Postoperative Complications

This article is for second- and third-year nursing students. It assumes that the students have the passed all the pre-requisites to reach the second and third years. Knowing and understanding post operative complications is essential knowledge for students and qualified nurses working in hospitals.

A cursory look at the 30 day mortality figures shows that some patients die within 30 days after surgery. Some of these deaths are due to preventable complications. It is for this reason that good post operative care is essential. It should be a priority of the entire treatment team and associated professionals to prevent post operative complications.

All surgical procedures and interventions have complications. Simpler procedures involving local anaesthesia have lesser complications than major interventions involving the heart and brain. Very young children, older people, and more frail individuals are more likely to succumb to surgical interventions or their complications than younger and healthier patients.

Postoperative complications can be subdivided in many different ways. However, I have chosen to subdivide them into immediate, short term and long term complications related to surgery and anesthesia. Anesthetic complications are those which are related to the anesthesia, including hypoventilation, and changes in the level of consciousness. Surgery related complications are those which are specifically due to the procedure; Generally these are at the site of the procedure but may become systemic when the whole body becomes involved for example bacteremia and septicemia. It must be remembered that these are artificial divisions for learning purposes. In practice the patient must be seen holistically.

The table below shows the frequency of complications following major orthopedic surgery. Higher risk surgeries have more complications and less serious surgeries have fewer complications. Mortality figures from different surgeries are shown in table two at the end of this article. Prevention and early intervention can affect 30 day mortality figures and patient outcomes.

Table 1: Frequency of systemic complications after major orthopedic surgery.

During the transfer of a patient from the recovery room to the ward it is important for the nurse to have the following equipment: airway, portable supply of oxygen and a portable suction machine. This is because the patient’s breathing is compromised by anaesthesia and the surgical procedure. Walled oxygen and suctioning equipment are not available during transport. We know that the patient may need support during this time. All hospitals are equipped with portable suction machines and oxygen cylinders for this purpose. If not you should recommend this to the person in charge.

Post Operative Complications: Immediate

Medications used to anesthesia patients decrease the patient’s respiratory rate and tidal volume. This may result in the patient having low levels of oxygen in the blood. This is called hypoxemia. In severe cases this will lead to confusion, palpitations, and irregular heartbeats. Severe hypoxia may result in coma and death of the patient. Follow the principles of airway, breathing and circulation (ABC) checks. It is routine to check these parameters. If the patient is coughing and clearing his throat it is a good sign. It means that his gag reflex is intact and that he has the strength to clear his airway. Make sure that the patients color is good, that lung expansion is equal bilaterally and that oxygen saturation is above 95% at all times.

Nurses caring for patients who are anesthetised must not leave any patient under any circumstances. Such patients must always be connected to a pulse oxymeter, cardiac monitor and a respirator unless the patient is being wakened following surgery.

If you as a Student Nurse accompany a Registered Nurse to receive a patient from the operating theater note the procedures being performed very carefully. Note how the Recovery Room Nurse formally hands over the patient to the Ward Nurse. Usually, the receiving nurse has to sign that she has received the patient. This implies that the patient is fit to be transferred to the ward. So if you are the nurse receiving the patient you must not agree to take the patient back to the ward if he is not breathing satisfactorily or is not sufficiently awake. Other reasons for not taking the patient back to the ward include excessive bleeding and unsatisfactory vital signs.

Low Blood Pressure or hypotension

This is another complication which is seen frequently. It may be the result of a number of intra operative situations. These include bleeding, movement of fluids, certain medications, heart failure, and infection. A patient who is hypotensive is likely to complain of light-headedness, confusion and generalized weakness. If hypotension is severe it may lead to abnormal cardiac rhythms, coma and death. Take the patient’s blood pressure carefully before you transfer him to the ward. If he is hypotensive correct this condition before taking him to the ward. If the situation is not correctable the patient may need closer observation by a special nurse or may need to be transferred to the High Dependency Unit or the Intensive Care Unit.

In addition to checking the blood pressure it is a good practice to check capillary refill and peripheral perfusion.

Always inspect the patient’s wound before transferring him to the patient. Heavily blood stained dressings are indicative of severe external bleeding. The surgeon and treatment team must be aware of the patient’s condition. Sometimes there is continuous bleeding; at other times the solution may be a simple one. For example: All that is needed is extra padding.

Document the vital signs of the patient when you receive him and also when the patient reaches the ward.

