This course is designed to help the nurse prevent, recognize, and manage commonly identified postoperative complications.
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Syllabus
Terms related to Postoperative Complications:
Anesthesia: Medications that produce a decreased level of consciousness, analgesia, relaxation, and/or a loss of reflexes.
Atelectasis: The complete or partial collapse of a lung.
Dehiscence: Partial or complete separation of wound edges.
Deep vein thrombosis (DVT): Formation of a blood clot or thrombus in a large vein, usually in the legs.
Emergence delirium: An abnormal mental state caused by anesthetic medications given during surgery to induce sedation.
Evisceration: Protrusion of organs through surgical incisions.
Hypothermia: A body temperature less than 96.9° F.
Perioperative nursing: A wide variety of nursing activities carried out before, during, and after surgery.
Perioperative phase: The three phases of perioperative patient care include the preoperative, intraoperative, and postoperative phases.
Postanesthesia care unit (PACU): A care area where postoperative patients are monitored as they recover from surgerical anesthesia, also known as the recovery room. The purpose of a PACU is to stabilize patients and provide close monitoring.
Pulmonary embolism (PE): A blood clot in the pulmonary arteries.
Shock: The body’s reaction to acute peripheral circulatory failure due to an abnormality of circulatory control or a loss of circulating fluid. The two main types of shock are hypovolemic (caused by low volume) and septic shock (caused by systemic infection) .
Thrombophlebitis: Inflammation in a vein associated with thrombus formation (Hinkle & Cheever, 2018).
The postoperative period starts when the patient is transferred from the operating room to the postanesthesia care unit (PACU) and ends when the patient completes all of their post-surgical follow-up appointments. The postoperative period is the longest of all the perioperative periods. Patients are at risk for complications, which in turn affect recovery and quality of life after surgery. Once the patient is in the PACU, nurses are primarily responsible for recognizing signs and symptoms of actual or potential problems and intervening appropriately to minimize risk, morbidity, and mortality (Hinkle & Cheever, 2018).
The following are the most common postoperative complications:
- Respiratory complications
- Cardiovascular complications
- Complications of awakening from anesthesia, emergence delirium, delayed awakening
- Complications of thermoregulation
- Gastrointestinal complications
- Skin complications (Hinkle & Cheever, 2018).
Anatomy and Physiologic Response to Surgery
The metabolic phenomenon of the surgical stress response can be explained in three key components: (a) sympathetic nervous system activation; (b) endocrine response; and (c) immunologic changes, including cytokine production (Cevasco, Ashley, & Cooper, 2012).
In response to the effects on the sympathetic nervous system, catecholamine secretion increases from the adrenal medulla. As a result, circulating norepinephrine and epinephrine levels rise, which results in tachycardia and hypertension and affects other organs such as the liver, pancreas, and kidneys (Cevasco et al., 2012).
Cortisol levels rise with the start of surgery. As a result, blood glucose concentrations increase in accordance with the intensity of the surgery. Consequently, extensive or complicated surgeries will lead to longer and more drastic elevations in blood glucose. Glycemic control is critical in surgical diabetic patients as the physiologic stress caused by surgery may cause an increase in blood glucose levels which could lead to impaired wound healing, infection, amongst others (Cevasco et al., 2012).
In addition to the sympathetic and endocrine responses to surgery, the immune system produces excess cytokines. Cytokines such as interferons and interleukins are responsible for the local effects of mediating and maintaining the inflammatory response to tissue injury. Cytokine production reflects the extent of tissue trauma. Cytokine levels are lowest in minimally-invasive procedures and highest in more complicated procedures such as joint replacements and colorectal surgery (Cevasco et al., 2012).
Incidence
Research by the International Surgical Outcomes Study Group (2016), led by Queen Mary University of London, reported that the number of surgical procedures performed globally continues to rise. They found that more than 310 million patients undergo surgery worldwide each year. The group’s primary findings indicate that over a 12-month period, 50 million patients suffer complications following surgery in hospitals, and that over 1.5 million die from those complications (The International Surgical Outcomes Study Group, 2016).
