Postoperative Care Flashcards
Measurable fluid losses
EBL, fluid given intraoperatively, urine output
What fraction of fluid administered stays intravascularly? How much isotonic fluid must be given to replenish 1mL blood loss?
1/3 of fluid stays (2/3 moves to EC space)
3mL of isotonic fluid per 1mL of fluid loss
Insensible fluid losses
Evaporation during procedures especially in long procedures w/open peritoneal cavity. Difficult to quantify and must be estrimated based on urine output, vitals, and other physiologic measurements
Estimating maintenance fluid requirements by body weight
- 100mL/kg/24hr for first 10kg
- 50ml/kg/24hr for second 10kg
- 20ml/kg/24hr for anything above 20kg
Replenishing Na, K and Cl
- D5-0.5HS
2. KCl 20mEq/L
Replenishing fluid after large EBL
- Lactated ringer for first 24hrs
2. 0.9NS for first 24hrs
How do fluid requirements change with recovery
After GI function returns, 3rd space fluid volume will be excreted by the kidneys and thus fluid requirements will decrease during this phase. continued IV fluids may result in fluid overload, edema, and pulmonary edema
Normal urine output rate
0.5-1ml/kg/hr (e.g. 50mL/hr)
Causes of post-operative urine diuresis
- Preexisting renal disease with inabiltiy to concentrate urine
- Diabetes insipidus
- Combination of causes
- Post-obstructive diuresis (diuresis after clearance of an obstructino)
Causes of postobstructive diuresis
- Chronic obstruction
- Edema
- CHF
- HTN
- Wt gain
- Azotemia
Causes of diuresis
- Impaired concentration ability (pathologic)
- Impaired sodium resorption (pathologic)
- retained urea, sodium, and water (physiologic)
Implications of different urine osmolalities
- Urine w/low osmolaltiy = pathologic concentrating defect
2. Urine w/high osmolality = osmotic diuresis
Causes of oliguria
- mechanical obstruction (catheter etc.)
2. Severe dehydration (must volume resuscitate +/- CVP line or pulmonary artery catheter)
What does a pulmonary artery catheter tell you?
Indicator of preload and CO adequacy
Causes of hematuria
- Obstruction w/overdistention of bladder causing injury to bladder wall
- Malignancy
- INfection
- Kidney stones
- Trauma
- Prostatitis
- Med sfx causing hemorrhagic cystitis (Cyclophosphamide)
Sx/tx of urosepsis
- Cloudy urine
- Fever after insertion of catheter
- Hypotension
- Sepsis workup
- Broad-spec ABx
- Pulmonary artery catheter
Sources of post op fever
- Pneumonia
- URI
- UTI
- DVT
- Infected indwelling cather
- Drug-related fever
Most common cause of fever immediately post-op = atelectasis. Tx = pulmonary toilet + IS
Second most common cause of post-op fever = UTI (POD # 3!)
HPI workup for post op fever
- Sputum production
- Cough
- Abdominal pain
- Nausea
- Vomiting
- Pain at wound site
- Drainage from wound
- Bowel function
- Difficulty urinating
- Blood in urine
When does pulmonary edema occur post-op?
A few days after surgery when pts begin to mobilize 3rd space fluids
Workup for post-op UTI. Tx?
- PE
- Bladder US
- Insertion of catheter
- TMP-SMX
- Ciprofloxacin
- Maintain hydration
Post-op evaluation of wound healing? Tx?
- Cellulitis? ABx
- Fluctuance
- Infected indwelling IV/catheter? Remove the IV/catheter
- Infected staple site? Remove some of the staples and drain pus. Perform culture and treat locally with irrigation and wet to dry dressings 2x/day. +/- ABx
- Suppurative phlebitis (infected thrombus at venipuncture site)? Remove catheter and SURGICALLY EXCISE the infected vein until the first patent noninfected collateral branch. IV ABx + heal by secondary intention
Enteric contents draining from a wound s/p necrotic bowel resection
- Small bowel fistula formation
- Leak at jejunosotomy insertion site
- Breakdown of small bowel anastamosis
- Missed enterotomy
Work up for post-op peritonitis
- Surgical Re-exploration of the abdomen
- CT scan to r/o intra-abdominal collection (if fluid collection found then drain percutaneously)
3.
Tx for fistula formation leaking enteric contents
- NPO
- TPN diet
- Measure fistula output/day
- Monitor serum electrolytes
Most fistulas will heal on their own in a couple of weeks. - If fistula is not closing then perform small bowel series to determine cause of continued drainage
- If no resolution in 5-6wks, surgical correction is indicated
Causes of failure of fistula to heal
- Foreign body
- Radiation damage
- Infection/IBD
- Epithelialization of fistulous tract
- Neoplasm
- Distal bowel obstruction
Most important immediate steps in eval of high post-op fever
- r/o wound infection from gas-forming organisms (Clostridium - necrotizing fasciitis)
- remove bandages and inspect the wound
Treatment of gram +, spore forming rod infection with crepitis, brown skin discoloration, watery brown discharge, and bleb formation.
Tx of clostridial myositis and cellulitis by clostridium perfringens includes High dose penicillin G, wound debridement, hyperbaric O2 therapy.
Causes of post-op SOB. Workup?
- Atelectasis
- Bronchitis (higher in smokers)
- Pneumonia (higher in smokers)
CXR, ABGs, Gram stain/culture of sputum, empiric ABx tx if pt is febrile (start AFTER culture is sent)
Causes of hemoptysis/blood streated sputum
- Malignancy (esp if hemoptysis predates hospital admission)
- Bronchitis
- Pneumonia
- TB (infarction caused by PE)
Causes of acute hypotension and hypoxia
- PE (tx w/heparin)
- MI (obtain ECG)
- Pneumothorax (may require intubation)
