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Flashcards in Complications Deck (169):
1

What is atelectasis?

Collapse of the alveoli

2

What is the etiology of atelectasis?

Inadequate alveolar expansion, high levels of inspired oxygen

3

What are the signs of atelectasis?

Fever, decreased breath sounds with rales, tachypnea, tachycardia, and increased density on CXR

4

What are the risk factors for atelectasis?

COPD, smoking, abdominal or thoracic surgery, over-sedation, poor pain control

5

What is the most common cause of fever during PODs #1 and #2?

Atelectasis

6

What prophylactic measures can be taken against atelectasis?

Preoperative smoking cessation, incentive spirometry, good pain control

7

What is the treatment for atelectasis?

Postoperative incentive spirometry, deep breathing, coughing, early ambulation, NT suctioning, and chest PT

8

What is postoperative respiratory failure?

Respiratory impairment with increased respiratory rate, SOB, dyspnea

9

What is the differential diagnosis for postoperative respiratory failure?

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

What is the treatment for postoperative respiratory failure?

Supplemental O2, chest PT, suctioning, intubation, and ventilation if necessary

11

What is the initial workup for postoperative respiratory failure?

ABG, CXR, EKG, pulse oximetry, and auscultation

12

What are the indications for intubation and ventilation in postoperative respiratory failure?

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

What are the possible causes of postoperative pleural effusion?

Fluid overload, pneumonia, diaphragmatic inflammation with possible subphrenic abscess formation

14

What is the treatment of postoperative wheezing?

Albuterol nebulizer

15

Why may it be dangerous to give a patient with chronic COPD supplemental O2?

This patient uses relative hypoxia for respiratory drive, and supplemental O2 may remove the drive

16

What is a pulmonary embolism?

DVT that embolizes to the pulmonary arterial system

17

What is DVT?

Deep Vein Thrombosis:
A clot that forms in the pelvic or lower extremity veins

18

Is DVT more common in the right or left iliac vein?

Left is more common (4:1) because the aortic bifurcation crosses and possibly compresses the left iliac vein

19

What are the signs and symptoms of DVT?

Lower extremity pain, swelling, tenderness, Homan's sign, PE.
Up to 50% are asymptomatic.

20

What is Homan's sign?

Calf pain with dorsiflexion of the foot seen classically with DVT, but actually found in fewer than 33% of patients with DVT

21

What test is used to evaluate for DVT?

Duplex U/S

22

What is Virchow's triad?

1. Stasis
2. Endothelial injury
3. Hypercoagulable state

23

What are the risk factors for DVT and PE?

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

What are the signs and symptoms of PE?

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