Postoperative complications

Surgical Infections

Dr. Mahmoud W. Qandeel

Outlines
• Postoperative fever
• Myocardial infarction
• Fluid status
• Surgical site infection
• Tetanus
• Abscess
• Cellulitis
• Necrotizing fasciitis
• Clostridium Myositis and Gas Gangrene

Dr. Mahmoud W. Qandeel

 Postoperative Fever
“5 W’s ”: useful mnemonic or common causes of postoperative ever
Wind
Water
Wound infection
Walk
Wondering drugs

Dr. Mahmoud W. Qandeel

A. Wind: Pulmonary complications occur on postoperative days 1–3,
usually as a result of incisional pain, shallow breathing, and depressed
cough from narcotics.

1. Atelectasis: Due to peripheral collapse of alveoli.

– Treated with pulmonary toilet (i.e., deep breathing, early ambulation, and
incentive spirometer) to recruit most o the alveoli.
– More severe cases may need bronchoscopy to remove a mucus plug.

2. Pneumonia: presents as ever, cough, leukocytosis, and pulmonary

infiltrate on chest x-ray

Dr. Mahmoud W. Qandeel

Atelectasis
• = Collapse of pulmonary alveoli
• It is the most common postoperative complication

• Contributing factors:
– Anesthetic agents causing:
• ↓ Mucociliary clearance
• Dry secretions
– Pain (more with upper abdominal incisions),
– Narcotic drugs → limitation of respiration

• Clinical picture:
• Postoperative fever (24 hrs)
• Tachycardia, tachypnoea
• Decreased air entry, decreased breath sounds, basal lung dullness
• CXR: basal lung congestion and collapse.

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel
Risk Factors

• Major upper abdominal surgery performed via a vertical midline incision would be
expected to have the greatest impact on postoperative pulmonary function.

• Other operative factors would include thoracotomy, residual intraperitoneal sepsis,

age older than 59 years, prolonged preoperative hospitalization, colorectal or
gastroduodenal surgery, procedure longer than 3.5 hours, and higher body mass
index.

• Lower abdominal and extremity surgery are associated with fewer pulmonary
complications when compared with thoracic and upper abdominal surgery.

Dr. Mahmoud W. Qandeel

B. Water:
Urinary tract infections occur on postoperative days 3–5 due to
urinary catheterization; aided by early postoperative removal of
catheters.

C. Wound infections:
• Usually cause ever postoperative days 3–7.
• More virulent forms (streptococcal or Clostridium infections)
cause necrotizing infection earlier.

Dr. Mahmoud W. Qandeel

D. Walk:
• Deep venous thrombosis (DVT) usually occurs in the lower extremities
and can cause fever at any postoperative point.
• Immobilization and hypercoagulable state associated with surgery can
increase the risk o thrombosis.
• Complications of DVT can include pulmonary emboli with associated
tachycardia, tachypnea, and hypoxemia.

E. Wonder drugs:
Any drug can cause “drug fever,” especially antibiotics, which are often
used empirically.
Dr. Mahmoud W. Qandeel
Others : Less common causes include

• Anastomotic leak after bowel surgery,

• Sinusitis,
• Pancreatitis,
• Pseudomembranous colitis,
• Postpericardiotomy syndrome (5–7 days postoperatively), and
• Perirectal abscess.

Dr. Mahmoud W. Qandeel

 Postop. Day-related classification

Immediate Days 0-2 Days 3-5 Days 5-7 Days 7-10 Any time
post-op

Addisonian Atelectasis UTI Localized DVT & PE Line sepsis

crisis wound
infection
Thyroid storm Necrotizing Pneumonia Intra- Anastomotic Drug fever
soft tissue abdominal leak
infection abscess
MH Wound C. difficile Transfusion
cellulitis reaction

Dr. Mahmoud W. Qandeel

 Myocardial Infarction (MI)
• Perioperative MI: often non–S -segment elevation MI (NSTEMI)
• Symptoms : presents as shortness of breath, chest pain, or
arrhythmias.
• Treatment: Mortality from perioperative MI is 30%; therefore,
suspicion requires ECG, troponins, and early management.

