Postoperative complications

Ashru Neupane
Objectives
● To know about common complications in postoperative period
● To know about cardiovascular complications and its management
● To know about respiratory complications and its management
● To know about PACU
Post operative complications
● Cardiovascular complications
● Respiratory complications
● Renal complications
● Metabolic complications
● Incidental trauma
● Skeletal muscle
● Hypothermia and shivering
● Hyperthermia
● Persistent sedation/Delayed Emergence
● Altered mental status
● Postoperative nausea and vomiting
Circulatory complications

Hypotension
Causes- hypovolemia, left ventricular dysfunction, or excessive arterial vasodilation.

Hypovolemia is the most common cause.

● Inadequate fluid replacement, wound drainage, or hemorrhages
● Vasoconstriction from hypothermia may mask hypovolemia
● Spinal and epidural anesthesia
● Venodilators such as nitroglycerine
● sepsis and allergic reactions
● tension pneumothorax or cardiac tamponade
● Removal of more than 500 to 1000 mL of ascites fluid during surgical procedure
● Left ventricular dysfunction in previously healthy persons is unusual.
● Seen in patients with underlying CVS disease
● Associated with severe metabolic disturbances. Precipitated by fluid
overload, myocardial ischemia, arrhythmias.
Treatment
● Fluid bolus -250–500 mL crystalloid or 100–250 mL colloid
● vasopressor or inotrope (dopamine or epinephrine) -If refractory
● If does not respond - echocardiography /invasive hemodynamic monitoring
Hypertension
Occurs within the first 30 min

Causes-
● Noxious stimulation from incisional pain
● endotracheal intubation
● bladder distention
● preoperative discontinuation of antihypertensive medication
● neuroendocrine stress response to surgery or increased sympathetic tone
● Fluid overload or intracranial hypertension
● Mild hypertension- No treatment
● Marked hypertension can precipitate postoperative bleeding, myocardial
ischemia, heart failure, or intracranial hemorrhage- so good control is needed.
● Control pain and potential bladder distention
● Mild to moderate elevations- IV labetalol , ACE inhibitor,a calcium channel
blocker.
● Marked hypertension in patients with limited cardiac reserve-intra arterial
pressure monitoring and IV infusion of nitroprusside, nitroglycerin, nicardipine,
clevidipine, or fenoldopam.
Arrhythmias
Causes-
● Respiratory disturbances- hypoxemia, hypercarbia, and acidosis.
● Residual effects from anesthetic agents
● increased sympathetic nervous system activity
● other metabolic abnormalities,
● preexisting cardiac or pulmonary disease
Bradycardia
● residual effects of cholinesterase inhibitors
● opioids
● β-adrenergic blockers.

Tachycardia
● pain
● hypovolemia
● fever
● anticholinergic agent
● βagonist
Premature atrial and ventricular beats causes-
● hypokalemia
● hypomagnesemia
● increased sympathetic tone
● myocardial ischemia.

Diagnosed with a 12-lead ECG

Treatment
● Give oxygen
● Control HR/BP
● NTG
● Beta blocker
● Aspirin
● Statin
● Correct anemia ,control pain
● If ischemia:call surgeon and cardiologist
● If needed plan for PCI/Fibrinolysis after consultation
● Patient with Coronary artery disease and congestive heart failure are at high
risk.
● 1st sign is hypotension
● Can cloud hypotension due to use of other sedatives.
● Most common sign is - Tachycardia for myocardial ischemia
● Patient who seems at risk for coronary artery disease, new-onset tachycardia
that is not caused by pain should be taken seriously.
● Transmural myocardial infarctions outside the PACU show no ECG diagnostic
changes 10% to 30% of the time.
● Early suspicion and treatment is needed.
Treatment
● Intervention with nitrates, opioids, βblockers, and even anticoagulants may
save a life.
● If needed, timely access to the cardiac catheterization laboratory or for
anxiolytic drug therapy.
● Involvement and communication with the surgical must be immediate and
decisions, especially as to anticoagulation and lytic therapy.
The potential problems of
● Bleeding
● Volume shift
● Respiratory compromise

Could cause decompensation in patient with congestive cardiac failure patient.

