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Chapter 27: Surgical Intensive Care Unit

Khalid Sherani; Jennifer Cabot; Stephen M. Pastores

INTRODUCTION

Surgical procedures constitute a sudden insult to the body, which can result in a myriad of life-threatening complications.1 While most postoperative complications occur 1 to 3 days after surgery, others can take weeks to present.2

Some complications may occur after any type of operation and have predictable time courses (Table 27-1). Others are more specific to the operation performed and the patient’s medical history (Table 27-2). Postoperative fever is one of the most common complications encountered after any type of operation and requires a systematic approach to identify the etiology (Table 27-3).

TABLE 27-1General Postoperative Complications
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TABLE 27-1General Postoperative Complications

  • Immediate (hours to days)

    • Complications of anesthesia: malignant hyperthermia, allergic reaction, arrhythmia, hypotension, hypertension

    • Hemorrhage: primary (cut ends of vasculature), secondary (congenital bleeding diathesis, consumptive coagulopathy, anticoagulant-related)

    • Hypoxia: aspiration pneumonitis, atelectasis, pulmonary edema, transfusion reaction

    • Oliguria: inadequate fluid replacement, bladder atony secondary to anesthetics, acute tubular necrosis secondary to medications, hypotension, or rhabdomyolysis

    • Shock: hypovolemic (blood or fluid loss), distributive (sepsis, side effect of anesthesia), cardiogenic (post-surgical MI), obstructive (acute PE)

    • Thromboembolic events: cerebrovascular accident, MI, PE

  • Early (days)

    • Acute kidney injury: prerenal, intrinsic, obstructive

    • Anastomotic breakdown/wound dehiscence

    • Dehydration

    • Delirium

    • Electrolyte imbalance

    • Hypoxic respiratory insufficiency: acute respiratory distress syndrome, pneumonia, PE

    • Ileus/Ogilvie syndrome

    • Infection: local wound infection or systemic infection (pneumonia, urinary, intravascular catheters, abscess)

    • Thromboembolic events: deep venous thrombosis, PE

    • Urinary retention

    • Transfusion-associated reactions

  • Late (weeks to months)

    • Abscess

    • Fistula

    • Hernia: incisional, internal

MI = myocardial infarction; PE = pulmonary embolism.

TABLE 27-2Procedure-Specific Complications
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TABLE 27-2Procedure-Specific Complications
Type of Procedure Specific Complications
Gastrointestinal surgery

  • Bowel operations

    • Anastomotic complications/leak

    • Bowel obstruction

    • Fluid collections

    • Ileus/Ogilvie syndrome

    • Nerve damage (presacral plexus)

  • Gallbladder operations

    • Common bile duct injury/leak

    • Pancreatitis
Thoracic surgery

  • Air leak, pneumothorax, and bronchopleural fistula

  • Lobar torsion

  • Pleural effusions and hemothorax

  • Postpneumonectomy syndrome

  • Postpneumonectomy pulmonary edema
Cardiac surgery

  • Arrhythmias (bradycardia, supraventricular, ventricular)

  • Myocardial ischemia

  • Shock (blood loss, vasodilation due to warming, cardiopulmonary bypass–induced inflammation and capillary leak, decrease in ventricular compliance due to ischemia-reperfusion injury)
Vascular surgery

  • Cerebrovascular accident

  • Compartment syndrome due to

    • Bleeding

    • Reperfusion edema

  • Cranial nerve injuries

  • Graft-related complications

    • Fistula formation

    • Hemorrhage

    • Infection

    • Ischemia

    • Rethrombosis

  • Multisystem organ failure
Urological surgeries

  • Bleeding/hematuria

  • Electrolyte abnormalities (most commonly hyponatremia)

  • Retrograde ejaculation

  • Sphincter damage/incontinence

  • Urinary tract infections (urethritis, cystitis, pyelonephritis, prostatitis)
Neck surgeries

  • Airway obstruction secondary to compression from hematoma

  • Electrolyte abnormalities (most commonly hypocalcemia due to parathyroid gland damage/removal)

  • Facial or recurrent laryngeal nerve damage
TABLE 27-3Etiologies of Postoperative Fever
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TABLE 27-3Etiologies of Postoperative Fever

  • Immediate

    • Drug fever

    • Malignant hyperthermia (rare)

    • Transfusion reaction

  • Acute

    • Catheter-associated infections

    • Skin and soft tissue infections

    • Urinary tract infection

    • Ventilator-associated pneumonia/aspiration pneumonia/pneumonitis

  • Subacute

    • Antibiotic-associated fever

    • Catheter-associated infections/thrombophlebitis

    • Clostridium difficile colitis

    • Skin and soft tissue infections, ...

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