Non-respiratory postoperative complications

Many complications can interrupt a patient's recovery, but you can prevent most of them. Some important ones involve his lungs; these are in the next section. Infections are more likely if he is HIV positive (Chapter 28a).

If he is to recover uneventfully from an abdominal operation, his gut must start to work soon. The passage of flatus and bowel sounds show that his small gut is starting to work; his large gut starts a day or two later. If all goes well, he should start eating in 2[nd]3 days. But eating will be delayed if he is recovering from peritonitis, from an anastomosis of his stomach or upper small gut, or from ileus (10.13), or if he is anorexic from any other cause, such as burns or severe sepsis. If he does not eat he starves, and although he may be able to live for several weeks without eating, he will waste severely. Unfortunately, the common intravenous fluids provide little energy and no protein, and you are unlikely to have the necessary solutions of proteins and amino acids for parenteral nutrition. But if you can get some food into him, as described below, it may save his life.

You are fortunate in that deep venous thrombosis and pulmonary embolism are uncommon in the developing world.

NON-RESPIRATORY POSTOPERATIVE COMPLICATIONS For postoperative bleeding and shock, see Section 3.10. For the anaesthetic complications see A 4.5 and 4.6.

VOMITING If a patient VOMITS IMMEDIATELY AFTER THE OPERATION turn him on his side. It may be due to the anaesthetic, especially ether, or to morphine or pethidine. He is likely to recover quickly. If he vomits for more than 8 hours or copiously at any time, start gastric aspiration.

If he VOMITS AFTER 48 HOURS, this is likely to be more serious, and may be due to ileus, postoperative gut obstruction, or rarely to acute gastric dilatation. If you don't replace his fluids and electrolytes, he will become severely hypovolaemic. He may lose much potassium if he continues to vomit, so replace this (A 15.5).

If he is VOMITING WITH A DISTENDED, SILENT ABDOMEN, he has ileus (10.13). This may be due to postoperative peritonitis (6.2, 10.13) which also causes pain, fever, and toxaemia. The nature of his previous operation, such as a pelvic abscess or an injury to his large gut, usually suggests its site. Later, watch for an abdominal (6.3) or subphrenic (6.4) abscess.

URINE OUTPUT [s7]POSTOPERATIVELY If he passes NO URINE, or only a little, and his bladder is not distended: (1) He may be dehydrated. (2) He may be hypovolaemic. (3) He may have suffered a period of low blood pressure during the operation, which has caused tubular necrosis and renal failure. (4) He may have retention due to an enlarged prostate or a stricture. Some degree of urinary suppression is normal for 24 to 60 hours after major surgery, as a normal response to stress.

If he passes a little urine of high specific gravity, and is obviously dehydrated, give him 1000[nd]2000 ml of saline as rapidly as you can. If his urinary output does not improve, give him 500 to 1000 ml of intravenous mannitol, or 40 to 80 mg of intravenous frusemide. If this produces a diuresis, he was severely dehydrated. If it produces no flow, he may have tubular necrosis and renal failure. If so, go to Section 53.3.

CAUTION ! (1) If he is a child, don't overhydrate him. Give him about 30 ml/kg of fluid for the first 2 hours, and repeat it over the next 3[nd]4 hours if necessary. (2) Before you diagnose anuria, make sure that his Foley catheter is not blocked!

If he passes NO URINE, and he has a bladder which is distended and dull to percussion, he has retention. This is common after perineal operations especially in an old man. Stand him by the edge of his bed, and run a tap. The sound of running water may make him urinate. If this fails, aspirate his bladder suprapubically (entrust this task to the nurses, 23.6). Often it is only needed once. If the problem recurs and provided he has not had an intestinal anastomosis, try carbachol 250[gm]g subcutaneously, if necessary repeated twice at 30 minute intervals. If this fails, catheterize him.

FEVER [s7]POSTOPERATIVELY Most patients have a mild fever for 1[nd]4 days after a major abdominal operation.

If he has more than minimal FEVER postoperatively, suspect pulmonary collapse (9.11), streptococcal wound sepsis (2.10, 9.12), a urinary tract infection (especially if he has been catheterized), a drug reaction, malaria, an abscess either under his diaphragm or somewhere else (6.3), Gram-negative or anaerobic wound infection (54.13), pneumonia, peritonitis (6.2), septicaemia or septic shock (53.4), a subphrenic (6.4) or a pelvic abscess (6.5), or deep vein thrombosis.

If he has PERSISTENT FEVER, and a raised white count, and is not improving, suspect that he has an abscess somewhere in his peritoneum, especially if you operated on him for peritonitis, or infected his peritoneum during the operation. Examine him carefully every day. If he also has a raised diaphragm and fluid in his costophrenic angle, he has a subphrenic abscess until you have proved otherwise[md]see Section 6.4. If he also has diarrhoea with the passage of mucus, he probably has a pelvic abscess. The passage of mucus is a particularly valuable sign. Avoid ''blind' antibiotic treatment unless his condition is critical. It may merely mask the problem which will become worse later.

FEEDING DIFFICULTIES [s7]POSTOPERATIVELY If his RETURN TO NORMAL EATING IS MUCH DELAYED, he will waste considerably. Here is a variation of the instructions in Section 58.11. Let him eat what he can of his usual staple, such as rice, maize, or potatoes, and supplement this with nasogastric feeding (4.9), using the high-energy milk feed that you usually give to malnourished children. A convenient mix for a litre of feed is: dried skim milk 86 g, sugar 67 g, oil 86 ml, water 811 ml. Or, evaporated milk 443 ml, sugar 67 g, oil 52 ml, water 448 ml. Or, ''Nespray' 118 g, sugar 65 g, oil 54 ml, water 813 ml. This provides 1370 kcal/l. If he is to recover on this alone he needs at least 2 and preferably 3 litres of it daily. Watch his fluid balance (A 15.5), and give him 10 mmol/day of potassium, which is 10 ml of the commonly used solution (58.11, A 15.1).

If he cannot take fluids by mouth, pass a small plastic tube and start by feeding him 200 ml of a quarter- strength feed every 3 hours. Increase this to the limit of nausea and diarrhoea, until he is having 2 to 2.5 l of full-strength feed in 24 hours.

If he is VERY WASTED , and you have done an operation on his stomach or duodenum, consider feeding him through a jejunostomy (9.7). This is seldom necessary if he can be fed by mouth or by nasogastric tube.