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Postoperative care and complications
Introduction
The 2011 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) reported that, every year in the UK, there are between 20,000 and 25,000 deaths in patients undergoing surgical procedures. Although most of these deaths were in high-risk patients, the enquiry concluded that improvements in preoperative, intraoperative and postoperative care were required.
Recovery following an operation falls into three phases: immediate postoperative care in a recovery area, continued recovery in hospital and ongoing rehabilitation and convalescence following discharge. The first two phases will be outlined in this chapter, as they are primarily concerned with the prevention, detection and management of complications. A timeline for the development of postoperative complications is shown in Fig. 11.1 .
Immediate postoperative care
Patients who have received a general anaesthetic should be observed in a dedicated recovery area, situated adjacent to theatre, until they are conscious and vital signs are stable. Clinical notes documenting the operation with postoperative instructions should accompany the patient to the recovery area, along with an anaesthetic record of their progress during surgery. Major life-threatening complications can occur in the immediate postoperative period, including airway obstruction, respiratory failure, myocardial infarction, haemorrhage and cardiac arrest. A recovery area provides specially trained personnel and equipment for the observation and treatment of acute pulmonary, cardiovascular and fluid derangements that are major causes of life-threatening complications.
Monitoring the airway, breathing and circulation is mandatory. The nature of the surgery and any comorbidities will determine the intensity of postoperative monitoring required; however, the patient’s pulse, blood pressure, respiratory rate, oxygen saturation, temperature and level of consciousness are observed routinely. Continuous electrocardiogram (ECG) monitoring is undertaken, and oxygenation is assessed using a pulse oximeter. If appropriate, wound dressings, the nature and volume of effluent into surgical drains and urinary output are also monitored. Monitoring of the central venous pressure (CVP) may be indicated depending on the gravity of the operation and the patient’s cardiorespiratory status.
A patient may initially remain intubated but following extubation should receive supplemental oxygen via a face mask or nasal prongs and encouraged to take frequent deep breaths. Shallow breathing may imply ongoing neuromuscular blockade requiring administration of a reversal agent. Cyanosis is an ominous sign indicating hypoxaemia that, in the early postoperative period, may be caused by airway obstruction or impaired ventilation.
Managing immediate postoperative complications in the recovery setting involves a combination of anaesthetic and surgical input. Acute cardiorespiratory issues will likely be primarily managed by the anaesthetic team. From a surgical perspective, haemorrhage is a significant potential early complication.
Intraoperative bleeding, i.e., primary haemorrhage, should be resolved during the operation. Any significant blood loss and required blood products should be recorded in the operation note, along with more intensive postoperative monitoring. Reactionary haemorrhage, arising within 24 hours of an operation, most commonly results from a slipped ligature, a missed vessel or the dislodgement of a diathermy coagulum as a patient’s blood pressure recovers. Significant blood loss into a surgical drain, particularly if associated with hypovolaemic shock, is an indication for immediate transfer back to the operating theatre for re-exploration and control of the bleeding source. Superficial bleeding into a surgical wound rarely requires immediate action; however, patients who have undergone a neck dissection must be monitored for this. If necessary, the wound can be reopened in the recovery area to prevent airway compression and asphyxia. Secondary haemorrhage typically occurs 7 to 10 days after an operation and may be due to infection eroding a blood vessel. Rigid drain tubes may also occasionally erode into a large vessel causing dramatic late postoperative bleeding.
11.1 Summary
Recovery in hospital
General care
Patients may be transferred from recovery to an intensive care unit, high dependency unit or surgical ward depending on the operative procedure, their progress and comorbidities. Monitoring of vital signs continues, along with observing output from the urinary catheter, nasogastric tube or surgical drain. The frequency of observations can generally be reduced as the patient recovers but should be increased again if there is clinical concern. Surgical ward rounds involve assessing vital signs and charts, a focused history and examination, reviewing available results and formulating a management plan. Reviewing the drug chart is important to ensure that regular medication and thromboprophylaxis are prescribed and administered, and that analgesia and antibiotic prescriptions are appropriate.
Analgesia
Effective postoperative pain relief is crucial to recovery, allowing the patient to mobilise as soon as possible, return to preoperative function and reduce the risk of deep vein thrombosis (DVT). Following thoracic and abdominal surgery, effective analgesia aids ventilation thereby reducing the risk of atelectasis and hospital-acquired pneumonia. The World Health Organisation (WHO) Analgesic Ladder should be considered, ranging from simple analgesics to weak opioids followed by strong opioids. As patients recover, it is important to step down the analgesic ladder as the side effects associated with stronger analgesics are generally more profound. A combination of analgesic medication is often required, and the route of administration should also be considered. A patient may return from theatre with an epidural, local anaesthetic wound catheters or patient-controlled analgesia (PCA).
Nausea and vomiting
Postoperative nausea and vomiting (PONV) is a significant issue for approximately 20% of patients. Clinical assessment must include the risk of aspiration, and insertion of a nasogastric tube may be required. For most patients, however, an antiemetic will settle their symptoms, and this can also be considered prophylactically, if the patient is at risk. Several risk factors related to the patient, anaesthetic and surgical parameters are recognised ( Summary 11.2 ).
