postop complications & pain management

Question 1

• highly sensitive to stretch, ischemia and inflammation
• Ache, dull, crampy, diffuse, spastic, gnawing, constant

Answer 1

visceral nociceptive

Question 2

• stimulation of nociceptors in ligaments, tendons,
  bones, blood vessels, fascia and muscles
• Broken bone, sprains

Answer 2

deep somatic nociceptive

Question 3

well-defined and easily located activation of nociceptors in skin or other superficial structures

Answer 3

superficial somatic nociceptive

Question 4

two pre-op local anesthetics

Answer 4

lidocaine
marcaine

Question 5

• Preferred mode of administering opioids for moderate/severe postop pain
• easy and minimizes risk for OD
• which 3 meds can be given like this?

Answer 5

Patient controlled analgesia (PCA)
hydromorphone, morphine, fentanyl

Question 6

• harder to dose bc of short half life but used in liver patients bc no first pass effect
• synthetic derivative of morphine; 100x more potent

Answer 6

fentanyl

Question 7

what anelgesia is MC used for epidurals vs spinals?

Answer 7

epidurals: fentanyl
spinals: bupivacaine (marcaine)

Question 8

how are postdural HA treated? (3)

Answer 8

rest, IVF, blood patch

Question 9

• rapid onset; semisynthetic opioid agonist
• IV meds

Answer 9

hydromorphone

Question 10

• IV med that reduces narcotic demand used for 48h postop
• works as antipyretic

Answer 10

acetaminophen (ofirmev)

Question 11

• potent NSAID used with caution in renal pts/elderly
• reduces narcotic demand
• can only be dosed for 5 days d/t renal risk

Answer 11

ketorolac (toradol)

Question 12

• most commonly used oral meds
• SE includes N/V, constipation, hypotension, sedation, respiratory dep, urinary retention
• easy to withdrawal

Question 13

• Long lasting pain control
• Patch stays on for up to 3 days
• Transmits opioid transdermally
• New adjunct to modern day pain contro

Answer 13

fentanyl/lidocaine patch

Question 14

• SE profile low
• Helpful with neuropathic pain by binding to Ca+ channels to decrease impulse conduction which increases GABA synthesis (inhibitory pathway to pain transmission)
• No ceiling drug – If pain not controlled, increase the dose

Answer 14

anticonvulsants

Question 15

• Produces pain relief by enhancing the descending pain inhibition pathway
• Helpful with neuropathic and phantom pain
• Can be helpful with insomnia and depression associated with pain
• Concerns about toxicity

Answer 15

TCA (amitriptyline)

Question 16

• Helpful for sleep, anxiety disorders and muscle
  spasms
• Can cause dependence, increased aggression
• Caution with elderly
• Avoid if possible

Answer 16

Benzos

Question 17

should you stop the home dosing for people who take narcotics at home?

Answer 17

NO

Question 18

what are the 5 Ws of fevers

Answer 18

• Wind: atelectasis vs pneumonia; first 24 to 48h
• Wound: after post op day 3
• Water: UTI; 24-72hrs
• Walking: PE?
• Wonder drugs: anytime

Question 19

3 causes of intraoperative or PACU fever

Answer 19

• MH
• infection
• drug/transfusion reaction (often hypotension and rash)

Question 20

• necrotizing wound infections (clostridia or streptococcus)
• preexisting infection

Answer 20

fever w/in 24 hrs (infection)

Question 21

fever 2-3 days; what are 3 possible causes

Answer 21

UTI
pneumonia– XR, procalcitonin
IV related complications

Question 22

test to distinguish bacteria from other causes of infection or inflammation

Answer 22

procalcitonin

Question 23

fever 3days to 1 week what are 3 possible causes

Answer 23

infections, DVT/PE, drug fever

Question 24

how are deep surgical site infections diagnosed?

Answer 24

CT targeted at the site

Question 25

- sick patient post op day 5-7; associated mortality - causes peritonitis and sepsis - requires emergent re-op to fix the leak

Answer 25

anastomotic leak

Question 26

- inflammation/infection of the parotid gland from prolonged NPO/dry mouth - Associated with sialolithiasis - tx: abx plus sour lozenges to stimulate saliva

Answer 26

parotitis

Question 27

- acute gallbladder infection from prolonged NPO status/acute illness. - Requires cholecystectomy or cholecystostomy tube

Answer 27

alcalculous cholecystitis

Question 28

- associated with copious diarrhea and often profound leukocytosis.

Answer 28

C. diff

Question 29

usually associated with NG tubes

Answer 29

sinusitis

Question 30

____ rarely causes post op fever

Answer 30

malignancy

Question 31

when does major post op bleeding usually manifest?

Answer 31

within 24h postop

Question 32

H/H of what level should be allowed in healthy person

Answer 32

7/21-- allow lower level

Question 33

FeNa under 1% vs above 2-3%?

Answer 33

under 1 is prerenal while above 2-3 is ATN or postrenal dz

Question 34

what two classes of meds are risk factors for urinary retention

Answer 34

narcotics or decongestants

Question 35

3 ways to monitor urinary retention

Answer 35

- voided output - bladder scan if no void over 6hrs - straight cath to record residual volume

Question 36

3 ways to treat urinary retention

Answer 36

- straight cath q 6h or sooner if uncomfy - foley if over 2 straight caths required (leave in 2-7days) - consider Flomax

Question 37

if someone is delirius what must be ruled out

Answer 37

post op CVA-- get head CT if not going away after usual treatment

Question 38

- neurogenic obstruction d/t inflammation, manipulation, peritonitis - distended, hypoactive BS, **dilated bowel** - **NO PAIN!!!** - tx: reduce oral intake (liquid or light meals), provide IV fluids

Answer 38

ileus

Question 39

mild permissive ____ glycemia ok because it's a physiologic response to stress?

Answer 39

HYPER-- treat if over 200mg/dl; can impair healing

Question 40

- no sx or increased WOB or hypoxemia - managed with aggressive pulmonary toilet, suctioning PRN, supplemental O2 PRN

Answer 40

atelectasis

Question 41

wound infections usually appear how many days post-op

Answer 41

wound infection