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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.

TABLE 87-1Complications of General Surgical Procedures
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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 embolism Dyspnea is main symptom, high index of suspicion
GI complications
 Intestinal obstruction Obtain radiographs, search for causes
 Intra-abdominal abscess CT diagnosis, early administration of broad-spectrum antibiotics
 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 infection 2–5 d, oral antibiotics, most discharged
 Urinary retention Rapid catheter drainage, most discharged
 Acute renal failure Prerenal, renal, and postrenal causes, most admitted
Wound complications
 Hematoma Caused by poor hemostasis, can drain most, but be careful with neck hematomas and hematomas after 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 fasciitis Pain out of proportion to physical findings
 Dehiscence Be careful with abdominal incisions (potential for evisceration)
Vascular complications
 Superficial thrombophlebitis Usually aseptic, provide local therapy and discharge
 Deep venous thrombosis Upper and lower extremity, perform Doppler studies
Complications of drug therapy
 Diarrhea Consider pseudomembranous colitis
 Drug fever Many drugs implicated, requires admission
 Tetanus Can occur after GI surgery
Procedure-specific complications See text

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.

TABLE 87-2Common Causes of Postoperative Fevers in General Surgical Patients
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