Post-op - OTHER Flashcards
A patient is halfway through surgery when he develops hypotension. Soon, ST depression and T wave flattening are noticed on the EKG monitor.
- Likely diagnosis
- Dx
- Tx
- Perioperative MI
- usually triggered by hypotension
- detected on EKG monitor (ST depression, T wave flattening) - Dx:
Troponins
3. Tx: Mortality >50-90% (greater than non-surgery-associated MI) Clot busters Emergency angioplasty Coronary stent
A patient is recovering from surgery in the hospital. On POD2, he complains of shortness of breath, nausea, and cold sweats. His heart rate is increased. CXR is negative.
- Likely diagnosis
- Dx
- Tx
- Post-operative MI
- typically w/in 2-3 POD
- only 1/3 have chest pain; complications of MI in the rest - Dx:
EKG
Troponins
3. Tx: Mortality >50-90% (greater than non-surgery-associated MI) Clot busters Emergency angioplasty Coronary stent
On POD7, an elderly patient has still not been able to ambulated due to weakness and pain. He begins complaining of sudden chest pain that is worse with change in position and with breathing. He also says he is short of breath. He is very anxious and is sweating. The nurse notes tachycardia and the doctors notices JVD. CXR and EKG are unremarkable.
- Likely dx
- Dx
- Tx
- Prevention
- Pulmonary embolism
- around POD7 in elderly and/or immobilized patients
- pleuritic cp of sudden onset w/SOB
- anxious, diaphoretic, tachycardic, distended neck veins (low CVP ~excludes the diagnosis) - Dx:
ABG: hypoxemia, hypocapnia
Pulmonary angiogram (gold standard) - rarely done
Spiral CT w/contract (CT angio) - standard test
V/Q scan (nuclear) - alternative if IV contrast prohibited - Tx:
Heparin
IVC filtern if recurrent on anticoagulation, or if anticoagulation prohibited - Prevention:
SCDs (sequential compression devices)
Anticoagulation if high risk
–Risk factors: age >40, pelvic or leg fractures, venous injury, femoral venous catheter, anticipated prolonged immobilization
A patient comes in inebriated and combative. He is bleeding profusely and it is deemed necessary to take him to emergency surgery.
What would be the risk of intubating this awake patient?
What could be done to prevent it?
How does one treat it?
Aspiration
- distinct hazard in awake intubations in combative patients with a full stomach.
- may be immediately lethal
- may lead to chemical injury of tracheobronchial tree & subsequent pulmonary failure or secondary PNA
Prevention:
-NPO & antacids before induction
Treatment:
- lavage & removal of acid/particular matter w/help of bronchoscopy
- then, bronchodilators and respiratory support
- *steroids DO NOT help**
A patient comes in after a car accident and is quickly taken to the OR with several broken ribs and an unknown source of abdominal bleeding. He is intubated and put on positive pressure ventilation, and surgery is begun. The patient becomes progressively more difficulty to bag and develops an steadily declining BP and steadily rising CVP.
- Likely diagnosis
- Dx
- Tx
- Intraoperative tension pneumothorax
- can develop in patients with traumatized lungs (ex: recent blunt trauma with punctures by broken ribs) once they are subjected to positive pressure breathing - Dx: Clincal
- progressively more difficult to bag
- steadily declining BP and increasing CVP
- other s/sx of tension pneumo - Tx:
- If abdomen open, quick decompression through diaphragm
- If not, needle inserted through anterior chest wall into pleural space (sneaking under surgical drapes)
- Formal chest tube placed later
A patient is recovering in the hospital after surgery. She becomes confused and disoriented.
- Likely cause & its likely etiology
- Dx
- Tx
- Hypoxia, 2/2 sepsis
- first thing to think of with post-op disorientation/confusion - Check blood gases
- Respiratory support
A patient has had a complicated post-op course, including sepsis and hypoxia. There is no e/o CHF, but a CXR shows bilateral pulmonary infiltrates.
- Likely diagnosis
- Dx
- Tx
- Adult Respiratory Distress Syndrome (ARDS)
- in patients with stormy complicated post-op course, often complicated by sepsis as precipitating event
- bl pulmonary infiiltrates w/out e/o CHF
- hypoxia - Dx: clinical + CXR
- Tx:
- Positive end-expiratory pressure (PEEP)
* taking care not to use excessive volume, which have been shown to result in barotrauma*
- Seek/correct source of sepsis
A patient with a history of alcohol abuse undergoes surgery. After a few days recovering the hospital, he becomes confused and combative and begins to hallucinate and shake. His blood pressure is elevated.
- Likely diagnosis
- Dx
- Tx
- Delirium tremens
- very common in alcoholic when drinking is suddenly interrupted by surgery
- 2-3 days post op
- confused, hallucinate, combative, shake, BP and temp elevation, seizures… - Dx: clinical
- Tx:
Standard: IV benzos
Sometimes preferred in surgical community: IV alcohol (5% in 5% dextrose)
A confused post-op patient has received large amounts of D5W and has had quick weight gain. She begins to have convulsions.
