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Introduction 9/12/2019 Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e Chapter 87: Complications of General Surgical Procedures Edmond A. Hooker INTRODUCTION Outpatient surgical procedures are common, and with increasing pressure for cost containment, admitted patients are being discharged earlier in their postoperative course. As a result, more patients are coming to the ED with postoperative fever, respiratory complications, GU complaints, wound infections, vascular problems, and complications of drug therapy (Table 87-1). This chapter reviews the complications common to all surgical procedures and those specific to a single procedure. 1/24 9/12/2019 TABLE 87-1 Complications of General Surgical Procedures Complication Important Points Fever "Five Ws" (wind, water, wound, walking, wonder drugs) are common causes Pulmonary complications Atelectasis <24 h, treat with pulmonary toilet, discharge unless ill or hypoxemic Pneumonia 2–7 d, polymicrobial, most require admission Pneumothorax Multiple causes, consider expiratory views, consider needle aspiration Pulmonary Dyspnea is main symptom, high index of suspicion embolism GI complications Intestinal Obtain radiographs, search for causes obstruction Intra-abdominal CT diagnosis, early administration of broad-spectrum antibiotics abscess Pancreatitis Always consider in postoperative patients with abdominal pain Cholecystitis Usually in older patients, can be acalculous Fistulas Can be high output, admit if concerns over output GU complications Urinary tract 2–5 d, oral antibiotics, most discharged infection Urinary retention Rapid catheter drainage, most discharged 2/24 9/12/2019 Complication Important Points Acute renal Prerenal, renal, and postrenal causes, most admitted failure Wound complications Hematoma Caused by poor hemostasis, can drain most, but be careful with neck hematomas and hematomas aer vascular surgery Seroma Painless swelling, clear fluid, drain and discharge Infection Open, drain, and culture specimens; be careful with wounds associated with respiratory tract, GI tract, or GU tract, or secondary to trauma Necrotizing Pain out of proportion to physical findings fasciitis Dehiscence Be careful with abdominal incisions (potential for evisceration) Vascular complications Superficial Usually aseptic, provide local therapy and discharge thrombophlebitis Deep venous Upper and lower extremity, perform Doppler studies thrombosis Complications of drug therapy Diarrhea Consider pseudomembranous colitis Drug fever Many drugs implicated, requires admission Tetanus Can occur aer GI surgery Procedure-specific See text complications 3/24 9/12/2019 The operating surgeon should be called when one of his or her patients appears in the ED with a surgical complication. This is not just a courtesy, but provides continuity of care important for the patient's well- being. FEVER Fever is a common presenting complaint (Table 87-2). A mnemonic for the common causes of postoperative fever is the "five Ws": wind (atelectasis or pneumonia), water (urinary tract infection), wound, walking (deep vein thrombosis), and wonder drugs (drug fever or pseudomembranous colitis).1 Respiratory complications, such as atelectasis, and IV catheter–related problems, such as thrombophlebitis, are the predominant causes of fever in the first 72 hours. Necrotizing streptococcal and clostridial infections also occur in surgical wounds early in the postoperative course. 4/24 9/12/2019 TABLE 87-2 Common Causes of Postoperative Fevers in General Surgical Patients Cause of Fever Presentation Signs and Symptoms Diagnostic Test Treatment Atelectasis First 24 h Isolated fever; may have Chest Pulmonary toilet; tachypnea, dyspnea, radiography admission if unsure and/or tachycardia or patient is ill appearing Pneumonia 3–7 d Dyspnea, chest pain, Chest Admission and productive cough, fever, radiography coverage with and/or tachypnea broad-spectrum antibiotics Urinary tract 2–5 d Oen none; possibly Urinalysis Admission if patient infections dysuria is elderly or toxic Skin and so tissue 5–10 d Increasing pain, Examination, Drainage, packing, infection erythema, swelling, aspiration and outpatient drainage, and and/or opening antibiotic therapy tenderness at incision of wound site Thrombophlebitis <3 d Warm, tender, and None If not septic, warm (septic and sterile) swollen vein soaks If septic, surgical removal Deep vein 4–6 d Extremity swelling and US Admission and thrombosis pain anticoagulation Intra-abdominal 4–21 d Fever and elevated WBC CT Admission and abscesses count without specific antibiotic focal abdominal findings administration Pseudomembranous Anytime Diarrhea Stool testing Vancomycin colitis using administration immunoassay 5/24 9/12/2019 Cause of Fever Presentation Signs and Symptoms