LessonsReduction of Risk Potential
The postoperative complications, by day
Anticipate what goes wrong after surgery and when, distinguish expected findings from reportable ones, and name the prevention for each.
The first hours
In recovery and the first hours, the risks are airway, bleeding and volume.
- Airway obstruction from a tongue or residual anesthetic; position and stimulate, and do not leave.
- Hemorrhage: check under the client as well as the dressing, since blood tracks down and a dry dressing can sit over a soaked sheet.
- Hypovolemia: urine output below 30 mL an hour in an adult means a kidney that is not being perfused.
- Urinary retention: no void by six to eight hours, with suprapubic fullness.
Malignant hyperthermia is an anesthetic emergency, not a fever: rigidity — often of the jaw first — and a sharply rising carbon dioxide, with the temperature rising late. The treatment is dantrolene.
Days one to three
- Atelectasis is the usual cause of a fever in the first 48 hours. Prevented by deep breathing, the incentive spirometer hourly while awake, and getting the client up.
- Paralytic ileus: absent bowel sounds and distension beyond the expected day or two, with no flatus passed.
- Pain that is not controlled, which is itself a cause of the atelectasis above, because a client who cannot breathe deeply will not.
There is an order to postoperative fever that is worth carrying: wind in the first two days, water — a urinary infection — around day three, wound around day five, walking — a deep vein thrombosis — after that, and wonder drugs at any point.
Later, and the ones that must not be missed
- Deep vein thrombosis: unilateral calf pain, swelling and warmth. Prevented by early mobilization, compression and prophylactic anticoagulation.
- Pulmonary embolism: sudden breathlessness, chest pain and tachycardia in someone who was recovering.
- Wound infection around day five: increasing pain, redness spreading beyond the edge, purulent drainage, fever.
- Dehiscence and evisceration: the client often reports a "giving way" sensation. Cover with sterile saline-soaked gauze, position with knees bent, keep the client nil by mouth, and call the surgeon — do not attempt to replace anything.
Worth remembering
- Check under the client for blood, not only the dressing.
- Wind, water, wound, walking, wonder drugs — the order of postoperative fever.
- Rigidity with a rising carbon dioxide under anesthesia is malignant hyperthermia; the drug is dantrolene.
- For evisceration: sterile saline gauze, knees bent, nil by mouth, and call — never push it back.