Complications, Chapter22 P138-156 Flashcards
1
Q
ATELECTASIS
What is it?
P138
A
Collapse of the alveoli
2
Q
ATELECTASIS
What is the etiology?
P138
A
Inadequate alveolar expansion (e.g., poor ventilation of lungs during surgery, inability to fully inspire secondary to
pain), high levels of inspired oxygen
3
Q
ATELECTASIS
What are the signs?
P139
A
Fever, decreased breath sounds with rales, tachypnea, tachycardia, and increased density on CXR
4
Q
ATELECTASIS
What are the risk factors?
P139
A
Chronic obstructive pulmonary disease (COPD), smoking, abdominal or thoracic surgery, oversedation, poor pain control (patient cannot breathe deeply secondary to pain on inspiration)
5
Q
ATELECTASIS
What is its claim to fame?
P139
A
Most common cause of fever during PODs #1 to #2
6
Q
ATELECTASIS
What prophylactic measures can be taken?
P139
A
Preoperative smoking cessation, incentive spirometry, good pain contro
7
Q
ATELECTASIS
What is the treatment?
P139
A
Postoperative incentive spirometry, deep breathing, coughing, early ambulation, NT suctioning, and chest PT
8
Q
POSTOPERATIVE RESPIRATORY FAILURE
What is it?
P139
A
Respiratory impairment with increased respiratory rate, shortness of breath, dyspnea
9
Q
POSTOPERATIVE RESPIRATORY FAILURE
What is the differential diagnosis?
P139
A
Hypovolemia, pulmonary embolism, administration of supplemental O(2) to a patient with COPD, atelectasis,
pneumonia, aspiration, pulmonary edema, abdominal compartment syndrome, pneumothorax, chylothorax, hemothorax, narcotic overdose, mucous plug
10
Q
POSTOPERATIVE RESPIRATORY FAILURE
What is the treatment?
P139
A
Supplemental O2, chest PT; suctioning, intubation, and ventilation if necessary
11
Q
POSTOPERATIVE RESPIRATORY FAILURE
What is the initial workup?
P139
A
ABG, CXR, EKG, pulse oximetry, and auscultation
12
Q
POSTOPERATIVE RESPIRATORY FAILURE
What are the indications for intubation and ventilation?
P139
A
Cannot protect airway (unconscious), excessive work of breathing, progressive hypoxemia (PaO(2) 50), RR> 35
13
Q
POSTOPERATIVE RESPIRATORY FAILURE
What are the possible causes of postoperative pleural
effusion?
P140
A
Fluid overload, pneumonia, and diaphragmatic inflammation with possible subphrenic abscess formation
14
Q
POSTOPERATIVE RESPIRATORY FAILURE
What is the treatment of postoperative wheezing?
P140
A
Albuterol nebulizer
15
Q
POSTOPERATIVE RESPIRATORY FAILURE
Why may it be dangerous to give a patient with chronic
COPD supplemental oxygen?
P140
A
This patient uses relative hypoxia for respiratory drive, and supplemental O(2) may remove this drive!
16
Q
PULMONARY EMBOLISM
What is a pulmonary embolism (PE)?
P140
A
DVT that embolizes to the pulmonary arterial system
17
Q
PULMONARY EMBOLISM
What is DVT?
P140
A
Deep Venous Thrombosis—a clot forming in the pelvic or lower extremity veins
18
Q
PULMONARY EMBOLISM
Is DVT more common in the right or left iliac vein?
P140
A
Left is more common (4:1) because the aortic bifurcation crosses and possibly compresses the left iliac vein
19
Q
PULMONARY EMBOLISM
What are the signs/symptoms of DVT?
P140
A
- Lower extremity pain, swelling, tenderness, Homan’s sign, PE
- Up to 50% can be asymptomatic!
20
Q
PULMONARY EMBOLISM
What is Homan’s sign?
P140
A
Calf pain with dorsiflexion of the foot seen classically with DVT, but actually found in fewer than one third of patients
with DVT
21
Q
PULMONARY EMBOLISM
What test is used to evaluate for DVT?
P140
A
Duplex ultrasonography
22
Q
PULMONARY EMBOLISM
What is Virchow’s triad?
P140
A
- Stasis
- Endothelial injury
- Hypercoagulable state (risk factors for thrombosis)
23
Q
PULMONARY EMBOLISM
What are the risk factors for DVT and PE?
