few minutes or hours, no more bleeding occurs.
Unfortunately, the clotting system is sometimes not good enough to clog a cut artery and, when the muscles in the artery relax, bleeding may start again and result in life-threatening hemorrhage. Now, no surgeon is going to knowingly leave a surgical site with bleeding still occurring, so when he leaves a dry field, why does bleeding occur one or two hours later, sometimes necessitating taking the patient back to surgery? It may be caused by a clip or tie coming off a vessel, but it may also be from inadequate clotting in vessels that the surgeon cauterized during surgery. Sometimes bleeding is minimal and can be observed but, if the patient shows signs of falling blood pressure, increasing pulse, and falling blood count such as hematocrit and hemoglobin (see Chapter 25), the surgeon must take the patient back to surgery and stop the bleeding.
Aside from the problem of bleeding or hemorrhage, the first thing commonly seen after surgery is an elevated temperature or fever. Many experts claim that a mild fever is a natural response to surgery for the first twentyfour to forty-eight hours, but it is always important for your doctor to evaluate the cause of the fever. The most common cause during the first two days after surgery is usually due to a pulmonary or lung problem. During surgery or in the period directly afterward, the lungs may not be completely expanded, and this condition, called atelectasis, can cause fever. It is corrected by deep breathing or a procedure known as incentive spirometry, where a patient breathes against a resistance to fully expand the lungs. Inspiring or breathing in through a tube has this effect and will clear the atelectasis and prevent the development of pneumonia. As you can imagine, in some children, debilitated, and older people, this can be a major problem.
The next most common cause of postoperative fever is urinary tract infection, which may be due to catheterization or preexisting problems and is treatable with antibiotics.
Wound infection problems come next. First, let's consider minor phlebitis, which may be as simple as an infected site where an IV has been placed, to a more extensive involvement of the veins in the arms or legs. The problem at the IV site is usually managed by changing the site of the IV and applying warm compresses, but antibiotics may also be indicated. Other wound problems may be infections in the surgical site skin, and leakage at a connection in the intestine. These kinds of infection usually occur after three or four days and may lead to actual separation of the wound, called dehiscence, or a more serious condition called evisceration, where the whole wound closure breaks down and the abdomen opens up.
Other less common but serious postoperative causes of fever are pancreatitis and parotitis.
The next problem the surgeon must watch for is major phlebitis in the large veins in the legs or pelvis. More common in obese patients, this problem can occur in anyone, especially if they are in bed for prolonged periods. That is why many surgeons use special compression stockings and foot pumps which keep the blood circulating in the legs and prevent blood clots in the veins that may cause blood clots to go to the lungs (pulmonary embolism). In Chapter 19, we will discuss this potentially lethal complication in more detail, along with another similar problem called fat embolism.
After surgery, other complications may be related to heart function, such as arrhythmias, (abnormal heart rates where it beats too fast, too slow or irregularly,) heart attack (myocardial infarction), or an acute problem called “shock..” Now the word “shock” is bandied about by everyone, while to a physician it has a more specific meaning, namely, a failure of the blood circulation with poor blood flow into the tissues. Obviously, this leads to failure of many organs, such as the heart itself, the kidneys, lungs, liver, and brain and can cause death rapidly. We won't go into the complex management of shock except to say that we try to prevent it by anticipating problems that may lead to it. These include heart failure, severe infection throughout the body called sepsis, and hypovolemic shock due to rapid loss of large volumes of blood or severe dehydration by loss of fluids from the blood into the tissues.
Another group of postoperative complications is psychiatric in nature. I have seen many patients, especially those who have to be in the intensive care unit for any period of time, develop what we call postoperative psychosis. They become disoriented and act “crazy.” Frequently, they are individuals who are normally in very good control of their emotions and also in control of their own lives. When placed in a situation where they are totally dependent on doctors and nurses for their every need, something inside them “clicks,” and they develop this psychosis, which often requires help from a psychiatrist, or special medications and sedatives. The condition almost always clears when the patient recovers fully from the operation.
We will talk more about the specific problems and complications of surgeries in Part II of the book under each heading rather than discuss them here. Additional general problems, however, can include kidney failure, gastric distention or failure of the stomach to empty (it enlarges and causes you to vomit), acidbase imbalance, (a complex problem with the fluids and chemicals in your blood,) liver failure, and abdominal abscesses. Anesthetic problems will be covered completely in Chapter 21.
So I admonish you to be aware of the fact that surgery is an art and a skill, that the human body is not like a machine, and it may not always react to the stress of surgery as we expect. Be realistic and understanding and know that the well-trained surgeon may have complications with a patient even under the best of conditions.
Chapter 13
INFECTIONS AND ANTIBIOTICS
“On the Antiseptic Principle in the Practice of Surgery”
Written in 1867 by Lister became a sort of liturgy,
When physicians learned about nasty small “bugs”
And then learned how to treat >em with drugs.
This was the third of the three great discoveries
That opened the door for surgical recoveries.
The first, you recall, was the tying of vessels.
Number two, anesthesia, by Morton and Wells.
So now we will challenge the worst of infections,
With drugs we have made with some complex confections,
And E. Coli, Staph and Strep can be driven,
When antibiotics correctly are given.
In the mid-eighteen hundreds some remarkable research was done by Louis Pasteur in the study of bacteria that led eventually to the publishing by Joseph Lister of his book, “On the Antiseptic Principle in the Practice of Surgery.” We have to imagine back one hundred and fifty years when it was considered normal for physicians to go from patient to patient without washing hands and to perform surgery with the very minimum of cleanliness. Ignasz Semmelweiss noticed that the wealthy women patients in the obstetrical ward where babies were delivered had a much higher incidence of puerperal sepsis, or infections during childbirth, than the poor women, and he discovered that the reason was that doctors were frequently examining the wealthy women in labor without gloves or washing hands, and carrying bacteria from one patient to the next. The poor women were rarely examined and surprisingly had almost no puerperal sepsis. He tried to convince his colleagues to wash their hands between exams but they scoffed at him, and he was ridiculed to the point where he eventually went crazy! In retrospect, we owe him a great deal of gratitude and credit for his pioneering work in antisepsis.
Penicillin was discovered in 1929 by Alexander Fleming and began to be clinically used by the 1940's. Since then, there has been an explosion of drug development, so that today we have a very large armamentarium of drugs to use in the treatment of infections. There is even a specialty in medicine called Infectious Disease,
