postoperative complications

Question 1

hypotension/tachycardia immediate post-op ddx and work-up

Answer 1

ddx: bleeding (intrapertioneal vs retroperitoneal vs IVC compression from expanding hematoma) vs cardiopulmonary event
immediate eval: ABCs, LOC, type/degree of pain, EKG, abdominal/pelvic exam

Question 2

suspected cardiopulmonary event post op. immediate next steps in treatment?

Answer 2

• face mask O2
• ensure IV access
• ABG, EKG, BMP, CBC, cardiac enzymes
• if MI normal, must rule out PE with CT pulmonary angiography

Question 3

if bleeding suspected, next steps

Answer 3

• if vaginal hyst, reasonable to consider transvaginal approach
• TLH/TAH-> XL

Question 4

ddx of pulmonary complications

Answer 4

• atelectasis
• PNA
• PE
• ARDS

Question 5

atelectasis

Answer 5

• collapse of alveoli
• can worsen outcomes in pts with comorbidities
• exam: diminished breath sounds, dullness to percussion, poor oxygenation
• prevention/tx: lung expansion therapies

Question 6

Hospital acquired PNA

• dx criteria
• microbiology
• tx

Answer 6

• dx criteria: radiographic infiltrate + 2 of 3: leukocytosis, fever > 38C, purulent secretion
• microbiology: polymicrobial, have to watch for MRSA and psuedomonas
• based on hospital antibiogram- zosyn is reasonable; MRSA coverage with vanc. sputum cx possible prior to tx.
• prevention: coughing/deep breathing, elevating HOB 30-45 degrees, ambulation

Question 7

vaginal bleeding from cuff s/p hyst weeks out. ddx

Answer 7

• granulation tissue
• retained suture or foreign material
• entraped fallopian tube or obowel
• traumatic bleeding (tampon, sex)

Question 8

vaginal apex mass ddx weeks out from surgry

Answer 8

• pelvic hematoma
• pelvic abcess
• entrapped bowel or fallopian tube
• urinoma
• foreign body

Question 9

differentiaion of of SBO and ileus post-op?

Answer 9

• uniform gaseous distention of small and large bowel in ileus
• Px of ileus: ngt in selective cases, gum chewing
• SBO clinically more likely to have tachycardia, oliguria, and fever. exam: distention, high pitched bowel sounds
• Dx: CT with PO contrast (water soluble, Gastrografin)

Question 10

ddx diarrhea post-op

Answer 10

• viral gastroenetiritis
• SBO
• bowel dysfunction due to meds including abx
• c diff

Question 11

testing and tx for c diff

Answer 11

• if 3 or more unformed stools in 24 hours, recommend c diff testing (NAAT toxin genes, and culture)
• tx with PO flagyl qid x 14 days. or fidamoxicin
• 2nd line vanc
• after tx order colonosocpy

Question 12

what are risks of transfusion reactions?

Answer 12

• acute hemolytic transfusion reaction: immune mediated hemolysis, usually RBO inocomptaibility
• delayed hemolytic transfusion reaction: days to weeks after
• febrile nonhemolytic transfusion reaction: most common.
• allergic reaction: Ab-mediated response to donor plasma proteins, can be anaphylactic.
• infection: at this point, bacteria more common than virus contamination
• TRALI

Question 13

• clinical characterstics, dx of each risk of blood transfusion:

Answer 13

• acute hemolytic: chills, fever, urticaria, tachy, dyspnea, n/v, chest pain pain, hypotension. labs: increased LDH, bilirubin, urine/serum free Hgb. sequelae can include ATN, DIC. get CBC, BMP, coags, LFTs
• delayed hemolytic: more mild sx, sometimes jaundice, fever, lower hgb levels
• Febrile nonhemolytic: chills, and greater than 1C.
• Noncardiogenic pulmonary edema: diffuse b/l pulmonary infiltrates on CXR

Question 14

tx of each complication of blood transfusion:

Answer 14

• acute hemolytic transfusion: stop transfusion, diuresis with lasix/mannitol. consider alkalinization of urine, poss with IV bicarb.
• delayed hemolytic: no intervention needed
• febrile nonhemolytic: stop transfusion, supportive tx. pre-mediate with antipyretic next time.
• anaphylactic: if anaphylactic - IM or IV epinephrine