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postoperative complication

Etiology: - risk factors for post-operative mortality (see mortality under Complications) - frailty, opioid use - risk factors for postoperative delirium (see delirium under Complications) Complications: 1) delirium a) advanced age b) history of alcoholism c) pre-existing cognitive impairment d) pre-existing physical impairment e) metabolic abnormalities f) > 50% risk of postoperative delirium with 3 or more of above g) dexmedetomidine may diminish postoperative delirium [15] - may not be beneficial after extubation h) perioperative gabapentin may increase risk of delirium & antipsychotic use [24] 2) immobility (mobilize early & aggressively) a) pressure ulcers b) osteoporosis c) pulmonary: atelectasis, aspiration, pneumonia d) thromboembolism: 1] deep vein thrombosis 2] pulmonary embolism, especially abdominal surgery [2] 3] risk of venous thromboembolism may be elevated for 12 weeks after surgery in women [4] 4] risk of venous thromboembolism greatest in 1st 12 weeks after surgery 5] increased risk for venous thromboembolism persists for 12 months [3] 6] risk for arterial thrombosis or venous thrombosis is increased by sepsis (RR=3.3), septic shock (RR-5.7) & systemic inflammatory response syndrome (RR=2.5) [10] 7] venous thromboembolism more common after transfusion (RR=2) [18] e) cardiovascular deconditioning: decreased cardiac output & stroke volume, orthostatic hypotension f) metabolic/endocrine: insulin resistance, altered Ca+2 metabolism, negative nitrogen balance g) sensory deprivation, loneliness, depression h) fecal impactation, constipation 3) post-operative nausea & vomiting 4) malnutrition a) generally associated with poorer surgical outcomes b) patients most likely to benefic from peri-operative nutritional support 1] > 10% weight loss (in last 3 months) & 2] functional impairment coinciding with weight loss a] inactivity b] muscle weakness c] shortness of breath d] impaired wound healing e] albumin < 3.2 g/dL f] altered mental status 4) infection 5) incontinence - urinary retention may be related to opioid use 6) postoperative cognitive impairment 7) metabolic complications - postoperative hyponatremia 8) post-operative myocardial infarction a) peak incidence 24-48 hours b) chest pain in 50% c) heart failure, hypotension, supraventricular tachycardia d) electrocardiogram is usually abnormal 1] new Q waves 2] ST segment changes 3] conduction block [3] e) serum Troponin T after noncardiac surgery predicts 30 day mortality: [6] - < 0.01 ng/mL (1%) - 0.02 ng/mL (4%) - 0.03-0.30 ng/mL (9.3%) - > 0.30 ng/mL (16.9%) f) perioperative myocardial infarction predicts 30 day mortality [7] 9) postoperative cardiac arrhythmias after cardiac surgery [16] - supraventricular arrhythmias & ventricular arrhythmias - perioperative beta-blockade of benefit [16] 10) renal failure a) older age, male [14], female [3] b) emergency or high-risk surgery c) lower preoperative eGFR [3,14] (strongest predictor) d) pharmaceuticals - ACE inhibitor or ARB [14] - diuretic use [3] - larger number of prescribed drugs [14] e) liver disease f) peripheral arterial disease g) BMI >= 32 h) COPD requiring bronchodilator i) intraoperative vasopressors 11) pulmonary complications: [5] - older age - limitations in activities of daily living - low preoperative oxygen saturation, subsumes - smoking - preexisting pulmonary disease - COPD, obstructive sleep apnea [3] - no absolute value of FEV1 or FEV1/FVC precludes surgery [27] - values do not help predict perioperative pulmonary complications - obesity - hypercapnia - respiratory infection during the previous month - preoperative hemoglobin level <10 g/dL - chronic heart failure [3] - poor health or functional dependence [3] - systemic disease, including sepsis [3] - low serum albumin [3] - renal failure [3] - head & neck surgery - upper abdominal or thoracic procedure - open aortic surgery - duration of surgery > 2-3 hours - emergency procedure - also see postoperative respiratory failure 12) adhesions [8,9] - abdominal surgery, pelvic surgery - small bowel obstruction - female infertility - difficulties at reoperation - chronic abdominal pain 13) incisional hernia - abdominal surgery [9] 14) persistence of surgical incision site pain (3% at 1 year) [23] 15) postoperative bleeding - NSAIDs not associated with postoperative bleeding [22] 16) mortality - nearly all deaths associated with non-cardiac surgery occur in the postoperative period rather than during surgery [20] - 30-day mortality for patients with myocardial injury after noncardiac surgery (increased serum troponin I) is 10% vs 1% (normal serum troponin I) [6] - frailty is associated with excess risk for postoperative mortality after elective surgery [13] - 1 year mortality increased 30% in seniors with substantial opioid use in the year prior to surgery [21] - mortality after elective surgery in the United States is 1.30% for black men & 0.85% for white men [25] Notes: - preoperative high-intensity interval training may improve cardiorespiratory fitness & reduce postoperative complications [26] - functional capacity most important factor predicting postoperative mortality in elderly >= 80 years of age undergoing orthopedic surgery [11] - chronic hepatitis medically stable does not increase risk of post-operative complications [3] - preoperative score to estimate postoperative mortality developed in France (not validated in U.S.) [12] - reduced nurse staffing increases risk for postoperative complications [17] - postoperative mortality associated with missed nursing care may result from inadequate nurse staffing [17]

Related

post-operative management

Specific

complications of bone marrow transplantation device malfunction ovarian remnant syndrome post-cholecystectomy syndrome post-laminectomy syndrome; failed-back syndrome post-operative nausea & vomiting postcardiotomy syndrome posterior fossa syndrome postoperative atrial fibrillation; perioperative atrial fibrillation postoperative cognitive impairment postoperative delirium postoperative fever postoperative infection postoperative respiratory failure postpericardiotomy syndrome slit ventricle syndrome surgical site infection wound dehiscence

General

complication

References

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