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

• delirium
  • advanced age
  • history of alcoholism
  • pre-existing cognitive impairment
  • pre-existing physical impairment
  • metabolic abnormalities
  • > 50% risk of postoperative delirium with 3 or more of above
  • dexmedetomidine may diminish postoperative delirium
    • may not be beneficial after extubation
  • perioperative gabapentin may increase risk of delirium & antipsychotic use
• immobility (mobilize early & aggressively)
  • pressure ulcers
  • osteoporosis
  • pulmonary: atelectasis, aspiration, pneumonia
  • thromboembolism:
    • deep vein thrombosis
    • pulmonary embolism, especially abdominal surgery
    • risk of venous thromboembolism may be elevated for 12 weeks after surgery in women
    • risk of venous thromboembolism greatest in 1st 12 weeks after surgery
    • increased risk for venous thromboembolism persists for 12 months
    • 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)
    • venous thromboembolism more common after transfusion (RR=2)
  • cardiovascular deconditioning: decreased cardiac output & stroke volume, orthostatic hypotension
  • metabolic/endocrine: insulin resistance, altered Ca+2 metabolism, negative nitrogen balance
  • sensory deprivation, loneliness, depression
  • fecal impactation, constipation
• post-operative nausea & vomiting
• malnutrition
  • generally associated with poorer surgical outcomes
  • patients most likely to benefic from peri-operative nutritional support
    • > 10% weight loss (in last 3 months) &
    • functional impairment coinciding with weight loss
      • inactivity
      • muscle weakness
      • shortness of breath
      • impaired wound healing
      • albumin < 3.2 g/dL
      • altered mental status
• infection
• incontinence
  • urinary retention may be related to opioid use
• postoperative cognitive impairment
• metabolic complications
  • postoperative hyponatremia
• post-operative myocardial infarction
  • peak incidence 24-48 hours
  • chest pain in 50%
  • heart failure, hypotension, supraventricular tachycardia
  • electrocardiogram is usually abnormal
    • new Q waves
    • ST segment changes
    • conduction block
  • serum Troponin T after noncardiac surgery predicts 30 day mortality:
    • < 0.01 ng/mL (1%)
    • 0.02 ng/mL (4%)
    • 0.03-0.30 ng/mL (9.3%)
    • > 0.30 ng/mL (16.9%)
  • perioperative myocardial infarction predicts 30 day mortality
• postoperative cardiac arrhythmias after cardiac surgery
  • supraventricular arrhythmias & ventricular arrhythmias
  • perioperative beta-blockade of benefit
• renal failure
  • older age, male, female
  • emergency or high-risk surgery
  • lower preoperative eGFR (strongest predictor)
  • pharmaceuticals
    • ACE inhibitor or ARB
    • diuretic use
    • larger number of prescribed drugs
  • liver disease
  • peripheral arterial disease
  • BMI >= 32
  • COPD requiring bronchodilator
  • intraoperative vasopressors
• pulmonary complications:
  • older age
  • limitations in activities of daily living
  • low preoperative oxygen saturation, subsumes
    • smoking
    • preexisting pulmonary disease
      • COPD, obstructive sleep apnea
      • no absolute value of FEV1 or FEV1/FVC precludes surgery
        • 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
  • poor health or functional dependence
  • systemic disease, including sepsis
  • low serum albumin
  • renal failure
  • head & neck surgery
  • upper abdominal or thoracic procedure
    • open aortic surgery
  • duration of surgery > 2-3 hours
  • emergency procedure
  • also see postoperative respiratory failure
• adhesions
  • abdominal surgery, pelvic surgery
  • small bowel obstruction
  • female infertility
  • difficulties at reoperation
  • chronic abdominal pain
• incisional hernia
  • abdominal surgery
• persistence of surgical incision site pain (3% at 1 year)
• postoperative bleeding
  • NSAIDs not associated with postoperative bleeding
• mortality
  • nearly all deaths associated with non-cardiac surgery occur in the postoperative period rather than during surgery
  • 30-day mortality for patients with myocardial injury after noncardiac surgery (increased serum troponin I) is 10% vs 1% (normal serum troponin I)
  • frailty is associated with excess risk for postoperative mortality after elective surgery
  • 1 year mortality increased 30% in seniors with substantial opioid use in the year prior to surgery
  • mortality after elective surgery in the United States is 1.30% for black men & 0.85% for white men

Notes

• preoperative high-intensity interval training may improve cardiorespiratory fitness & reduce postoperative complications
• functional capacity most important factor predicting postoperative mortality in elderly >= 80 years of age undergoing orthopedic surgery
• chronic hepatitis medically stable does not increase risk of post-operative complications
• preoperative score to estimate postoperative mortality developed in France (not validated in U.S.)
• reduced nurse staffing increases risk for postoperative complications
  • postoperative mortality associated with missed nursing care may result from inadequate nurse staffing

More general terms

• complication

More specific terms

• 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

Additional terms

• post-operative management