Dr. Mahmoud W. Qandeel

 Fluid Status
• Hypovolemia :
– Common early after surgery due to third-space fluid sequestration
– Symptoms : presents as tachycardia, hypotension, and oliguria
– Treatment: hydration

• Overhydration:
– On postoperative days 3–4, the body begins to mobilize this fluid intravascularly
with high renal output, causing congestive heart failure, tachyarrhythmias, or
pulmonary congestion with impaired oxygenation requiring further diuresis.

Dr. Mahmoud W. Qandeel

Surgical Infections

Dr. Mahmoud W. Qandeel

 Surgical Site Infection
• Definition: infection present in any location along the surgical tract
• Common organisms :
– Staphylococcus aureus most common infection overall
– Escherichia coli: most common gram-negative rod
– Bacteroides fragilis: most common anaerobe
• Features : fever on postoperative days 5–8 with local tenderness,
cellulitis, drainage, and wound dehiscence

Dr. Mahmoud W. Qandeel

Treatment:
– Superficial infections need incision and drainage;
– Deeper wound infections or necrosis need operative debridement and
antibiotics.

Prophylactic antibiotics
• Follow these general rules.
A. Significant risk or postoperative infection exists.
B. Discontinue after surgery (usually before 1 day).
C. Antibiotics effective against the pathogens most likely present.
D. Benefits should outweigh risks of allergy or superinfection.

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel
 Surgical site infection
• Infection related to an operative procedure that occurs at or near the
surgical incision within 30 days or 90 days if prosthetic material is
implanted at surgery.

• Could be:
1. Superficial
2. Deep
3. Organ space
• Most commonly occur 4-6 days post-op
• Erythema, tender, edema
• 2.5% of abdominal incisions
Dr. Mahmoud W. Qandeel
 Tetanus
• Active immunization: tetanus toxoid injections provide protective titers in 30
days; given in infancy with boosters every 10 years.
• Prophylaxis : any person with penetrating injury
A. Unknown tetanus status: must receive tetanus immunization
B. If more than 5 years since last immunization: must receive a booster
C. Contaminated wounds without immunization: require both tetanus toxoid and passive
immunity with tetanus immune globulin (protective for 1 month)

• Devitalized tissue : must be debrided

• Antibiotics : High doses of penicillin are administered prophylactically with
extensive necrosis or suspected Clostridium tetani infection.
Dr. Mahmoud W. Qandeel
 Abscesses
Cutaneous abscess
• Furuncle (boil): cutaneous staphylococcal abscess associated with acne
and skin disorders
• Carbuncle: spreads through the dermis into subcutaneous tissues;
common with diabetes
• Hidradenitis suppurativa: Infections of the apocrine sweat glands in the
groin and axilla that occur as chronic recurrent abscesses and are often
caused by staphylococci. treatment includes drainage, antibiotics, and
excision of the involved area containing multiple abscesses or sinus
tracts.

Dr. Mahmoud W. Qandeel

Intra -abdominal abscesses
• Most common sites are the subphrenic and subhepatic spaces, pelvis, and
periappendiceal and pericolonic areas.
– External: caused by penetrating trauma or surgical procedure
– Internal: caused by a per orated viscus (e.g., appendix) or bacterial seeding (e.g., tubo-
ovarian abscess)
• Clinical features: fever, pain, leukocytosis, tachycardia, and sepsis
• Diagnosis: Needs high clinical suspicion.
– Computed tomography (C ) or ultrasound can confirm diagnosis.
• Treatment: Mainstay is drainage.
– Unilocular abscess: can be drained percutaneously
– Multilocular abscess: Complex or necrotic debris may require surgical drainage

Dr. Mahmoud W. Qandeel

 Cellulitis
• Definition: inflammation of the dermal and subcutaneous
tissue due to nonsuppurative bacterial invasion
• Clinical features : Produces erythema, edema, and tenderness.
May invade the lymphatics, causing red
• tender streaks (lymphangitis).
• III. Treatment: antibiotics, usually penicillin because
Streptococcus is usually the causative organism

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel
24
Dr. Mahmoud W. Qandeel
 Necrotizing fasciitis
• Necrotizing infections can manifest with bullae, skin necrosis, pain
beyond the margins of erythema, crepitus, gas on imaging, hypotension,
or other signs of SIRS.

