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Surgery 🤓 > Complications, Chapter22 P138-156 > Flashcards

Complications, Chapter22 P138-156 Flashcards

1
Q

ATELECTASIS
What is it?
P138

A

Collapse of the alveoli

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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

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3
Q

ATELECTASIS
What are the signs?
P139

A

Fever, decreased breath sounds with rales, tachypnea, tachycardia, and increased density on CXR

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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)

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5
Q

ATELECTASIS
What is its claim to fame?
P139

A

Most common cause of fever during PODs #1 to #2

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6
Q

ATELECTASIS
What prophylactic measures can be taken?
P139

A

Preoperative smoking cessation, incentive spirometry, good pain contro

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7
Q

ATELECTASIS
What is the treatment?
P139

A

Postoperative incentive spirometry, deep breathing, coughing, early ambulation, NT suctioning, and chest PT

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8
Q

POSTOPERATIVE RESPIRATORY FAILURE
What is it?
P139

A

Respiratory impairment with increased respiratory rate, shortness of breath, dyspnea

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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

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10
Q

POSTOPERATIVE RESPIRATORY FAILURE
What is the treatment?
P139

A

Supplemental O2, chest PT; suctioning, intubation, and ventilation if necessary

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11
Q

POSTOPERATIVE RESPIRATORY FAILURE
What is the initial workup?
P139

A

ABG, CXR, EKG, pulse oximetry, and auscultation

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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

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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

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14
Q

POSTOPERATIVE RESPIRATORY FAILURE
What is the treatment of postoperative wheezing?
P140

A

Albuterol nebulizer

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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!

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16
Q

PULMONARY EMBOLISM
What is a pulmonary embolism (PE)?
P140

A

DVT that embolizes to the pulmonary arterial system

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17
Q

PULMONARY EMBOLISM
What is DVT?
P140

A

Deep Venous Thrombosis—a clot forming in the pelvic or lower extremity veins

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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

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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!
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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

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21
Q

PULMONARY EMBOLISM
What test is used to evaluate for DVT?
P140

A

Duplex ultrasonography

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22
Q

PULMONARY EMBOLISM
What is Virchow’s triad?
P140

A
  1. Stasis
  2. Endothelial injury
  3. Hypercoagulable state (risk factors for thrombosis)
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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)

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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

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25
Q

PULMONARY EMBOLISM
What are the associated lab findings?
P141

A

ABG—decreased PO(2) and PCO(2)

from hyperventilation

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26
Q

PULMONARY EMBOLISM
Which diagnostic tests are indicated?
P141

A

CT angiogram, V-Q scan (ventilationperfusion scan), pulmonary angiogram is the gold standard

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27
Q

PULMONARY EMBOLISM
What are the associated CXR findings?
P141

A
  1. Westermark’s sign (wedge-shaped area of decreased
    pulmonary vasculature resulting in hyperlucency)
  2. Opacity with base at pleural edge from
    pulmonary infarction
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28
Q

PULMONARY EMBOLISM
What are the associated EKG findings?
P141

A

> 50% are abnormal; classic finding is cor pulmonale (S1Q3T3 RBBB and right-axis deviation); EKG most commonly shows flipped T waves or ST depression

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29
Q

PULMONARY EMBOLISM
What is a “saddle” embolus?
P141

A

PE that “straddles” the pulmonary artery and is in the lumen of both the right and left pulmonary arteries

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30
Q

PULMONARY EMBOLISM
What is the treatment if the patient is stable?
P141

A

Anticoagulation (heparin followed by long-term

[3–6 months] Coumadin®) or Greenfield filter

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31
Q

PULMONARY EMBOLISM
What is a Greenfield filter?
P141 (picture)

A

Metallic filter placed into IVC via jugular vein to catch emboli prior to lodging in the pulmonary artery

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32
Q

PULMONARY EMBOLISM
Where did Dr. Greenfield get the idea for his IVC filter?
P142

A

Oil pipeline filters!

