04. Postoperative Medical Complications

Myocardial Infarction

  • Time Frame: Usually presents with 0-48hrs after noncardiac surgery
  • Risk Factors: See section Preoperative Cardiac Evaluation for Noncardiac Surgery
  • Presentation: Often silent without chest pain. Symptoms may include chest pain, dyspnea, hypotension, pulmonary edema, arrhythmia, nausea, or altered mental status
  • Screening: Per AHA 2014 guidelines, unclear benefit to screening with troponin or EKG in patients without symptoms of myocardial infarction (Class 2b). European Society of Cardiology recommends considering screening with troponin prior to and 48-72 hours after surgery in high risk patients
  • Management: For management see Cardiology

Atrial Fibrillation/Flutter

  • Time Frame: Usually presents 0-72 hours after surgery
  • Surgical Risk Factors: Thoracic, pulmonary, vascular, and abdominal surgeries
  • Triggers: Systemic inflammation, increased adrenergic tone, electrolyte abnormalities, anemia, hypothermia, hyper/hypovolemia, hypoxia
  • Presentation: Chest pain, dyspnea, dizziness, fatigue, anxiety
  • Diagnosis: High risk patients or critically ill patients should be on tele postoperatively. If patient is not on tele, obtain EKG
  • Management: Mainstay of management should be to reverse the underlying trigger. If no prior history and <48 hours, no need for long-term anticoagulation. For further management, see Cardiology

Pulmonary Edema

  • Time Frame: Usually 0-72 hours after surgery
  • Risk: Heart failure, significant volume resuscitation, prolonged procedures
  • Presentation: dyspnea, new oxygen requirement, volume overload
  • Diagnosis: CXR or POCUS in a symptomatic patient
  • Management: Diuresis

Delirium

  • Time Frame: Anytime during hospitalization and can take months to fully resolve
  • Risk: Underlying dementia or cognitive impairment, prior delirium, advanced age, long procedure, prolonged ICU stay, pain, poor sleep
  • Presentation: Hyperactive or hypoactive with waxing and waning attention and concentration
  • Prevention: Delirium precautions, frequent reorientation, minimize lines, minimize interventions overnight, early mobilization, avoid physical restraints, promote sleep in hospital
  • Management: Address common modifiable causes post-operatively such as pain, electrolyte disturbances, dehydration, poor PO intake, infection, hypoglycemia, organ failure (liver or renal), new medications. Pursue frequent reorientation involving family and all caretakers. Only utilize medications (antipsychotics>>> benzodiazepines) if the patient is an immediate harm to self or others

Cerebrovascular Event

  • Time Frame: Defined as within 30 days of surgery. Incidence of clinically evident stroke is 0.3-0.7%, unrecognized stroke may be as high as 7%
  • Risk: Cardiac disease, prior stroke, carotid stenosis, DM, CKD
  • Prevention: Maintain BP within 20% of baseline, avoid severe hypotension, for anticoagulation management in patients with thromboembolic risk see Perioperative Medication Management
  • Diagnosis: CTA stroke protocol vs MRI brain
  • Management: See Neurology: Acute Ischemic Stroke

Acute Kidney Injury

  • Time Frame: Usually 0-72 hours after surgery
  • Risk: Prolonged procedure, significant bleeding, BPH or urinary retention, chronic kidney disease, heart failure, cirrhosis, NSAIDs
  • Diagnosis: Rise in Cr with associated decrease in eGFR
  • Etiology:
    • Prerenal: Hypovolemia during/after surgery, hemorrhage, sepsis, cardiogenic shock
    • Intrarenal: Acute tubular necrosis due to contrast induced nephropathy, shock with hypoperfusion, new medications (antibiotics, NSAIDs), urinary tract infection
    • Postrenal: Urinary retention after Foley removal
  • Management: Address underlying etiology and remove precipitating factors

Infection

  • Time Frame: Depends on the site of the infection
  • Risk: Immobilization, atelectasis, immunocompromised state, DM, prolonged hospitalization, organ failure
  • Prevention: Perioperative antibiotics as indicated, thorough surgical site and skin exam, early mobilization, incentive spirometry and EZPAP, prompt removal of unnecessary lines, early removal of Foley and rectal tube
  • Management: Antibiotic regimens should be tailored based on 1) patient risk factors for drug resistance, specific organisms, and immunocompromise 2) the site of the infection, 3) the context of the infection. Cultures should be obtained prior to initiating antibiotics.

Fleisher, L. A., Fleischmann, K. E., Auerbach, A. D., et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Developed in collaboration with the American College of Surgeons, American Society of Anesthesiologists, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and Society of Vascular Medicine Endorsed by the Society of Hospital Medicine. J Nucl Cardiol 2015, 22 (1), 162-215.

Kristensen, S. D., Knuuti, J., Saraste, A., et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur J Anaesthesiol 2014, 31 (10), 517-73.