• Common sites of origin are the genitalia, perineum (Fournier’s

gangrene), and abdominal wall.

Dr. Mahmoud W. Qandeel

Necrotizing fasciitis

Dr. Mahmoud W. Qandeel

Three types of necrotizing infections can be distinguished based on the
organisms involved.

• Type 1 is the most common, with a polymicrobial source including

gram-positive cocci, gram-negative rods, and anaerobes (Bacteroides
species, Clostridium perfringens and septicum), occurring in the
perineum and trunk of the immunocompromised host.
• Occasionally an entry site can be identified (incisions, lines, or intestinal
perforation), but in 20% to 50% of cases, a risk factor is not identified.

Dr. Mahmoud W. Qandeel

• Type 2 is a less common, monomicrobial infection with β-hemolytic
streptococci or staphylococci (MRSA rising in frequency to 40%).
• It can be associated with toxic shock and occur in a previously healthy
host, typically on the trunk or extremities, with a history of trauma
commonly elicited.

• Type 3 is a rare but fulminant subset resulting from a V. vulnificus

infection of traumatized skin in sea divers.

Dr. Mahmoud W. Qandeel

• Laboratory findings are nonspecific.
– Leukocytosis,
– Low calcium,
– Elevated lactate, creatine kinase, and creatinine may be seen.
– Coagulopathy and
– Acidemia.

• Blood cultures may or may not be positive.

Dr. Mahmoud W. Qandeel

 Management
• ICU for initial evaluation, resuscitation, and treatment.

• Operative exploration and debridement should not be delayed.

• Broad-spectrum IV antibiotics should be started as soon as possible,

with vancomycin (for MRSA) in addition to clindamycin or linezolid (to
inhibit toxin synthesis) and gram-negative rod coverage (in the form of a
third-generation cephalosporin or a quinolone).

Dr. Mahmoud W. Qandeel

• Surgery is the definitive treatment.

• Incisions should be made over the involved skin, parallel to

neurovascular bundles, extending to and exposing the deep
fascia to assess tissue viability.

Dr. Mahmoud W. Qandeel

• Necrotic tissue will appear dull, gray, and avascular and should be excised.
• Characteristic “murky dishwater”– like fluid.

• Borders for debridement are where tissue planes cease to readily separate.

• Rapid quantitative tissue cultures (if available) and frozen section analysis
may help guide the debridement.

• Revision surgery should be planned (“second look”) within 24 to 48 hours.

Dr. Mahmoud W. Qandeel

• In Fournier’s gangrene, one should aim to preserve the anal sphincter
as well as the testicles (blood supply is independent of the overlying
tissue; usually not infected).

• Wound closure is performed once bacteriologic, metabolic, and

nutritional balances are obtained.

• Mortality ranges from 25% to 40% and is higher in truncal and perineal
cases.

Dr. Mahmoud W. Qandeel

Necrotizing fasciitis

Dr. Mahmoud W. Qandeel

Necrotizing Fasciitis

Dr. Mahmoud W. Qandeel

 Clostridium Myositis and Gas Gangrene
• Clostridium perfringens : causative agent; anaerobic, gram-positive
bacilli secreting alphalecithinase toxin
• The following make wounds susceptible to this infection:
– Extensive necrosis: creates a redox potential for the anaerobe
– Impaired blood flow to the area: as in vascular thrombosis
– Gross contamination
– Immunocompromise: as in diabetes or patients on steroid therapy

Dr. Mahmoud W. Qandeel

• Clinical features : can occur as early as 6 hours after injury

• Presentation: severe pain (out of proportion to exam), weakened pulse,

diaphoresis, tenderness to touch, and crepitus
• Tests:
– Falling hematocrit and rising bilirubin from hemolysis.
– Gram-positive bacilli with spores without white blood cells in drainage and air in
soft tissue on x-ray.
• Treatment: Extensive debridement o tissue; delay is usually catastrophic.

