Complications Flashcards
(169 cards)
1
Q
What is atelectasis?
A
Collapse of the alveoli
2
Q
What is the etiology of atelectasis?
A
Inadequate alveolar expansion, high levels of inspired oxygen
3
Q
What are the signs of atelectasis?
A
Fever, decreased breath sounds with rales, tachypnea, tachycardia, and increased density on CXR
4
Q
What are the risk factors for atelectasis?
A
COPD, smoking, abdominal or thoracic surgery, over-sedation, poor pain control
5
Q
What is the most common cause of fever during PODs #1 and #2?
A
Atelectasis
6
Q
What prophylactic measures can be taken against atelectasis?
A
Preoperative smoking cessation, incentive spirometry, good pain control
7
Q
What is the treatment for atelectasis?
A
Postoperative incentive spirometry, deep breathing, coughing, early ambulation, NT suctioning, and chest PT
8
Q
What is postoperative respiratory failure?
A
Respiratory impairment with increased respiratory rate, SOB, dyspnea
9
Q
What is the differential diagnosis for postoperative respiratory failure?
A
Hypovolemia, PE, administration of supplemental O2 to a patient with COPD, atelectasis, pneumonia, aspiration, pulmonary edema, abdominal compartment syndrome, PTX, chylothorax, hemothorax, narcotic overdose, mucous plug
10
Q
What is the treatment for postoperative respiratory failure?
A
Supplemental O2, chest PT, suctioning, intubation, and ventilation if necessary
11
Q
What is the initial workup for postoperative respiratory failure?
A
ABG, CXR, EKG, pulse oximetry, and auscultation
12
Q
What are the indications for intubation and ventilation in postoperative respiratory failure?
A
Cannot protect airway (unconscious), excessive work of breathing, progressive hypoxemia (PaO2 < 55 despite supplemental O2), progressive acidosis (pH < 7.3 and PCO2 > 50), RR > 35
13
Q
What are the possible causes of postoperative pleural effusion?
A
Fluid overload, pneumonia, diaphragmatic inflammation with possible subphrenic abscess formation
14
Q
What is the treatment of postoperative wheezing?
A
Albuterol nebulizer
15
Q
Why may it be dangerous to give a patient with chronic COPD supplemental O2?
A
This patient uses relative hypoxia for respiratory drive, and supplemental O2 may remove the drive
16
Q
What is a pulmonary embolism?
A
DVT that embolizes to the pulmonary arterial system
17
Q
What is DVT?
A
Deep Vein Thrombosis:
A clot that forms in the pelvic or lower extremity veins
18
Q
Is DVT more common in the right or left iliac vein?
A
Left is more common (4:1) because the aortic bifurcation crosses and possibly compresses the left iliac vein
19
Q
What are the signs and symptoms of DVT?
A
Lower extremity pain, swelling, tenderness, Homan’s sign, PE.
Up to 50% are asymptomatic.
20
Q
What is Homan’s sign?
A
Calf pain with dorsiflexion of the foot seen classically with DVT, but actually found in fewer than 33% of patients with DVT
21
Q
What test is used to evaluate for DVT?
A
Duplex U/S
22
Q
What is Virchow’s triad?
A
- Stasis
- Endothelial injury
- Hypercoagulable state
23
Q
What are the risk factors for DVT and PE?
A
Postoperative status, multiple trauma, paralysis, immobility, CHF, obesity, OCPs, tamoxifen, cancer, advanced age, polycythemia, MI, HIT syndrome, hypercoagulable state (protein C/ protein S deficiency)
24
Q
What are the signs and symptoms of PE?
A
SOB, tachypnea, hypotension, chest pain, occasionally fever, loud pulmonic component of S2, hemoptysis with pulmonary infarct
25
What are the associated lab findings with PE?
ABG: decreased PO2 and PCO2 (from hyperventilation)
26
Which diagnostic tests are indicated for PE?
CT angiogram, VQ scan, pulmonary angiogram
27
What are the associated CXR findings with PE?
1. Westermark's sign (wedge-shaped area of decreased pulmonary vasculature resulting in hyperlucency)
2. Opacity with base at pleural edge from pulmonary infarction
28
What are the associated EKG findings with PE?
