Postoperative Complications - Neurological:

1. Motor weakness

DDx: Residual neuromuscular blockade, electrolyte imbalance, hypothermia, stroke.

Clinical picture: Somnolence, shallow breathing, uncoordinated movements, agitation. Potentially desaturations and hypercapnia secondary to hypoventilation.

Treatment: Treat underlying cause. Residual neuromuscular blockade may be treated with neostigmine and glycopyrrolate or Sugammadex.


2. Post-operative nausea/vomiting (PONV)

Risk factors:

  • Patient factors: Female, non-smoker, history of PONV or motion sickness.
  • Anesthesia factors: Use of volatile anesthetics, nitrous oxide, use of intraoperative and postoperative opioids.
  • Surgical risk factors:Duration of surgery, type of surgery (laparoscopy, ENT, breast, neurosurgery, strabismus, laparotomy, plastic surgery).

Prevention:

  • Intraop: Total intravenous anesthesia (TIVA), pharmacologic prophylaxis (dexamethasone, ondansetron), multimodal analgesia to decrease opioid use, adequate hydration.

Treatment: Pharmacological treatment includes dimenhydrinate, dexamethasone, ondansetron, metoclopramide, low-dose haloperidol.


3. Delayed recovery

Definition: Unconsciousness persisting >15 minutes of discontinuing anesthetic agents.

Etiology:

  • Drugs: Residual intravenous (ex opioids, benzos) or volatile anesthetics.
  • Patient factors: Extremes of age, obesity, poor baseline physical status.
  • Metabolic: Hypoxia, hypercapnia, hypoglycemia, ketoacidosis, electrolyte imbalance.
  • Neurological: Intracranial hemorrhage, cerebral ischemia, seizures, CVA.

Treatment: Directed towards underlying cause. Most likely causes should be investigated and treated first.


4. Post-operative delirium

Definition: Transient mental dysfunction that can result in increased morbidity, delayed functional recovery, and prolonged hospital stay; commonly seen in the elderly.

Prevention: Identify and treat underlying medical issues, avoid precipitating medications, optimize fluid status, treat pain, tranquil post-operative care setting.

DDx: Drugs, withdrawal, infection, metabolic disturbances (especially hypoglycemia), structural causes like cerebral hemorrhage or ischemia.

Treatment: Ensure pain is treated and any potential underlying causes are treated. After, may consider pharmacological intervention like benzodiazepines (avoid in elderly as may cause paradoxical reaction) and antipsychotics like haloperidol.



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