Postoperative management

Postoperative management of the surgical patient has two important components: supporting the patient's return to baseline health and recognizing and treating adverse events that may occur following surgery. Facilitating early oral intake, early mobilization, optimal pain control, and adequate hydration are some of the key elements required to ensure that the patient returns to baseline health. Preventative measures include ambulation, incentive spirometry, and ulcer and DVT prophylaxis. Postoperative adverse events are common and vigilance for early signs of infection, hemorrhage, ileus, and urinary retention is required. Fever is a common manifestation of postoperative complications and must be approached systematically to reach a definitive diagnosis.

See also “Preoperative management.”

This section discusses the routine inpatient management of postoperative patients. For management immediately following procedural sedation, see “Recovery and discharge after procedural sedation.” For patients requiring intensive care, see “Care of the critically ill patient.”

Approach ^[1]

• Monitor and support postoperative recovery.
• Prevent, identify, and treat any postoperative complications.
• Implement surgical wound management to promote wound healing.
• Consider multidisciplinary care and consults for medically complex or older patients.

Monitoring ^[2][3][4]

Based on the type of surgery and patient factors, obtain and monitor the following frequently.

• Vital signs
• Focused physical examination, including assessment of the surgical site
• Input & output values
  • IV fluid intake
  • Urine output: If output is < 0.5 mL/kg/hour for > 6 hours, ^[5]
    • Check catheter patency.
    • Consider possible causes of AKI; (see also “Diagnostic criteria of AKI”).
  • Surgical drain output
    • Total output over 24 hours ^[6]
    • Appearance of drainage (e.g., serous, bloody, purulent, feculent )
  • Stool output

Postoperative preventive measures ^[1][2][7][8]

The following measures are initiated after surgery to prevent common postoperative complications. For preventative measures performed prior to surgery, see “Preoperative assessment.”

• Initiate the following as soon as possible:
  • Oral intake or enteral nutrition to prevent villous atrophy ^[9][10]
  • Early mobilization: Consider physical therapy and/or occupational therapy consults. ^[11]
  • Deep breathing with or without incentive spirometry ^[12][13]
  • Removal of lines, tubes, and drains to prevent healthcare-associated infections
• Assess the need for and, if indicated, provide:
  • Acute pain management
  • IV fluid therapy, e.g., ongoing fluid loss replacement, maintenance fluid therapy
  • Electrolyte repletion
  • Inpatient management of hyperglycemia ^[14][15]
• Initiate prophylactic interventions based on individual risk factors.
  • Stress ulcer prophylaxis ^[16]
  • Venous thromboembolism prophylaxis, typically with low-dose LMWH or UFH, before and after surgery ^[17]
    • Main indications include immobility, especially if bedridden
    • LMWH is preferred after most major (non-neurosurgical) procedures in patients who do not have a high risk of bleeding (see “Periprocedural bleeding risk assessment”).
    • UFH is preferred in patients with severe renal insufficiency.
    • See “Approach to VTE prophylaxis” for additional information.
  • Aspiration precautions ^[2]

Surgical wound management ^[18]

• Frequently examine the incision site to monitor the wound healing process.
  • Mild tenderness and redness are often present during the initial phases of wound healing.
  • Signs of surgical site infection include fever, severe tenderness, erythema, purulent drainage, and induration.
• Manage wound dressings.
  • Leave the initial postoperative dressing in place for at least 48 hours. ^[18]
  • Change the dressing regularly to facilitate healing.
  • Provide adequate analgesia during dressing changes if needed.
• Counsel patients on wound care. ^[19]
  • Recommend avoiding trauma and maneuvers that increase tension around the surgical site
  • Educate patients on outpatient dressing changes; order home nurse visits if needed.

Definition ^[20]

Temperature > 38°C (100.4°F) in the postoperative period

Etiology

Immediately life-threatening causes of postoperative fever ^[33]

To avoid poor outcomes, immediately life-threatening causes of fever should be promptly identified and managed.

• Necrotizing soft tissue infection
• Pulmonary embolism
• Alcohol withdrawal
• Adrenal insufficiency
• Malignant hyperthermia
• Anastomotic leak
• Myocardial infarction

Diagnostics ^[1][4]

• Perform a thorough clinical evaluation, including patient history and focused physical examination.
• Rule out life-threatening causes of postoperative fever.
• Consider diagnostic studies based on clinical presentation and time of onset.
• If infection is suspected, consider:
  • Routine laboratory studies (e.g., CBC, urinalysis)
  • Cultures (e.g., blood cultures, urine cultures, and/or wound cultures)
  • Imaging (e.g., chest x-ray)
• Consider further imaging (e.g., CT abdomen and pelvis, lower extremity venous ultrasound) in patients with persistent fever without an identifiable cause.

