No surgery is free of complications. While it is important to accept that complications arise despite the surgeon’s best efforts, emphasis should be placed on ensuring preoperative and postoperative measures are continually implemented to minimize complication rates. A surgical complication is any deviation from the expected course of recovery from surgery.
Complications can be classified as general (events related simply to having surgery) or specific (related only to certain procedures). They can also be classified in relation to the time period after surgery. Regardless of the nature or timing of the complication, all surgical complications cause morbidity and/or mortality, which are not only distressing for the patient and her family, but also for the surgeon!
| Complications and their management |
> Classification of surgical complications
There are several ways to classify surgical complications: The broadest classification is general or specific . Classification regarding the timing of complication after surgery can be divided into immediate (within 24 hours after surgery), early (within 30 days after surgery), and late/delayed (after 30 days after surgery).
> Clivean-Dindo classification
This universally validated classification is also widely used in clinical practice. The classification system used for postoperative complications was first proposed in 1992 and has since been updated in 2004, extending its use to all adult surgical specialties.
The Clavien-Dindo classification has 5 grades that reflect a progression in the severity of postoperative complications. It is focused on the management of surgical complications. The advantage of using this classification is that it standardizes the reporting of postoperative complications in a simple and reproducible manner, and therefore allows auditing of physicians and hospitals, to maintain the provision of excellent care.
| Avoidance of complications |
While complications remain an integral part of surgery, risk assessment and prevention are essential. SSIs alone, as a postoperative complication, are a financial burden on both health systems and patients; in the latter, due to the loss of their labor income due to the disability caused.
Preoperative clinical risk assessment allows clinicians to identify and optimize the assessment of comorbidities, to reduce the risk of perioperative complications that may arise. Among the “simple” prophylactic measures are mentioned: transfusions of blood products to optimize hematological blood indices, administration of antibiotics at the time of anesthetic induction, adjustment of pre-existing medications, stopping smoking and starting taking nutritional supplements.
Another measure is the implementation of the WHO Checklist at the time of surgery. Its correct compliance has led to a significant reduction in the incidence of perioperative complications. By identifying and addressing errors, of which the entire team involved is aware, patient mortality is reduced by 50% and morbidity by 30%.
| Principles of management of surgical complications |
To manage any medical or surgical emergency it is essential to follow an ABCDE approach. However, before one is able to handle a complication, the deviation from what is expected must be recognized early. A recovery path is needed. This is feasible by using early warning systems, which alert clinicians about deviation of vital signs from preset parameters, obtaining regular blood tests and other more specific studies (e.g., a swab of pus for microbiological study, chest x-ray or computed tomography).
Once the complication is recognized, the implementation of a definitive management plan is required in a timely manner. In the hospital, a junior surgeon will more frequently encounter atelectasis, postoperative pain, bleeding, infection, and venous thromboembolism.
> Postoperative pain
Acute pain is perhaps the most common surgical symptom; 40-80% of patients experience moderate to severe pain on the day of surgery.
Pain is defined as a sensory and emotional sensation associated with actual or potential tissue damage. If not adequately treated, pain can have significant adverse consequences including tachycardia, hypertension, increased opioid use, respiratory compromise due to ineffective cough, and diaphragmatic paralysis which in turn causes atelectasis and pneumonia, patient dissatisfaction, and development of chronic pain (duration >3 months from the date of the procedure).
Pain is subjective, complex, multifaceted and difficult to treat. Preexisting pain, anxiety, catastrophizing, and type of surgery are recognized predictors of postoperative pain. Therefore, preventive and postoperative analgesia must be multimodal, targeting the different biochemical and psychological pathways of pain, to achieve satisfactory results.
Verbal and visual tools are used to assess pain. Frequent evaluation of pain and the doses and/or type of analgesia is of great importance. The WHO analgesic scale is used for pain management. Simple analgesia such as paracetamol and non-steroidal anti-inflammatories and escalated doses of opiates should be started depending on the response.
The route of administration of analgesics must also be multimodal. Early in the postoperative phase, when pain is at its highest, oral analgesia is less effective due to variability in plasma concentrations. Intravenous analgesia, particularly opioids, allows for more rapid titration of doses. However, caution should be taken with adverse effects such as respiratory depression and sedation, as these can occur rapidly with high opioid concentrations. The subcutaneous route is better tolerated than intramuscular analgesia and both routes have the same efficiency.
