Introduction

Despite good preoperative assessment, surgical and anaesthetic technique and perioperative management, unexpected symptoms or signs arise after operation that may herald a complication. Detecting these early by regular monitoring and surgical review means early treatment can often forestall major deterioration. This chapter uses a problem-orientated approach to help junior (and more senior) doctors deal with such problems. The management of more serious complications is described in the next chapter.

Managing problems such as pain, fever or collapse requires correct diagnosis then early treatment. Determining the cause can be challenging, particularly if the patient is anxious, in pain or not fully recovered from anaesthesia. It is vital to see and assess the patient and if necessary, arrange investigations, whatever the hour, when deterioration suggests potentially serious but often remediable complications. Consider also whether and when to call for senior help.

Methods of management

Postoperative pain can be minimised by preoperative counselling, perioperative measures and postoperative analgesia. Counselling lets the patient know the probable extent of pain, the plans for pain relief and the likely degree of mobility after operation. During the operation pre-emptive analgesia ensures that pain does not become established.

This may involve:

Analgesia for minor and intermediate surgery

Patients vary greatly in their pain tolerance and need for analgesics. For minor and intermediate surgery, pre-emptive analgesia usually means simple analgesic tablets are sufficient. However, anxiety, exhaustion and sleep deprivation may reduce pain tolerance and the amount of analgesia must be adapted to individual need.

Analgesia for major surgery and trauma

(see Box 11.1)

Many hospitals now provide an acute pain service, run by anaesthetists and specialist nurses. This team can plan individual analgesic strategies and help deal with pain problems as they arise. True objective rating of pain is difficult but some form of visual analogue scale chart can be helpful (Fig. 11.1).

Following major abdominal and perineal operations epidural analgesia using local anaesthetic drugs and morphine can be invaluable. A single dose can provide anaesthesia for the operation, e.g. transurethral prostatectomy, plus several hours of complete postoperative analgesia. For more extensive surgery, an epidural cannula can be left in situ to allow ‘topping-up’ to extend postoperative analgesia. These patients need careful observation for signs of toxicity, severe hypotension or respiratory depression. Note that moderate hypotension is merely an indication of satisfactory sympathetic blockade.

For major surgery and trauma where epidural analgesia is inappropriate, the analgesic dose needs to be enough to eliminate the pain without causing dangerous side-effects, and to be given often enough for continuous pain relief. Effective pain control can be achieved by allowing patients to give themselves small intravenous increments of opiates using a patient-controlled analgesia (PCA) device (Fig. 11.2). This allows presetting of the incremental dose (often 1 mg of morphine), with a 5 minute lockout to prevent it being given too frequently, as well as control of the total dose. Continuous effective pain relief is thus easily achieved and the total dose used is often less than with intermittent injections. This technique causes minimal sedation and respiratory depression whilst maintaining excellent continuous analgesia, although it can cause opiate-induced nausea.

Excessive postoperative pain

If the pain is not controlled by an apparently adequate dose and frequency of analgesia, complications should be suspected. The dose should first be reviewed in relation to the expected severity of pain and the weight of the patient.

As a rule, serious complications cause deterioration in the patient’s general condition, whereas the patient remains well with less serious complications such as urinary retention or constipation.