The most common infectious causes of postoperative fever include surgical site infections (SSIs), pneumonia, catheter-associated UTIs, and primary bloodstream infections. The most common noninfectious causes include febrile drug reactions and venous thromboembolism. ^[33]

Treatment ^[4][28]

• Treat the underlying cause of postoperative fever.
• Minimize risk factors for preventable causes.
  • Discontinue all unnecessary medications.
  • Ensure source control for sepsis (e.g., remove or replace IV catheters).
• Treatment of suspected infection may involve:
  • Antibiotic therapy
    • In hemodynamically unstable patients, initiate immediate broad-spectrum antibiotic therapy if there is concern for sepsis or septic shock. ^[34]
    • In stable patients with suspected infection, initiate appropriate antibiotics based on the type of infection.
  • Surgical intervention (e.g., abscess drainage, debridement of SSI)
• Start antipyretics (e.g., acetaminophen) as needed.

Early (< 2 days) postoperative fever does not always require treatment if life-threatening causes of postoperative fever have been ruled out and there is no suspicion of infection. ^[1][4]

Etiology ^[35]

Bleeding can occur at sites other than the surgical wound (e.g., during central line insertion) in patients with hemostasis and bleeding disorders.

Clinical features

• Signs of hemorrhagic shock, e.g., tachycardia, hypotension, decreased urine output
• Hematoma and/or ecchymoses
• Signs of anemia

Diagnostics ^[38]

• Primarily a clinical diagnosis
• Routine laboratory studies: ↓ Hb, ↓ Hct
• Obtain further diagnostic studies depending on the suspected cause, e.g.:
  • Diagnostic workup of bleeding disorders
  • Targeted imaging (e.g., CT, MRI) to assess for mechanical causes

Recognition of bleeding is the first step in diagnosis.

Treatment ^[38]

• Hemodynamically unstable patients: Initiate immediate management of hemorrhagic shock.
• Pursue immediate surgical management for mechanical causes.
• Provide supportive management as indicated.
  • Initiate management of acute bleeding in patients with bleeding disorders.
  • In patients with hemorrhagic shock and/or severe anemia, initiate immediate packed red blood cell transfusion (see also “Indications for pRBC transfusion”).
  • See also “Massive transfusion.”

Definition ^[4]

• Hematoma: a collection of blood due to unsuccessful hemostasis or coagulation
• Seroma: a collection of serum, lymphatic fluid, and liquified fat often due to the presence of an empty cavity following surgery

Clinical features

• Most commonly occurs several days after surgery
• May be asymptomatic
• Localized swelling
• Pain or discomfort
• Drainage of fluid
  • Hematoma: dark
  • Seroma: clear
• Hematoma: purple discoloration

Treatment ^[4]

• Small or asymptomatic: expectant management
• Large or symptomatic ; ^[4]
  • Exploration and drainage
  • Wound packing until granulation tissue is formed
  • Wound closed by delayed primary intention or by secondary intention
• Monitor for wound infections (bacteria can access deep layers of the fascia and can multiply in the stagnant fluid).

Definition ^[39]

An incisional skin and soft tissue infection or organ/space infection located at the site of recent surgery, typically arising within 30 days postoperatively

Epidemiology

• Accounts for ∼ 20% of all health care-associated infections ^[39]
• Most common nosocomial infection among patients undergoing surgery ^[40]
• Incidence: ∼ 2% of all surgical wounds ^[41]

Etiology ^[39]

• Causative pathogens ^[40][42]
  • During the first 48–72 hours (uncommon): includes selected pathogens that cause necrotizing fasciitis
    • Group A Streptococcus (GAS), e.g., S. pyogenes
    • Clostridium spp., e.g., C. perfringens ^[43]
  • 48–72 hours after surgery; : SSI due to endogenous organisms at the surgical site, e.g., bacteria on the skin (e.g., S. aureus) or in the genital or gastrointestinal tracts (e.g., E. coli)
  • > 30 days after surgery: indolent organisms (e.g., coagulase-negative staphylococci) ^[44]
• Risk factors ^[45][46]
  • Patient-related factors
    • Corticosteroid therapy
    • Malnutrition
    • Obesity
    • Diabetes mellitus
    • Older age
    • Smoking
    • Preexisting infections or microbial colonization (e.g., with S. aureus)
    • Immunosuppression or altered immune response
    • Prolonged preoperative hospital stay
  • Procedure-related factors
    • Suboptimal preparation
    • Environmental: inadequate ventilation and increased traffic in the operating room
    • High degree of wound contamination (e.g., class III or IV surgical wound)
    • Prolonged surgery
    • Incorrect surgical technique
    • Improper sterile technique or instruments

Classification of surgical wounds ^[45][47]

Wounds can be classified preoperatively and/or postoperatively based on clinical characteristics. The classification may be used to predict the risk of developing an SSI and the necessity of perioperative antibiotic prophylaxis.