Preventive Measures
Common postoperative complications can be prevented using basic nursing care principles such as following:
- Proper andwashing
- Maintaining strict surgical aseptic technique
- Pulmonary exercises (e.g. turn, cough, deep breathing, and incentive spirometer use)
- Early ambulation
- Leg exercises
- Sequential compression devices
- Hydration
Additionally, obtaining a complete and detailed history and physical assessment can serve as an excellent guide to identifying and preventing complications during and after surgery. Nevertheless, educating patients and families of potential complications and identifying complications early on are critical (Hinkle & Cheever, 2018). See Table 1 for risk factors associated with surgical complications.
Table 1: Selected Risk Factors of Surgical Complications
Selected Surgical Complications | Selected Risk Factors |
Respiratory complications | Preexisting pulmonary conditions (such as obstructive disease, restrictive disease, and respiratory infection {pneumonia}), smoking, immobility, obesity, and age. |
Cardiovascular complications | Immobility, age, congestive heart failure, coronary artery disease, cerebrovascular disease, dysrhythmias, myocardial infarction, hemorrhagic idsorders, hypertension, ptosthetic heart value, venous thromboembolism, stress, obesity, alcohol abuse, and drug abuse. |
Complications of awakening from anesthesia, emergence delirium, delayed awakening | Acid-base disturbances, age, blood loss, alcohol withdrawal, hypoxia, decreased cardiac output, infection, medication adverse effects, dementia, preexisting mental illnesses, and preoperative anxiety. |
Complications of thermoregulation | Low body mass index, pediatric and elderly patients, anemia, and family history. |
Gastrointestinal complications | Immobility, manipulation of bowel during surgery, anesthetic medications, slow intestinal peristaltic movements, and age. |
Skin complications | Vomiting, valsalva maneuver, heavy coughing, straining, smoking, obesity, infection, and age. |
(Hinkle & Cheever, 2018)
Clinical Manifestations
Respiratory complications may include airway obstruction, hypoventilation, atelec
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tasis, aspiration, bronchospasms, pulmonary edema, pneumonia, PE, and/or pneumothorax. Potential signs and symptoms of inadequate oxygenation caused by the above conditions may include agitation, restlessness, confusion, coma, muscle twitches, seizures, hypotension or hypertension, tachycardia, dysrhythmias, poor capillary refill, cyanosis, tachypnea, and low oxygen saturation (below 90%). Signs and symptoms of inadequate ventilation caused by the above conditions may include tachypnea, nasal flaring, intercostal retractions, diminished lung sounds, abnormal airway sounds, diminished chest movements, and diaphragmatic breathing. Potential signs and symptoms of pneumonia (see figure 1 below) include fever, crackles, rhonchi, hypoxia, chest congestion, cough, chest pain upon inspiration, fatigue and sputum that is thick, frothy, blood-tinged, yellow, or green (Hinkle & Cheever, 2018).
Cardiovascular and peripheral circulatory system complications seen in postoperative patients may include dysrhythmias, bleeding, myocardial infarction, PE, and/or DVT. Signs and symptoms of inadequate tissue perfusion (hypovolemic shock) caused by the above conditions may include confusion, impaired motor and sensory function, cool and clammy skin, cyanosis, low urine output (less than 1ml/kg/hr), low blood pressure, weak and rapid heart rate, and decreased oxygen saturation (below 90%). Signs and symptoms of dysrhthymias include palpitations, chest pain, dizziness, shortness of breath, fainting, and sweating. Signs and symptoms of DVT include unilateral swelling in the extremity, redness, pain/tenderness, and warmth (Hinkle & Cheever, 2018). Signs and symptoms of a PE may include shortness of breath, tachypnea, chest pain that is worse with deep inhalation, tachycardia, light-headedness, loss of consciousness, hemoptysis, hypotension, anxiety/feeling of impending doom, and sweating (The Centers for Disease Control and Prevention, 2019; National Institutes of Health, n.d.)