- Likely diagnosis
- Dx
- Prevention
- Tx
- Hyponatremia 2/2 water intoxication
- May be quickly induced by liberal administration of Na-free IV fluid (ex: D5W) in post-op patient
- May slowly develop 2/2 high levels of ADH (triggered by trauma response or secreted by tumor)
- May also develop as a result of large loss of isotonic fluids (usually via GI), forcing water retention if not properly replaced with isotonic fluids - Dx:
If rapid:
-Clinical s/sx: –> consfusion, convulsions, coma, death
-Chart: large fluid intake, quick weight gain, rapidly lowering serum sodium concentration (hours) - Prevention:
- include Na in IVF - Dx: Controversial; High mortality (esp. young women)
Rapidly developed:
-small amounts of hypertonic saline (aliquots of 100ml of 5% or 500ml of 3%)
-+/- osmotic diuretics
Slowly developed (inappropriate ADH):
-water restriction
GI loss of isotonic fluids:
-volume restoration with isotonic fluids (NS, LR)
A post-op patient is confused and lethargic. His chart shows a large urinary output, creating a negative net I&O. His weight has also rapidly gone down.
- Likely diagnosis
- Dx
- Tx
- Hypernatremia 2/2 large unreplaced water loss
Rapid development via:
-surgical damage to posterior pituitary w/diabetes insipidus
-unrecognized osmotic diuresis
*every 3 mEq/L that Na is >140 represents ~1L water loss
Slow development (days)
-brain adapts –> only sxs of volume depletion - Dx
- Clinical: confusion, lethargy, coma (if develops rapidly)
- Rapidly rising serum sodium concentration w/rapid weight loss and net negative I&O - Tx:
- rapid replacement of fluid deficit (hours) with slow correction of tonicity (days)
* if developed slowly, cushion tonicity with D5 1/2 NS
* if developed rapidly, may safely use more diluted fluid (D 5 1/3 NS, NS, or even D5W)
A patient with a PMHx of cirrhosis and esophageal varices just had surgery for portocaval shunt. He is found in a coma.
- Likely diagnosis
- Dx
- Tx
- Ammonium intoxication
- common source of coma in the cirrhotic patient with bleeding esophageal varices undergoing surgery for portocaval shunt - Dx
- Ammonia levels - Tx
- Lactulose or Rifaximin
A post-op patient complains that she cannot urinate. She just had a hysterectomy. She says she feels the urge to void, but cannot do it.
- Likely diagnosis
- Dx
- Tx
- Post-op urinary retention
- extremely common, especially after surgery to lower abdomen, pelvis, perineum, or groin.
- feels need to void - Dx: clinical, relief w/cath
- Tx
In-and-out bladder cath up to 6hrs post-op if no spontaneous voiding has occurred
Indwelling (Foley) cath at the 2nd or 3rd consecutive catheterization
If there is no urinary output with catheter, look for plugged or kinked catheter (usually mechanical, not biological prob)
A post-op patient has low urinary output. Her vitals are otherwise wnl.
- What is low urinary output?
- Likely etiologies
- Dx
- Tx
- Low UOP: temporarily increased UOP
—Renal failure pts –> no response
Urinary sodium:
— Dehydrated pts: 40 mEq/L
Fractional excretion of sodium (FENa)
= (Urinary Na x Plasma Cr) / (Plasma Na x Urinary Cr) x 100
—Renal failure pt: >1
A patient is on POD2 after an abdominal surgery. He complains of an inability to defecate. On exam, he has no bowel sounds and is mildly distended but has no pain. Upon questioning, he says he has not passed gas either.
- Likely diagnosis
- Dx
- Tx
- What might prolonged this problem?
- Paralytic ileus
- expected in first few days after abdominal surgery
- no bowel sounds, flatus, or BMs; no pain; mild distension
2. Dx: Abdominal films (supine, upright) --dilated small bowel loops --air in colon/rectum w/out transition zone to suggest obstruction --no e/o free air to suggest perf Abdominal CT if unclear Labs to look for causes --WBC for infection --HypoK worsens ileus, HypoMg --> hypoK --Cr and BUN as uremia --> ileus --LFTs & lipase as gallbladder or pancreas dysfxn --> ileus
- Tx:
NPO, NG tube for decompression - Hypokalemia
A patient was diagnosed with a paralytic ileus due to lack of BMs, flatus, and bowel sounds, but has not recovered after a week.
- Likely dx
- Dx
- Tx
- Early mechanical bowel obstruction 2/2 adhesions
- can happen during post-op period
- what was assumed paralytic ileus but which didn’t resolve in 5-7 days is probably early mechanical obstruction - Dx
Abdominal films: dilated small bowel loops & air-fluid levels
Abdominal CT: confirms dz; demonstrates transition point btwn proximal dilated bowel & distal collapsed bowel @obstruction site - Tx: Surgical correction