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33
Q

PULMONARY EMBOLISM
When is a Greenfield filter indicated?
P142

A

If anticoagulation is contraindicated or patient has further PE on adequate anticoagulation or is high risk (e.g., pelvic and femur fractures)

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34
Q

PULMONARY EMBOLISM
What is the treatment if the patient’s condition is unstable?
P142

A

Consider thrombolytic therapy; consult thoracic surgeon for possible Trendelenburg operation; consider catheter suction embolectomy

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35
Q

PULMONARY EMBOLISM
What is the Trendelenburg operation?
P142

A

Pulmonary artery embolectomy

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36
Q

PULMONARY EMBOLISM
What is a “retrievable” IVC filter?
P142

A

IVC filter that can be removed (“retrieved”)

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37
Q

PULMONARY EMBOLISM
What percentage of retrievable IVC filter are actually removed?
P142

A

Only about 20%

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38
Q

PULMONARY EMBOLISM
What prophylactic measures can be taken for DVT/PE?
P142

A

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

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39
Q

ASPIRATION PNEUMONIA
What is it?
P142

A

Pneumonia following aspiration of vomitus

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40
Q

ASPIRATION PNEUMONIA
What are the risk factors?
P142

A

Intubation/extubation, impaired consciousness (e.g., drug or EtOH overdose), dysphagia (esophageal disease),
nonfunctioning NGT, Trendelenburg position, emergent intubation with full stomach, gastric dilatation

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41
Q

ASPIRATION PNEUMONIA
What are the signs/symptoms?
P142

A

Respiratory failure, CP, increased sputum production, fever, cough, mental status changes, tachycardia, cyanosis, infiltrate on CXR

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42
Q

ASPIRATION PNEUMONIA
What are the associated CXR findings?
P143

A

Early—fluffy infiltrate or normal CXR Late—pneumonia, ARDS

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43
Q

ASPIRATION PNEUMONIA
Which lobes are commonly involved?
P143

A

Supine—RUL

Sitting/semirecumbent—RLL

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44
Q

ASPIRATION PNEUMONIA
Which organisms are commonly involved?
P143

A

Community acquired—gram-positive/ mixed

Hospital/ICU—gram-negative rods

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45
Q

ASPIRATION PNEUMONIA
Which diagnostic tests are indicated?
P143

A

CXR, sputum, Gram stain, sputum culture, bronchoalveolar lavage

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46
Q

ASPIRATION PNEUMONIA
What is the treatment?
P143

A

Bronchoscopy, antibiotics if pneumonia develops, intubation if respiratory failure occurs, ventilation with PEEP if ARDS
develops

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47
Q

ASPIRATION PNEUMONIA
What is Mendelson’s syndrome?
P143

A

Chemical pneumonitis secondary to aspiration of stomach contents (i.e., gastric acid)

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48
Q

ASPIRATION PNEUMONIA
Are prophylatic antibiotics indicated for aspiration pneumonitis?
P143

A

NO

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49
Q

GASTROINTESTINAL COMPLICATIONS
What are possible NGT complications?
P143

A 
- Aspiration-pneumonia/atelectasis 
(especially if NGT is clogged)
- Sinusitis
- Minor UGI bleeding
- Epistaxis
- Pharyngeal irritation, gastric irritation
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50
Q

GASTRIC DILATATION
What are the risk factors?
P143

A

Abdominal surgery, gastric outlet obstruction, splenectomy, narcotics

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51
Q

GASTRIC DILATATION
What are the signs/symptoms?
P143

A

Abdominal distension, hiccups, electrolyte abnormalities, nausea

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52
Q

GASTRIC DILATATION
What is the treatment?
P143

A

NGT decompression

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53
Q

GASTRIC DILATATION
What do you do if you have a patient with high NGT
output?
P144