P140
A
Postoperative status, multiple trauma, paralysis, immobility, CHF, obesity, BCP/tamoxifen, cancer, advanced age,
polycythemia, MI, HIT syndrome, hypercoagulable state (protein C/protein S deficiency)
24
Q
PULMONARY EMBOLISM
What are the signs/symptoms of PE?
P141
A
Shortness of breath, tachypnea, hypotension, CP, occasionally fever, loud pulmonic component of S2, hemoptysis with pulmonary infarct
25
PULMONARY EMBOLISM
What are the associated lab findings?
P141
ABG—decreased PO(2) and PCO(2)
| from hyperventilation
26
PULMONARY EMBOLISM
Which diagnostic tests are indicated?
P141
CT angiogram, V-Q scan (ventilationperfusion scan), pulmonary angiogram is the gold standard
27
PULMONARY EMBOLISM
What are the associated CXR findings?
P141
1. Westermark’s sign (wedge-shaped area of decreased
pulmonary vasculature resulting in hyperlucency)
2. Opacity with base at pleural edge from
pulmonary infarction
28
PULMONARY EMBOLISM
What are the associated EKG findings?
P141
>50% are abnormal; classic finding is cor pulmonale (S1Q3T3 RBBB and right-axis deviation); EKG most commonly shows flipped T waves or ST depression
29
PULMONARY EMBOLISM
What is a “saddle” embolus?
P141
PE that “straddles” the pulmonary artery and is in the lumen of both the right and left pulmonary arteries
30
PULMONARY EMBOLISM
What is the treatment if the patient is stable?
P141
Anticoagulation (heparin followed by long-term
| [3–6 months] Coumadin®) or Greenfield filter
31
PULMONARY EMBOLISM
What is a Greenfield filter?
P141 (picture)
Metallic filter placed into IVC via jugular vein to catch emboli prior to lodging in the pulmonary artery
32
PULMONARY EMBOLISM
Where did Dr. Greenfield get the idea for his IVC filter?
P142
Oil pipeline filters!
33
PULMONARY EMBOLISM
When is a Greenfield filter indicated?
P142
If anticoagulation is contraindicated or patient has further PE on adequate anticoagulation or is high risk (e.g., pelvic and femur fractures)
34
PULMONARY EMBOLISM
What is the treatment if the patient’s condition is unstable?
P142
Consider thrombolytic therapy; consult thoracic surgeon for possible Trendelenburg operation; consider catheter suction embolectomy
35
PULMONARY EMBOLISM
What is the Trendelenburg operation?
P142
Pulmonary artery embolectomy
36
PULMONARY EMBOLISM
What is a “retrievable” IVC filter?
P142
IVC filter that can be removed (“retrieved”)
37
PULMONARY EMBOLISM
What percentage of retrievable IVC filter are actually removed?
P142
Only about 20%
38
PULMONARY EMBOLISM
What prophylactic measures can be taken for DVT/PE?
P142
LMWH (Lovenox®) 40 mg SQ QD; or 30 mg SQ b.i.d.; subQ heparin (5000 units subQ every 8 hrs; must be started
preoperatively), sequential compression device BOOTS beginning in O.R. (often used with subQ heparin), early ambulation
39
ASPIRATION PNEUMONIA
What is it?
P142
Pneumonia following aspiration of vomitus
40
ASPIRATION PNEUMONIA
What are the risk factors?
P142
Intubation/extubation, impaired consciousness (e.g., drug or EtOH overdose), dysphagia (esophageal disease),
nonfunctioning NGT, Trendelenburg position, emergent intubation with full stomach, gastric dilatation
41
ASPIRATION PNEUMONIA
What are the signs/symptoms?
P142
Respiratory failure, CP, increased sputum production, fever, cough, mental status changes, tachycardia, cyanosis, infiltrate on CXR
42
ASPIRATION PNEUMONIA
What are the associated CXR findings?
P143
Early—fluffy infiltrate or normal CXR Late—pneumonia, ARDS
43
ASPIRATION PNEUMONIA
Which lobes are commonly involved?
P143
Supine—RUL
| Sitting/semirecumbent—RLL
44
ASPIRATION PNEUMONIA
Which organisms are commonly involved?
P143
Community acquired—gram-positive/ mixed
| Hospital/ICU—gram-negative rods
45
ASPIRATION PNEUMONIA
Which diagnostic tests are indicated?