> 50% are abnormal.
Classic finding is cor pulmonale (S1Q3T3 RBBB and right-axis deviation).
EKG most commonly shows flipped T waves or ST depression.
29
What is a saddle embolus?
PE that straddles the pulmonary artery and is in the lumen of both the right and left pulmonary arteries
30
What is the treatment for PE if the patient is stable?
Anticoagulation (heparin followed by long-term warfarin) or Greenfield filter
31
What is a Greenfield filter?
Metallic filter placed into IVC via jugular vein to catch emboli prior to lodging in the pulmonary artery
32
When is a Greenfield filter indicated?
If anticoagulation is contraindicated or patient has further PE on adequate anticoagulation or is high risk (e.g. pelvic or femur fractures)
33
What is the treatment for PE if the patient's condition is unstable?
Consider thrombolytic therapy.
Consult thoracic surgeon for possible Trendelenburg operation.
Consider catheter suction embolectomy
34
What is the Trendelenburg operation?
Pulmonary artery embolectomy
35
What is a retrievable IVC filter?
IVC filter that can be removed
36
What percentage of retrievable IVC filter are actually removed?
20%
37
What prophylactic measures can be taken for DVT/PE?
LMWH 40 mg SQ QD or 30 mg SQ bid; subQ heparin (5000 units q8h); sequential compression device boots beginning in OR; early ambulation
38
What is aspiration pneumonia?
Pneumonia following aspiration of vomitus
39
What are the risk factors for aspiration pneumonia?
Intubation/extubation, impaired consciousness, dysphagia, nonfunctioning NGT, Trendelenburg position, emergent intubation with full stomach, gastric dilatation
40
What are the signs and symptoms of aspiration pneumonia?
Respiratory failure, chest pain, increased sputum production, fever, cough, mental status changes, tachycardia, cyanosis, infiltrate on CXR
41
What are the associated CXR findings with aspiration pneumonia?
Early: fluffy infiltrate or normal CXR
Late: pneumonia, ARDS
42
Which lobes are commonly involved in aspiration pneumonia?
Supine: RUL
Sitting: RLL
43
Which organisms are commonly involved in aspiration pneumonia?
Community acquired: gram-positive/mixed
| Hospital: gram-negative rods
44
Which diagnostic tests are indicated for aspiration pneumonia?
CXR, sputum, Gram stain, sputum culture, bronchoalveolar lavage
45
What is the treatment for aspiration pneumonia?
Bronchoscopy, antibiotics if pneumonia develops, intubation if respiratory failure, ventilation with PEEP if ARDS
46
What is Mendelson's syndrome?
Chemical pneumonitis secondary to aspiration of stomach contents (i.e. gastric acid)
47
Are prophylactic antibiotics indicated for aspiration pneumonia?
No
48
What are possible NGT complications?
Aspiration pneumonia, atelectasis, sinusitis, minor UGI bleeding, epistaxis, pharyngeal irritation, gastric irritation
49
What are the risk factors for gastric dilatation?
Abdominal surgery, gastric outlet obstruction, splenectomy, narcotics
50
What are the signs and symptoms of gastric dilatation?
Abdominal distension, hiccups, electrolyte abnormalities, nausea
51
What is the treatment for gastric dilatation?
NGT decompression
52
What do you do if you have a patient with high NGT output?
Check high AXR and, if the NGT is in duodenum, pull back the NGT into stomach
53
What is postoperative pancreatitis?
Pancreatitis resulting from manipulation of the pancreas during surgery or low blood flow during the procedure (i.e. cardiopulmonary bypass), gallstones, hypercalcemia, medications, idiopathic
54
What lab tests are performed for postoperative pancreatitis?
Amylase and lipase
55
What is the initial treatment for postoperative pancreatitis?
Same as that for the other causes of pancreatitis (e.g. NPO, aggressive fluid resuscitation, +/- NGT PRN)
56
What are the postoperative causes of constipation?
Narcotics, immobility
57
What is the treatment for constipation?
OBR
58
What is OBR?
