5. Postoperative Care and Complications

I. Postoperative Care

Goal: Safe recovery after anesthesia/surgery, early detection of complications, pain control and return to normal function
Most important period → First 24-48 h, but risk depends on operation type and patient condition
Basic principle → Observe trends, not only single values

Precise Observation / Monitoring

Vital signs → Temperature, BP, pulse/HR, respiratory rate, oxygen saturation
Breathing → Airway, work of breathing, cough, sputum, chest pain, signs of aspiration/atelectasis/PE
Circulation → Perfusion, capillary refill, skin color, shock signs, chest pain, arrhythmia
Neurological state → Consciousness, delirium, agitation, pain score, residual anesthesia effect
Fluid balance → IV fluids, oral intake, urine output, losses from drains/NG tube/stoma
Urination and stool → Urinary retention, oliguria, flatus, bowel movement, ileus signs
Drains → Position, patency, amount, color/quality, sudden increase or change
Wound → Bleeding, hematoma, swelling, erythema, discharge, dehiscence, pain
Catheters/cannulas → IV line, central line, urinary catheter, epidural catheter, oxygen, tubes

Pain Control

Regular pain assessment → Rest pain + movement/cough pain
Multimodal analgesia → Paracetamol, NSAID if safe, regional/epidural, local blocks, opioids as needed
PCA can be used after major surgery
Good analgesia enables breathing exercises, coughing, mobilization and nutrition
Avoid excessive opioids → Respiratory depression, ileus, nausea/vomiting, delirium

Respiratory Care

Oxygen therapy according to saturation and clinical status
Deep breathing exercises, coughing, incentive spirometry if used locally
Chest physiotherapy in high-risk patients
Early mobilization reduces atelectasis, pneumonia and VTE risk
High-risk → Thoracic/upper abdominal surgery, elderly, obesity, smoking, COPD, prolonged anesthesia

Early Mobilization and Physiotherapy

Start as early as possible according to operation and hemodynamic stability
Prevents → DVT/PE, atelectasis, pneumonia, ileus, pressure ulcer, muscle loss
Methods → Sitting up, standing, walking, active/passive limb movement, breathing exercises
Mobilization plan should be written clearly after major operations

Thrombosis / VTE Prophylaxis

Purpose → Prevent DVT and pulmonary embolism, especially in high-risk patients
Assess VTE risk + bleeding risk
Mechanical → Elastic compression stockings, intermittent pneumatic compression pump
Movement → Early mobilization, active/passive extremity movement
Medication → LMWH, unfractionated heparin, fondaparinux/DOAC in selected operations according to protocol
Duration depends on procedure and risk; extended prophylaxis may be needed after major cancer/orthopedic/pelvic surgery

Check stockings daily → Skin injury, correct size, heel pressure, contraindications

Fluid, Electrolyte and Renal Care

Monitor intake/output and daily weight if needed
Urine output target often at least 0.5 ml/kg/h in adult postoperative monitoring
Correct hypovolemia, electrolyte disturbance and acid-base problems
Avoid both dehydration and fluid overload
Oliguria causes → Hypovolemia, bleeding, sepsis, renal injury, obstruction, urinary retention

Gastrointestinal Care and Nutrition

Early enteral/oral nutrition as tolerated and according to operation type
ERAS principle → Avoid unnecessary prolonged fasting after surgery
Monitor nausea/vomiting, abdominal distension, flatus, stool, stoma output
Prevent/treat PONV → Antiemetics, minimize opioids, correct fluid/electrolytes
Nasogastric tube is not routine; use for vomiting, ileus, obstruction or selected surgery

Wound, Drain and Catheter Care

Maintain sterility and use aseptic technique for dressing changes
Observe wound daily or according to protocol
Drain output → Quantity + quality: blood, bile, pus, urine, feculent fluid, pancreatic/serous fluid
Remove drains/tubes/catheters as early as safely possible
Check IV cannulas/central lines for infection, thrombosis, extravasation
Educate patient before discharge → Wound care, fever, redness, discharge, pain, dyspnea, calf swelling, when to return

II. Postoperative Complications

Postoperative complication: Unwanted event after surgery/anesthesia causing delayed recovery, morbidity or mortality
Can be surgical, anesthetic, medical/systemic or care-related
Early warning signs → Tachycardia, hypotension, fever, oliguria, increasing pain, dyspnea, confusion, rising CRP/WBC/lactate

Classification by Timing

Timing	Typical complications
Immediate 0-24 h	Bleeding, shock, airway obstruction, aspiration, anesthetic complications, malignant hyperthermia, acute MI/arrhythmia
Early 1-7 days	Atelectasis, pneumonia, SSI, UTI, line infection, ileus, nausea/vomiting, anastomotic leak, DVT/PE, urinary retention, delirium
Late > 7 days	Abscess, fistula, wound dehiscence, incisional hernia, anastomotic stricture/leak, malnutrition, poor wound healing, late DVT/PE

Surgical Complications

1. Bleeding / Hemorrhage

Can be intra-abdominal, intrathoracic, wound, GI, drain bleeding
Signs → Tachycardia, hypotension, pallor, cold sweat, falling Hb, increasing bloody drain output, abdominal distension
Treatment → ABCDE, IV access, fluids/blood, coagulation correction, imaging if stable, reoperation/intervention if ongoing

