Postoperative Care

Question 1

What is post-op fluid management?

Answer 1

Replace blood lost during surgery + provide maintenance IVF + make up for fluid loss in drains/NG tubes/fistulas

Question 2

How do you replace surgical blood loss?

Answer 2

Replace in a 3:1 ratio with IVF

Question 3

How do you replace maintenance IVF?

Answer 3

Administer D5 1/2 NS + KCl using the 100/50/20 rule for daily fluid requirements, or the 4/2/1 rule for hourly fluids

Question 4

What is the third space?

Answer 4

Fluid sequestered into ISF due to inflammation or injury, mobilized 3-5 days after recovery –> requires decrease in IVF rate

Question 5

What is malignant hyperthermia?

Answer 5

T>104 following anesthesia with high risk of myoglobinuria; tx dantrolene, 100% oxygen, and cooling blankets

Question 6

What is bacteremia?

Answer 6

T>104 and chills within 1 hour or an invasive procedure; get blood Cx x3 and start empiric abx

Question 7

What are the complications of aspiration?

Answer 7

Complication of awake intubations; leads to sudden death, chemical pneumonitis, or secondary pneumonia

Question 8

How do you manage aspiration?

Answer 8

Prevent via NPO and antacids before intubating, Tx BAL and bronchodilators

Question 9

How do you manage a tension pneumothorax?

Answer 9

Complication of intubation in weak or traumatized lungs, presents as “difficult to bag”, progressive hypotension and JVD; Tx is emergent needle decompression + chest tube

Question 10

What is normal urine output post-op?

Answer 10

At least 0.5-1 mL/h/kg

Question 11

What is post-op urine retention?

Answer 11

Presents as a need to void, but inability to do so; Tx is straight cath at 6 hours post-op and Foley after 2nd straight cath
UOP = 0 is likely due to a kinked or plugged Foley
UOP < 0.5 is either due to fluid deficit or acute renal failure; give a bolus of 500 mL IVF and if UOP responds, then it’s due to a fluid deficit

Question 12

What are the potential causes of post-op hematuria?

Answer 12

Consider bladder overdistention, cancer, infection, kidney stones, trauma, prostatitis, and cyclophosphamide; get urology consult

Question 13

What do you consider with post-op fever?

Answer 13

Consider the five W's: 
Wind (atelectasis POD 1)
Water (UTI POD 3)
Walking (DVT POD 5)
Wound infection (POD 7)
Wonder Drug (drug-induced fever)

Question 14

How do you treat post-op atelectasis?

Answer 14

Partial lung collapse, dx bilateral inspiratory crackles, prevent with pulmonary toilet and incentive spirometry
Can develop into pneumonia POD 3 if left untreated

Question 15

What is urosepsis?

Answer 15

UTI + septic shock; presents as cloudy urine, fever, hypotension, and a change in mental status; dx by urinalysis and urine Cx, tx with empiric abx + IVF

Question 16

How do you treat a wound infection?

Answer 16

Dx examine wound site for erythema and fluctuance; if cellulitis –> abx only
if abscess –> drain pus and BID dressing changes

Question 17

What is suppurative phlebitis?

Answer 17

Infected thrombus at site of venipuncture; Tx is to remove catheter and surgical excision of infected vein to the first non-infected branch, leave wound open, and give IV abx

Question 18

How do you treat a GI fistula?

Answer 18

GI fistula causes leakage of GI contents from wound site; tx is NPO, TPN, and protect abdominal wall until body can heal itself

Question 19

What prevents the healing of a fistula?

Answer 19

FRIEND: foreign body, radiation, infection, epithelialization, neoplasm, distal obstruction
Fistula x peritonitis = requires surgical exploration
Fistula x abscess = percutaneous drainage

Question 20

Post-op chest pain concerns

Answer 20

MI : presents as acute chest pain +/- other classic signs; Dx CK-MB or troponin I, treat the complications
PE: presents as chest pain, hypoxia, and prominent JVD; Dx is V/Q scan, Tx is heparin –> IVC filter if PE recur while anticoagulated

Question 21

How do you treat ARDS?

Answer 21

Presents as hypoxia due to septic shock

Tx intubation with high PEEP and permissive hypercarbia, then look for source of sepsis

Question 22

When do you see delirium tremens?

Answer 22

Presents as hallucinations in an alcoholic POD 2-3, prevention is key and tx is controversial

Question 23

What is hepatic encephalopathy?

Answer 23

Presents as coma in a liver failure patient s/p TIPS due to ammonia toxicity

Question 24

How does wound dehiscence present?

Answer 24

Presents as salmon-colored fluid soaking dressings s/p open laparotomy POD 5; stabilize wound site, surgical closure at a later date

Question 25

What is evisceration?

Answer 25

Wound dehiscence + intestines spilling out; keep patient in bed and cover bowel with sterile dressings, emergency surgical closure necessary

Question 26

How does hypernatremia present?

Answer 26

Every 3 Na over 140 indicates 1 L of water loss, presents as volume depletion (slow) or altered MS (rapid); give D5 1/2 NS to correct imbalance

Question 27

How does hyponatremia present?

Answer 27

Due to SIADH or isotonic fluid loss with free water resorption, presents as coma and convulsions; tx is water restriction and LR/NS

Question 28

What causes hypokalemia?

Answer 28

Due to diarrhea or vomiting, give K+ at a rate of <10 mEq/hr

Question 29

What causes hyperkalemia?

Answer 29

Renal failure, aldosterone blockers, or release from dead tissue (crush injury, ischemic bowel, etc.); tx C BIG K Die – calcium gluconate, bicarb-insulin-glucose, kayexalate, and dialysis

Question 30

What is primary intention?

Answer 30

Close approximation of wound edges via sutures or staples
Timing: epithelialized by POD 2, max collagen in 5-7 days, avoid weight-lifting for 4-6 weeks, complete healing by 6 months

Question 31

What is secondary intention?

Answer 31

Contaminated wounds left open to prevent abscess formation; granulation tissue forms first, then comes contraction via myofibroblasts, then finally a delayed epithelialization

Question 32

What is third intention?

Answer 32

Wound initially left open, then delayed primary closure afterwards

Question 33

What is an incisional hernia?

Answer 33

Presents as bulging at wound site with increased abdominal pressure, needs to be repaired surgically

Question 34

What is a hypertrophic scar?

Answer 34

Raised scar within site of incision, observe until scar is stable, then steroids + excision

Question 35

What is keloid?

Answer 35

Raised scar that extends beyond site of incision; will grow back if excised

Question 36

How do you treat a wound infection?

Answer 36

Red and tender area on incision site; Tx is drainage and BID wet-to-dry dressing changes
No abx unless cellulitis is spreading

Question 37

When do you use prophylactic antiobiotics with a wound?

Answer 37

Recommended for any clean-contaminated or contaminated procedures, insertion of prosthetic material, immunosuppression, or poor blood supply;
give single dose 1 hour pre-op and single dose post-op

Question 38

What are the wound types?

Answer 38

Clean wound: no entry into GI, GU, or respiratory tracts; <10% infection rate, Tx is primary closure
Contaminated wound: major wound contamination (e.g. bowel spillage or stab wounds) ; Tx is secondary closure