Shock, Sepsis & Multisystem · Topic 16 of 16
Postoperative Care & Complications
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Postoperative Care & Complications
Early fever is usually benign and self-limiting; later fever is often infection. Open an infected incision, and take a fascial gap back to the OR.
First moves
Why it happens
A common cause of postoperative fever
IL-1, IL-6 and TNF raise the hypothalamic set point without infection, part of the inflammatory, hypermetabolic response to an operation. Most fever in the first 48 hours is benign and self-limiting; fever after 48 hours is more likely infectious.
Postoperative fever: before or after 48 hours?
| First 48 hours | After 48 hours | |
|---|---|---|
| What it means | Usually benign and self-limiting | More likely infectious |
| Surgical site infection | Rare | A more common source; inspect the wound carefully |
| Organisms if SSI | Almost always S. pyogenes or Clostridium | Depends on the operative site |
Fever after 48 hours: where to look
Search by focused exam, not shotgun testing
Do not let atelectasis end the search in an ill-appearing patient: a systematic review found no good evidence linking it to fever. Older teaching and the 'wind' mnemonic list atelectasis (Merck still does); the 2011 CHEST review and Cleveland Clinic approach do not support it.
Surgical site infection
Open the incision first; antibiotics only for a systemic response
SSI antibiotics, once systemic
First-generation cephalosporin or antistaphylococcal penicillin
Vancomycin with MRSA riskCover gram-negatives and anaerobes, such as a cephalosporin plus metronidazole
Dressings, delirium, bowels and discharge
Dehiscence and evisceration
Sometimes the only clue is a large serous discharge from the skin wound
Evisceration evidence is case-level plus standard surgical teaching. For exposed bowel managed open over days, the Vanderbilt atlas warns against plain wet gauze and uses petroleum-jelly gauze.
Urinary retention
Straight catheterize an uncomfortable distended bladder or no urination for 6–8 hours
PONV
The number of mechanisms matters more than which drug is chosen
Postoperative dyspnea
Oversedation can blunt dyspnea and tachypnea
Prevention and enhanced recovery
Enhanced recovery: multimodal, opioid-sparing analgesia and early mobilization
An infected incision needs opening first; antibiotics are the add-on, not the treatment.
Sources · IDSA 2014 Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections (surgical site infections) · Pile JC. Evaluating postoperative fever: a focused approach. Cleve Clin J Med 2006;73 Suppl 1:S62–S66 · Merck Manual Professional — Postoperative Care (updated Jun 2026) · Davis R. Closure of Laparotomy Wound Dehiscence. Vanderbilt Open Manual of Surgery in Resource-Limited Settings · Management of post-operative nausea and vomiting in adults. The Pharmaceutical Journal (summary of the Fourth Consensus Guidelines) · Gan TJ et al. Fourth Consensus Guidelines for the Management of Postoperative Nausea and Vomiting. Anesth Analg 2020;131(2):411–448 · CDC NHSN Patient Safety Component Manual — Surgical Site Infection Event (2026) · Berríos-Torres SI et al. CDC Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg · Mavros MN et al. Atelectasis as a cause of postoperative fever: where is the clinical evidence? Chest 2011 · Missori G et al. Vaginal Evisceration of Small Bowel With Extraperitoneal Ileal Resection of the Herniated Loops: A Case Report. Front Surg 2022 · Likith YA, Kullolli G et al. Use of Rotterdam Risk Index in the Assessment of Risk Factors in Abdominal Wound Dehiscence. Cureus 2026 · Kumar NP, Ch N et al. Postoperative Urinary Retention After General Surgical Procedures: Incidence, Risk Factors, and Short-Term Outcomes. Cureus 2026 · Clinical practice guidelines for enhanced recovery after colon and rectal surgery (ASCRS/SAGES): commentary with recommendation table. Ann Laparosc Endosc Surg · Vaginal small-bowel evisceration 15 years post Wertheim hysterectomy: a case report and review of literature. Front Surg 2026 · Penetrating Abdominal Trauma With Small Bowel Evisceration: A Clinical Image. Clin Case Rep 2026 · Merck Manual Professional — Fever · Adams SR, Lee RM. Medical Care of the Surgical Patient: Postoperative Fever. Proceedings of UCLA Health 2018;22 · Follow your institution's protocols.