Postoperative Care

Question 1

For every 1 mL of EBL, how many mL of isotonic fluid should be given?

Answer 1

3

2/3rds of fluid given leaves intravascular space rapidly

Question 2

Rule of thumb for insensible (unmeasurable) losses?

Answer 2

due to evaporation…longer, larger procedures (like open abdomen) result in more insensible losses obviously
5-10 ml/kg/hr in bigger procedures
1-2 ml/kg/hr in smaller procedures

Question 3

How to calculate maintenance fluids

Answer 3

units in ml/kg/24 hours

first 10 kg = 1000 ml
next 10 kg = 500 ml
each kg after 20 kg = 20 per kg

can use D5 0.5 NS plus KCl or 0.9 NS for first 24 hr if there was lots of blood loss during operation

Question 4

How do fluid requirements typically change after procedure?

Answer 4

excess fluid will begin to drain from third spacing so fluid requirements will tend to decrease…adjust fluids accordingly to avoid volume overload

Question 5

Post op patient is oliguric with significant tachycardia….

Answer 5

full work up and physical
big concern for HYPOVOLEMIA…fluid resusitate with isotonic bolus and recheck h/h…if doesn’t respond concern for post op bleed from surgical site

Question 6

normal UOP

Answer 6

0.5 - 1 ml/kg/hr

Question 7

Besides Bun:Cr, urine lytes, bladder scan, FeNa, and osmolality, what else can be checked when evaluating oliguria

Answer 7

check cardiac output and preload via pulmonary artery catheter and echocardiogram to determine heart/venticular function

Question 8

What is suppurative phlebitis and how to manage?

Answer 8

infected thrombus in vein and/or indwelling catheter…treat by removing catheter and can be surgically treated by exicising infected vein. Blood cultures will usually be positive. Give IV antibiotics and wound should be open

Question 9

Bad wound infection with skin discloroation, foul odor, crepitius, bleb formation, brown discharge…culture obtained showing gram positive spore producing rods…

Answer 9

GAS GANGRENE from clostridium

immediately debride, hyperbaric oxygen to prevent germination of spores,adminsiter high dose penicillin G

Question 10

Differential for post up hemoptysis

Answer 10

tuberculosis, bronchitis, pneumonia, malignancy, or pulmonary infarct from PULMONARY EMBOLISM

Question 11

When to surgically explore in patient with small bowel fistula…

Answer 11

when patient shows signs of peritonitis…otherwise CT scan is required to rule out intra-abdominal collection, which can usually be drained percutaneously through CT guidance…

Question 12

How to nonsurgically manage enterocutaneous fistula…

Answer 12

NPO, TPN, measure fistula output daily and making sure to check electrolytes daily…most fistulas will heal in several weeks (although some don’t)…

do a fistulogram if fistula isn’t healing to find explanations…if persists for more than 5 weeks, consider definitive repair procedure

Question 13

What factors are assocaited with a fistula that is unable to heal?

Answer 13

FRIEND
Foreign body in wound
Radiation damage to area
Infection or IBD
Epitheliaization of fistulous tract
Neoplasm
Distal bowel obstruction