A patient's recovery after surgery may be affected by one or more surprises that the staff does not expect. It is important that recovery staff be prepared for the unexpected.

Surprises may include:

(1) delirium tremens

(2) withdrawal from other drugs of abuse

(3) undisclosed herbal supplements

(4) myasthenia gravis (myasthenic crisis)

(5) hypothyroidism or thyroid storm

(6) hypadrenalism (Addisonian crisis)

(7) malnutrition

(8) inherited metabolic disorder (urea cycle disorder, maple syrup urine disease, etc)

(9) allergic reaction to drugs, hydatid cyst contents, etc

(10) coagulation disorder (either hyper or hypocoagulable)

(11) acute pancreatitis or cholecystitis

(12) adverse drug reaction

(13) anticoagulant-related bleeding

(14) cryoglobulinemia

(15) cytokine release syndrome

(16) deterioration in previous borderline organ failure

(17) diaphragmatic paralysis

(18) dysautonomic crisis

(19) foreign body in airway

(20) fulminant sepsis

(21) hypertensive crisis wit MAO inhibitor

(22) lactic acidosis

(23) malignant hyperthermia

(24) paradoxical embolism

(25) parathyroid storm

(26) pheochromocytoma or carcinoid tumor

(27) pulmonary embolism including air or fat embolism

(28) seizure disorder

(29) sickle cell crisis

(30) sudden rise in intracranial pressure, especially with craniosynostosis

(31) syphilic visceral crisis

(32) toxic shock syndrome

(33) transfusion reaction

(34) tumor lysis syndrome

(35) undiagosed trauma

(36) unexpected tumor or tumor metastasis

(37) withdrawal from medications (including corticosteroids)


Triggers include:

(1) physiologic stress

(2) perioperative medicines

(3) fasting

(4) interruption of usual medications


Risk factors for a surprise:

(1) incomplete preoperative assessment

(2) failure of the patient to disclose important informton

(3) emergency surgery

(4) patient stupor, coma or intoxication

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