis of bowel at stoma, necrosis, retraction, skin breakdown, and stomal stricture
- Most complications are due to technical errors at the time of operation.
- Urinary retention: Due to anesthetics
Commonly Associated Conditions
- Adrenal insufficiency when on chronic steroids preoperatively
- Liver failure in patients with pre-existing disease
- Delirium tremens in alcoholics
- Thyroid storm in patients with undiagnosed hyperthyroidism
- Parotitis in the elderly
Operative procedures can lead to severe anxiety in children aged 1–2 years, with lasting emotional disturbance in 20%.
90% of patients age >65 years experience depression after surgery, with activities of daily living impaired in 50%. Increase human contact to prevent withdrawal and reduce symptoms.