Use of echocardiography helps in diagnosis

Postoperative pulmonary complications
● Mechanical, hemodynamic, and pharmacologic factors related to surgery and
anesthesia impair ventilation, oxygenation, and airway maintenance.

● Heavy smoking, obesity, sleep apnea, severe asthma, and COPD increase
the risk of postoperative ventilatory events.
Inadequate postoperative ventilation

Suspect when-
● Respiratory acidemia occurs coincident with tachypnea, anxiety, dyspnea,
labored ventilation, or increased sympathetic nervous system activity
● Hypercarbia reduces the arterial pH below 7.30
● PaCO2 progressively increases with a progressive decrease in arterial pH.
Inadequate respiratory drive
● Residual effects of anesthetics agent may blunt the ventilatory responses.
Sedatives add on to depression from opioids or anesthetics and reduce the
conscious desire to ventilate.

● Hypoventilation and hypercarbia can evolve insidiously the peak depressant

effect of an IV opioid given just before transfer.

● Patients might communicate lucidly and even complain of pain while

experiencing significant opioid-induced hypoventilation.
● Children with URTI are more prone to breath-holding, severe cough, and arterial
desaturations <90% during recovery.

● Intracranial Hemorrhage present with hypoventilation, especially after posterior

fossa craniotomy.

● Treatment- If excess hypoventilation from opioids then forced arousal and careful
titration of IV naloxone reverses respiratory depression without affecting analgesia.
● Flumazenil directly reverses depressant effects of benzodiazepines on ventilatory
drive.
Increase upper airway resistance.

Causes
● obstruction in the pharynx (posterior tongue displacement)
● change in AP/ lateral dimensions from soft tissue collapse.
● Larynx (laryngospasm, laryngeal edema)
● Large airways (extrinsic compression from hematoma, tumor, or tracheal
stenosis).

Simple maneuvers such as improving the level of consciousness, lateral

positioning, chin lift, mandible elevation, or placement of an airway relives
obstruction.
● Soft-tissue edema in neck procedures. Treated with nebulized epinephrine/
steroid.

● Pathologic airway obstruction (e.g., severe edema, epiglottitis, retropharyngeal

abscess, encroaching tumors) may require intubation, airway manipulation is
dangerous because minor trauma convert to total obstruction.

● Sedatives/muscle relaxants used to facilitate intubation can worsen obstruction

by compromising the patient’s efforts to maintain the airway.Equipment and
personnel necessary for emergency cricothyroidotomy or tracheostomy should
be available.
● Preoperative spirometric evidence of increased airway resistance predicts
postoperative bronchospasm.
● Prolonged expiratory time or audible turbulent air flow (wheezing) during
forced vital capacity expiration.
● Resistance is higher during expiration because intermediate diameter airways
are compressed by positive intrathoracic pressure
● Spontaneously breathing patients exhibit accessory muscle recruitment,
labored ventilation, and increased work of breathing.Mechanically ventilated
patients have high peak inspiratory pressures.
Treatment

● Levalbuterol or metaproterenol nebulizer in oxygen. Epinephrine - relaxes

Smooth muscle- S/E tachycardia/ flushing
● Administration of steroid therapy but chances of recurrence.
● Bronchospasm that is resistant to β2 - anticholinergic.
● If life-threatening- IV epinephrine infusion
● Increased small airway resistance caused by mechanical factors (e.g., loss of
lung volume, retained secretions, pulmonary edema) does not resolve with
bronchodilators. Restoration with incentive spirometry or deep tidal
ventilation.
● Reducing left ventricular filling pressures might relieve airway resistance
caused by increased lung water.
 Decreased compliance

Reduced pulmonary compliance increases the elastic work of breathing.