A

Check high abdominal x-ray and, if the NGT is in duodenum, pull back the NGT into the stomach

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54
Q

POSTOPERATIVE PANCREATITIS
What is it?
P144

A

Pancreatitis resulting from manipulation of the pancreas during surgery or low blood flow during the procedure
(i.e., cardiopulmonary bypass), gallstones, hypercalcemia, medications, idiopathic

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55
Q

POSTOPERATIVE PANCREATITIS
What lab tests are performed?
P144

A

Amylase and lipase

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56
Q

POSTOPERATIVE PANCREATITIS
What is the initial treatment?
P144

A

Same as that for the other causes of pancreatitis (e.g., NPO, aggressive fluid resuscitation, NGT PRN)

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57
Q

CONSTIPATION
What are the postoperative causes?
P144

A

Narcotics, immobility

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58
Q

CONSTIPATION
What is the treatment?
P144

A

OBR

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59
Q

CONSTIPATION
What is OBR?
P144

A

Ortho Bowel Routine: docusate sodium (daily), dicacodyl suppository if no bowel movement occurs, Fleet® enema if
suppository is ineffective

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60
Q

SHORT BOWEL SYNDROME
What is it?
P144

A

Malabsorption and diarrhea resulting from extensive bowel resection (120 cm of small bowel remaining)

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61
Q

SHORT BOWEL SYNDROME
What is the initial treatment?
P144

A

TPN early, followed by many small meals chronically

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62
Q

POSTOPERATIVE SMALL BOWEL OBSTRUCTION (SBO)/ILEUS
What causes SBO?
P144

A

Adhesions (most of which resolve spontaneously), incarcerated hernia (internal or fascial/dehiscence)

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63
Q

POSTOPERATIVE SMALL BOWEL OBSTRUCTION (SBO)/ILEUS
What causes ileus?
P145

A

Laparotomy, hypokalemia or narcotics, intraperitoneal infection

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64
Q

POSTOPERATIVE SMALL BOWEL OBSTRUCTION (SBO)/ILEUS
What are the signs of resolving ileus/SBO?
P145

A

Flatus PR, stool PR

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65
Q

POSTOPERATIVE SMALL BOWEL OBSTRUCTION (SBO)/ILEUS
What is the order of recovery of bowel function after
abdominal surgery?
P145

A

First—small intestine
Second—stomach
Third—colon

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66
Q

POSTOPERATIVE SMALL BOWEL OBSTRUCTION (SBO)/ILEUS
When can a postoperative patient be fed through a
J-tube?
P145

A

From 12 to 24 postoperative hours because the small intestine recovers function first in that period

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67
Q

JAUNDICE
What are the causes of the following types of postoperative jaundice:
Prehepatic
P145

A

Hemolysis (prosthetic valve), resolving hematoma, transfusion reaction, postcardiopulmonary bypass, blood
transfusions (decreased RBC compliance leading to cell rupture)

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68
Q

JAUNDICE
What are the causes of the following types of postoperative jaundice:
Hepatic
P145

A

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

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69
Q

JAUNDICE
What are the causes of the following types of postoperative jaundice:
Posthepatic
P145

A

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®])

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70
Q

JAUNDICE
What blood test results would support the assumption that
hemolysis was causing jaundice in a patient?
P145

A

Decreased—Haptoglobin, Hct
Increased—LDH, reticulocytes
Also, fragmented RBCs on a peripheral smear

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71
Q

BLIND LOOP SYNDROME
What is it?
P146

A

Bacterial overgrowth in the small intestine

72
Q

BLIND LOOP SYNDROME
What are the causes?
P146

A

Anything that disrupts the normal flow of intestinal contents (i.e., causes stasis)

73
Q

BLIND LOOP SYNDROME
What are the surgical causes of B12 deficiency?
P146

A

Blind loop syndrome, gastrectomy (decreased secretion of intrinsic factor) and excision of the terminal ileum (site of
B12 absorption)