Dr. Mahmoud W. Qandeel

Most common cause of postoperative fever third day ? (1/2017)

A. Atelectasis
B. UTI
C. Wound infection
D. DVT
E. Abscess

Dr. Mahmoud W. Qandeel

Most common cause of postoperative fever third day ? (1/2017)

A. Atelectasis
B. UTI
C. Wound infection
D. DVT
E. Abscess

Dr. Mahmoud W. Qandeel

On postoperative day 5 post hepatic resection a healthy 55 year
old patient is noted to have fever 38.6 c . Which of the
following is the most common associated ? (4/2017)

A . UTI
B . Wound infection
C . Pneumonia
D . Intra_abdominal abscess
E . Intravenous catheter related infection

Dr. Mahmoud W. Qandeel

On postoperative day 5 post hepatic resection a healthy 55 year
old patient is noted to have fever 38.6 c . Which of the
following is the most common associated ? (4/2017)

A . UTI
B . Wound infection
C . Pneumonia
D . Intra_abdominal abscess
E . Intravenous catheter related infection

Dr. Mahmoud W. Qandeel

Which of the following procedures would be expected to have
the greatest impact on postoperative pulmonary function?

A. Low anterior resection

B. Femoropopliteal bypass
C. Subtotal gastrectomy
D. Open cholecystectomy
E. Total abdominal hysterectomy

Dr. Mahmoud W. Qandeel

Which of the following procedures would be expected to have
the greatest impact on postoperative pulmonary function?

A. Low anterior resection

B. Femoropopliteal bypass
C. Subtotal gastrectomy
D. Open cholecystectomy
E. Total abdominal hysterectomy

Dr. Mahmoud W. Qandeel

A 24-year-old man presents with a traumatic wound to the le extremity.
It had been injured in a all 4 days previously. At home, the patient noted
increased redness, pain, and swelling, with the discharge of some foul-
smelling pus. In the emergency department, he has a high temperature,
heart rate of 132 beats per minute, and systolic blood pressure of 85 mm
Hg. The leg is tensely distended, extremely tender, and there is some
purulent drainage around a region of necrotic skin. The most appropriate
treatment for this patient is:
A. Oral antibiotics
B. IV isotonic fluids
C. Phenylephrine
D. Low-dose dopamine
E. Intubation and drainage of the abscess

Dr. Mahmoud W. Qandeel

A 24-year-old man presents with a traumatic wound to the le extremity.
It had been injured in a all 4 days previously. At home, the patient noted
increased redness, pain, and swelling, with the discharge of some foul-
smelling pus. In the emergency department, he has a high temperature,
heart rate of 132 beats per minute, and systolic blood pressure of 85 mm
Hg. The leg is tensely distended, extremely tender, and there is some
purulent drainage around a region of necrotic skin. The most appropriate
treatment for this patient is:
A. Oral antibiotics
B. IV isotonic fluids
C. Phenylephrine
D. Low-dose dopamine
E. Intubation and drainage of the abscess

Dr. Mahmoud W. Qandeel

A 52-year-old woman undergoes uneventful partial colectomy for a
large polyp o the sigmoid colon. During the procedure, placement
of a Foley catheter demonstrates good urine output. Four days
later, she develops a fever. Which of the following is the LEAST
likely cause of her fever?

A. Pneumonia
B. Wound infection
C. UTI
D. Perirectal abscess
E. Deep venous thrombosis (DVT)
Dr. Mahmoud W. Qandeel
A 52-year-old woman undergoes uneventful partial colectomy for a
large polyp o the sigmoid colon. During the procedure, placement
of a Foley catheter demonstrates good urine output. Four days
later, she develops a fever. Which of the following is the LEAST
likely cause of her fever?

A. Pneumonia
B. Wound infection
C. UTI
D. Perirectal abscess
E. Deep venous thrombosis (DVT)
Dr. Mahmoud W. Qandeel