2. Anastomotic Leak

Failure of anastomosis → Luminal content leaks into surrounding tissue/cavity
Often occurs around postoperative day 3-7, but can be earlier/later
Signs → Fever, tachycardia, abdominal pain, ileus, peritonitis, sepsis, abnormal drain content, rising CRP/WBC
Diagnosis → CT with contrast, labs, drain analysis if relevant
Treatment → NPO, IV antibiotics, drainage, source control; percutaneous drainage or reoperation depending on severity

3. Ileus / Bowel Obstruction

Postoperative ileus: Temporary impairment of bowel motility after surgery
Signs → Abdominal distension, nausea/vomiting, no flatus/stool, diffuse discomfort
Risk → Abdominal surgery, opioids, electrolyte disturbance, sepsis, immobility
Treatment → Mobilization, minimize opioids, correct electrolytes, IV fluids, NG tube if vomiting/distension
Mechanical obstruction must be excluded if prolonged/severe

4. Peritonitis, Abscess, Fistula, Sepsis

Peritonitis → Diffuse abdominal pain, guarding, fever, ileus, sepsis after leak/perforation
Abscess → Persistent fever, localized pain, raised inflammatory markers; CT diagnosis
Fistula → Abnormal communication; enterocutaneous fistula presents with intestinal content from wound/drain
Sepsis → Infection + organ dysfunction; surgical source control is essential
Treatment principle → Resuscitation + antibiotics + drainage/debridement/reoperation when needed

5. Wound Healing Disorders

Hematoma → Blood collection; pain/swelling; infection risk
Seroma → Serous/lymph fluid collection
Surgical site infection → Redness, warmth, swelling, pain, purulent discharge, fever
Wound dehiscence → Partial/complete disruption of wound closure
Burst abdomen → Deep fascial dehiscence after laparotomy; emergency if evisceration
Incisional hernia → Late fascial failure with protrusion at scar

Risk factors → Infection, obesity, diabetes, malnutrition, anemia, steroids, smoking, cough, ascites, poor technique, emergency surgery
SSI treatment → Open/drain pus if needed, culture, debridement, antibiotics if cellulitis/systemic/deep infection

Non-Surgical / Systemic Complications

1. Respiratory System

Atelectasis → Common early; fever, low saturation, basal crackles; prevent with breathing exercises and mobilization
Aspiration → Chemical pneumonitis/pneumonia after gastric content aspiration
Pneumonia → Fever, cough, sputum, hypoxia, infiltrate on X-ray
Pleural effusion / pulmonary edema → Dyspnea, hypoxia; consider fluid overload, heart failure
Pulmonary embolism → Sudden dyspnea, tachycardia, chest pain, hypoxia, syncope
ARDS → Severe inflammatory respiratory failure, often with sepsis/aspiration/major trauma

PE diagnosis → CT pulmonary angiography if stable; bedside echo/US in unstable/high-risk cases
PE treatment → Anticoagulation, oxygen/support; thrombolysis/embolectomy in selected massive PE

2. Cardiovascular System

Arrhythmia → AF common after major surgery; check electrolytes, hypoxia, sepsis, pain
Heart failure → Dyspnea, edema, pulmonary edema; often fluid overload/ischemia/arrhythmia trigger
Acute myocardial infarction → Chest pain may be absent; ECG + troponin if suspicious/high-risk
Hypertensive crisis → Pain, withdrawal, fluid overload, missed medication, neurologic/cardiac risk
Thrombosis/embolism → DVT, PE, arterial thrombosis in high-risk patients
Shock → Hypovolemic, septic, cardiogenic, obstructive; treat cause urgently

3. Renal / Urinary

Urinary retention → Common after anesthesia, opioids, pelvic/inguinal surgery; bladder scan + catheter if needed
Acute kidney injury → Oliguria, rising creatinine; causes include hypovolemia, sepsis, nephrotoxins, obstruction
UTI → Fever, dysuria, catheter-associated infection; remove catheter early when safe

4. Neurological / General

Delirium → Elderly, infection, hypoxia, pain, opioids, electrolyte disorder, urinary retention
PONV → Postoperative nausea/vomiting; risk of dehydration, aspiration, wound stress
Fever → Common sign; evaluate timing and source
Pressure ulcer → Immobility, poor nutrition, vascular disease
Malnutrition / poor wound healing → Especially after major surgery, cancer, sepsis, prolonged ileus

Postoperative Fever: Practical Differential

Early fever can be inflammatory/atelectasis-related, but do not dismiss persistent fever
Look systematically → Wind, water, wound, walking, wonder drugs

Wind → Atelectasis, pneumonia, aspiration, PE
Water → UTI, catheter infection, urinary retention
Wound → SSI, cellulitis, abscess, dehiscence
Walking → DVT/PE
Wonder drugs → Drug fever, transfusion reaction

Prevention of Complications

Good surgical technique and hemostasis
Strict aseptic protocol
Appropriate antibiotic prophylaxis
Early mobilization and respiratory physiotherapy
VTE prophylaxis according to risk
Fluid, electrolyte and glucose monitoring
Early enteral nutrition and nutrition support if needed
Effective handover and escalation when warning signs appear
Remove unnecessary catheters/drains/lines early

Exam focus: Postoperative care means precise observation, pain control, breathing care, early mobilization, VTE prophylaxis, early enteral nutrition, and wound/drain/catheter checks. For complications, classify by timing, then separate surgical complications from respiratory, cardiovascular, renal/urinary and general complications.