As an increasing number of surgical procedures occur in outpatient settings and inpatient lengths of stay decrease, the emergency physician will encounter more postoperative patients and their complications. Common clinical situations presenting to the emergency department include: fever, respiratory complications, genitourinary complaints, wound infections, vascular problems, and complications of drug therapy. Specific problems not covered in other chapters of this book are discussed here.
The causes of postoperative fever are the 5 Ws: wind (respiratory), water (urinary tract infection [UTI]), wound, walking (deep venous thrombosis [DVT]), and wonder drugs (drug fever or pseudomembranous colitis [PMC]). Fever in the first 24 hours is usually due to atelectasis, but wound infections with necrotizing fasciitis, or clostridial infections must also be considered. In the first 72 hours, pneumonia, atelectasis, intravenous catheter-related thrombophlebitis, and infections are the major causes. UTIs are seen 1 to 5 days postoperatively. DVT does not typically occur until 5 days after the procedure, and wound infections generally manifest 7 to 10 days after surgery. Antibiotic-induced PMC is seen 6 weeks after surgery.
Postoperative pain, splinting, and inadequate clearance of secretions lead to atelectasis. Fever, tachypnea, tachycardia, and mild hypoxia may be seen. Pneumonia may develop 24 to 96 hours later (see Chapter 30). Pulmonary embolism can occur any time postoperatively (see Chapter 25).
UTIs occur after any procedure, but more commonly after instrumentation of the GU tract or bladder catheterization. Elderly men, patients undergoing anorectal or prolonged operations, and those receiving spinal or epidural anesthesia are at increased risk for urinary retention presenting with lower abdominal pain and the inability to urinate (see Chapter 54). Decreased urine output should raise concerns for renal failure resulting from multiple causes, particularly volume depletion (see Chapter 50).
Hematomas with pain and swelling at the surgical site result from inadequate hemostasis. A small portion of the wound may be opened to rule out infection. Seromas are collections of clear fluid under the wound. Wound infections present with pain, swelling, erythema drainage and tenderness. Risk factors include extremes of age, diabetes, poor nutrition, necrotic tissue, poor perfusion, foreign bodies, and hematomas. Necrotizing fasciitis should be considered in a systemically ill patient with rapidly expanding infection and pain out of proportion to examination (see Chapter 90). Superficial or deep fascial wound dehiscence can occur due to diabetes, poor nutrition, chronic steroid use, and inadequate or improper closure of the wound. Operative exploration may be required to determine the extent of dehiscence.
Superficial thrombophlebitis manifests with erythema, warmth, and fullness of the affected vein. It usually occurs in the upper extremities after intravenous catheter insertion or in the lower extremities due to stasis ...