Classification and clinical features of SSI ^[39][45]

Diagnostics ^[40]

• Routine laboratory studies
  • CBC: leukocytosis
  • Inflammatory markers (e.g., ESR, CRP): may be elevated
  • Creatinine: to establish baseline renal function to adjust antibiotic dosage
• Microbiological studies
  • Wound culture and Gram stain (e.g., for incisional SSI): sample of purulent drainage collected using sterile techniques
  • Abscess culture (e.g., for organ/space SSI): sample obtained from drainage catheter or image-guided drainage
• Imaging: targeted study (e.g., ultrasound, CT, MRI) to assess for deep tissue or organ/space infection (e.g., abscess)

Treatment

General principles

• Immediately initiate treatment of life-threatening skin and soft tissue infections, e.g.:
  • Necrotizing soft tissue infections
  • Staphylococcal toxic shock syndrome
• Pursue surgical management for all SSIs.
• Start empiric antibiotic therapy in patients with any of the following:
  • Erythema and induration extending ≥ 5 cm from the wound edge
  • Fever ≥ 38.5°C (101.3°F)
  • Heart rate ≥ 110/minute
  • WBC count ≥ 12,000 cells/mm³
• Initiate targeted antibiotic therapy once bacterial culture results are available.
• Consider infectious diseases consult.
• For intraabdominal organ/space SSIs, see “Intraabdominal abscess.”

Not all patients with an SSI need antibiotics; surgical management alone may be sufficient.

If antibiotics are indicated, obtain samples for microbiological studies prior to starting empiric antibiotic therapy, if possible.

Surgical management ^[4][48]

• Suture removal, incision, and drainage ^[40]
• Debridement of necrotic tissue (e.g., necrotizing soft tissue infection).
• Regular dressing changes and daily wound inspections
• Delayed closure once the infection has resolved
• See “Secondary wound closure” for more details.

Empiric antibiotic therapy for SSI ^[40]

Choose initial empiric antibiotics based on the location of surgery (e.g., intraabdominal, genital) and presence of complications (e.g., necrotizing infection). Antibiotic duration depends on the severity and extent of the infection.

• Incisional SSI not involving the genital or GI tracts
  • Low risk of MRSA: cefazolin OR oxacillin ^[40]
  • High risk of MRSA: vancomycin , daptomycin, OR linezolid ^[40]
• Incisional SSI involving the perineum, axilla, or GI or genital tracts
  • Third-generation cephalosporin; (e.g., ceftriaxone ) PLUS metronidazole ^[40]
  • Levofloxacin PLUS metronidazole ^[40]
  • Carbapenem (e.g., meropenem ) ^[40]
• Suspected necrotizing soft tissue infection
  • Unclear pathogen or mixed infection: broad-spectrum antibiotic therapy (see “Empiric antibiotic therapy for skin and soft tissue infections” for dosages)
  • Group A Streptococcus or C. perfringens: penicillin PLUS clindamycin ^[40]
• Presence of surgical implant or device: Regimens vary based on the infected area (see “Device-related infections” for dosages).
• Intraabdominal organ/space infection: See “Empiric antibiotic therapy for intraabdominal infections.”

Necrotizing soft tissue infections are a medical emergency and require immediate surgical consultation and treatment.

Complications

• Wound dehiscence
• Secondary hemorrhage
• Bloodstream infection, which may lead to sepsis and septic shock

Prevention ^[41][49]

• Optimize blood glucose levels.
• Encourage smoking cessation one month before surgery.
• Delay elective procedures until all infections, even those remote from the surgical site, have resolved.
• Adequate skin preparation in the operating room
• Perioperative antibiotic prophylaxis if required
• See “Prevention of surgical site infections” for detailed preventive measures.

Definition ^[50]

A gap at the site of the sternal division following median sternotomy, which may or may not be accompanied by infection

Risk factors ^[51][52]

• Patient-related factors
  • Obesity
  • Diabetes mellitus
  • Smoking
  • Chronic obstructive pulmonary disease
  • Chronic cough
  • Heart failure
  • Osteoporosis
  • Previous sternotomy
• Procedure-related factors
  • Prolonged cardiopulmonary bypass
  • Coronary artery bypass grafting
  • Harvesting of bilateral internal mammary arteries
  • Excessive blood transfusions
  • Paramedian sternotomy

Pathomechanism ^[52][53]

The sternum can either heal normally, resolving postoperative sternal instability, or develop a dehiscence due to fractures of the bone and sternal wires.