Airway problems are common immediately after the patient has been “reversed” and the endotracheal tube has been removed. When the patient is undergoing surgery an endotracheal tube is used to ventilate the patient with a respirator. After reversal the patient is able to breathe for himself. Initially, the patient may be restless and may cough quite a lot because the ETT causes localized irritation. The patient may cough up sputum or specks of blood. If the patient coughs up food please notify the anesthetist as the patient may have aspirated. Suction the patient’s mouth and airway to clear it of foreign particles.

A nurse receiving the report on a patient who is compromised from a respiratory should not agree to transfer the patient to the ward because both operating theater and Intensive Care Units are better able to deal with patients that are compromised or have aspirated.

The nurse caring for the patient will need to attend to the patient immediately if he is wheezing or complains of chest pain. Most often pulmonary (lung) complications arise due to lack of deep breathing during the post operative period. Pain and discomfort after a surgical procedure makes it hard to take deep breaths or cough to clear pulmonary secretions. Deep breathing exercises and use of incentive respirometer are recommended to help clear secretions.

Thirst

Thirst is defined as the desire to have a drink, usually of water. In the post operative stage this is often very severe. As stated earlier the patient has been starved and dried out for the last 20 or so hours. Further, he has had a tube inserted into his dry throat and the cuff inflated in the throat.

When the patient wakes up he is most likely to ask to have a drink of water. Many a times, he is not able to speak. Do anticipate this. Give him a sip of water if not contraindicated. If contraindicated, then allow him to gargle his mouth or moisten it with a small chip of ice.

Listen (auscultate) for abdominal sounds. If present and water is not contraindicated then water may be given. Start of with sips of water. A lot of water, given quickly, will result in vomiting.

Urinary retention

This is another frequent complication of anesthesia particularly in older male patients. This complication will become evident after a few hours when the patient has not passed urine. A number of strategies can be implemented to help the patient void. These include sitting the patient on the side of the bed, running the tap, standing him up and letting him have a shower. If all interventions fail it may me necessary to catheterize the patient. A doctors order will be necessary for this procedure. Urinary Retention has been included in this section because it is due to the effect of an anesthetic gases and lying down for a prolonged period of time.

Picture of an intubated patient. The ETT is connected to a catheter mount. A face mask is ready to be placed on the face as soon as the ETT is removed.

Nausea and vomiting

Patients recovering from anesthesia often complain of nausea and vomiting. Vomiting is defined as forcing the contents of the stomach out through the esophagus to the exterior. Nausea is defined as having the urge to vomit.

The human body has many ways to respond to medications and poisons which have been introduced into it. Sneezing ejects dust / pollen / irritants from the nose. Coughing helps clear the lungs and throat. Diarrhea clears the intestines. Similarly nausea and vomiting clear the stomach.

Vomiting is a forceful action accomplished by a fierce, downward contraction of the diaphragm. At the same time, the abdominal muscles tighten against a relaxed stomach with an open sphincter. The contents of the stomach are propelled up and out. Vomiting is a complex reflex act which is coordinated by the vomiting center of the brain in response to signals from the mouth, stomach, and intestines. This is generally in response to medications (anesthetics and medications) or infections in the blood stream.

Allergic Reactions to Anesthetics and Medications.

An allergic reaction is said to occur when an allergen is introduced into the human body through the skin, inhaled through the lungs, swallowed, or injected.

During history-taking it is imperative that the patient be asked if he is allergic to any food, medication or environmental substance. Allergic reactions are common, hay fever is an allergic response. Mild hay fever may be treated at home but severe allergic responses can life-threatening.

First time exposure to an allergen does not usually produce any reaction. However repeated exposures may lead to more serious reactions which may be life threatening. Generalized allergic responses may cause the patient to go into an anaphylactic shock, broncho spasm or generalized rash. Most of the time an allergic reaction occurs the moment exposure occurs. However, sometimes a reaction develops after 24 hours.

Anaphylaxis

This is defined as a sudden and severe allergic reaction which has occurred within minutes of exposure. This is a medical emergency and immediate medical intervention must be called for. The patient’s condition will deteriorate very rapidly and death may occur within 15 minutes in the absence of proper treatment.

Respiratory depression

Anesthetic medications and pain relieving medications often depress the respiratory rate. In severe cases the patient may stop breathing and go into a period of apnea or respiratory arrest. Both these conditions may be short term or prolonged depending upon the amount of medications on board and the general health of the patient. Prolonged apnea means that patient had a respiratory arrest. Prolonged apnea (respiratory arrest) is a life-threatening condition and is a medical emergency which requires immediate medical attention and first aid. If you are in Australia call code blue if your patient is not breathing.

Complications of apnea include cyanosis, seizures, cardiac arrest, coma and death.