Low compliance progressive respiratory muscle fatigue, hypoventilation, and

respiratory acidemia.
Causes -
● Reduction of FRC.
● Pulmonary edema increase lung’s weight/inertia/surface tension.
● Pulmonary contusion/hemorrhage -interferes with lung expansion
● Extrathoracic factors such as tight muscles of the chest/ dressings and gas in
the stomach/bowel reduce chest wall compliance
● retained CO2 impair diaphragm movement.
● An intra-abdominal tumor, hemorrhage, ascites, bowel obstruction.
Treatment
● Work of breathing is improved by resolving problems that reduce compliance.
Allowing patients to recover in a semi-sitting (semi-Fowler) position reduces
work of breathing.
● Incentive spirometry and chest physiotherapy help restore lung volume, as
does PEEP or CPAP.
● In patients with COPD and highly compliant lungs, positive airway pressure
might force the rib cage and diaphragms toward their excursion limits,
accentuating inspiratory muscular effort.
Neuromuscular and skeletal problems

● Residual paralysis compromises airway patency and ability to clear

secretions.
● Marginal reversal can be more dangerous than near-total paralysis.
● A somnolent patient exhibiting mild stridor and shallow ventilation from
marginal neuromuscular function might be overlooked.
● Patients with neuromuscular abnormalities such as myasthenia gravis,
Eaton–Lambert syndrome responses to muscle relaxants. Medications (e.g.,
antibiotics, furosemide, propranolol, phenytoin) potentiate neuromuscular
relaxation, as does hypocalcemia or hypermagnesemia.
● High work of breathing, muscle weakness, or increased ventilatory
demands,nonfunctional diaphragm impairs minute ventilation.
● The ability to sustain head elevation in a supine position, a forced vital
capacity of 10 to 12 mL/kg, an inspiratory pressure more negative than −25
cm H2O, and tactile train-of-four assessment imply that strength of ventilatory
muscles is adequate to sustain ventilation and to take a large enough breath
to cough.
Treatment
● The use of NIV techniques such as CPAP or bilevel ventilation
● Voluntary limitation of chest expansion to avoid pain (splinting) causes
labored, rapid, shallow breathing characteristic of inadequate ventilation
which improves with analgesia and positioning.
● Ventilation with small tidal volumes due to thoracic restriction or reduced
compliance leads to dyspnea, labored breathing, and accessory muscle
recruitment in spite of appropriate minute ventilation.
● spontaneous hyperventilation to compensate for a metabolic acidemia might
generate tachypnea or labored breathing,
Increased dead space
Ventilation of unperfused deadspace /poorly perfused alveoli /high
ventilation/perfusion (V·/Q·) ratios is less effective in removing CO2.

Patients with high V·D/V·T are at greater risk for postoperative ventilatory failure.

Causes
● PEEP or CPAP
● Pulmonary embolization
● Decreased cardiac output
● Irreversible increases in ARDS related to sepsis, TRALI, or hypoxia
Increased CO2 production
During anesthesia, CO2 production falls to approximately 60% of the normal 2 to 3
mL/kg/min as hypothermia lowers metabolic activity and neuromuscular relaxation
reduces tonic muscle contraction.