Tubes, drains and catheters
If a nasogastric tube is present, free drainage of gastric contents may be supplemented by intermittent manual aspiration; the tube can be removed once the volume of aspirate diminishes. It is not necessary to wait until bowel sounds have returned or flatus has been passed. Nasogastric tubes are uncomfortable and may prevent coughing with expectoration, so they should not be retained for longer than necessary, if used at all. Surgical drains are generally removed when the nature and volume of effluent is satisfactory. If a urinary catheter has been placed, it should be removed once the patient is mobile.
Fluid balance
A regular assessment of fluid balance is very important for surgical patients. Guidelines on intravenous fluid therapy for adult surgical patients (GIFTASUP) were formulated by the British Association of Parenteral and Enteral Nutrition (BAPEN). More recently, guidelines on intravenous fluid therapy in adults in hospital have been published by the National Institute for Health and Care Excellence (NICE).
Key considerations are whether a patient needs intravenous fluid and if this is for resuscitation, routine maintenance or to replace existing deficits and/or ongoing losses. An understanding of both fluid and electrolyte status and requirements is essential. It is also crucial to consider a patient’s comorbidities when prescribing intravenous fluid, particularly those affecting the cardiorespiratory and renal systems.
Assessing a patient’s fluid and electrolyte requirements involves information gained from their history, clinical examination, observations and blood results. If a patient requires intravenous fluid for routine maintenance, the prescription should initially consist of 25 to 30 mL/kg/day of water; approximately 1 mmol/kg/day of sodium, potassium and chloride; and 50 to 100 g/day of glucose (NICE guidelines). In situations where there are ongoing losses, the electrolyte composition of the fluid should be considered and replaced; for example, gastric fluid is rich in sodium, chloride and potassium. When resuscitation is required, balanced crystalloids are generally recommended (e.g., Hartmann solution or Ringer’s lactate) rather than 0.9% saline to reduce the risk of hyperchloraemic acidosis; an exception is made in cases of existing hypochloraemia, often from vomiting or nasogastric drainage.
Blood transfusion
Haemoglobin measurement guides the need for postoperative blood transfusion. As a rule, blood transfusion should be considered when a patient’s haemoglobin level drops below 70 g/L (NICE guidelines). In patients with cardiac comorbidities, higher haemoglobin levels may justify transfusion. Patients should only receive blood transfusions when necessary, given the risks, including evidence that preoperative blood transfusions are associated with higher recurrence rates in some malignancies such as colorectal cancer. Intravenous and oral iron also have a role in treating iron deficiency anaemia both pre- and postoperatively. Please see Chapter 4 for a detailed account of blood transfusion.
Nutrition
Nutrition in postoperative patients is often poorly managed. A few days ‘without nutrition’ may cause little harm, but enteral or parenteral nutrition is essential if starvation is prolonged. Enteral nutrition is preferred, as it is associated with fewer complications and is believed to augment gut barrier function. If a prolonged period of starvation is anticipated in the postoperative period, a feeding jejunostomy tube can be inserted at the time of surgery. Alternatively, a fine-bore nasogastric or nasojejunal feeding tube can be passed (see Chapter 5 ). If the enteral route cannot be used, total parenteral nutrition can be prescribed. Dietary intake should be monitored in all patients in the postoperative period and oral high-calorie supplements given if appropriate.
Physiotherapy
After many operations, regular physiotherapy is important. This may be focused on the chest, following thoracic or abdominal operations, to reduce the risk of atelectasis and pneumonia. It is particularly important for patients with existing respiratory comorbidity. Physiotherapy to aid early mobilisation is important following orthopaedic and major abdominal surgery, facilitating an earlier return to baseline function and reducing the risk of developing DVT.
Enhanced recovery after surgery (ERAS)
Evidence-based multidisciplinary ERAS protocols were initially proposed for patients undergoing colorectal surgery around 20 years ago. Since then, these have been shown to reduce morbidity, length of hospital stay and overall costs. ERAS protocols are now utilised in many forms of cancer surgery and major benign operations, for example, orthopaedic, cardiac and bariatric surgery. Key aspects of most protocols include preoperative optimisation, patient education, limited fasting, minimally invasive surgical techniques when feasible, multimodal analgesia, prophylactic use of antiemetics, early oral intake, minimising intravenous fluids and early mobilisation.
Complications of anaesthesia and surgery
General complications
Postoperative complications arise frequently, and the aim of good postoperative care is early recognition, assessment and treatment to minimise their impact when possible. Although complications can be specific to certain operative procedures, most encountered complications are seen across all surgical specialties (see Summary 11.3 ).
11.3 Summary
Common complications of anaesthesia and surgery
Pulmonary
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Atelectasis
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Pneumonia
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Respiratory failure
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Pleural effusion
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Pneumothorax
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Acute respiratory distress syndrome (ARDS)
Cardiac
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Myocardial ischaemia/infarction
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Cardiac failure
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Arrhythmias
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Postoperative shock
Urinary
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Urinary retention
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Urinary tract infection
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Acute kidney injury
Cerebral
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Cerebrovascular accident
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Delirium
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