Diagnostic Test Treatment Peritonitis 4–21 d Tachycardia and CT Admission and abdominal pain, antibiotic peritoneal irritation administration Pulmonary Anytime Shortness of breath, CT or Admission and embolism tachypnea, and/or ventilation– anticoagulation hemodynamic instability perfusion scanning Transfusion reaction First 24 h Fever, chills Transfusion Admission check for depending on incompatibility condition of patient Urinary tract infections become evident 1 to 5 days postoperatively. Seven to 10 days postoperatively, clinical manifestations of wound infections develop. Deep venous thrombosis can result in fever any time but usually not until the fih postoperative day. Antibiotic-induced pseudomembranous colitis occurs up to 6 weeks postoperatively. An approach for evaluating and managing fever in postoperative patients is presented in Table 87-3. 6/24 9/12/2019 TABLE 87-3 Evaluation and Management of Postoperative Fever History Presenting signs and symptoms Onset of symptoms, time since procedure Procedures performed and complications Medications History of blood transfusion Physical examination Particular attention to Operative sites and contiguous areas Sites of catheters and invasive monitors Signs of deep venous thrombosis and pulmonary embolism Decubitus ulcers Lungs Ancillary studies CBC with dierential Chest radiograph Gram stain and culture of wound exudate Urinalysis (urine culture if infected) Sputum Gram stain and culture Blood cultures CT to exclude intra-abdominal pathology If diarrhea present, consider immunoassay of specimen for Clostridium diicile toxin Further tests as indicated (e.g., CT, radionuclide studies, venography, arteriography) Treatment If source identified, start antibiotics; admission based on condition of patient If no source identified, consider admission, change all catheters and culture catheter specimens, stop all medication that might cause fever RESPIRATORY COMPLICATIONS 7/24 9/12/2019 ATELECTASIS Atelectasis, the collapse of pulmonary alveoli, is very common. Contributing factors include inadequate clearance of secretions aer general anesthesia, decreased intra-alveolar pressure, and postoperative pain, which results in hypoventilation. Although atelectasis can occur aer any procedure, it frequently occurs aer upper abdominal and thoracic surgery. The presentation varies from an isolated fever to tachypnea, dyspnea, and tachycardia. Evaluation includes chest radiography, pulse oximetry, and a CBC. Chest radiographs may show normal findings or exhibit platelike linear densities, triangular densities, or lobar consolidation. Mild hypoxemia from ventilation and perfusion mismatch is common, but hypercarbia is uncommon. Patients with mild atelectasis and no evidence of hypoxemia may be managed as outpatients with pain control and increased deep breathing. Admission is indicated for aggressive pulmonary toilet and supplemental oxygenation in debilitated patients, patients with underlying lung disease, patients with hypoxemia, or those in whom the diagnosis is in question. PNEUMONIA Pneumonia usually becomes evident between 24 and 96 hours postoperatively. Predisposing factors include prolonged ventilatory support and atelectasis. Presenting symptoms can include dyspnea, chest pain, productive cough, fever, and tachypnea. Postoperative pneumonia is likely to be polymicrobial. Aer specimens of sputum and blood are obtained for culture, parenteral antimicrobial therapy is given. There are many options for polymicrobial coverage. One option is levofloxacin, 750 milligrams IV once daily, and vancomycin, 1 gram IV twice daily. Admission to the hospital is generally indicated. PNEUMOTHORAX Pneumothorax can occur as a complication of thoracic wall surgery, breast biopsy, laparoscopic abdominal surgery, abdominal paracentesis, nasogastric and feeding tube insertion, thoracic surgery, central venous catheter insertion, endoscopic procedures, shoulder arthroscopy, and tracheostomy. For further discussion, see chapter 68, "Pneumothorax." PULMONARY EMBOLUS Pulmonary embolism may present any time during the postoperative period. For further discussion of signs, symptoms, and treatment, see chapter 56, "Venous Thromboembolism." GU COMPLICATIONS URINARY TRACT INFECTION Urinary tract infections can occur aer any surgical procedure, but the incidence increases in patients who have undergone instrumentation of the GU tract or bladder catheterization. The cause is direct 8/24 9/12/2019 contamination of the urinary bladder, most commonly with Escherichia coli. Other organisms isolated include Staphylococcus aureus, Staphylococcus epidermidis, Proteus mirabilis, Klebsiella, Pseudomonas, and enterococci. Oral antibiotics (ciprofloxacin, 500 milligrams PO twice daily, or levofloxacin, 750 milligrams
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