Postoperative management

Last updated: April 4, 2022

Summarytoggle arrow icon

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.”

  • Temperature > 38°C in the postoperative period
  • Etiology
Onset of fever Etiology
Infectious Noninfectious
Immediate
  • Intraoperatively or within a few hours of surgery
  • Infection acquired prior to surgery
Acute
Subacute
  • > 1 week but < 1 month after surgery
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.

  • Diagnostics
  • Treatment
    • Discontinue all unnecessary medications and remove or change urinary catheters and peripheral venous lines.
    • Acetaminophen
    • Patients who are hemodynamically unstable: broad-spectrum antibiotic therapy
Type of perioperative hemorrhage Definition Etiology
Primary hemorrhage
  • Intraoperative hemorrhage
Secondary hemorrhage < 24 hours

1–7 days

> 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).

Definition

Infection arising within 30 days of a surgical procedure at the site of the surgical incision.

Epidemiology

Etiology

Type of surgical wound Definition Incidence of SSI
Clean
  • All of the following:
    • Noninflamed operative wound
    • The respiratory, alimentary, genital, and urinary tracts have not been entered during surgery.
    • Primary wound closure with or without a drain.
  • 1.5%
Clean-contaminated
  • Noninflamed operative wound
  • The respiratory, alimentary, genital, and/or urinary tracts have been entered during surgery.
  • 8%
Contaminated
  • Fresh, open, accidental wounds
  • Inflamed operative wound without purulent drainage
  • Clean or clean-contaminated wounds with a break in sterile technique during surgery
  • 15%
Dirty or infected wounds
  • Old traumatic wounds
  • Inflamed operative wound with purulent drainage
  • 40%

Classification and clinical features

Type of SSI Incisional SSI Organ/space SSI
Superficial incisional SSI Deep incisional SSI
Definition
  • SSI involving any part of the body that is deeper than the fascia or muscle layers and was opened or manipulated during surgery
Clinical features

Diagnostics

Treatment

Complications

Prevention

  • 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
  • Perioperative antibiotic prophylaxis

References:[3][4][5][6][7]

Epidemiology

  • Incidence
    • 30–50% among postsurgical patients in the general population
    • Up to 80% in high-risk groups
  • Sex: >
PONV risk factors Adults Children
Patient-related
Procedure or treatment related

Differential diagnosis

PONV prophylaxis

Treatment of PONV [9][10]

Acute management checklist for PONV

Complications

References:[9]

Check the catheter for kinks or blockage if a catheterized patient develops signs of urinary retention (e.g., lower abdominal pain, bladder fullness).

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  1. Optimal Perioperative Care of the Geriatric Patient: Best Practices Guideline from ACS NSQIP®/American Geriatrics Society. https://www.facs.org/~/media/files/quality%20programs/geriatric/acs%20nsqip%20geriatric%202016%20guidelines.ashx. Updated: January 4, 2016. Accessed: February 21, 2017.
  2. Mavros MN, Velmahos GC, Falagas ME. Atelectasis as a Cause of Postoperative Fever. Chest. 2011; 140 (2): p.418-424. doi: 10.1378/chest.11-0127 . | Open in Read by QxMD
  3. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014; 59 (2): p.e10-52. doi: 10.1093/cid/ciu444 . | Open in Read by QxMD
  4. National Nosocomial Infections Surveillance (NNIS) Report, data summary from October 1986–April 1996, issued May 1996.
  5. National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 to June 2002, issued August 2002.
  6. Surgical Site Infection (SSI) Event.
  7. Kingsnorth AN, Majid AA. Fundamentals of Surgical Practice. Cambridge University Press ; 2006
  8. Lee DW, Lee HG, Jeong CY, Jeong SW, Lee SH. Postoperative nausea and vomiting after mastoidectomy with tympanoplasty: a comparison between TIVA with propofol-remifentanil and balanced anesthesia with sevoflurane-remifentanil.. Korean journal of anesthesiology. 2011; 61 (5): p.399-404. doi: 10.4097/kjae.2011.61.5.399 . | Open in Read by QxMD
  9. Gan TJ, Diemunsch P, Habib AS, et al. Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesth Analg. 2014; 118 (1): p.85-113. doi: 10.1213/ANE.0000000000000002 . | Open in Read by QxMD
  10. Pierre S, Whelan R. Nausea and vomiting after surgery. Continuing Education in Anaesthesia Critical Care & Pain. 2013; 13 (1): p.28-32. doi: 10.1093/bjaceaccp/mks046 . | Open in Read by QxMD

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