P143
CXR, sputum, Gram stain, sputum culture, bronchoalveolar lavage
46
ASPIRATION PNEUMONIA
What is the treatment?
P143
Bronchoscopy, antibiotics if pneumonia develops, intubation if respiratory failure occurs, ventilation with PEEP if ARDS
develops
47
ASPIRATION PNEUMONIA
What is Mendelson’s syndrome?
P143
Chemical pneumonitis secondary to aspiration of stomach contents (i.e., gastric acid)
48
ASPIRATION PNEUMONIA
Are prophylatic antibiotics indicated for aspiration pneumonitis?
P143
NO
49
GASTROINTESTINAL COMPLICATIONS
What are possible NGT complications?
P143
```
- Aspiration-pneumonia/atelectasis
(especially if NGT is clogged)
- Sinusitis
- Minor UGI bleeding
- Epistaxis
- Pharyngeal irritation, gastric irritation
```
50
GASTRIC DILATATION
What are the risk factors?
P143
Abdominal surgery, gastric outlet obstruction, splenectomy, narcotics
51
GASTRIC DILATATION
What are the signs/symptoms?
P143
Abdominal distension, hiccups, electrolyte abnormalities, nausea
52
GASTRIC DILATATION
What is the treatment?
P143
NGT decompression
53
GASTRIC DILATATION
What do you do if you have a patient with high NGT
output?
P144
Check high abdominal x-ray and, if the NGT is in duodenum, pull back the NGT into the stomach
54
POSTOPERATIVE PANCREATITIS
What is it?
P144
Pancreatitis resulting from manipulation of the pancreas during surgery or low blood flow during the procedure
(i.e., cardiopulmonary bypass), gallstones, hypercalcemia, medications, idiopathic
55
POSTOPERATIVE PANCREATITIS
What lab tests are performed?
P144
Amylase and lipase
56
POSTOPERATIVE PANCREATITIS
What is the initial treatment?
P144
Same as that for the other causes of pancreatitis (e.g., NPO, aggressive fluid resuscitation, NGT PRN)
57
CONSTIPATION
What are the postoperative causes?
P144
Narcotics, immobility
58
CONSTIPATION
What is the treatment?
P144
OBR
59
CONSTIPATION
What is OBR?
P144
Ortho Bowel Routine: docusate sodium (daily), dicacodyl suppository if no bowel movement occurs, Fleet® enema if
suppository is ineffective
60
SHORT BOWEL SYNDROME
What is it?
P144
Malabsorption and diarrhea resulting from extensive bowel resection (120 cm of small bowel remaining)
61
SHORT BOWEL SYNDROME
What is the initial treatment?
P144
TPN early, followed by many small meals chronically
62
POSTOPERATIVE SMALL BOWEL OBSTRUCTION (SBO)/ILEUS
What causes SBO?
P144
Adhesions (most of which resolve spontaneously), incarcerated hernia (internal or fascial/dehiscence)
63
POSTOPERATIVE SMALL BOWEL OBSTRUCTION (SBO)/ILEUS
What causes ileus?
P145
Laparotomy, hypokalemia or narcotics, intraperitoneal infection
64
POSTOPERATIVE SMALL BOWEL OBSTRUCTION (SBO)/ILEUS
What are the signs of resolving ileus/SBO?
P145
Flatus PR, stool PR
65
POSTOPERATIVE SMALL BOWEL OBSTRUCTION (SBO)/ILEUS
What is the order of recovery of bowel function after
abdominal surgery?
P145
First—small intestine
Second—stomach
Third—colon
66
POSTOPERATIVE SMALL BOWEL OBSTRUCTION (SBO)/ILEUS
When can a postoperative patient be fed through a
J-tube?
P145
From 12 to 24 postoperative hours because the small intestine recovers function first in that period
67
JAUNDICE
What are the causes of the following types of postoperative jaundice:
Prehepatic
P145
Hemolysis (prosthetic valve), resolving hematoma, transfusion reaction, postcardiopulmonary bypass, blood
transfusions (decreased RBC compliance leading to cell rupture)
68
JAUNDICE
What are the causes of the following types of postoperative jaundice:
Hepatic
P145
Drugs, hypotension, hypoxia, sepsis, hepatitis, “sympathetic” hepatic inflammation from adjacent right lower lobe infarction of the lung or pneumonia,
preexisting cirrhosis, right-sided heart failure, hepatic abscess, pylephlebitis (thrombosis of portal vein), Gilbert
syndrome, Crigler-Najjar syndrome, Dubin-Johnson syndrome, fatty infiltrate from TPN
69
JAUNDICE
What are the causes of the following types of postoperative jaundice:
Posthepatic
P145
Choledocholithiasis, stricture, cholangitis, cholecystitis, biliary-duct injury, pancreatitis, sclerosing cholangitis, tumors
(e.g., cholangiocarcinoma, pancreatic cancer, gallbladder cancer, metastases), biliary stasis (e.g., ceftriaxone [Rocephin®])
70
JAUNDICE
What blood test results would support the assumption that
hemolysis was causing jaundice in a patient?