74
Q

POSTVAGOTOMY DIARRHEA
What is it?
P146

A

Diarrhea after a truncal vagotomy

75
Q

POSTVAGOTOMY DIARRHEA
What is the cause?
P146

A

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
Q

DUMPING SYNDROME
What is it?
P146

A

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
Q

DUMPING SYNDROME
With what conditions is it associated?
P146

A

Any procedure that bypasses the pylorus or compromises its function (i.e., gastroenterostomies or pyloroplasty); thus,
“dumping” of chyme into small intestine

78
Q

DUMPING SYNDROME
What are the signs/symptoms?
P146

A

Postprandial diaphoresis, tachycardia, abdominal pain/distention, emesis, increased flatus, dizziness, weakness

79
Q

DUMPING SYNDROME
How is the diagnosis made?
P146

A

History; hyperosmolar glucose load will elicit similar symptoms

80
Q

DUMPING SYNDROME
What is the medical treatment?
P146

A

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
Q

DUMPING SYNDROME
What is the surgical treatment?
P147

A

Conversion to Roux-en-Y ( ± reversed jejunal interposition loop)

82
Q

DUMPING SYNDROME
What is a reversed jejunal interposition loop?
P147

A

Segment of jejunum is cut and then reversed to allow for a short segment of reversed peristalsis to slow intestinal transit

83
Q

ENDOCRINE COMPLICATIONS
DIABETIC KETOACIDOSIS (DKA)
What is it?
P147

A

Deficiency of body insulin, resulting in hyperglycemia, formation of ketoacids, osmotic diuresis, and metabolic acidosis

84
Q

ENDOCRINE COMPLICATIONS
DIABETIC KETOACIDOSIS (DKA)
What are the signs of DKA?
P147

A

Polyuria, tachypnea, dehydration, confusion, abdominal pain

85
Q

ENDOCRINE COMPLICATIONS
DIABETIC KETOACIDOSIS (DKA)
What are the associated lab values?
P147

A

Elevated glucose, increased anion gap, hypokalemia, urine ketones, acidosis

86
Q

ENDOCRINE COMPLICATIONS
DIABETIC KETOACIDOSIS (DKA)
What is the treatment?
P147

A

Insulin drip, IVF rehydration, K⁺

supplementation, ± bicarbonate IV

87
Q

ENDOCRINE COMPLICATIONS
DIABETIC KETOACIDOSIS (DKA)
What electrolyte must be monitored closely in DKA?
P147

A

Potassium and HYPOkalemia (Remember correction of acidosis and GLC/insulin drive K⁺ into cells and are
treatment for HYPERkalemia!)

88
Q

ENDOCRINE COMPLICATIONS
DIABETIC KETOACIDOSIS (DKA)
What must you rule out in a diabetic with DKA?
P147

A

Infection (perirectal abscess is classically missed!)

89
Q

ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
What is it?
P147

A

Acute adrenal insufficiency in the face of a stressor (i.e., surgery, trauma, infection)

90
Q

ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
How can you remember what it is?
P147

A

Think: ADDisonian = ADrenal Down

91
Q

ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
What is the cause?
P147

A

Postoperatively, inadequate cortisol release usually results from steroid administration in the past year

92
Q

ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
What are the signs/symptoms?
P148

A

Tachycardia, nausea, vomiting, diarrhea, abdominal pain,
± fever, progressive lethargy, hypotension, eventual
hypovolemic shock

93
Q

ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
What is its clinical claim to infamy?
P148

A

Tachycardia and hypotension refractory to IVF and pressors!