Complications of awakening from anesthesia may include emergence delirium and delayed awakening. Emergent delirium could occur during a patient transition from the unconscious state to a conscious state after surgery (Zafirova, 2019). Signs and symptoms of anesthesia complications may include hypoactivity or hyperactivity, agitation, psychosis, hostility, confusion, and aggressive behavior. It is critical to maintain staff and patient safety in these patients (Hinkle & Cheever, 2018).
Complications of thermoregulation refers to either hypothermia or malignant hyperthermia. Signs and symptoms of malignant hyperthermia include tachycardia, tachypnea, arrhythmia, rigidity, elevated body temperature, unstable blood pressure, cyanosis, and dilated pupils. Signs and symptoms of hypothermia include decreased body temperature, shivering, chills, slurred speech, slow and shallow breathing, weak pulse, confusion, and drowsiness (Hinkle & Cheever, 2018).
Gastrointestinal complications include abdominal pain, abdominal rigidity, diarrhea, nausea, vomiting, constipation, and abnormal bowel motility. Abnormal bowel motility could cause a medical condition called paralytic ileus. Common signs and symptoms of paralytic ileus include hypoactive or absent bowel sounds, belching, lack of flatulence, constipation, abdominal distention, nausea, and bile vomiting (Hinkle & Cheever, 2018).
Common skin complications include surgical site infection, surgical wound dehiscence, or evisceration. Chief manifestations include indications of infection such as redness, swelling, and purulent or greenish drainage around the surgical site. Infection can spread to the bloodstream (sepsis) and cause systemic symptoms such as low blood pressure, fever, tachycardia, and decreased level of consciousness. Signs and symptoms of wound dehiscence include surgical site pain, redness, warmth, broken sutures/staples without wound healing, and abnormal wound drainage. Surgical wound evisceration may present as protruding organs where the incision has opened. Evisceration is a surgical emergency and needs to be treated immediately (Hinkle & Cheever, 2018).
Nursing Assessment, Diagnosis, and Management
Respiratory complications require immediate assessment of the patient’s airway for patency and adequate gas exchange. The nurse should monitor oxygen saturation continuously to maintain a level of at least 90%. The nurse should assess the rate, depth, and pattern of breathing, auscultate lung sounds over all lung fields, check for symmetry of breath sounds and chest wall movement, and check the chest wall for accessory muscle use, sternal retraction, and diaphragmatic breathing. Hypoxia can be prevented with airway maintenance, high fowler’s positioning, and breathing exercises such as diaphragmatic breathing and incentive spirometry. The nurse should not allow the patient to eat or drink by mouth until their gag reflex returns to avoid aspiration. If hypoxia develops, oxygen therapy may be indicated to maintain an oxygen saturation above 90%. Due to severe respiratory complications, patients may require emergency reintubation, so it is critical to have emergency equipment at the bedside. Pneumonia is often diagnosed by a chest x-ray (see figure 2 below, which indicates aspiration pneumonia in a ventilated patient), sputum culture/gram stain, complete blood count, CT scan, or a plueral fluid culture. Pneumonia is typically managed by administering antibiotics as well as pain/fever relievers and cough suppressants/expectorants (Hinkle & Cheever, 2018).
Cardiovascular complications can be identified by assessing vital signs and heart sounds frequently in the immediate postoperative phase until the patient is stable. Cardiac monitoring is maintained until the patient is discharged from the PACU. The nurse should assess and compare distal pulses on both feet; observe color, sensation, and temperature of extremities; assess capillary refill; and assess homan’s sign for DVT. The most common medications used to manage dysrhythmias include beta blockers such as metoprolol (Lopressor), sotalol (Betapace), and antiarrythmic medications such as amiodarone (Pacerone). In patients with excessive bleeding, normovolemic status can be maintained by infusing isotonic fluids, blood and/or blood products and attempting to identify and correct the source of the bleeding (Hinkle & Cheever, 2018). Early ambulation and lower extremity exercises done hourly help to prevent DVT significantly. Certain surgical patients may require prophylaxis for DVT or PE, such as those undergoing total joint replacement (hip or knee), femoral neck fractures, or multiple traumas. The prophylactic anticoagulant recommended for DVT prevention is low molecular weight heparin, such as enoxaparin (Lovenox) subcutaneous injection or certain direct oral anticoagulants (DOACs) such as dabigatran (Pradaxa), rivaroxaban (Xarelto), or apixaban (Eliquis). Prophylatic anticoagulants can increase the risk of bleeding, so guidelines suggest to only use prophylactic anticoagulants in those with acceptable bleeding risk. Mechanical prophylaxis (such as sequential compression devices) are recommended for those with an increased risk for bleeding to prevent DVT (Schünemann et al., 2018).