```
Ortho Bowel Routine:
Docusate sodium (daily), dicacodyl suppository if no bowel movement occurs, Fleet enema if suppository is ineffective
```
59
What is short bowel syndrome?
Malabsorption and diarrhea resulting from extensive bowel resection (< 120 cm of small bowel remaining)
60
What is the initial treatment for short bowel syndrome?
TPN early, followed by many small meals chronically
61
What causes SBO?
Adhesions (most of which resolve spontaneously), incarcerated hernia (internal or fascial/dehiscence)
62
What causes ileus?
Laparotomy, hypokalemia or narcotics, intraperitoneal infection
63
What are the signs of resolving ileus/SBO?
Flatus PR, stool PR
64
What is the order of recovery of bowel function after abdominal surgery?
1. Small intestine
2. Stomach
3. Colon
65
When can a postoperative patient be fed through a J-tube?
From 12-24 postoperative hours because the small intestine recovers function first in that period
66
What are the pre-hepatic causes of postoperative jaundice?
Hemolysis (prosthetic valve), resolving hematoma, transfusion reaction, post-cardiopulmonary bypass, blood transfusions (decreased RBC compliance leading to cell rupture)
67
What are the hepatic causes of postoperative jaundice?
Drugs, hypotension, hypoxia, sepsis, hepatitis, "sympathetic" hepatic inflammation from adjacent right lower lobe infarction of the lung or pneumonia, preexisting cirrhosis, right-sided heart failure, hepatic abscess, pylephlebitis (thrombosis of portal vein), Gilbert syndrome, Crigler-Najjar syndrome, Dubin-Johnson syndrome, fatty infiltrate from TPN
68
What are the post-hepatic causes of postoperative jaundice?
Choledocholithiasis, stricture, cholangitis, cholecystitis, biliary-duct injury, pancreatitis, sclerosing cholangitis, tumors (e.g. cholangiocarcinoma, pancreatic cancer, gallbladder cancer, metastases), biliary stasis (e.g. ceftriaxone)
69
What blood test results would support the assumption that hemolysis was causing jaundice in a patient?
Decreased: haptoglobin, Hct
Increased: LDH, reticulocytes
Also, fragmented RBCs on a peripheral smear
70
What is blind loop syndrome?
Bacterial overgrowth in the small intestine
71
What are the causes of blind loop syndrome?
Anything that disrupts the normal flow of intestinal contents
72
What are the surgical causes of B12 deficiency?
Blind loop syndrome, gastrectomy (decreased secretion of intrinsic factor), excision of the terminal ileum (site of B12 absorption)
73
What is post-vagotomy diarrhea?
Diarrhea after a truncal vagotomy
74
What is the cause of post-vagotomy diarrhea?
After truncal vagotomy, a rapid transport of bile salts to the colon results in osmotic inhibition of water absorption in the colon, leading to diarrhea
75
What is dumping syndrome?
Delivery of hyperosmotic chyme to the small intestine causing massive fluid shifts into the bowel (normally the stomach will decrease the osmolality of the chyme prior to its emptying)
76
With what conditions is dumping syndrome associated?
Any procedure that bypasses the pylorus or compromises its function (i.e. gastroenterostomies or pyloroplasty).
Thus, dumping of chyme into the small intestine.
77
What are the signs and symptoms of dumping syndrome?
Postprandial diaphoresis, tachycardia, abdominal pain and distention, emesis, increased flatus, dizziness, weakness
78
How is the diagnosis of dumping syndrome made?
History, hyperosmolar glucose load will elicit similar symptoms
79
What is the medical treatment for dumping syndrome?
Small, multiple, low-fat/low-carb meals that are high in protein content.
Also, avoidance of liquids with meals to slow gastric emptying.
Surgery is a last resort.
80
What is the surgical treatment for dumping syndrome?
Conversion to Roux-en-Y (+/- reversed jejunal interposition loop)
81
What is a reversed jejunal interposition loop?
Segment of jejunum is cut and then reversed to allow for a short segment of reversed peristalsis to slow intestinal transit
82
What is diabetic ketoacidosis?