P145
Decreased—Haptoglobin, Hct
Increased—LDH, reticulocytes
Also, fragmented RBCs on a peripheral smear
71
BLIND LOOP SYNDROME
What is it?
P146
Bacterial overgrowth in the small intestine
72
BLIND LOOP SYNDROME
What are the causes?
P146
Anything that disrupts the normal flow of intestinal contents (i.e., causes stasis)
73
BLIND LOOP SYNDROME
What are the surgical causes of B12 deficiency?
P146
Blind loop syndrome, gastrectomy (decreased secretion of intrinsic factor) and excision of the terminal ileum (site of
B12 absorption)
74
POSTVAGOTOMY DIARRHEA
What is it?
P146
Diarrhea after a truncal vagotomy
75
POSTVAGOTOMY DIARRHEA
What is the cause?
P146
It is thought that after truncal vagotomy, a rapid transport of bile salts to the colon results in osmotic inhibition of water
absorption in the colon, leading to diarrhea
76
DUMPING SYNDROME
What is it?
P146
Delivery of hyperosmotic chyme to the small intestine causing massive fluid shifts into the bowel (normally the
stomach will decrease the osmolality of the chyme prior to its emptying)
77
DUMPING SYNDROME
With what conditions is it associated?
P146
Any procedure that bypasses the pylorus or compromises its function (i.e., gastroenterostomies or pyloroplasty); thus,
“dumping” of chyme into small intestine
78
DUMPING SYNDROME
What are the signs/symptoms?
P146
Postprandial diaphoresis, tachycardia, abdominal pain/distention, emesis, increased flatus, dizziness, weakness
79
DUMPING SYNDROME
How is the diagnosis made?
P146
History; hyperosmolar glucose load will elicit similar symptoms
80
DUMPING SYNDROME
What is the medical treatment?
P146
Small, multiple, low-fat/carbohydrate meals that are high in protein content; also, avoidance of liquids with meals to
slow gastric emptying; surgery is a last resort
81
DUMPING SYNDROME
What is the surgical treatment?
P147
Conversion to Roux-en-Y ( ± reversed jejunal interposition loop)
82
DUMPING SYNDROME
What is a reversed jejunal interposition loop?
P147
Segment of jejunum is cut and then reversed to allow for a short segment of reversed peristalsis to slow intestinal transit
83
ENDOCRINE COMPLICATIONS
DIABETIC KETOACIDOSIS (DKA)
What is it?
P147
Deficiency of body insulin, resulting in hyperglycemia, formation of ketoacids, osmotic diuresis, and metabolic acidosis
84
ENDOCRINE COMPLICATIONS
DIABETIC KETOACIDOSIS (DKA)
What are the signs of DKA?
P147
Polyuria, tachypnea, dehydration, confusion, abdominal pain
85
ENDOCRINE COMPLICATIONS
DIABETIC KETOACIDOSIS (DKA)
What are the associated lab values?
P147
Elevated glucose, increased anion gap, hypokalemia, urine ketones, acidosis
86
ENDOCRINE COMPLICATIONS
DIABETIC KETOACIDOSIS (DKA)
What is the treatment?
P147
Insulin drip, IVF rehydration, K⁺
| supplementation, ± bicarbonate IV
87
ENDOCRINE COMPLICATIONS
DIABETIC KETOACIDOSIS (DKA)
What electrolyte must be monitored closely in DKA?
P147
Potassium and HYPOkalemia (Remember correction of acidosis and GLC/insulin drive K⁺ into cells and are
treatment for HYPERkalemia!)
88
ENDOCRINE COMPLICATIONS
DIABETIC KETOACIDOSIS (DKA)
What must you rule out in a diabetic with DKA?
P147
Infection (perirectal abscess is classically missed!)
89
ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
What is it?