Delirium requires assessing the patient for lethargy, restlessness, irritability, coherence, orientation, awareness, motor function, sensory function, and strength in all four extremities. For example, neurocognitive assessment could be done using the Richmond agitation sedation scale (RASS) or the confusion assessment method for the intensive care unit (CAM-ICU) scale to identify emergence delirium. Delirium prevention and management requires maintaining hemodynamic stautus during and after surgery, maintaining adequate oxygenation, hydration, acid-base balance, fluid and electrolyte balance, and administering the lowest required anesthetic medication doses during surgery (Zafirova, 2019). The nurse should frequently re-orient the patient; maintain nutrition, hydration, rest/sleep, and oxygenation; encourage family to bring familiar objects from home, reduce stimuli, offer toileting frequently, and encourage early ambulation to help manage delirium nonpharmacologically. Severe delirium could be managed by administering neuroleptic medications such as haloperidol (Haldol) or other sedatives/antipsychotic medications (Hinkle & Cheever, 2018).
Hypothermia can be managed by keeping the patient dry, applying warming or thermal blankets, minimizing the surface area of the patient that is exposed, and administering warmed intravenous products as needed. Warming must be accomplished gradually, not rapidly. Malignant hyperthermia may be cause for terminating surgery if it occurs intraoperatively as it is often caused by the administration of anesthetic medications such as succinylcholine (Anectine) and halothane (Fluothane). The nurse should maintain the patient’s airway and apply 100% oxygen using a nonrebreather mask. If the patient is already intubated, mechanical ventilation should be used to maintain oxygenation. Typically, dantrolene sodium (Dantrium), a peripheral muscle relaxant, is used to treat this condition. The nurse will likely obtain blood gases and a metabolic profile and should apply cooling agents such as iced 0.9% sodium chloride or cooling blanket(s). The nurse should assess urine output during treatment to ensure that the patient is producing at least 30 ml/hr (Hinkle & Cheever, 2018).
Gastrointestinal complications such as postoperative nausea and vomiting, abdominal pain, abdominal distention, belching, and abdominal rigidity may be managed by assessing for bowel sounds in all four quadrants and at the umbilicus, assessing the nasogastric tube if present, and recording the color, consistency, and amount of gastrointestinal drainage. In addition to waiting until the gag reflex returns as mentioned above, the nurse should not allow the patint to have anything to eat until bowel sounds return and/or passage of flatus occurs. Often clear liquids are allowed after surgery, but water is not recommended as this may worsen postoperative nausea. The patient should be encouraged to try very small sips of clear juice or soda (Hinkle & Cheever, 2018).
To reduce the baseline risk factors for postoperative nausea and vomiting, suggestions include, (a) avoidance of general anesthesia when possible, using regional anesthesia instead, (b) avoidance of volatile anesthetics and nitrous oxide,(c) encouragement of adequate hydration, and (d) minimization of perioperative opioid use. Newer guidelines suggest to manage postoperative nausea and vomiting using a multimodal approach; specifically, a combination of 5HT3 receptor antagonists such as ondasetron (Zofran) and corticosteroids such as dexamethasone (Decadron) or methylpredisone (Medrol) to increase effectiveness of the therapy. Furthermore, antihistamines such as meclizine (Antivert), anticholinergics such as transdermal scopolamine patch (Transderm Scop), butyrophenones such as haloperidol (Haldol), and NK-1 receptor antagonist such as aprepitant (Emend) may help control postoperative nausea and vomiting effectively (Gan et al., 2014).