• Factors contributing to sternal instability include:
  • Primary nonunion
  • Poor surgical technique (e.g., insufficient holding power of sutures)
  • Mechanical stresses on the wound (e.g., chest exploration, intubation > 7 days or chronic ventilator dependence, premature overexertion)
  • Poor wound healing

Clinical features ^[52][54]

• Instability of the sternum
• Pain, chest wall discomfort at rest
• Tenderness on palpation
• Audible click during chest movements (e.g., coughing)
• Increased wound drainage
• Patients can be completely asymptomatic.

Diagnosis ^[55]

Early radiographic imaging is important to facilitate timely therapy.

• Chest x-ray
  • Evidence of dehiscence can be detected on x-ray up to 3 days before clinical manifestations.
  • Findings: lateral displacement of sternal wires, vertically-oriented midsternal lucent stripe (not always present)
• CT scan: used to differentiate between simple wire migration and sternal dehiscence

Management ^[51]

• Surgical wound closure
  • Immediate closure (rewiring or sternal plate fixation): indicated in clinically stable patients with a sternum that can be reapproximated and stabilized, and if there is no infection in the deep mediastinal space
  • Immediate closure using muscle flaps (e.g., pectoralis major, latissimus dorsi, rectus abdominis) and/or omental flaps: indicated in clinically stable patients with a sternum that cannot be reapproximated and stabilized, and if there is no infection in the deep mediastinal space

Complications ^[55][56]

• Soft tissue dehiscence
• Deep sternal wound infection (postoperative acute mediastinitis) ^[51][57][58]
  • Risk factors ^[51][57]
    • Obesity
    • Diabetes mellitus
    • Smoking
    • Nasal colonization with Staphylococcus aureus
    • Infections at any site
    • Chronic obstructive pulmonary disease
    • Hypoalbuminemia
  • Clinical features
    • Signs of infection such as purulent drainage, local erythema, and fever
    • Tachycardia, hypotension
    • Pain, crepitus and/or chest wall discomfort
  • Diagnostics ^[57][58]
    • Laboratory studies: leukocytosis and increased erythrocyte sedimentation rate
    • Microbiological studies
      • Blood cultures
      • Deep tissue cultures
    • Imaging
      • Chest x-ray: shows widening of the mediastinum, pleural effusion, pneumomediastinum, and/or mediastinal air-fluid levels
      • CT scan: used to assess the extent of mediastinal infection if present
  • Management ^[51]
    • Surgical drainage and debridement
    • Delayed wound closure (negative pressure wound therapy is applied before definitive surgical wound closure with flaps)
    • Long-term antibiotics (minimum of 4–6 weeks)
• Sternal instability
• Pneumonia
• Wire displacement: may lead to hemorrhage (resulting from puncture of e.g., great vessels, right ventricle, a main bronchus, the pleural space)
• Sternal osteomyelitis

Prevention ^[59]

• Identification and correction of risk factors
• Preoperative prevention and reduction of infection risk (e.g., antibiotic prophylaxis with cephalosporins and/or vancomycin)
• Optimization of glycemic control and nutritional status
• Smoking cessation

Epidemiology ^[60]

• Incidence
  • 30–50% among postsurgical patients in the general population
  • Up to 80% in high-risk groups
• Sex: ♀ > ♂

Risk factors ^[60]

Differential diagnosis

• < 1 week after surgery; : self-limiting gastric or intestinal atony; , or a more severe paralytic ileus
• > 1 week after abdominal surgery; : early mechanical bowel obstruction
• See also differential diagnoses of nausea and vomiting

PONV prophylaxis

• Reduction of baseline risk:
  • Choose regional anesthesia over general anesthesia whenever possible.
  • If general anesthesia is required, avoid the use of nitrous oxide and volatile anesthetics; use a propofol infusion instead.
  • Minimize the perioperative use of opiates.
  • Adequate hydration
• Additional measures:
  • 0–1 PONV risk factors (low PONV risk; ): no antiemetic
  • 2 PONV risk factors (medium PONV risk; ): one antiemetic
  • ≥ 3 PONV risk factors (high PONV risk; ): two or more antiemetics of different classes

Treatment of PONV ^[60][62]

• Address any contributing factors (e.g., discontinue opioid analgesics, start bowel regimen).
• Use an antiemetic that was not used for prophylaxis (see antiemetics).
  • 5-HT₃ antagonists
    • Ondansetron
    • Granisetron
    • Tropisetron
  • Alternatives
    • Dexamethasone
    • Droperidol
    • Promethazine

Acute management checklist for PONV

• Identify and treat acute abdomen.
• Rule out alternative etiologies (see differential diagnoses for nausea and vomiting).
• Address any contributing factors
• Small, frequent meals
• IV fluids
• Start antiemetic therapy.