94
Q

ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
Which lab values are classic?
P148

A

Decreased Na⁺, increased K⁺ (secondary to decreased aldosterone)

95
Q 
ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
How can the electrolytes with ADDisonian = ADrenal
Down be remembered?
P148 (picture)
A

Think: DOWN the alphabetical electrolyte stairs

96
Q

ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
What is the treatment?
P148

A

IVFs (D5 NS), hydrocortisone IV, fludrocortisone PO

97
Q

ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
What is fludrocortisone?
P148

A 
Mineralocorticoid replacement
(aldosterone)
98
Q

ENDOCRINE COMPLICATIONS
SIADH
What is it?
P148

A

Syndrome of Inappropriate AntiDiuretic Hormone (ADH) secretion (think of inappropriate increase in ADH secretion)

99
Q

ENDOCRINE COMPLICATIONS
SIADH
What does ADH do?
P148

A

ADH increases NaCl and H(2)O resorption in the kidney, increasing intravascular volume (released from posterior
pituitary)

100
Q

ENDOCRINE COMPLICATIONS
SIADH
What are the causes?
P149

A

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
Q

ENDOCRINE COMPLICATIONS
SIADH
What are the associated lab findings?
P149

A

Low sodium, low chloride, low serum osmolality; increased urine osmolality

102
Q

ENDOCRINE COMPLICATIONS
SIADH
How can the serum sodium level in SIADH be remembered?
P149

A

Remember, SIADH = Sodium Is Always

Down Here = hyponatremia

103
Q

ENDOCRINE COMPLICATIONS
SIADH
What is the treatment?
P149

A

Treat the primary cause and restrict fluid intake

104
Q

ENDOCRINE COMPLICATIONS
DIABETES INSIPIDUS (DI)
What is it?
P149

A

Failure of ADH renal fluid conservation resulting in dilute urine in large amounts
(Think: DI = Decreased ADH)

105
Q

ENDOCRINE COMPLICATIONS
DIABETES INSIPIDUS (DI)
What is the source of ADH?
P149

A

POSTERIOR pituitary

106
Q

ENDOCRINE COMPLICATIONS
DIABETES INSIPIDUS (DI)
What are the two major types?
P149

A
  1. Central (neurogenic) DI

2. Nephrogenic DI

107
Q

ENDOCRINE COMPLICATIONS
DIABETES INSIPIDUS (DI)
What is the mechanism of the two types?
P149

A
  1. Central DI decreased production of ADH

2. Nephrogenic DI = decreased ADH effect on kidney

108
Q

ENDOCRINE COMPLICATIONS
DIABETES INSIPIDUS (DI)
What are the classic causes of central DI?
P149

A

BRAIN injury, tumor, surgery, and infection

109
Q

ENDOCRINE COMPLICATIONS
DIABETES INSIPIDUS (DI)
What are the classic causes of nephrogenic DI?
P149

A

Amphotericin B, hypercalcemia, and chronic kidney infection

110
Q

ENDOCRINE COMPLICATIONS
DIABETES INSIPIDUS (DI)
What lab values are associated with DI?
P149

A

HYPERnatremia, decreased urine sodium, decreased urine osmolality, and increased serum osmolality

111
Q

ENDOCRINE COMPLICATIONS
DIABETES INSIPIDUS (DI)
What is the treatment?
P149

A

Fluid replacement; follow NA⁺ levels and urine output; central DI warrants vasopressin; nephrogenic DI may
respond to thiazide diuretics

112
Q

CARDIOVASCULAR COMPLICATIONS
What are the arterial line complications?
P150

A

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
Q

CARDIOVASCULAR COMPLICATIONS
What is an Allen test?
P150

A

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
Q

CARDIOVASCULAR COMPLICATIONS
What are the common causes of dyspnea following
central line placement?
P150

A

Pneumothorax, pericardial tamponade, carotid puncture (which can cause a hematoma that compresses the trachea), air embolism

115
Q

CARDIOVASCULAR COMPLICATIONS
What is the differential diagnosis of postoperative chest pain?
P150

A

MI, atelectasis, pneumonia, pleurisy, esophageal reflux, PE, musculoskeletal pain, subphrenic abscess, aortic dissection,
pneumo/chyle/hemothorax, gastritis