Apnea is induced for many surgical procedures. However, it can occur for many different reasons. Apnea in infants and small children is the most common cause of cardiac arrest and death. However, in adults respiratory arrest usually leads to cardiac arrest.

Pain and localized swelling around the incision site.

Pain and localized inflammation are common complications. Larger wounds will cause more pain and swelling. Smaller wounds will cause less discomfort. Appropriate pain management, bandaging, rest, and/or elevation are all essential to facilitate quick recovery.

Post Operative Bleeding: (hemorrhage)

Postoperative bleeding is subdivided into three types. These occur at different times, for different reasons and need to be managed differently.

1. Immediate bleeding: This occurs when true haemostasis is not achieved at the completion of the surgical procedure. If the bleeding is small then a pressure dressing or !0 x 10 cm. sq. gauze may be sufficient. Irrespective of the nurses’ intervention, always notify the surgical team.
2. Reactionary bleeding. This occurs within 48 hours of surgery and is due to the rise in blood pressure. During surgery blood pressure is low because of the large amount to anesthetic gases and pain medications. The rise in blood pressure opens up the divided blood vessels. These blood vessels were not bleeding at completion of surgery. In this situation only an extra bandage may be needed. Keep the treatment team notified of developments. If the bleeding does not stop then the patient may need to be taken back to theater.
3. Secondary bleeding: This occurs, usually around day seven, following surgery. It is often due to blood clots being destroyed by infection. Ulceration of local blood vessels may also cause secondary bleeding. This can be prevented by controlling infection. Managing the infection will bring about control of this type of bleeding. Immediate application of a pressure bandage will be needed. The surgeon will decide if the use of adrenaline or other clotting agent is indicated.

Soreness in the throat / sore throat

Post operative sore throat is usually due to a combination of factors. The dehydration, insertion of the endotracheal tube and inflation of the cuff all contribute to post operative sore throat. For many patients this may be a minor complication which will resolve spontaneously. For others it may be severe enough to cause full fledged sore throat and chest infection. As soon as the patient returns from the operating theater he should be given oral care. Mouth moistening agents should be used. When he is awake mouth gargles with plain water or slated water will be useful.

Mouth care is always nurse initiated and should be repeated at frequent intervals. Mouth care is even more important for patients who are on antibiotics and are not eating or drinking, as is usually the case postoperatively.

Restlessness and sleeplessness

These uneasy feelings are best equated with the “hangovers” associated with binge drinking. These feelings can be controlled be administering the right amount of pain medication and allowing the patient to get rid of anesthetic gases by returning to normal eating and drinking as soon as possible. Staying with the patient and telling him that surgery is over can be reassuring. Sometimes, it may be useful to request a family member to stay with the patient.

Patient safety is of utmost importance during this “restless stage” stage. Make sure that the cot sides are up and that the patient can be seen from the nurses station. If restlessness is severe then it may be necessary to have a medical assessment. If no medical reason is found, in the interest of patient safety it may be necessary to have an Enrolled Nurse or Patient Care Assistant stay with the patient.

Post operative complications: Intermediate

This group of complications may arise any time but generally arise after the second post operative day. These complications are not less important than immediate complications but their patho physiology is somewhat different and the underlying causes are different.

Pulmonary Embolus

In this condition a clot of blood which probably formed in a vein of the leg becomes dislodged and blocks an artery in the lungs. Additionally fat, air and tumor cell emboli are also know to occur. Risk factors for PE are Prolonged bed rest or inactivity (including long trips in planes, cars, or trains), oral contraceptives, surgery, childbirth, trauma and burns. Patients with certain clotting disorders have a higher risk.

Symptoms of PE include cough, desaturation (oxygen), bloody sputum, tachycardia, shortness of breath and splinting of the ribs. In extreme cases wheezing, clammy skin, cyanosis, nasal flaring, swelling in legs, lightheadedness, fainting, extreme anxiety and sweating will be present.

The picture below shows a blood clot in the pulmonary artery – a pulmonary embolus.

Deep Venous Thrombosis

This is a condition in which a clot of blood forms in a vein which is located deep inside the body. Post operatively this occurs in the veins of the legs. This post operative complication is caused by blood stasis, derangement of clotting factors and the inflammatory processes which occur during surgery and after surgery.

This clot of blood can interfere with blood flowing back to the heart. If this occurs there will be edema and pain in the affected leg. Alternatively the blood clot may break off and travel through the heart and cause occlusion in the pulmonary artery (pulmonary embolus).

Clots of blood can lodge in the brain, lungs heart or any other organ with devastating effects for the patient.

