Postoperative management

Last updated: November 8, 2023

Summarytoggle arrow icon

Postoperative management of the surgical patient has two important components: supporting the patient's return to baseline health and recognizing and treating adverse events that may occur following surgery. Facilitating early oral intake, early mobilization, optimal pain control, and adequate hydration are some of the key elements required to ensure that the patient returns to baseline health. Preventative measures include ambulation, incentive spirometry, and ulcer and DVT prophylaxis. Postoperative adverse events are common and vigilance for early signs of infection, hemorrhage, ileus, and urinary retention is required. Fever is a common manifestation of postoperative complications and must be approached systematically to reach a definitive diagnosis.

See also “Preoperative management.”

Prevention and early identification of postoperative complicationstoggle arrow icon

This section discusses the routine inpatient management of postoperative patients. For management immediately following procedural sedation, see “Recovery and discharge after procedural sedation.” For patients requiring intensive care, see “Care of the critically ill patient.”

Approach [1]

Monitoring [2][3][4]

Based on the type of surgery and patient factors, obtain and monitor the following frequently.

  • Vital signs
  • Focused physical examination, including assessment of the surgical site
  • Input & output values
    • IV fluid intake
    • Urine output: If output is < 0.5 mL/kg/hour for > 6 hours, [5]
    • Surgical drain output
      • Total output over 24 hours [6]
      • Appearance of drainage (e.g., serous, bloody, purulent, feculent )
    • Stool output

Postoperative preventive measures [1][2][7][8]

The following measures are initiated after surgery to prevent common postoperative complications. For preventative measures performed prior to surgery, see “Preoperative assessment.”

Surgical wound management [18]

  • Frequently examine the incision site to monitor the wound healing process.
  • Manage wound dressings.
    • Leave the initial postoperative dressing in place for at least 48 hours. [18]
    • Change the dressing regularly to facilitate healing.
    • Provide adequate analgesia during dressing changes if needed.
  • Counsel patients on wound care. [19]
    • Recommend avoiding trauma and maneuvers that increase tension around the surgical site
    • Educate patients on outpatient dressing changes; order home nurse visits if needed.

Postoperative complicationstoggle arrow icon

Postoperative complications [1][4][20][21]
Pulmonary [22]
Renal and urinary tract
Skin and soft tissue

Postoperative fevertoggle arrow icon

Definition [20]

Temperature > 38°C (100.4°F) in the postoperative period


Etiology of postoperative fever [4][20][21]
Onset of fever Infectious cause Noninfectious cause
Immediate Intraoperatively or within a few hours after surgery
  • Infection acquired prior to surgery
Acute ≤ 1 week after surgery
Subacute 1 week–1 month after surgery
Delayed > 1 month after surgery

Immediately life-threatening causes of postoperative fever [33]

To avoid poor outcomes, immediately life-threatening causes of fever should be promptly identified and managed.

Diagnostics [1][4]

The most common infectious causes of postoperative fever include surgical site infections (SSIs), pneumonia, catheter-associated UTIs, and primary bloodstream infections. The most common noninfectious causes include febrile drug reactions and venous thromboembolism. [33]

Treatment [4][28]

Early (< 2 days) postoperative fever does not always require treatment if life-threatening causes of postoperative fever have been ruled out and there is no suspicion of infection. [1][4]

Perioperative hemorrhagetoggle arrow icon

Etiology [35]

Etiology of perioperative hemorrhage [36][37]
Onset Cause
Intraoperative hemorrhage
Postoperative hemorrhage < 24 hours
1–7 days
> 1 week

Bleeding can occur at sites other than the surgical wound (e.g., during central line insertion) in patients with hemostasis and bleeding disorders.

Clinical features

Diagnostics [38]

Recognition of bleeding is the first step in diagnosis.

Treatment [38]

Hematomas and seromastoggle arrow icon

Definition [4]

  • Hematoma: a collection of blood due to unsuccessful hemostasis or coagulation
  • Seroma: a collection of serum, lymphatic fluid, and liquified fat often due to the presence of an empty cavity following surgery

Clinical features

  • Most commonly occurs several days after surgery
  • May be asymptomatic
  • Localized swelling
  • Pain or discomfort
  • Drainage of fluid
  • Hematoma: purple discoloration

Treatment [4]

  • Small or asymptomatic: expectant management
  • Large or symptomatic ; [4]
  • Monitor for wound infections (bacteria can access deep layers of the fascia and can multiply in the stagnant fluid).

Surgical site infection (SSI)toggle arrow icon

Definition [39]

An incisional skin and soft tissue infection or organ/space infection located at the site of recent surgery, typically arising within 30 days postoperatively


Etiology [39]

Classification of surgical wounds [45][47]

Wounds can be classified preoperatively and/or postoperatively based on clinical characteristics. The classification may be used to predict the risk of developing an SSI and the necessity of perioperative antibiotic prophylaxis.