For severe pain, patient-controlled analgesia and regional anesthesia are effective adjuncts to oral and parenteral administration. Administration often requires consultation with a pain specialist or anesthetist. But this should not deter the junior doctor from doing so at the first opportunity. Consultation with an acute pain service and implementation of the Enhanced Recovery After Surgery (ERAS) program should be implemented early in the postoperative recovery phase. The use of ERAS for major surgeries has been shown to significantly improve postoperative outcomes by having structured algorithms for recovery, including pain management, that involves the entire multidisciplinary team.
> Bleeding
Postoperative bleeding is classified as immediate, reactive, or secondary.
Immediate bleeding occurs in the intraoperative period or at the end of surgery, the latter being evident in the recovery room. It is due to inadequate hemostasis during surgery and almost always requires a return to the operating room.
Reactive bleeding is bleeding that occurs within the first 24 hours (commonly 4-6 hours) after surgery. One possible cause is a return to higher blood pressure, as intraoperative anesthetic agents cause hypotension. Other causes are warming of the patient and subsequent vasodilation, which initiates bleeding from the vessels, which was not evident at the time of surgery.
Secondary bleeding occurs 7-14 days after surgery and is the result of local infection. It is necessary to evaluate the bleeding profile and preventively apply measures and correct hematological problems and coagulation indices, which will mitigate the hemodynamic instability caused by significant bleeding, if it occurs. Before the operation, pre-existing anemia must be corrected through blood transfusions.
If the patient rejects blood transfusions due to religious or cultural beliefs, they will be iron. To achieve optimal oxygen-carrying capacity after transfusion, transfusion of packed red blood cells should be done 48-72 hours before surgery. Other preventive measures that can be taken include the intraoperative use of a cell salvage device and meticulous surgical technique.
Internal bleeding requires a high index of clinical suspicion. A drain full of blood in the first hours after surgery indicates reactionary bleeding. A lack of blood in the drain can be very misleading as if the bleeding is significant there may be clots blocking the drain. However, the presence of tachycardia, hypotension, pallor, oliguria, and an acute drop in hemoglobin in the setting of recent surgery is highly suggestive of postoperative bleeding.
Management of bleeding, regardless of the time of onset, focuses on maintaining hemodynamic stability. Hypovolemic shock is assessed using the Resuscitation Council ABCDE.
Wound-related bleeding may respond to the application of direct pressure to the wound. It is best to apply pressure for a sufficient period of time, usually at least 5 minutes. Examples of methods for managing bleeding from surgical wounds are: multiple gauze application, pressure pad, adhesive tape, hemostatic dressings (i.e., adrenaline-soaked gauze), and cauterization with silver nitrate.
Significant surgical bleeding requires activation of the hospital’s major bleeding protocol, in addition to notification to senior members of the surgical team. Rapid administration of hemostatic agents such as tranexamic acid and transfusion of blood products (red blood cells, platelets, fresh frozen plasma) are required. In cases of hemodynamic instability or inability to stop bleeding, it is necessary to urgently return to the operating room to restore hemostasis.
> Infection
In recent years, SSIs have attracted increasing attention. They are considered a financial and health burden around the world. Its heterogeneity has complicated the ability of epidemiological studies to report its true incidence. A review of the literature has reported that they account for approximately 15% of all hospital-acquired infections. Infected and contaminated procedures are associated with an increased risk of SSI, with an incidence of post-surgical colorectal infections of 2% to 45%.
SSIs are defined as an infection that occurs within 30 days of surgery, if no implant or foreign body has been left in situ, or within one year of surgery, in the presence of implants or foreign bodies. These infections significantly increase morbidity and psychosocial stress. The consequences are prolonged hospitalization, the need for greater resources for wound management, and a 5-fold increased risk of repeat hospitalization.
The clinical presentation of SSIs includes the 5 cardinal signs of inflammation: blush (redness), tumor (swelling), heat (increased heat), pain (pain), and loss of function along with an offensive discharge from the wound. , suture dehiscence, systemic inflammatory response (tachycardia, fever, hypotension) and elevated inflammatory markers. The risk of developing an SSI is multifactorial.
The implementation of SSI reduction packages, which assigns equal responsibility to all health professionals involved in patient care, allows preventive measures to be taken to reduce the risk, through the application of measures to reduce it. In some hospitals, this behavior has reduced the incidence of these infections.
WHO recommendations for safe surgery refer to the use of prophylactic antibiotics preoperatively and at the time of anesthetic induction, with a reported 50% reduction in the risk of SSI. Recently, the National Institute for Health and Care Excellence supported the use of negative pressure dressings for closed surgical incisions to reduce the risk of SSIs. If SSIs still occur despite the implementation of preventive measures, then management should focus on sepsis control.
Before starting antibiotics, samples for microbiological cultures should be taken by swabbing for pus and blood.