Skin complications such as surgical site infections can be prevented by adhering to aseptic technique, implementing environmental cleaning protocols, using appropriate barriers and surgical attire, performing proper skin antisepsis and hand hygiene, minimizing traffic in the operating room during surgical procedures, using adequate equipment sterilization methods, treating carriers of bacteria preoperatively, and using preoperative antimicrobial prophylaxis. The patient should be given the surgeon’s wound care instructions both verbally and in written format for their future reference at the time of discharge, and the nurse should be sure to explain the process fully to the patient and family. The incision may need to be kept dry for a period of time, depending on the surgical dressing used. Wound dehiscence and evisceration are diagnosed by assessing the surgical site dressing and any drains in place immediately. If sutures or staples open or separate, then the patient may develop dehiscence, which later can turn into an evisceration. Wound dehiscence may be managed by treating infection at the site with systemic antibiotics; surgical irrigation, debridement, and reclosure; or allowing the wound to heal by secondary intention. If found, the nurse should manage an evisceration by immediately notifying the provider and covering the wound with a nonadherent dressing pre-moistened with sterile normal saline. The nurse should not attempt to reinsert the protruding organ or viscera, but instead place the patient in a supine position with hips and knees bent, raise the head of the bed to 15-20°, assess their vital signs, provide reassurance, keep the dressing moist, document the incident and assist the surgeon as needed. The patient should be given a list of signs/symptoms to be watchful for regarding their incision, and the contact information for the surgeon to contact should they have any concerns or questions. Sutures and staples may need to be removed postoperatively, and this typically occurs two weeks after surgery depending on the surgeon’s preferences and the incision size/location (Hinkle & Cheever, 2018).
Other Critical Postoperative Areas Management
Postoperative pain is another critical parameter to address for optimal patient care outcomes. Optimal pain management begins in the preoperative period. Pain is subjective data. Optimal pain management depends upon several factors such as the patient’s past experience, belief, physical assessment, comorbidities, and the extent of the surgery. Newer guidelines suggest to apply a multimodal approach to pain management, which includes combining pharmacological measures with nonpharmacological measures such as transcutaneous electrical nerve stimulation (TENS), acupuncture, massage, cold and heat therapy, ambulation, and music therapy when available (Chou et. al., 2016).
Nutritional guidelines suggest to encourage early oral feedings in postoperative patients. Low risk patients may be instructed by anesthesia to have no solid food by mouth for six hours before surgery and clear liquids up to two hours before surgery. Most patients are recommended to have a clear liquid diet in the immediate postoperative phase, then advance their diet as tolerated. If caloric intake cannot be met by oral and enteral intake alone (less than 50% caloric requirement) for more than seven days, a combination of enteral and parenteral nutrition is recommeneded (Weimann et.al., 2017).
Physical therapy plays an important role in the patient healing and returning to his/her baseline as soon as possible. Guidelines suggest that early physical therapy evaluation (starting on postoperative day 0/surgery day) is associated with decreased length of stay and fewer surgical complications after surgery (Tsirakidis, DeLucia, Elsabrout, & Apold, 2019). Needless to say, nursing needs to collaborate within the multidisciplinary team and advocate for patients so they can receive optimal care.
Finally, educating the patient and family regarding potential complications that could occur after discharge is a primary reposnsibility of nursing. The nurse should review all of the surgeon’s postoperative instructions with the patient and at least one additional family member that will be present to help them at home, and provide those instructions in writing. The patient should be given contact information about who to call should they develop any fever, increased pain, or bleeding at the surgical site. This set of instructions should specify which medications the patient should start, continue, and stop taking. Postoperative instructions will also likely include activity suggestions or even restrictions that the patient should understand completely prior to discharge (Pietrangelo & Stephens, 2016).
Future Research/Directions
Postoperative nausea and vomiting is a significant concern for patients having surgery under general anesthesia. Hodge, McCarthy, and Peirce (2014) performed a study to investigate the effectiveness of an aromatherapy inhaler in relieving postoperative nausea and vomiting. They found that nausea assessment scores decreased significantly in both the placebo and treatment groups, but the decrease in the aromatherapy group was significantly more than was seen in the placebo group. There are also no known long-term or significant adverse effects associated with aromatherapy. As a result, more research is needed in the area of aromatherapy to reduce nausea and vomiting in postoperative patients (Hodge et al, 2014).