Complications

• Prolonged hospital stay
• Increased risk of aspiration pneumonia
• Secondary hemorrhage due to retching
• Mallory Weiss syndrome

Definition ^[63]

Inability to adequately void spontaneously after surgery

Risk factors ^[63]

• Patient-related factors
  • Age > 50 years
  • Male sex
  • Preexisting urinary tract obstruction (e.g., BPH)
  • Neurological disease (e.g., multiple sclerosis, diabetic neuropathy)
• Procedure-related factors
  • Long procedure duration
  • Inguinal hernia repair, gynecological or anorectal surgery, joint arthroplasty
  • Severe postoperative pain
  • Administration of excessive intravenous fluids (> 750 mL) ^[63]
  • Use of spinal or epidural anesthesia
  • Use of sedatives; and/or opioid analgesics
  • Perioperative administration of alpha agonists or anticholinergics (e.g., atropine)

Clinical features

• Suprapubic discomfort and/or pain
• Sensation of bladder fullness
• Palpable bladder

Urinary retention may be asymptomatic in patients with sensory deficits (e.g., due to spinal cord injuries or stroke) or after recent regional anesthesia.

Diagnostics ^[63]

• Primarily a clinical diagnosis
• Consider the following to support the diagnosis as necessary:
  • Bladder ultrasound; or bladder scanner: preferred methods of assessing bladder volume
  • Bladder catheterization
• Further evaluation is usually not necessary in patients with postoperative urinary retention; see “Diagnostics of urinary retention” for the assessment of other potential causes.

Management ^[63]

• Patients catheterized preoperatively: Assess for urinary catheter obstruction (e.g., kinking, blockage).
• Noncatheterized patients
  • Conservative management, e.g.:
    • Trial of void
    • Consider application of a suprapubic hot pack or gauze soaked with lukewarm water. ^[64]
  • If > 600 mL urine retained over 2 hours: bladder catheterization (intermittent catheterization or indwelling urine catheter) ^[63]
• Consider anuria or oliguria due to acute kidney injury in patients with decreased urine output.
• If symptoms persist despite adequate management, consider other causes of urinary tract obstruction and urinary retention.
• Offer pain management (e.g., NSAIDs) as needed.

Complications ^[63]

• Acute hydronephrosis (postrenal cause of AKI)
• Urinary tract infection
• Hospital-acquired infection due to prolonged hospital stay

• Postoperative ileus is one of the most common causes of paralytic ileus.
• Details are covered separately; see “Postoperative ileus.”

Epidemiology ^[65][66]

• Occur in up to ∼ 25% of patients who undergo major surgery ^[65]
• A common cause of: ^[67]
  • Postoperative morbidity and mortality
  • Prolonged postoperative hospitalization

Risk factors ^[65][67]

Etiology ^[22][69]

Management ^[22][69][70]

• Provide immediate symptom-based management.
  • Life-threatening symptoms: ABCDE approach, ICU admission
  • Respiratory distress and/or hypoxemia: supplemental oxygen, additional respiratory support
  • Hemodynamic instability: immediate hemodynamic support
• Obtain appropriate diagnostic testing. ^[70][82]
  • Laboratory studies, e.g., ABG, Hgb/Hct, electrolytes, d-dimer, cardiac biomarkers
  • Imaging, e.g., CXR, POCUS, CT pulmonary angiography (CTPA) ^[70][82][83]
  • ECG
• Treat the underlying cause of postoperative pulmonary complications.
• Consult pulmonology for
  • Diagnostic uncertainty
  • Further management of chronic lung disease

Prevention ^[65]

• Prior to surgery
  • Perform a preoperative pulmonary assessment.
  • Address any modifiable risk factors for postoperative pulmonary complications. ^[22][65]
• Following surgery: Initiate postoperative preventive measures.
  • Pain control
  • Consider using a postoperative protocol or bundle, e.g., “I COUGH.” ^[12][67][84]
    • Incentive spirometry
    • Coughing and deep breathing
    • Oral care
    • Understanding of postoperative instructions
    • Get out of bed early and frequently
    • Head of bed elevation

Following surgery, think “I COUGH” and pain control to prevent postoperative pulmonary complications. ^[12][84]

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