P147
Acute adrenal insufficiency in the face of a stressor (i.e., surgery, trauma, infection)
90
ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
How can you remember what it is?
P147
Think: ADDisonian = ADrenal Down
91
ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
What is the cause?
P147
Postoperatively, inadequate cortisol release usually results from steroid administration in the past year
92
ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
What are the signs/symptoms?
P148
Tachycardia, nausea, vomiting, diarrhea, abdominal pain,
± fever, progressive lethargy, hypotension, eventual
hypovolemic shock
93
ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
What is its clinical claim to infamy?
P148
Tachycardia and hypotension refractory to IVF and pressors!
94
ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
Which lab values are classic?
P148
Decreased Na⁺, increased K⁺ (secondary to decreased aldosterone)
95
```
ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
How can the electrolytes with ADDisonian = ADrenal
Down be remembered?
P148 (picture)
```
Think: DOWN the alphabetical electrolyte stairs
96
ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
What is the treatment?
P148
IVFs (D5 NS), hydrocortisone IV, fludrocortisone PO
97
ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
What is fludrocortisone?
P148
```
Mineralocorticoid replacement
(aldosterone)
```
98
ENDOCRINE COMPLICATIONS
SIADH
What is it?
P148
Syndrome of Inappropriate AntiDiuretic Hormone (ADH) secretion (think of inappropriate increase in ADH secretion)
99
ENDOCRINE COMPLICATIONS
SIADH
What does ADH do?
P148
ADH increases NaCl and H(2)O resorption in the kidney, increasing intravascular volume (released from posterior
pituitary)
100
ENDOCRINE COMPLICATIONS
SIADH
What are the causes?
P149
Mainly lung/CNS: CNS trauma, oat-cell lung cancer, pancreatic cancer, duodenal cancer, pneumonia/lung abscess, increased PEEP, stroke, general anesthesia, idiopathic, postoperative, morphine
101
ENDOCRINE COMPLICATIONS
SIADH
What are the associated lab findings?
P149
Low sodium, low chloride, low serum osmolality; increased urine osmolality
102
ENDOCRINE COMPLICATIONS
SIADH
How can the serum sodium level in SIADH be remembered?
P149
Remember, SIADH = Sodium Is Always
| Down Here = hyponatremia
103
ENDOCRINE COMPLICATIONS
SIADH
What is the treatment?
P149
Treat the primary cause and restrict fluid intake
104
ENDOCRINE COMPLICATIONS
DIABETES INSIPIDUS (DI)
What is it?
P149
Failure of ADH renal fluid conservation resulting in dilute urine in large amounts
(Think: DI = Decreased ADH)
105
ENDOCRINE COMPLICATIONS
DIABETES INSIPIDUS (DI)
What is the source of ADH?
P149
POSTERIOR pituitary
106
ENDOCRINE COMPLICATIONS
DIABETES INSIPIDUS (DI)
What are the two major types?
P149
1. Central (neurogenic) DI
| 2. Nephrogenic DI
107
ENDOCRINE COMPLICATIONS
DIABETES INSIPIDUS (DI)
What is the mechanism of the two types?
P149
1. Central DI decreased production of ADH
| 2. Nephrogenic DI = decreased ADH effect on kidney
108
ENDOCRINE COMPLICATIONS
DIABETES INSIPIDUS (DI)
What are the classic causes of central DI?
P149
BRAIN injury, tumor, surgery, and infection
109
ENDOCRINE COMPLICATIONS
DIABETES INSIPIDUS (DI)
What are the classic causes of nephrogenic DI?
P149
Amphotericin B, hypercalcemia, and chronic kidney infection
110
ENDOCRINE COMPLICATIONS
DIABETES INSIPIDUS (DI)
What lab values are associated with DI?
P149
HYPERnatremia, decreased urine sodium, decreased urine osmolality, and increased serum osmolality
111
ENDOCRINE COMPLICATIONS
DIABETES INSIPIDUS (DI)
What is the treatment?
P149
Fluid replacement; follow NA⁺ levels and urine output; central DI warrants vasopressin; nephrogenic DI may
respond to thiazide diuretics
112
CARDIOVASCULAR COMPLICATIONS
What are the arterial line complications?
P150
Infection; thrombosis, which can lead to finger/hand necrosis; death/hemorrhage from catheter disconnection (remember to perform and document the Allen test
before inserting an arterial line or obtaining a blood gas sample)
113
CARDIOVASCULAR COMPLICATIONS
What is an Allen test?