Deficiency of body insulin, resulting in hyperglycemia, formation of ketoacids, osmotic diuresis, and metabolic acidosis
83
What are the signs of DKA?
Polyuria, tachypnea, dehydration, confusion, abdominal pain
84
What are the associated lab values with DKA?
Elevated glucose, increased anion gap, hypokalemia, urine ketones, acidosis
85
What is the treatment for DKA?
Insulin drip, IVF rehydration, K supplementation, +/- bicarbonate IV
86
What electrolyte must be monitored closely in DKA?
Potassium and hypokalemia (corrections of acidosis and glucose/insulin drive K into cells and are treatment for hyperkalemia)
87
What must you rule out in a diabetic with DKA?
Infection (perirectal abscess is classically missed)
88
What is Addisonian crisis?
Acute adrenal insufficiency in the face of a stressor (i.e. surgery, trauma, infection)
89
What is the cause of Addisonian crisis?
Postoperatively, inadequate cortisol release usually results from steroid administration in the past year
90
What are the signs and symptoms of Addisonian crisis?
Tachycardia, N/V/D, abdominal pain, +/- fever, progressive lethargy, hypotension, eventual hypovolemic shock
91
Clinically, what is infamous about Addisonian crisis?
Tachycardia and hypotension refractory to IVF and pressors
92
Which lab values are classic for Addisonian crisis?
Decreased Na, increased K (secondary to decreased aldosterone)
93
What is the treatment for Addisonian crisis?
IVFs (D5 NS), hydrocortisone IV, fludrocortisone PO
94
What is fludrocortisone?
Mineralocorticoid replacement
95
What is SIADH?
Syndrome of Inappropriate AntiDiuretic Hormone
96
What does ADH do?
ADH increases NaCl and H2O resorption in the kidney, increasing intravascular volume (released from posterior pituitary)
97
What are the causes of SIADH?
CNS trauma, oat-cell lung cancer, pancreatic cancer, duodenal cancer, pneumonia, lung abscess, increased PEEP, stroke, general anesthesia, idiopathic, postoperative, morphine
98
What are the associated lab findings with SIADH?
Low sodium, low chloride, low serum osmolality, increased urine osmolality
99
How can the serum sodium level in SIADH be remembered?
SIADH = Sodium Is Always Down Here = hyponatremia
100
What is the treatment for SIADH?
Treat primary cause, restrict fluid intake
101
What is diabetes insipidus?
Failure of ADH renal fluid conservation resulting in dilute urine in large amounts
102
What is the source of ADH?
Posterior pituitary
103
What are the 2 major types of diabetes insipidus?
1. Central DI
| 2. Nephrogenic DI
104
What is the mechanism of the 2 types of DI?
1. Central: decreased production of ADH
| 2. Nephrogenic: decreased ADH effect on kidney
105
What are the classic causes of central DI?
Brain injury, tumor, surgery, infection
106
What are the classic causes of nephrogenic DI?
Amphotericin B, hypercalcemia, chronic kidney infection
107
What lab values are associated with DI?
Hypernatremia, decreased urine sodium, decreased urine osmolality, increased serum osmolality
108
What is the treatment for DI?
Fluid replacement, follow Na levels and urine output.
Central: vasopressin
Nephrogenic: consider thiazide diuretics
109
What are the arterial line complications?
Infection; thrombosis (which can lead to finger/hand necrosis); death/hemorrhage from catheter disconnection
110
What is the Allen test?
Measures for adequate collateral blood flow to the hand via the ulnar artery:
1. Patient clenches fist and clinician occludes radial and ulnar arteries
2. Patient opens fist and clinician releases only the ulnar artery
If the palm exhibits immediate strong blush upon release of ulnar artery, then ulnar artery can be assumed to have adequate collateral flow if the radial artery were to thrombose
111
What are the common causes of dyspnea following central line placement?
PTX, pericardial tamponade, carotid puncture (which can cause a hematoma that compresses the trachea), air embolism
112
What is the differential diagnosis of postoperative chest pain?