116
Q

CARDIOVASCULAR COMPLICATIONS
What is the differential diagnosis of postoperative
atrial fibrillation?
P150

A

Fluid overload, PE, MI, pain (excess catecholamines), atelectasis, pneumonia, digoxin toxicity, hypoxemia, thyrotoxicosis, hypercapnia, idiopathic, acidosis,
electrolyte abnormalities

117
Q 
CARDIOVASCULAR COMPLICATIONS
MYOCARDIAL INFARCTION (MI)
What is the most dangerous period for a postoperative
MI following a previous MI?
P150
A

Six months after an MI

118
Q

CARDIOVASCULAR COMPLICATIONS
MYOCARDIAL INFARCTION (MI)
What are the risk factors for postoperative MI?
P150

A

History of MI, angina, Qs on EKG, S3, JVD, CHF, aortic stenosis, advanced age, extensive surgical procedure, MI within 6 months, EKG changes

119
Q

CARDIOVASCULAR COMPLICATIONS
MYOCARDIAL INFARCTION (MI)
How do postoperative MIs present?
P151

A
  • Often without chest pain
  • New onset CHF, new onset cardiac dysrhythmia, hypotension, chest pain, tachypnea, tachycardia, nausea/
    vomiting, bradycardia, neck pain, arm pain
120
Q

CARDIOVASCULAR COMPLICATIONS
MYOCARDIAL INFARCTION (MI)
What EKG findings are associated with cardiac ischemia/MI?
P151

A

Flipped T waves, ST elevation, ST depression, dysrhythmias (e.g., new onset A fib, PVC, V tach)

121
Q

CARDIOVASCULAR COMPLICATIONS
MYOCARDIAL INFARCTION (MI)
Which lab tests are indicated?
P151

A

Troponin I, cardiac isoenzymes

elevated CK mb fraction

122
Q

CARDIOVASCULAR COMPLICATIONS
MYOCARDIAL INFARCTION (MI)
What is the treatment of postoperative MI?
P151

A 
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
Q 
CARDIOVASCULAR COMPLICATIONS
MYOCARDIAL INFARCTION (MI)
How can the treatment of postoperative MI be
remembered?
P151
A 
“BEMOAN”:
BEta-blocker (as tolerated)
Morphine
Oxygen
Aspirin
Nitrates
124
Q

CARDIOVASCULAR COMPLICATIONS
MYOCARDIAL INFARCTION (MI)
When do postoperative MIs occur?
P151

A

Two thirds occur on PODs #2 to #5

often silent and present with dyspnea or dysrhythmia

125
Q

CARDIOVASCULAR COMPLICATIONS
POSTOPERATIVE CVA
What is a CVA?
P151

A

CerebroVascular Accident (stroke)

126
Q

CARDIOVASCULAR COMPLICATIONS
POSTOPERATIVE CVA
What are the signs/symptoms?
P151

A

Aphasia, motor/sensory deficits usually lateralizing

127
Q

CARDIOVASCULAR COMPLICATIONS
POSTOPERATIVE CVA
What is the workup?
P151

A

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
Q

CARDIOVASCULAR COMPLICATIONS
POSTOPERATIVE CVA
What is the treatment?
P152

A

ASA, ± heparin if feasible postoperatively Thrombolytic therapy is not usually postoperative option

129
Q

CARDIOVASCULAR COMPLICATIONS
POSTOPERATIVE CVA
What is the perioperative prevention?
P152

A

Avoid hypotension; continue aspirin therapy preoperatively in high-risk patients if feasible; preoperative carotid Doppler
study in high-risk patients

130
Q

MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
What is it?
P152

A

Increase in serum creatinine and decrease in creatinine clearance; usually associated with decreased urine output