Surgical wound classification [45]
Definition Rate of infection [4]
Class I (clean)
  • All of the following:
    • Noninflamed operative wound
    • The respiratory, alimentary, genital, or urinary tracts have not been entered during surgery.
    • Primary wound closure with or without a drain
  • 1–3%
Class II (clean-contaminated)
  • Noninflamed and uninfected operative wound
  • The respiratory, alimentary, genital, and/or urinary tracts have been entered during surgery without contamination.
  • 5–8%
Class III (contaminated)
  • 20–25%
Class IV (dirty or infected)
  • Old traumatic wounds with evidence of infection, necrotic tissue, and/or visceral perforation
  • Inflamed operative wound with purulent drainage
  • 30–40%

Classification and clinical features of SSI [39][45]

Classification of surgical site infections (SSIs)
Clinical features of SSIs Onset Tissue involvement

Superficial incisional SSI

  • Within 30 days postoperatively
Deep incisional SSI
  • Within 30–90 days postoperatively [40]
Organ/space SSI
  • Can involve any part of the body deeper than the fascia or muscle layers that was opened or manipulated during surgery

Diagnostics [40]


General principles

Not all patients with an SSI need antibiotics; surgical management alone may be sufficient.

If antibiotics are indicated, obtain samples for microbiological studies prior to starting empiric antibiotic therapy, if possible.

Surgical management [4][48]

Empiric antibiotic therapy for SSI [40]

Choose initial empiric antibiotics based on the location of surgery (e.g., intraabdominal, genital) and presence of complications (e.g., necrotizing infection). Antibiotic duration depends on the severity and extent of the infection.

Necrotizing soft tissue infections are a medical emergency and require immediate surgical consultation and treatment.


Prevention [41][49]

Sternal dehiscencetoggle arrow icon

Definition [50]

A gap at the site of the sternal division following median sternotomy, which may or may not be accompanied by infection

Risk factors [51][52]

Pathomechanism [52][53]

The sternum can either heal normally, resolving postoperative sternal instability, or develop a dehiscence due to fractures of the bone and sternal wires.

  • Factors contributing to sternal instability include:
    • Primary nonunion
    • Poor surgical technique (e.g., insufficient holding power of sutures)
    • Mechanical stresses on the wound (e.g., chest exploration, intubation > 7 days or chronic ventilator dependence, premature overexertion)
    • Poor wound healing

Clinical features [52][54]

  • Instability of the sternum
  • Pain, chest wall discomfort at rest
  • Tenderness on palpation
  • Audible click during chest movements (e.g., coughing)
  • Increased wound drainage
  • Patients can be completely asymptomatic.

Diagnosis [55]

Early radiographic imaging is important to facilitate timely therapy.

  • Chest x-ray
    • Evidence of dehiscence can be detected on x-ray up to 3 days before clinical manifestations.
    • Findings: lateral displacement of sternal wires, vertically-oriented midsternal lucent stripe (not always present)
  • CT scan: used to differentiate between simple wire migration and sternal dehiscence

Management [51]

Complications [55][56]

Prevention [59]

Postoperative nausea and vomitingtoggle arrow icon

Epidemiology [60]

  • Incidence
    • 30–50% among postsurgical patients in the general population
    • Up to 80% in high-risk groups
  • Sex: >

Risk factors [60]

PONV risk factors
Adults Children
Procedure or treatment related

Differential diagnosis

PONV prophylaxis

Treatment of PONV [60][62]

Acute management checklist for PONV


Postoperative urinary retentiontoggle arrow icon

Definition [63]

Inability to adequately void spontaneously after surgery

Risk factors [63]

Clinical features

Urinary retention may be asymptomatic in patients with sensory deficits (e.g., due to spinal cord injuries or stroke) or after recent regional anesthesia.

Diagnostics [63]

Management [63]

Complications [63]

Postoperative ileustoggle arrow icon

Postoperative pulmonary complicationstoggle arrow icon

Epidemiology [65][66]

  • Occur in up to ∼ 25% of patients who undergo major surgery [65]
  • A common cause of: [67]
    • Postoperative morbidity and mortality
    • Prolonged postoperative hospitalization

Risk factors [65][67]

Risk factors for postoperative pulmonary complications [65][67]
Factors that increase the risk of postoperative pulmonary complications
Patient factors
Immediate preoperative factors
Surgical factors
Anesthesia and analgesia factors

Etiology [22][69]

Causes of postoperative pulmonary complications [22][69][70]
Clinical features Diagnostic findings
Postoperative respiratory failure [22][71]
Acute respiratory distress syndrome (ARDS) [72]
Pulmonary embolism [73][74]
Pneumothorax [75][76]



Postoperative pulmonary edema[79]
Pleural effusion [80]
Postoperative atelectasis [81]
Pulmonary aspiration

Management [22][69][70]

Prevention [65]

Following surgery, think “I COUGH” and pain control to prevent postoperative pulmonary complications. [12][84]

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Referencestoggle arrow icon

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