Common risks for DVT are prolonged sitting (including long car rides and air travel) or bed rest during and after surgery. Hip surgery, knee surgery and gynecological surgeries are more likely to cause DVT than other surgeries. Patients who have cancer and are older than 60 years are also in the high risk category.

The nurse looking after a post operative patient must always be alert to the possibility of this complication. In Australia, it is standard practice to administer heparin following surgery or to use foot pumps and anti-embolitic stockings (TEDS). Prevention of DVT is instrumental in the prevention of pulmonary embolus.

Warfarin, heparin, enoxaparin are frequently used in the prevention of DVT. A system called the International Normalized Ratio (INR) is used to measure the ability of the patient’s blood to clot properly. The patient’s treatment team of Doctors will adjust warfarin to keep the INR between 2 and 3. It is the Nurses responsibility to inform the doctor as soon as a PTT or INR results arrive from the laboratory.

Deep venous thrombosis can lead to PE. PE is one of the most frequent causes of sudden deaths in the post operative patient.

Post operative fever

ost operative fever has been studied extensively. It is a common phenomenon. Studies show that patients develop fever post operatively even when there is not underlying infection. This fever normally subsides on or about the fourth post operative day, depending upon the type of operation.

Post operative fever is often due to the five Ws: Water, Wind, Walk, Wound, & Weird drugs.
WATER = urinary tract infections.
WIND = Respiratory tract infections.
WALK = Deep Venous Thrombosis
WOUND = surgical wound infection, inflammation
WEIRD DRUGS = drug fever

Myocardial Infarctions

A myocardial infarction (heart attack) is said to occur when reduced blood flow causes the heart muscle to starve for oxygen. Heart muscle may die or become permanently disabled. A heart attack is a medical emergency and must be managed as such.

There are many causes of heart attacks. In this section we are concerned those which are surgery related. Emotional stress and surgery can cause an MI.

When caring for a post operative patient the Nurse must be alert to signs and symptoms of a heart attack. Pain in the chest, radiating into the left arm associated with nausea, vomiting and peripheral shut down are the most common S&S. However, some heart attacks may be silent. Elderly patients and diabetics are most likely to suffer from silent heart attacks. Any discomfort in the chests the patient may have in the chest.

THROMBOLYTIC THERAPY cannot be used for post operative patients but early interventions with other nursing and medical interventions can be life saving. Aspirin 150 to 325 mg should be administration as soon as possible.

Post Operative Complications: Long Term

These post operative complications can arise at any time but generally arise a few days after surgery.

Failure of wound to heal / Wound dehisence

Following surgery it is important the nurse to plan for optimal recovery of the patient. This includes taking all necessary steps to promote wound healing. Patients who are poorly nourished, chronically ill, and have other co-morbidities are likely to have delayed wound healing. Psychiatrically ill patients or other patients who place stress on a new wound may burst the stitches. If the wound is not healing well then the treatment team must be informed.

Constipation

This is defined vaguely as, “lack of regular bowel movements”. Scientifically constipation refers to infrequent or hard stools, or difficulty passing stools. Constipation may also involve pain during the passage of a bowel movement, inability to pass a bowel movement after straining or pushing for more than 10 minutes, or no bowel movements after more than 3 days.

Post-operative constipation

This is due to a combination of several factors surrounding the pre, intra and post operative processes. “Nil by mouth” pre-operatively leads to dehydration and slowing down of the motility of the intestinal tract because there is no stimulation of the stretch receptors in the GI tract. Dehydration is common as fluid is lost during the operative procedure. Lastly, many medications, including atropine (administered to dry up secretions in the mouth) and morphine (pain relief) are constipating. In the healthy adult constipation is most often caused by a low-fiber diet, lack of physical activity, not drinking enough water, or delay in going to the bathroom when the urge to defecate arises, particularly after breakfast. Stress and travel can also contribute to constipation. Early return to regular fluid intake, normal activity, fiber intake, correction of dehydration will reduce the probability of constipation.

Paralyitc ileus

This is a common complication following abdominal surgery. It is defined as a partial or complete blockage of the bowel which results in the failure of the intestinal contents to pass through. The nurse receiving the patient from the operating theater must auscultate the abdomen to listen for abdominal sounds. Early auscultation and detection a hypoactive bowel will facilitate early intervention. Paralytic ileus is sometimes called pseudo-obstruction, in children, it is the major cause of intestinal obstruction.

Other causes of paralytic ileus include narcotic medications, mesenteric ischemia, intraperitoneal infections. Mesenteric ischemia (decreased blood supply to the support structures in the abdomen sometimes occurs when the abdominal organs are moved in the abdomen during surgery.