MI, atelectasis, pneumonia, pleurisy, esophageal reflux, PE, musculoskeletal pain, subphrenic abscess, aortic dissection, PTX, chylothorax, hemothorax, gastritis
113
What is the differential diagnosis of postoperative atrial fibrillation?
Fluid overload, PE, MI, pain (excess catecholamines), atelectasis, pneumonia, digoxin toxicity, hypoxia, thyrotoxicosis, hypercapnia, idiopathic, acidosis, electrolyte abnormalities
114
What is the most dangerous period for a postoperative MI following a previous MI?
Six months after an MI
115
What are the risk factors for postoperative MI?
History of MI, angina, Qs on EKG, S3, JVD, CHF, aortic stenosis, advanced age, extensive surgical procedure, MI within 6 months, EKG changes
116
How do postoperative MIs present?
Often without chest pain.
New onset CHF, new onset cardiac dysrhythmia, hypotension, chest pain, tachypnea, tachycardia, N/V, bradycardia, neck pain, arm pain.
117
What EKG findings are associated with cardiac ischemia/MI?
Flipped T waves, ST elevation, ST depression, dysrhythmias (e.g. new onset AFib, PVC, VTach)
118
Which lab tests are indicated with MI?
Troponin I, cardiac isoenzymes (elevated CK mb fraction)
119
What is the treatment for postoperative MI?
Nitrates (paste or drip), aspirin, oxygen, pain control with IV morphine, beta-blocker (as tolerated), heparin (possibly, thrombolytics are contraindicated in the postoperative patient), ICU monitoring
120
How can the treatment of postoperative MI be remembered?
```
BEMOAN:
BEta-blocker (as tolerated)
Morphine
Oxygen
Aspirin
Nitrates
```
121
When do postoperative MIs occur?
66% occur on POD #2-5 (often silent and present with dyspnea or dysrhythmia)
122
What is a CVA?
CerebroVascular Accident (stroke)
123
What are the signs and symptoms of a CVA?
Aphasia, motor/sensory deficits usually lateralizing
124
What is the workup for a CVA?
Head CT (must rule out hemorrhage if anticoagulation is going to be used); carotid Doppler U/S (evaluate for carotid occlusive disease)
125
What is the treatment for a CVA?
ASA, +/- heparin if feasible postoperatively.
| Thrombolytic therapy is not usually postoperative option.
126
What is the perioperative prevention of CVA?
Avoid hypotension; continue aspirin therapy preoperatively in high-risk patients if feasible; preoperative carotid Doppler U/S in high-risk patients
127
What is postoperative renal failure?
Increase in serum creatinine and decrease in creatinine clearance.
Usually associated with decreased urine output.
128
What is anuria?
< 50 cc urine output in 24 hours
129
What is oliguria?
Between 50-400 cc of urine output in 24 hours
130
What is the differential diagnosis for postoperative renal failure?
1. Inadequate blood perfusing kidney: inadequate fluids, hypotension, CHF.
2. Kidney parenchymal dysfunction: ATN, nephrotoxic contrast or drugs.
3. Obstruction to outflow of urine from kidney: Foley catheter obstruction/stone, ureteral/urethral injury, BPH, bladder dysfunction (e.g. medications, spinal anesthesia).
131
What is the workup for postoperative renal failure?
BUN, Cr, urine electrolytes/Cr, FENa, U/A, renal U/S
132
What is FENa?
Fractional Excretion of Na
133
What is the formula for FENa?
(Una / Pna) X (Pcr / Ucr) X 100
134
What is the BUN/Cr ratio in prerenal vs renal failure?
Prerenal: > 20:1
Renal: < 20:1
135
What is the urine specific gravity in prerenal vs renal failure?
Prerenal: > 1.020 (as body tries to hold on to fluid)
Renal: < 1.020 (kidney has decreased ability to concentrate urine)
136
What is the urine Na in prerenal vs renal failure?
Prerenal: < 20
Renal: > 40
137
What is the urine osmolality in prerenal vs renal failure?
Prerenal: > 450
Renal: < 300 mOsm/kg
138
What are the indications for dialysis in postoperative renal failure?
