What are common post-operative complications and management strategies for an adult patient with a history of general surgery?

Common Ward Calls in General Surgery and Management Solutions

Most Frequent Post-Operative Complications by Timing

The majority of post-operative complications occur within 1-3 days after surgery (43%), with specific complications following distinct temporal patterns that guide diagnosis and management. 1

Early Complications (< 24 hours)

• Hypotension (43% of cases occur in first 24 hours) - Assess for bleeding, hypovolemia, or cardiac causes; resuscitate with balanced crystalloids and identify source 1
• Myocardial infarction (47% occur within 24 hours) - Obtain ECG and troponins; initiate cardiology consultation 1
• Respiratory depression (55% occur within 24 hours) - Reduce opioid dosing, consider naloxone if severe, ensure adequate ventilation 1

Days 1-3 Post-Operatively

• Congestive heart failure (46% occur days 1-3) - Diuresis, fluid restriction, cardiology consultation 1
• Pulmonary embolus (50% occur days 1-3) - CT angiography if suspected, anticoagulation per protocol 1
• Respiratory failure (76% occur days 1-3) - May require reintubation, incentive spirometry, chest physiotherapy 2, 1
• Acute kidney injury (31% occur days 1-3, with second peak at days 8-30) - Check creatinine, hold nephrotoxic medications, ensure adequate hydration 3, 1

Days 4-7 Post-Operatively

• Pneumonia (38% occur days 4-7) - Chest X-ray, sputum cultures, antibiotics; selective nasogastric decompression reduces risk 2, 1
• Atelectasis - Incentive spirometry and deep breathing exercises are effective prevention strategies 2

Days 8-30 Post-Operatively

• Sepsis (71% occurs days 8-30) - Blood cultures, imaging for source (abscess, anastomotic leak), broad-spectrum antibiotics 1
• Cerebrovascular accident (53% occurs days 8-30) - Neurological examination, CT head, neurology consultation 1
• Anastomotic leak (typically 5-14 days) - Water-soluble contrast study, manage conservatively with drainage, antibiotics, NPO, and jejunal feeding if contained; reoperation if unstable 2

Throughout Post-Operative Period

• Cardiac arrhythmias - ECG, electrolyte correction, rate/rhythm control as indicated 1
• Gastrointestinal bleeding - Hemoglobin monitoring, endoscopy if indicated, transfusion if necessary 1

High-Risk Patient Populations Requiring Enhanced Monitoring

Patients with specific risk factors require intensified surveillance using physiological track-and-trigger systems to prevent failure to rescue. 2

Elderly and Frail Patients (≥65 years)

• Screen for frailty using validated tools - Frail patients have dose-dependent increased failure to rescue rates 2
• Comprehensive geriatric assessment - Proactive CGA improves outcomes in emergency laparotomy patients 2
• Higher risk of delirium - Monitor with validated delirium screening tools 3

Patients with Comorbidities

• COPD patients (OR 1.79 for pulmonary complications) - Incentive spirometry, deep breathing exercises, selective nasogastric decompression 2
• Diabetic patients - Stop metformin the night before surgery; do not restart until 48 hours post-operatively with confirmed adequate renal function (eGFR ≥60 mL/min) 2, 4
• Patients on anticoagulation - Monitor for bleeding complications; most strabismus surgeons do not routinely stop anticoagulants 2

Surgery-Specific Risk Factors

• Emergency surgery - Higher complication rates than elective procedures 5
• Open versus laparoscopic approach - Open surgery associated with higher complication rates 5
• Prolonged operative time - Significant risk factor for complications 5
• Contaminated/dirty wounds - Higher infection risk 5

Specific Management Protocols

Fever Management

• Postoperative fever is common - Systematic evaluation for infectious (wound infection, pneumonia, urinary tract infection, deep abscess) versus non-infectious causes (atelectasis, drug fever, thrombophlebitis) 3
• Timing guides differential - Very early fever (<48 hours) often atelectasis; later fever (>3 days) more concerning for infection 3

Postoperative Nausea and Vomiting

• Ondansetron 8 mg twice daily - Most common adverse reactions include headache (24%), malaise/fatigue (13%), constipation (9%) 6
• Monitor for serotonin syndrome - Especially with concurrent SSRIs/SNRIs 6
• QT prolongation risk - Use caution in patients with cardiac risk factors 6

Nasogastric Tube Management

• Selective use superior to routine use - Significantly lower rates of pneumonia and atelectasis with selective (only if symptomatic) versus routine nasogastric decompression after abdominal surgery 2
• No difference in aspiration rates - Between selective and routine approaches 2

Pain Management

• Short-acting neuroaxial blockade reduces pulmonary complications - Compared to long-acting neuroaxial blockade 2
• Epidural analgesia superior to other opioid routes - For preventing postoperative pulmonary complications 7

Failure to Rescue Prevention

The difference between high and low mortality hospitals is not complication incidence but effective rescue once complications occur. 2

• Implement physiological track-and-trigger systems - MEWS or NEWS calculated from routine ward observations 2
• Rapid response team activation - Including intensivist experienced in postoperative surgical patients 2
• Higher nurse-to-patient ratios - Modifiable institutional factor that reduces failure to rescue 2
• Infectious and pulmonary complications are synergistic - Create cascade of complications requiring early intervention 2

Key Preventive Strategies

Respiratory Complications

• Incentive spirometry and deep breathing exercises - Good evidence for risk reduction 2
• Smoking cessation 4-8 weeks preoperatively - Significantly reduces respiratory and wound-healing complications 7
• Avoid routine nasogastric decompression - Use selectively only 2, 7

Renal Protection

• Metformin management critical - Stop night before surgery, restart only after 48 hours with confirmed eGFR ≥60 mL/min to prevent lactic acidosis (mortality 30-50%) 2, 4
• Adequate hydration with balanced crystalloids - Especially in patients on ACE inhibitors, ARBs, or diuretics 4

Infection Prevention

• Wound classification guides antibiotic prophylaxis - Clean, clean-contaminated, contaminated, or dirty 5
• Implementation of infection control practices - Reduces postoperative complications 5

Common Pitfalls to Avoid

• Missing early signs of anastomotic leak - High index of suspicion required; contrast studies may miss clinically significant leaks 2
• Restarting metformin too early - Must wait 48 hours and confirm adequate renal function 2, 4
• Routine rather than selective nasogastric decompression - Increases pneumonia risk 2
• Inadequate monitoring of high-risk patients - Frail elderly and those with multiple comorbidities require enhanced surveillance 2
• Delayed recognition of complication cascade - Initial pulmonary or infectious complication can trigger multiple secondary complications 2