Nosocomial (hospital acquired) infections

Nosocomial infections are frequent causes of delayed wound healing. It is for this reason that many hospitals discharge patients early if home care is available. Nosocomial infections cost millions of dollars each year to treat and manage. Proper and aseptic wound care techniques are important in preventing nosocomial infections. If a post operative wound appears infected notify the physician. Also take a wound swab when doing the wound dressings and send it to the laboratory for M,C&S. Microscopy, Culture and Sensitivity.

Nosocomial infections are best prevented by following proper aseptic techniques before, during and after the operation both in the ward and in the operating theater.

Generalized weakness

Surgery, patho physiology of the underlying disease, effects of pre, intra and post operative medications cause the patient to be generally weak. In some conditions the patient may end up being on bed rest for a prolonged period. Also short periods of bed rest can weaken the patient significantly. It is for this reason that early ambulation is always aimed for. When a patient is in bed passive exercises should be given either by a Registered Nurse or a physiotherapist.

Studies show that circulation to the brain increases by 20% during passive exercises to the limbs. Muscle tone and strength can be maintained, during prolonged periods of bed rest, with active and passive exercises. Foot drop, DVT and PE can also be prevented with these interventions.

If the patient is able to move then he should be encouraged to be as active as is necessary for his condition.

Postoperative depression and Dysthymia are common post operatively.

The degree of depression is on a continuum, minimal depression is often described as “feeling sad, blue, unhappy, miserable, or down in the dumps”. However clinical depression is characterized by sadness, loss, anger, or frustration that interfere with everyday living for an extended period of time. This may be a reaction to a real or a perceived loss. Depression will affect recovery time. If your patient displays any of the following signs and symptoms then the treatment team needs to be informed.

1. Trouble falling asleep or excessive sleeping
2. Loss of appetite, often with weight gain or loss. This will be difficult to assess if the patient has come in for minor surgery.
3. Fatigue, lack of energy and lethargy
4. Feelings of worthlessness
5. Self-hate and loss of temperament with others
6. Inappropriate guilt for minor reasons
7. Extreme difficulty focusing on simple tasks
8. Agitation, restlessness, and irritability
9. Inactivity and withdrawal from usual activities
10. Feelings of hopelessness and helplessness
11. Recurring thoughts of death and suicidal ideation

Sometimes a stressful or unhappy event (surgery) may trigger onset of a depressive episode. Therefore the nurse needs to be constantly vigilant about the occurrence of depression. A disappointing prognosis, social isolation and unfamiliar surroundings are more likely to cause depression.

Gait abnormalities

These abnormalities are defined as walking abnormalities due to “loss of” or “disturbed” control from the CNS. Common causes include anesthetic gases, pain medications, disturbances in the cochlea of the ear (balance system) and diseases of the legs, feet, brain, and spine.

Abnormal gait should resolve shortly after surgery. If it does not, then notify the treatment team. If it is a post operative complication then it must be investigated and treated.

Post surgery abnormal gaits must be differentiated from abnormal gaits which existed before surgery. These may include:

1. Inner ear disturbances (vestibular abnormalities) and vertigo
2. Disorders of the Central nervous system – brain problems which cause muscular problems resulting in gait disturbance. Multiple sclerosis and cerebral palsy are two examples.
3. Degeneration, diseases and trauma of the Spinal cord

Table 2. Thirty-day mortality rate and complications, by type of surgery (
n = 1102)

(* includes faciomaxillary surgery)

Flatulence

Flatulence is commonly called “farting”. It is usually due excessive gas in the bowel. Post operative flatulence is rare. It is due to “swallowed air” or to air which entered the stomach during intubation and ventilation. In fact flatulence is to be observed for in patients who have had abdominal surgery. Here, the presence of flatulence indicates the return of normal bowel functioning. Post operative flatulence normally resolves spontaneously when the patient becomes ambulatory and resumes normal activities.

Hiccups

This is a common complication after abdominal surgery. A hiccup is defined as a forced, involuntary expiration. It is usually caused by spasm of the diaphragm. The distinctive sound of a hiccough is produced closure of the vocal cords.

Hiccups are not dangerous or life threatening but they can be extremely uncomfortable to the patient and the person caring for the patient. Nursing interventions which have been shown to be effective include taking deep breaths, swallowing a sip of cold, loosening clothing around the waist and the valsalva manoeuvre.

Medical interventions include the prescription of a small dose Chlorpromazine PO. In my experience it has never worked.

Disclaimer: This article is for education purposes only. It may not be used for diagnosis or treatment. Only qualified and registered doctors are authorised to diagnose and treat patients.