Fluid overload, refractory hyperkalemia, BUN > 130, acidosis, uremic complication (encephalopathy, pericardial effusion)
139
What is DIC?
Activation of the coagulation cascade leading to thrombosis and consumption of clotting factors and platelets and activation of fibrinolytic system (fibrinolysis), resulting in bleeding
140
What are the causes of DIC?
Tissue necrosis, septic shock, massive large-vessel coagulation, shock, allergic reactions, massive blood transfusion reaction, cardiopulmonary bypass, cancer, obstetric complications, snake bites, trauma, burn injury, prosthetic material, liver dysfunction
141
What are the signs and symptoms of DIC?
Acrocyanosis or other signs of thrombosis, then diffuse bleeding from incision sites, venipuncture sites, catheter sites, or mucous membranes
142
What are the associated lab findings with DIC?
Increased fibrin-degradation products, elevated PT/PTT, decreased platelets, decreased fibrinogen (level correlates well with bleeding), presence of schistocytes, increased D-dimer
143
What is the treatment for DIC?
Removal of cause; IVFs; O2; platelets; FFP; cryoprecipitate (fibrin); Epsilon-aminocaproic acid (as needed in predominantly thrombotic cases); heparin and antithrombin III (indicated in predominantly thrombotic cases as needed)
144
What is abdominal compartment syndrome?
Increased intra-abdominal pressure usually seen after laparotomy or after massive IVF resuscitation
145
What are the signs and symptoms of abdominal compartment syndrome?
Tight distended abdomen, decreased urine output, increased airway pressure, increased intra-abdominal pressure
146
How is intra-abdominal pressure measured?
Read intrabladder pressure (Foley catheter hook up to manometry after instillation of 50-100 cc of water)
147
What is normal intra-abdominal pressure?
< 15 mmHg
148
What intra-abdominal pressure indicates need for treatment?
> 25 mmHg, especially if signs of compromise
149
What is the treatment for abdominal compartment syndrome?
Release the pressure by placing drain and/or decompressive laparotomy (leaving fascia open)
150
What is a Bogata bag?
Sheet of plastic (empty urology irrigation bag or IV bag) used to temporarily close the abdomen to allow for more intra-abdominal volume
151
What is urinary retention?
Enlarged urinary bladder resulting from medications or spinal anesthesia
152
How is urinary retention diagnosed?
Physical (palpable bladder), PVR
153
What is the treatment for urinary retention?
Foley catheter
154
With massive bladder distention, how much urine can be drained immediately?
Most would clamp after 1 L and then drain the rest over time to avoid a vasovagal reaction
155
What is the classic sign of urinary retention in an elderly patient?
Confusion
156
What are the signs and symptoms of wound infection?
Erythema, swelling, pain, heat
157
What is the treatment for wound infections?
Open wound; leave open with wet-to-dry dressing changes; antibiotics if cellulitis present
158
What is fascial dehiscence?
Acute separation of fascia that has been sutured closed
159
What is the treatment for fascial dehiscence?
Bring back to the OR emergently for reclosure of the fascia
160
What is a wound hematoma?
Collection of blood (blood clot) in operative wound
161
What is the treatment for a wound hematoma?
Acute: Remove with hemostasis
Subacute: Observe (heat helps resorption)
162
What is a wound seroma?
Post-operative collection of lymph and serum in the operative wound
163
What is the treatment of a wound seroma?
Needle aspiration, repeat if necessary (prevent with closed drain)
164
What are the signs and symptoms of pseudomembranous colitis?
Diarrhea, fever, hypotension, tachycardia
165
What is the incidence of bloody diarrhea in pseudomembranous colitis?
10%
166
What classic antibiotic causes C. difficile overgrowth?
Clindamycin (but almost all antibiotics can cause it)
167
How is pseudomembranous colitis diagnosed?
C. difficile toxin in stool, fecal WBC, flex sig (see a mucous pseudomembane in lumen of colon)
168
What is the treatment for pseudomembranous colitis?
1. Flagyl (PO or IV)
| 2. PO vancomycin if refractory to Flagyl
169
What is the indication for emergent colectomy for pseudomembranous colitis?
Toxic megacolon
