Postoperative Care

Question 0

Estimate of maintenance fluid requirements?

Answer 0

First 10 kg – 100 mL per kilogram per day
Next 10 kg – 50
Beyond – 20 per kilogram

Aka 1500+20(weight-20)

Question 1

Calculation of intraoperative fluid requirements?

Answer 1

replacement fluid = Urine output + 3xEBL

Three times EBL because 2/3 of replacement fluid moves extravascularly

Question 2

For average patient – fluids to replace sodium, potassium, chloride?

Answer 2

D5 1/2NS + KCl 20 mEq/L

Question 3

G.I. Tract that contains fluid with:

1. Highest and Lowest sodium?
2. Highest potassium?
3. Highest and Lowest chlorine?
4. Highest and lowest bicarb?

Answer 3

1. Small intestine and Large intestine
2. Large intestine; everywhere else equal
3. Gastric aspirate; large intestine
4. Pancreatic juice; gastric aspirate

Question 4

Electrolyte composition of:

1. D5W
2. D10W
3. Normal saline
4. 1/2 normal saline
5. LR

Answer 4

1. 50 mg/dL glucose
2. 100 mg/dL glucose
3. 154 mEq per liter NECO
4. 77 mEq per liter NaCl
5. 130 Na, 110 Cl, 28 lactate, minimal K, Ca

Question 5

How do patients fluid requirements change during postoperative course?

Complications for not adjusting IV intake postoperatively?

Answer 5

1. Begins to mobilize fluid from third space accumulation.
2. Excess fluid must be excreted by kidney, increasing intravascular space
3. Therefore IV fluid requirements decrease during recovery.

Overload, edema, pulmonary edema

Question 6

Normal urine output?

Answer 6

.5-1 mL/Kg/hr

Question 7

Patient admitted to hospital. Diuresis 400 mL per hour over next four hours and develops blood pressure of 80/60 – potential causes?

Answer 7

1. Diabetes insipidus
2. Renal disease with inability to concentrate urine
3. Postobstructive diuresis

Question 8

Conditions that make patients more prone to postobstructive diuresis? Course of obstructive diuresis?

Answer 8

Chronic obstruction, CHF, hypertension, azotemia, edema

Self-limited, BUN and creatinine return to normal in 1-2 days

Question 9

When to collect urine to determine cause of diuresis? Interpretation?

Answer 9

More than 200 mL per hour for two consecutive hours

Low osmolality – pathologic concentrating defect
High osmolality – osmotic diuresis

Question 10

Post operative patient has urine output of 10 mL per hour for four hours – Management?

Answer 10

1. Check for mechanical problem with catheter (irrigate catheter and confirm position)
2. If fails, Volume resuscitation for patient
3. If it fails, central line to measure CVP
4. If normal, pulmonary artery catheter for preload and cardiac output

Question 11

Postoperative patient develops gross hematuria with first liter of urine drained - differential?

Answer 11

1. Kidney stones
2. Over distention of bladder causing bladder wall injury
3. Trauma from Foley
4. Infection - prostatitis
5. Medications – cyclophosphamide

Question 12

The most common cause if fever in the immediate postoperative period? Differential? Management?

Answer 12

1. Atelectasis (Incentive spirometry but No antibiotics)
2. Pneumonia (Antibiotics)
3. Pulmonary edema

Question 13

Postoperative patient – when would pulmonary edema most likely occur? Why?

Answer 13

Several days after operation when 3rd space fluids mobilize

Question 14

Postoperative patient with suspected urinary retention – work up?

Answer 14

Bladder ultrasound or catheter insertion

Question 15

Postoperative patient – find pus on the skin at venipuncture exit site diagnosis? Other signs/symptoms?Treatment?

Answer 15

Suppurative phlebitis (infected thrombus in vein around indwelling catheter)

High fevers and positive blood cultures

1. Remove catheter
2. surgically excise vein
3. Antibiotics
4. Leave wound open

Question 16

Patient with purulent drainage from wound site – fluctuance indicates?

Answer 16

Fluid Collection beneath skin – remove sutures/staples and drain pus

Question 17

Patient who had removal of necrotic bowel and jejunostomy – POD5, notice intestinal contents draining from wound. Possible origin? Management?

Answer 17

1. Leak at jejunostomy insertion site
2. Breakdown of small bowel anastomosis
3. Missed enterotomy
4. Surgical reexploration if signs of peritonitis
5. Otherwise CT guided percutaneous drainage

Question 18

Patient who had removal of necrotic bowel – POD5, notice intestinal contents draining from wound. Fistula draining adequately – management?

Answer 18

Manage non-operatively as enterocutaneous fistula

1. NPO
2. TPN
3. Daily measurement of fistula output, serum electrolytes
4. Should heal within five weeks

Question 19

Factors associated with failure of fistula to heal?

Answer 19

FRIEND

Foreign bodies in the wound
Radiation damage
Infection or IBD
Epithelization of fistulous tract
Neoplasm
Distal bowel obstruction