References
The Centers for Disease Control and Prevention. (2019). What is Venous Thromboembolism? Retrieved from https://www.cdc.gov/ncbddd/dvt/facts.html
Cevasco, M., Ashley, S., & Cooper, Z. (2012). Physiologic response to surgery. In McKean, S., Ross, J., Dressler, D., Brotman, D., & Ginsberg, J. (Eds.), Principles and Practice of Hospital Medicine. New York, NY: McGraw-Hill Companies.
Chou R., Gordon D.B., De Leon-Casasola, O.A., Rosenberg J.M., Bickler, S., Brennan,...Wu, C.L. (2016). Management of postoperative pain: A clinical practice guideline from the American pain society, the American society of regional anesthesia and pain medicine, and the American society of anesthesiologists' committee on regional anesthesia, executive committee, and administrative council. Journal of Pain, 17 (2), 131-157.
Gan, T. J., Diemunsch, P., Habib, A., Kovac, A., Kranke, P., Meyer, T. A…….Tramèr, M. R.
(2014). Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesthesia & Analgesia, 118 (1). doi: 10.1213/ANE.0000000000000002
Häggström, M. (2014). Medical gallery of Mikael Häggström [image]. WikiJournal of Medicine 1 (2). doi:10.15347/wjm/2014.008
Heilman, J. (2017) Aspiration Pneumonia [image]. Retrieved from https://en.wikipedia.org/wiki/Aspiration_pneumonia#/media/File:AspirationPneumonia.png
Hinkle, J.L., & Cheever, K.H. (2018). Postoperative Nursing Management. In Brunner & Suddarth (14thEds.), Textbook of Medical-Surgical Nursing (p. 456-464). Philadelphia, PA: Wolters Kluwer.
Hodge, N. S., McCarthy, M. S., & Peirce, R. M. (2014). A prospective randomized study of the effectiveness of aromatherapy for relief of postoperative nausea and vomiting. Journal of PeriAnesthesia Nursing, 29(1), 5–11. Doi: 10.1016/j.jopan.2012.12.004.
The International Surgical Outcomes Study Group. (2016). Global patient outcomes after elective surgery: Prospective cohort study in 27 low-, middle-, and high-income countries. British Journal of Anaesthesia, 117(5). Doi: 10.1093/bja/aew316
National Institutes of Health. (n.d.). Venous Thromboembolism. Retrieved on November 1, 2019 from https://www.nhlbi.nih.gov/health-topics/venous-thromboembolism
Pietrangelo, A. & Stephens, C. (2016). Postoperative Care. Retrieved from https://www.healthline.com/health/postoperative-care
Schünemann, H., Cushman,M., Burnett, A.E., Kahn, S.R, Beyer-Westendorf, J., Spencer, F……… Wiercioch, W. (2018). American Society of Hematology 2018 guidelines for management of venous thromboembolism: prophylaxis for hospitalized and nonhospitalized medical patients. Blood Adv, 2 (22). doi: 10.1182/bloodadvances.2018022954
Tsirakidis, L., DeLucia, L., Elsabrout, K. & Apold, S. (2019). Early postoperative physical therapy evaluation after total hip and knee arthroplasty reduces hospital length of stay. Journal of Acute Care Physical Therapy, 10(4), pp 151-157.doi: 10.1097/JAT.0000000000000104
Weimann, A., Braga B.M., Carli C.F., Higashiguchi D.T., Hübner E.M., Klek F.S……Singer, P. (2017). ESPEN guidelines: Clinical nutrition in surgery. Clinical Nutrition, 36. doi: 10.1016/j.clnu.2017.02.013
Zafirova, Z. (2019, September). Emergence delirium and agitation in the perioperative period. Retrieved from https://emedicine.medscape.com/article/2500079-overview