P150
Measures for adequate collateral blood flow to the hand via the ulnar artery:
- Patient clenches fist; clinician occludes radial and ulnar arteries; patient opens fist and clinician releases only the ulnar artery
- If the palm exhibits immediate strong blush upon release of ulnar artery, then ulnar artery can be assumed to have adequate collateral flow if the radial artery were to thrombose
114
CARDIOVASCULAR COMPLICATIONS
What are the common causes of dyspnea following
central line placement?
P150
Pneumothorax, pericardial tamponade, carotid puncture (which can cause a hematoma that compresses the trachea), air embolism
115
CARDIOVASCULAR COMPLICATIONS
What is the differential diagnosis of postoperative chest pain?
P150
MI, atelectasis, pneumonia, pleurisy, esophageal reflux, PE, musculoskeletal pain, subphrenic abscess, aortic dissection,
pneumo/chyle/hemothorax, gastritis
116
CARDIOVASCULAR COMPLICATIONS
What is the differential diagnosis of postoperative
atrial fibrillation?
P150
Fluid overload, PE, MI, pain (excess catecholamines), atelectasis, pneumonia, digoxin toxicity, hypoxemia, thyrotoxicosis, hypercapnia, idiopathic, acidosis,
electrolyte abnormalities
117
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CARDIOVASCULAR COMPLICATIONS
MYOCARDIAL INFARCTION (MI)
What is the most dangerous period for a postoperative
MI following a previous MI?
P150
```
Six months after an MI
118
CARDIOVASCULAR COMPLICATIONS
MYOCARDIAL INFARCTION (MI)
What are the risk factors for postoperative MI?
P150
History of MI, angina, Qs on EKG, S3, JVD, CHF, aortic stenosis, advanced age, extensive surgical procedure, MI within 6 months, EKG changes
119
CARDIOVASCULAR COMPLICATIONS
MYOCARDIAL INFARCTION (MI)
How do postoperative MIs present?
P151
- Often without chest pain
- New onset CHF, new onset cardiac dysrhythmia, hypotension, chest pain, tachypnea, tachycardia, nausea/
vomiting, bradycardia, neck pain, arm pain
120
CARDIOVASCULAR COMPLICATIONS
MYOCARDIAL INFARCTION (MI)
What EKG findings are associated with cardiac ischemia/MI?
P151
Flipped T waves, ST elevation, ST depression, dysrhythmias (e.g., new onset A fib, PVC, V tach)
121
CARDIOVASCULAR COMPLICATIONS
MYOCARDIAL INFARCTION (MI)
Which lab tests are indicated?
P151
Troponin I, cardiac isoenzymes
| elevated CK mb fraction
122
CARDIOVASCULAR COMPLICATIONS
MYOCARDIAL INFARCTION (MI)
What is the treatment of postoperative MI?
P151
```
Nitrates (paste or drip), as tolerated
Aspirin
Oxygen
Pain control with IV morphine
ℬ-blocker, as tolerated
Heparin (possibly; thrombolytics are contraindicated in the
postoperative patient)
ICU monitoring
```
123
```
CARDIOVASCULAR COMPLICATIONS
MYOCARDIAL INFARCTION (MI)
How can the treatment of postoperative MI be
remembered?
P151
```
```
“BEMOAN”:
BEta-blocker (as tolerated)
Morphine
Oxygen
Aspirin
Nitrates
```
124
CARDIOVASCULAR COMPLICATIONS
MYOCARDIAL INFARCTION (MI)
When do postoperative MIs occur?
P151
Two thirds occur on PODs #2 to #5
| often silent and present with dyspnea or dysrhythmia
125
CARDIOVASCULAR COMPLICATIONS
POSTOPERATIVE CVA
What is a CVA?
P151
CerebroVascular Accident (stroke)
126
CARDIOVASCULAR COMPLICATIONS
POSTOPERATIVE CVA
What are the signs/symptoms?
P151
Aphasia, motor/sensory deficits usually lateralizing
127
CARDIOVASCULAR COMPLICATIONS
POSTOPERATIVE CVA
What is the workup?
P151
Head CT scan; must rule out hemorrhage if anticoagulation is going to be used; carotid Doppler ultrasound study to
evaluate for carotid occlusive disease
128
CARDIOVASCULAR COMPLICATIONS
POSTOPERATIVE CVA
What is the treatment?