During recovery, metabolic rate and CO2 production can increase by 40%. High
C02 -
● Shivering
● High work of breathing
● Infection
● sympathetic nervous system activity
● rapid carbohydrate metabolism
● Malignant hyperthermia
Inadequate postoperative oxygenation
● PaO2 is the best indicator.
● pulse oximetry has less information on alveolar-arterial gradients.
● Adequate arterial oxygenation does not mean that cardiac output, arterial
perfusion pressure, or distribution of blood flow will maintain tissue
oxygenation.
● Sepsis, hypotension, anemia, or hemoglobin dissociation abnormalities can
generate tissue ischemia despite adequate oxygenation.
● A PaO2 below 65 to 70 mmHg causes significant hemoglobin desaturation,
although tissue oxygen delivery might be maintained at lower levels.
● Treatment-Maintaining PaO2 between 80 and 100 mmHg (saturation 93% to
97%) ensures adequate oxygen availability.
● During mechanical ventilation, a PaO2 above 80 mmHg with 0.4 FiO2 and 5-
cm H2O PEEP, CPAP or spontaneous breathing trial predicts sustained
adequate oxygenation after extubation.
Obstructive sleep apnea
● Causes -Hypersomnolence, decreased ability to concentrate, increased
irritability, as well as aggressive and distractible behavior in children.
● May cause episodic oxygen desaturation, hypercarbia,cardiac dysfunction.
● Mild OSA apnea–hypopnea index 5–14 events/hour,Moderate-15–29 events/
hour, Severe OSA>30 events/hour.
● Postoperative management concerns include analgesia, oxygenation, patient
positioning, and monitoring. Regional anesthesia with minimal sedation is
best for recovery vs use of opioids. Supplemental oxygen immediately post
op. CPAP or NIV should continue.
● In PACU patients placed on room air, 30% of patients younger than 1 year of
age, 20% aged 1 to 3 years, 14% aged 3 to 14 years, and 7.8% of adults had
hemoglobin saturations fall below 90%, with many falling below 85% .
● Monitoring with pulse oximetry is essential throughout the PACU.
● Patients with lung disease or obesity, those recovering from thoracic or upper
abdominal procedures, and those with preoperative hypoxemia are at risk.
● Supplemental oxygen should be administered only to patients at high risk of
hypoxemia or with low SpO2 readings.
● supplemental oxygen be administered in the PACU during initial recovery and
perhaps during transport to the PACU.
Perioperative aspiration
● Depression of airway reflexes places patients at risk for intraoperative
pulmonary aspiration that may manifest in the PACU, or for aspiration during
recovery.
● Aspiration of gastric contents,of clear oral secretions during induction, face
mask ventilation, or emergence is common.
● Cough, mild tracheal irritation, or transient laryngospasm are immediate
sequelae, a large Volume aspiration -infection, small airway obstruction, or
pulmonary edema.
● Aspirated “sterile” blood causes minor airway obstruction but is rapidly
cleared by mucociliary transport, resorption, and phagocytosis.
● Massive blood aspiration or aspiration of clots obstructs airways, interferes
with oxygenation
● Complications are often localized and treated with antibiotics and supportive
care once the foreign matter is expelled or removed.
Post anesthesia care unit
Design
● Near OT ,open ward design
● Proximity to radiographic, laboratory, and other intensive care facilities on the
same floor.
● Well lit room and large enough, easy access to for infusion pumps,
ventilators
● Minimum of 7 ft between beds and 120 sq ft per Patient.
● Multiple electrical outlets, including at least one with backup emergency
power, and at least one outlet each for oxygen and suction, should be present
at each bed space.
Equipment
● Pulse oximetry (SpO2), electrocardiogram (ECG), and automated noninvasive
blood pressure (NIBP) monitors are mandatory for each patient.
● Appropriate equipment must be available for those patients with intraarterial,
central venous, pulmonary artery, or intracranial pressure monitoring.
● Capnography
● Mercury or electronic thermometers.
● forced-air warming device, heating lamp, or a warming/cooling.
● Own supplies of basic and emergency equipment, including airway equipment
and supplies, such as oxygen cannulas, a selection of masks, oral and nasal
airways, laryngoscopes, endotracheal tubes, LMAs, a cricothyrotomy kit, and
self-inflating bags for ventilation.
● Respiratory therapy equipment for aerosol bronchodilator treatments,
continuous positive airway pressure (CPAP), and ventilators should be in
close proximity to the recovery room. A difficult airway equipment and
supplies cart with a bronchoscope and a video laryngoscope.
● A supply of catheters for venous, arterial, and central venous cannulation.
● A defibrillation device with transcutaneous pacing capabilities, and an
emergency cart with drugs and supplies for advanced life support
● Transvenous pacing catheters; pulse generators; and tracheostomy, chest
tube, and vascular cut-down trays are typically present, depending on the
surgical patient population.
● Point-of-care ultrasonography
Staffs
● Expertise in airway management and advanced cardiac life support, and
problems relating to wound care, drainage catheters, and postoperative
hemorrhage.
● Anaesthesiologist should be immediately available.
● The management of the patient in the PACU should reflect a coordinated
effort involving qualified anesthesia , surgeons, nurses, respiratory therapists.
● The anesthesia team emphasizes management of analgesia, airway, cardiac,
pulmonary, and metabolic problems, whereas the surgical team problem
related to surgery .
● A ratio of one recovery nurse for two patients.
Thank you