131
Q 
MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
Define the following terms:
Anuria
P152
A

50 cc urine output in 24 hours

132
Q 
MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
Define the following terms:
Oliguria
P152
A

Between 50 cc and 400 cc of urine output in 24 hours

133
Q 
MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
What is the differential diagnosis?
Prerenal
P152
A

Inadequate blood perfusing kidney: inadequate fluids, hypotension, cardiac pump failure (CHF)

134
Q 
MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
What is the differential diagnosis?
Renal
P152
A

Kidney parenchymal dysfunction: acute tubular necrosis, nephrotoxic contrast or drugs

135
Q 
MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
What is the differential diagnosis?
Postrenal
P152
A

Obstruction to outflow of urine from kidney: Foley catheter obstruction/stone, ureteral/urethral injury, BPH, bladder
dysfunction (e.g., medications, spinal anesthesia)

136
Q

MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
What is the workup?
P152

A

Lab tests: electrolytes, BUN, Cr, urine lytes/Cr, FENa, urinalysis, renal ultrasound

137
Q

MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
What is FENa?
P152

A

Fractional Excretion of Na (sodium)

138
Q

MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
What is the formula for FENa?
P153

A

“YOU NEED PEE” = UNP
(UNa x Pcr / PNa x Ucr) x 100
(U = urine, cr = creatinine, Na⁺ = sodium, P = plasma)

139
Q 
MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
Define the lab results with prerenal vs renal failure:
BUN/Cr ratio
P153
A

Prerenal: >20:1
Renal:

140
Q 
MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
Define the lab results with prerenal vs renal failure:
Specific gravity
P153
A

Prerenal: >1.020 (as the body tries to hold on to fluid)
Renal: 1.020 (kidney has decreased ability to concentrate
urine)

141
Q 
MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
Define the lab results with prerenal vs renal failure:
FENa
P153
A

Prerenal: 2%

142
Q 
MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
Define the lab results with prerenal vs renal failure:
Urine Na⁺ (sodium)
P153
A

Prerenal: 40

143
Q 
MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
Define the lab results with prerenal vs renal failure:
Urine osmolality
P153
A

Prerenal: >450
Renal:

144
Q

MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
What are the indications for dialysis?
P153

A

Fluid overload, refractory hyperkalemia,
BUN >130, acidosis, uremic complication
(encephalopathy, pericardial effusion)

145
Q

MISCELLANEOUS
DIC
What is it?
P153

A

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
Q

MISCELLANEOUS
DIC
What are the causes?
P153

A

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
Q

MISCELLANEOUS
DIC
What are the signs/symptoms?
P154

A

Acrocyanosis or other signs of thrombosis, then diffuse bleeding from incision sites, venipuncture sites, catheter sites, or mucous membranes

148
Q

MISCELLANEOUS
DIC
What are the associated lab findings?
P154

A

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
Q

MISCELLANEOUS
DIC
What is the treatment?
P154

A
  • 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
Q

MISCELLANEOUS
ABDOMINAL COMPARTMENT SYNDROME
What is it?
P154

A

Increased intra-abdominal pressure usually seen after laparotomy or after massive IVF resuscitation (e.g., burn
patients)

151
Q

MISCELLANEOUS
ABDOMINAL COMPARTMENT SYNDROME
What are the signs/symptoms?
P154

A

Tight distended abdomen, decreased urine output, increased airway pressure, increased intra-abdominal pressure

152
Q

MISCELLANEOUS
ABDOMINAL COMPARTMENT SYNDROME
How to measure intra-abdominal pressure?
P154

A

Read intrabladder pressure (Foley catheter hooked up to manometry after instillation of 50–100 cc of water)

153
Q

MISCELLANEOUS
ABDOMINAL COMPARTMENT SYNDROME
What is normal intra-abdominal pressure?
P154