P152
ASA, ± heparin if feasible postoperatively Thrombolytic therapy is not usually postoperative option
129
CARDIOVASCULAR COMPLICATIONS
POSTOPERATIVE CVA
What is the perioperative prevention?
P152
Avoid hypotension; continue aspirin therapy preoperatively in high-risk patients if feasible; preoperative carotid Doppler
study in high-risk patients
130
MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
What is it?
P152
Increase in serum creatinine and decrease in creatinine clearance; usually associated with decreased urine output
131
```
MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
Define the following terms:
Anuria
P152
```
50 cc urine output in 24 hours
132
```
MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
Define the following terms:
Oliguria
P152
```
Between 50 cc and 400 cc of urine output in 24 hours
133
```
MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
What is the differential diagnosis?
Prerenal
P152
```
Inadequate blood perfusing kidney: inadequate fluids, hypotension, cardiac pump failure (CHF)
134
```
MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
What is the differential diagnosis?
Renal
P152
```
Kidney parenchymal dysfunction: acute tubular necrosis, nephrotoxic contrast or drugs
135
```
MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
What is the differential diagnosis?
Postrenal
P152
```
Obstruction to outflow of urine from kidney: Foley catheter obstruction/stone, ureteral/urethral injury, BPH, bladder
dysfunction (e.g., medications, spinal anesthesia)
136
MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
What is the workup?
P152
Lab tests: electrolytes, BUN, Cr, urine lytes/Cr, FENa, urinalysis, renal ultrasound
137
MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
What is FENa?
P152
Fractional Excretion of Na (sodium)
138
MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
What is the formula for FENa?
P153
“YOU NEED PEE” = UNP
(UNa x Pcr / PNa x Ucr) x 100
(U = urine, cr = creatinine, Na⁺ = sodium, P = plasma)
139
```
MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
Define the lab results with prerenal vs renal failure:
BUN/Cr ratio
P153
```
Prerenal: >20:1
Renal:
140
```
MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
Define the lab results with prerenal vs renal failure:
Specific gravity
P153
```
Prerenal: >1.020 (as the body tries to hold on to fluid)
Renal: 1.020 (kidney has decreased ability to concentrate
urine)
141
```
MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
Define the lab results with prerenal vs renal failure:
FENa
P153
```
Prerenal: 2%
142
```
MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
Define the lab results with prerenal vs renal failure:
Urine Na⁺ (sodium)
P153
```
Prerenal: 40
143
```
MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
Define the lab results with prerenal vs renal failure:
Urine osmolality
P153
```
Prerenal: >450
Renal:
144
MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
What are the indications for dialysis?
P153
Fluid overload, refractory hyperkalemia,
BUN >130, acidosis, uremic complication
(encephalopathy, pericardial effusion)
145
MISCELLANEOUS
DIC
What is it?
P153
Activation of the coagulation cascade leading to thrombosis and consumption of clotting factors and platelets and
activation of fibrinolytic system (fibrinolysis), resulting in bleeding
146
MISCELLANEOUS
DIC
What are the causes?
P153
Tissue necrosis, septic shock, massive large-vessel coagulation, shock, allergic reactions, massive blood transfusion reaction, cardiopulmonary bypass, cancer,
obstetric complications, snake bites, trauma, burn injury, prosthetic material, liver dysfunction
147
MISCELLANEOUS
DIC
What are the signs/symptoms?
P154
Acrocyanosis or other signs of thrombosis, then diffuse bleeding from incision sites, venipuncture sites, catheter sites, or mucous membranes
148
MISCELLANEOUS
DIC
What are the associated lab findings?
P154
Increased fibrin-degradation products, elevated PT/PTT, decreased platelets, decreased fibrinogen (level correlates well with bleeding), presence of schistocytes
(fragmented RBCs), increased D-dimer
149
MISCELLANEOUS
DIC
What is the treatment?
P154
- Removal of the cause; otherwise supportive: IVFs, O(2), platelets, FFP, cryoprecipitate (fibrin), Epsilonaminocaproic
acid, as needed in predominantly thrombotic cases
- Use of heparin is indicated in cases that are predominantly thrombotic with antithrombin III supplementation as needed
150
MISCELLANEOUS
ABDOMINAL COMPARTMENT SYNDROME
What is it?