Broad-spectrum antibiotics should be started according to individual confidence guidelines and then, at the first opportunity, switched to narrow-spectrum antibiotics, depending on sensitivity, to avoid the development of antibiotic resistance. In addition to antimicrobial therapy, superficial wound infections may require opening at the bedside to drain the accumulated collection.
Collections from deeper wounds will require drainage through surgical or radiological intervention. Adjuncts such as vacuum-assisted closure devices and beneficial maggot therapy in chronically infected or poorly healing wounds can also be used for the management of SSIs. In chronic wounds, iodine and silver dressings can be used to reduce the bacterial load.
Infections are not limited to the surgical site. In the postoperative period, urinary tract and lung infections are also observed all too frequently. Care should be taken when inserting intraoperative urinary catheters and ensuring non-contact aseptic technique. Removal of urinary catheters should be done as soon as possible. Early mobilization, chest physiotherapy and stimulation of deep inspirations are advised, in addition to ensuring adequate analgesia, to reduce the risks of acquiring an in-hospital lung infection.
| cardiac complications |
The most common cardiac arrhythmias in the postoperative period are sinus tachycardia and atrial fibrillation. Cardiac arrhythmia can manifest itself against the background of infection, bleeding and pain. Anastomotic leaks, for example, may present with atrial fibrillation due to subsequent sepsis. Sinus tachycardia and subsequent bradycardia are seen in hypovolemic shock, either secondary to hemorrhage or fluid depletion due to poor postsurgical intake. Attention should be paid to the heart rate trend in the Early Warning Vital Signs Score. It often means something is wrong.
| Atelectasis |
Respiratory compromise is evidenced by the presence of hypoxia and hypercapnia, signs that are frequently observed at the time of induction of general anesthesia. Postoperatively, atelectasis and pneumonia are the most common complications, with significant consequences of morbidity and mortality, if not recognized and treated in time.
Atelectasis usually occurs on the first or second postoperative day. Atelectasis is defined as the partial or complete collapse of lung tissue. This collapse provides a nidus for infection and predisposes to other postoperative pulmonary complications. Depending on the amount of lung tissue involved, atelectasis may be asymptomatic or present with mild pyrexia and oxygen desaturation.
Surgery-specific ERAS protocols have revolutionized postoperative recovery by providing the multidisciplinary team with a path forward that will optimize care of physiological function and minimize the surgical stress response, thereby improving recovery.
It is recommended to routinely practice early mobilization, favoring the patient’s upright position, in addition to omitting the nasogastric tube if it is not necessary, preventing fluid overload and inducing deep breathing exercises.
| venous thromboembolism |
Hospital-acquired venous thromboembolism (VTE) accounts for 50 to 60% of all VTE. The use of national and hospital guidelines has led to increased awareness of this condition, with reductions in VTE-related deaths. Pulmonary embolisms (PEs) can also occur, especially after orthopedic surgery.
The fundamental pillar for the management of VTE and PE associated with surgery is thromboprophylaxis. Preoperative Assessment Clinics identify patients who are at high risk for VTE, including malignancy, obesity, smoking, previous VTE, thrombotic disorders, prolonged anesthesia and surgery time (>90 minutes), and reduced mobility.
Every effort should be made to keep the patient hydrated and promote mobility, to avoid the Virchow triad (endothelial injury, hypercoagulable state, and venous stasis) that leads to the development of VTE.
VTE prophylaxis consists of mechanical and pharmacological methods.
Mechanical methods include antiembolic stockings and intermittent pneumatic compression devices. Pharmacological prophylaxis consists of administering low molecular weight heparin by subcutaneous injection or infusion of unfractionated heparin.
When there is a high index of clinical suspicion, it is acceptable to begin treatment while awaiting the results of the requested studies. The preferred treatment is the injection of doses of low molecular weight heparin or a non-vitamin K antagonist oral anticoagulant. The use of the latter for the treatment of VTE should be discussed with a hematologist, from an individualized approach.
Fibrinolytic agents are contraindicated after surgery, but may be used in life-threatening VTE. If the VTE spreads, thrombectomy or embolectomy, whether radiological or surgical, and the insertion of a filter in the inferior vena cava can be used to prevent its spread to the pulmonary arteries.
| Conclusion |
- It is essential to recognize complications early and provide aggressive management, both preoperatively and when they begin, to mitigate the appearance of their postoperative effects.
- Infection, bleeding, venous thromboembolism, respiratory and cardiac complications, in addition to specific complications of surgery, are problems that commonly arise for the junior surgeon.
- As “prevention is better than cure”, the responsibility of the multidisciplinary team involved must be alert to implement preventive steps, in order to optimize postoperative results.
