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 in quickly returning the patient to baseline health. Preventative measures include ambulation, incentive spirometry, and ulcer and DVT prophylaxis. Postoperative adverse events are common and vigilance is required for early signs of infection, hemorrhage, ileus, or urinary retention. Fever is a common presentation for postoperative complications and must be approached systematically to reach a definitive diagnosis.
See also “Preoperative management.”
Monitor blood pressure, pulse, oxygen saturation, temperature, urine output, and surgical drain output; if a patient has a urine output < 0.5 mL/kg/hour for > 6 hours: check catheter patency and consider possible prerenal, intrinsic renal, and postrenal causes of AKI
- Prerenal: e.g., renal hypoperfusion due to hypovolemia, hypotension, or decreased cardiac output during surgery
- Intrinsic renal: e.g., due to AIN caused by infection or allergic reaction (e.g., to antibiotics) or ATN due to hypoperfusion or nephrotoxic substances
- Postrenal: e.g., obstruction of the urinary tract due to obstructed catheter, BPH, stones
- Supportive care in intubated patients
- Pain management according to
- Stress ulcer prophylaxis with proton pump inhibitors
- Thromboprophylaxis with low-dose LMWH or UFH before and after surgery, especially for immobile, bedridden patients
- Incentive spirometry (a medical device, spirometer, that is used to maintain and improve lung function after surgery) and breathing exercises in order to prevent lung atelectasis
- Fluids: and
- Enteral nutrition; should be started as soon as possible to prevent villous atrophy.
- Early mobilization
Surgical wound management
- Daily examination of the incision site and wound drainage
- Assess the wound healing process
- Assess for signs of wound-related complications (e.g., fever, severe tenderness, erythema, induration); possible causes include , n, , , and/or
- Regular wound dressings (every 24–48 hours) to facilitate healing
- Counsel patients to avoid maneuvers that increase tension on the surgical wound.
- Provide adequate analgesia with NSAIDs (e.g., ibuprofen).
- Temperature > 38°C in the postoperative period
|Onset of fever||Etiology|
|Immediate|| || || |
|Subacute|| || |
|Delayed|| || |
The most common infectious causes of postoperative fever are surgical site infections, pneumonia, catheter-related urinary tract infections, and primary bloodstream infections. The most common noninfectious cause is febrile drug reaction.
|Type of perioperative hemorrhage||Definition||Etiology|
|Primary hemorrhage|| |
|Secondary hemorrhage||< 24 hours|
|> 1 week|
While postoperative bleeding from the surgical wound is common (due to, e.g., infection or mechanical stress on the incision), it is important to remember that bleeding may also occur at other sites than the wound in patients with hemostatic disorders (e.g., due to central line insertion).
Infection arising within 30 days of a surgical procedure at the site of the surgical incision.
- 15–20% of all healthcare-associated infections
- Most common nosocomial infection among patients undergoing surgery
- Incidence: ∼ 5% of all surgical wounds
- Causative pathogens
- Risk factors
|Type of surgical wound||Definition||Incidence of SSI|
|Clean-contaminated|| || |
|Dirty or infected wounds|| || |
Classification and clinical features
|Type of SSI||Incisional SSI||Organ/space SSI|
|Superficial incisional SSI||Deep incisional SSI|
- Incisional SSI: wound swab for Gram stain and wound culture
- Organ/space SSI: imaging (e.g., CT, MRI)
- Surgical therapy
Empiric antibiotic therapy for SSI
Antibiotic of choice
- SSI in a clean wound over the trunk, head and neck, or limb:
- SSI in a clean-contaminated wound; or in a clean wound over the perineal region: cephalosporin PLUS metronidazole, levofloxacin PLUS metronidazole, or carbapenem
- If group A Streptococcus or C. perfringens; infection is suspected: penicillin and clindamycin
- Targeted antibiotic therapy may be initiated once results of the bacterial culture are available.
- Optimize blood glucose levels.
- Stop smoking one month before surgery.
- Delay the elective procedure until all infections, even those remote from the surgical site, are treated.
- Skin antisepsis in the operating room
- 30–50% among postsurgical patients in the general population
- Up to 80% in high-risk groups
- Sex: ♀ > ♂
|PONV risk factors||Adults||Children|
|Procedure or treatment related|
- < 1 week after surgery; : self-limiting gastric or intestinal atony; , or a more severe
- > 1 week after abdominal surgery; : early
- See also differential diagnoses of nausea and vomiting
- Reduction of baseline risk:
- Additional measures:
Treatment of PONV 
- Address any contributing factors (e.g., discontinue opioid analgesics, start bowel regimen).
- Use an antiemetic that was not used for prophylaxis (see antiemetics).
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.
- Prolonged hospital stay
- Increased risk of
- Secondary hemorrhage due to retching
- Mallory Weiss syndrome
- Definition: failure to void > 4 hours after surgery
- Long duration of procedure
- Inguinal hernia repair, gynecological, anorectal surgery, joint arthroplasty
- Severe postoperative pain
- Excessive administration of intravenous fluids (> 750 mL)
- Spinal or epidural anesthesia
- Use of sedatives; and or opioid analgesics
- Perioperative administration of α-agonists or anticholinergics (e.g., atropine)
- Diagnostics: Bladder ultrasound; is not required but may be performed to assess the bladder volume.
- If the patient is catheterized preoperatively
- Check the catheter for kinking or blocks in the lumen.
- If no kinking is present, consider .
- If the patient is not catheterized preoperatively
- If the patient is catheterized preoperatively
- Acute → postrenal cause of acute kidney injury
- Prolonged hospital stay → increased risk of hospital-acquired infections