10.2 Postoperative Complication Prevention

Immediate Postoperative Assessment and Handoff

When the patient arrives in the postanesthesia care unit (PACU) or on the surgical floor, the first priority is the airway, followed by breathing and circulation. The initial assessment includes airway patency, respiratory rate and effort with SpO2, vital signs (typically every 15 minutes until stable, then per policy), level of consciousness, pain, the surgical dressing and any drainage, IV sites and infusions, urinary output (goal at least 30 mL/hour), and neurovascular status of the operative extremity. The handoff from the anesthesia provider should include the procedure performed, type of anesthesia, estimated blood loss, fluids and blood products given, intraoperative complications or hemodynamic instability, allergies, and new orders. Never accept a transfer without a complete report.

Postoperative Fever Timeline

The classic "5 W's" mnemonic organizes the likely cause of postoperative fever by timing:

Atelectasis remains the classic answer for fever in the first 24-48 hours. Work up any fever with the timing, the surgical site, and the patient's symptoms in mind.

Atelectasis and Pneumonia Prevention

General anesthesia, incisional pain (especially upper abdominal and thoracic incisions), and shallow breathing cause alveolar collapse. Prevention includes the incentive spirometer (10 slow, deep breaths every hour while awake), coughing and deep breathing with incisional splinting, repositioning every 2 hours, early ambulation, and balanced pain control — uncontrolled pain causes splinting and hypoventilation, while oversedation depresses respiration. Signs of atelectasis include fever, diminished breath sounds or crackles at the bases, tachypnea, and falling SpO2.

DVT and Pulmonary Embolism Prophylaxis

Mechanical prophylaxis includes sequential compression devices (SCDs) worn continuously while in bed and removed for ambulation and skin checks, plus properly fitted graduated compression stockings. Pharmacologic prophylaxis is typically enoxaparin 40 mg subcutaneously once daily (30 mg every 12 hours for high-risk or orthopedic patients) or unfractionated heparin 5000 units subcutaneously every 8-12 hours. Key teaching points:

• No pillows behind the knees — this compresses the popliteal vein and promotes stasis
• Do not cross the legs; perform ankle pumps and leg exercises
• Maintain hydration and ambulate early

Signs of deep vein thrombosis (DVT) include unilateral calf pain, swelling, warmth, and redness. If DVT is suspected, do not massage or rub the leg — this can dislodge the clot. Keep the patient on bedrest per orders and notify the provider. (Homans' sign is no longer considered reliable.) Sudden dyspnea or chest pain suggests embolization — see Section 10.3.

Ileus and Constipation Prevention

Anesthesia, opioids, and bowel manipulation slow peristalsis. Paralytic ileus presents with absent or hypoactive bowel sounds beyond the expected window (small bowel activity returns within about 24 hours, gastric in 24-48 hours, colonic in 3-5 days), abdominal distention, nausea, and failure to pass flatus. Prevention and management: early ambulation, multimodal (opioid-sparing) analgesia, keeping the patient NPO until bowel function returns per orders, gradual diet advancement, and correcting hypokalemia, which worsens ileus. Constipation from opioids should be prevented proactively with a stimulant laxative such as senna (stool softeners alone are often insufficient), fluids, fiber, and mobility.

Urinary Retention

Anesthesia and opioids impair detrusor contraction and bladder sensation. Monitor for the first void, usually within 6-8 hours after catheter removal. If the patient cannot void or voids only small amounts, perform a bladder scan; retention is generally defined as a residual volume greater than 400-600 mL, managed with straight (in-and-out) catheterization per protocol. Remove indwelling catheters as early as possible — each catheter day increases the risk of catheter-associated urinary tract infection.

Early Mobilization Rationale

Early ambulation addresses nearly every postoperative complication at once: it improves ventilation and prevents atelectasis and pneumonia, promotes venous return and prevents DVT, stimulates peristalsis and prevents ileus and constipation, preserves muscle strength and functional status, and improves bladder emptying. Out of bed the evening of surgery or on postoperative day 1 is the standard goal for most major surgeries unless specifically contraindicated.

Wound Care and Drain Management

Document drainage by character and amount: serous (clear, straw-colored), serosanguineous (thin, pink — normal early), sanguineous (bloody — small amounts expected in the first hours; increasing amounts signal hemorrhage), and purulent (thick, odorous — infection). Nurses never remove drains; the provider does.

Empty closed drains using aseptic technique, and note the color, consistency, odor, and exact volume each time.

Hydration and Nutrition Progression

The diet advances as bowel function returns: NPO to clear liquids to full liquids to soft to regular, advancing only when the patient tolerates each step without nausea, vomiting, or distention. Maintain IV fluids until oral intake is adequate. Wound healing demands adequate calories and protein; vitamin C and zinc support collagen synthesis. For malnourished patients or prolonged ileus, anticipate enteral or parenteral nutrition orders. Monitor blood glucose in diabetic patients — hyperglycemia impairs healing and increases surgical site infection risk.