A

15 mm Hg

154
Q 
MISCELLANEOUS
ABDOMINAL COMPARTMENT SYNDROME
What intra-abdominal pressure indicates need for
treatment?
P154
A

≥25 mm Hg, especially if signs of

compromise

155
Q

MISCELLANEOUS
ABDOMINAL COMPARTMENT SYNDROME
What is the treatment?
P154

A

Release the pressure by placing drain and/or decompressive laparotomy (leaving fascia open)

156
Q

MISCELLANEOUS
ABDOMINAL COMPARTMENT SYNDROME
What is a “Bogata Bag”?
P155

A

Sheet of plastic (empty urology irrigation bag or IV bag) used to temporarily close the abdomen to allow for more intraabdominal volume

157
Q

MISCELLANEOUS
URINARY RETENTION
What is it?
P155

A

Enlarged urinary bladder resulting from medications or spinal anesthesia

158
Q

MISCELLANEOUS
URINARY RETENTION
How is it diagnosed?
P155

A

Physical exam (palpable bladder), bladder residual volume upon placement of a Foley catheter

159
Q

MISCELLANEOUS
URINARY RETENTION
What is the treatment?
P155

A

Foley catheter

160
Q

MISCELLANEOUS
URINARY RETENTION
With massive bladder distention, how much urine can be drained immediately?
P155

A

Most would clamp after 1 L and then drain the rest over time to avoid a vasovagal reaction

161
Q

MISCELLANEOUS
URINARY RETENTION
What is the classic sign of urinary retention in an elderly patient?
P155

A

Confusion

162
Q

MISCELLANEOUS
WOUND INFECTION
What are the signs/symptoms?
P155

A

Erythema, swelling, pain, heat (rubor, tumor, dolor, calor)

163
Q

MISCELLANEOUS
WOUND INFECTION
What is the treatment?
P155

A

Open wound, leave open with wet to dry dressing changes, antibiotics if cellulitis present

164
Q

MISCELLANEOUS
WOUND INFECTION
What is fascial dehiscence?
P155

A

Acute separation of fascia that has been sutured closed

165
Q

MISCELLANEOUS
WOUND INFECTION
What is the treatment?
P155

A

Bring back to the O.R. emergently for reclosure of the fascia

166
Q

MISCELLANEOUS
WOUND HEMATOMA
What is it?
P155

A

Collection of blood (blood clot) in operative wound

167
Q

MISCELLANEOUS
WOUND HEMATOMA
What is the treatment?
P155

A

Acute: Remove with hemostasis
Subacute: Observe (heat helps resorption)

168
Q

MISCELLANEOUS
WOUND SEROMA
What is it?
P156

A

Postoperative collection of lymph and serum in the operative wound

169
Q

MISCELLANEOUS
WOUND SEROMA
What is the treatment?
P156

A

Needle aspiration, repeat if necessary

prevent with closed drain

170
Q

MISCELLANEOUS
PSEUDOMEMBRANOUS COLITIS
What are the signs/symptoms?
P156

A

Diarrhea, fever, hypotension/tachycardia

171
Q

MISCELLANEOUS
PSEUDOMEMBRANOUS COLITIS
What is the incidence of bloody diarrhea?
P156

A

10%

172
Q

MISCELLANEOUS
PSEUDOMEMBRANOUS COLITIS
What classic antibiotic causes C. difficile?
P156

A

Clindamycin (but almost all antibiotics can cause it)

173
Q

MISCELLANEOUS
PSEUDOMEMBRANOUS COLITIS
How is it diagnosed?
P156

A

C. diff toxin in stool, fecal WBC, flex sig (see a mucous pseudomembrane in lumen of colon = hence the name)

174
Q

MISCELLANEOUS
PSEUDOMEMBRANOUS COLITIS
What is the treatment?
P156

A
  1. Flagyl (PO or IV)

2. PO vancomycin if refractory to Flagyl

175
Q

MISCELLANEOUS
PSEUDOMEMBRANOUS COLITIS
What is the indication for emergent colectomy?
P156

A

Toxic megacolon

Surgery 🤓 (29 decks)

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