P154
Increased intra-abdominal pressure usually seen after laparotomy or after massive IVF resuscitation (e.g., burn
patients)
151
MISCELLANEOUS
ABDOMINAL COMPARTMENT SYNDROME
What are the signs/symptoms?
P154
Tight distended abdomen, decreased urine output, increased airway pressure, increased intra-abdominal pressure
152
MISCELLANEOUS
ABDOMINAL COMPARTMENT SYNDROME
How to measure intra-abdominal pressure?
P154
Read intrabladder pressure (Foley catheter hooked up to manometry after instillation of 50–100 cc of water)
153
MISCELLANEOUS
ABDOMINAL COMPARTMENT SYNDROME
What is normal intra-abdominal pressure?
P154
15 mm Hg
154
```
MISCELLANEOUS
ABDOMINAL COMPARTMENT SYNDROME
What intra-abdominal pressure indicates need for
treatment?
P154
```
≥25 mm Hg, especially if signs of
| compromise
155
MISCELLANEOUS
ABDOMINAL COMPARTMENT SYNDROME
What is the treatment?
P154
Release the pressure by placing drain and/or decompressive laparotomy (leaving fascia open)
156
MISCELLANEOUS
ABDOMINAL COMPARTMENT SYNDROME
What is a “Bogata Bag”?
P155
Sheet of plastic (empty urology irrigation bag or IV bag) used to temporarily close the abdomen to allow for more intraabdominal volume
157
MISCELLANEOUS
URINARY RETENTION
What is it?
P155
Enlarged urinary bladder resulting from medications or spinal anesthesia
158
MISCELLANEOUS
URINARY RETENTION
How is it diagnosed?
P155
Physical exam (palpable bladder), bladder residual volume upon placement of a Foley catheter
159
MISCELLANEOUS
URINARY RETENTION
What is the treatment?
P155
Foley catheter
160
MISCELLANEOUS
URINARY RETENTION
With massive bladder distention, how much urine can be drained immediately?
P155
Most would clamp after 1 L and then drain the rest over time to avoid a vasovagal reaction
161
MISCELLANEOUS
URINARY RETENTION
What is the classic sign of urinary retention in an elderly patient?
P155
Confusion
162
MISCELLANEOUS
WOUND INFECTION
What are the signs/symptoms?
P155
Erythema, swelling, pain, heat (rubor, tumor, dolor, calor)
163
MISCELLANEOUS
WOUND INFECTION
What is the treatment?
P155
Open wound, leave open with wet to dry dressing changes, antibiotics if cellulitis present
164
MISCELLANEOUS
WOUND INFECTION
What is fascial dehiscence?
P155
Acute separation of fascia that has been sutured closed
165
MISCELLANEOUS
WOUND INFECTION
What is the treatment?
P155
Bring back to the O.R. emergently for reclosure of the fascia
166
MISCELLANEOUS
WOUND HEMATOMA
What is it?
P155
Collection of blood (blood clot) in operative wound
167
MISCELLANEOUS
WOUND HEMATOMA
What is the treatment?
P155
Acute: Remove with hemostasis
Subacute: Observe (heat helps resorption)
168
MISCELLANEOUS
WOUND SEROMA
What is it?
P156
Postoperative collection of lymph and serum in the operative wound
169
MISCELLANEOUS
WOUND SEROMA
What is the treatment?
P156
Needle aspiration, repeat if necessary
| prevent with closed drain
170
MISCELLANEOUS
PSEUDOMEMBRANOUS COLITIS
What are the signs/symptoms?
P156
Diarrhea, fever, hypotension/tachycardia
171
MISCELLANEOUS
PSEUDOMEMBRANOUS COLITIS
What is the incidence of bloody diarrhea?
P156
10%
172
MISCELLANEOUS
PSEUDOMEMBRANOUS COLITIS
What classic antibiotic causes C. difficile?
P156
Clindamycin (but almost all antibiotics can cause it)
173
MISCELLANEOUS
PSEUDOMEMBRANOUS COLITIS
How is it diagnosed?
P156
C. diff toxin in stool, fecal WBC, flex sig (see a mucous pseudomembrane in lumen of colon = hence the name)
174
MISCELLANEOUS
PSEUDOMEMBRANOUS COLITIS
What is the treatment?
P156
1. Flagyl (PO or IV)
| 2. PO vancomycin if refractory to Flagyl
175
MISCELLANEOUS
PSEUDOMEMBRANOUS COLITIS
What is the indication for emergent colectomy?
P156
Toxic megacolon
