Complications, Chapter22 P138-156 Flashcards Preview

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Flashcards in Complications, Chapter22 P138-156 Deck (175)
1

ATELECTASIS
What is it?
P138

Collapse of the alveoli

2

ATELECTASIS
What is the etiology?
P138

Inadequate alveolar expansion (e.g., poor ventilation of lungs during surgery, inability to fully inspire secondary to
pain), high levels of inspired oxygen

3

ATELECTASIS
What are the signs?
P139

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

4

ATELECTASIS
What are the risk factors?
P139

Chronic obstructive pulmonary disease (COPD), smoking, abdominal or thoracic surgery, oversedation, poor pain control (patient cannot breathe deeply secondary to pain on inspiration)

5

ATELECTASIS
What is its claim to fame?
P139

Most common cause of fever during PODs #1 to #2

6

ATELECTASIS
What prophylactic measures can be taken?
P139

Preoperative smoking cessation, incentive spirometry, good pain contro

7

ATELECTASIS
What is the treatment?
P139

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

8

POSTOPERATIVE RESPIRATORY FAILURE
What is it?
P139

Respiratory impairment with increased respiratory rate, shortness of breath, dyspnea

9

POSTOPERATIVE RESPIRATORY FAILURE
What is the differential diagnosis?
P139

Hypovolemia, pulmonary embolism, administration of supplemental O(2) to a patient with COPD, atelectasis,
pneumonia, aspiration, pulmonary edema, abdominal compartment syndrome, pneumothorax, chylothorax, hemothorax, narcotic overdose, mucous plug

10

POSTOPERATIVE RESPIRATORY FAILURE
What is the treatment?
P139

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

11

POSTOPERATIVE RESPIRATORY FAILURE
What is the initial workup?
P139

ABG, CXR, EKG, pulse oximetry, and auscultation

12

POSTOPERATIVE RESPIRATORY FAILURE
What are the indications for intubation and ventilation?
P139

Cannot protect airway (unconscious), excessive work of breathing, progressive hypoxemia (PaO(2) 50), RR> 35

13

POSTOPERATIVE RESPIRATORY FAILURE
What are the possible causes of postoperative pleural
effusion?
P140

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

14

POSTOPERATIVE RESPIRATORY FAILURE
What is the treatment of postoperative wheezing?
P140

Albuterol nebulizer

15

POSTOPERATIVE RESPIRATORY FAILURE
Why may it be dangerous to give a patient with chronic
COPD supplemental oxygen?
P140

This patient uses relative hypoxia for respiratory drive, and supplemental O(2) may remove this drive!

16

PULMONARY EMBOLISM
What is a pulmonary embolism (PE)?
P140

DVT that embolizes to the pulmonary arterial system

17

PULMONARY EMBOLISM
What is DVT?
P140

Deep Venous Thrombosis—a clot forming in the pelvic or lower extremity veins

18

PULMONARY EMBOLISM
Is DVT more common in the right or left iliac vein?
P140

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

19

PULMONARY EMBOLISM
What are the signs/symptoms of DVT?
P140

- Lower extremity pain, swelling, tenderness, Homan’s sign, PE
- Up to 50% can be asymptomatic!

20

PULMONARY EMBOLISM
What is Homan’s sign?
P140

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

21

PULMONARY EMBOLISM
What test is used to evaluate for DVT?
P140

Duplex ultrasonography

22

PULMONARY EMBOLISM
What is Virchow’s triad?
P140

1. Stasis
2. Endothelial injury
3. Hypercoagulable state (risk factors for thrombosis)

23

PULMONARY EMBOLISM
What are the risk factors for DVT and PE?
P140

Postoperative status, multiple trauma, paralysis, immobility, CHF, obesity, BCP/tamoxifen, cancer, advanced age,
polycythemia, MI, HIT syndrome, hypercoagulable state (protein C/protein S deficiency)

24

PULMONARY EMBOLISM
What are the signs/symptoms of PE?
P141

Shortness of breath, tachypnea, hypotension, CP, occasionally fever, loud pulmonic component of S2, hemoptysis with pulmonary infarct

25

PULMONARY EMBOLISM
What are the associated lab findings?
P141

ABG—decreased PO(2) and PCO(2)
(from hyperventilation)

26

PULMONARY EMBOLISM
Which diagnostic tests are indicated?
P141

CT angiogram, V-Q scan (ventilationperfusion scan), pulmonary angiogram is the gold standard

27

PULMONARY EMBOLISM
What are the associated CXR findings?
P141

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

PULMONARY EMBOLISM
What are the associated EKG findings?
P141

>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

PULMONARY EMBOLISM
What is a “saddle” embolus?
P141

PE that “straddles” the pulmonary artery and is in the lumen of both the right and left pulmonary arteries

30

PULMONARY EMBOLISM
What is the treatment if the patient is stable?
P141

Anticoagulation (heparin followed by long-term
[3–6 months] Coumadin®) or Greenfield filter

31

PULMONARY EMBOLISM
What is a Greenfield filter?
P141 (picture)

Metallic filter placed into IVC via jugular vein to catch emboli prior to lodging in the pulmonary artery

32

PULMONARY EMBOLISM
Where did Dr. Greenfield get the idea for his IVC filter?
P142

Oil pipeline filters!

33

PULMONARY EMBOLISM
When is a Greenfield filter indicated?
P142

If anticoagulation is contraindicated or patient has further PE on adequate anticoagulation or is high risk (e.g., pelvic and femur fractures)

34

PULMONARY EMBOLISM
What is the treatment if the patient’s condition is unstable?
P142

Consider thrombolytic therapy; consult thoracic surgeon for possible Trendelenburg operation; consider catheter suction embolectomy

35

PULMONARY EMBOLISM
What is the Trendelenburg operation?
P142

Pulmonary artery embolectomy

36

PULMONARY EMBOLISM
What is a “retrievable” IVC filter?
P142

IVC filter that can be removed (“retrieved”)

37

PULMONARY EMBOLISM
What percentage of retrievable IVC filter are actually removed?
P142

Only about 20%

38

PULMONARY EMBOLISM
What prophylactic measures can be taken for DVT/PE?
P142

LMWH (Lovenox®) 40 mg SQ QD; or 30 mg SQ b.i.d.; subQ heparin (5000 units subQ every 8 hrs; must be started
preoperatively), sequential compression device BOOTS beginning in O.R. (often used with subQ heparin), early ambulation

39

ASPIRATION PNEUMONIA
What is it?
P142

Pneumonia following aspiration of vomitus

40

ASPIRATION PNEUMONIA
What are the risk factors?
P142

Intubation/extubation, impaired consciousness (e.g., drug or EtOH overdose), dysphagia (esophageal disease),
nonfunctioning NGT, Trendelenburg position, emergent intubation with full stomach, gastric dilatation

41

ASPIRATION PNEUMONIA
What are the signs/symptoms?
P142

Respiratory failure, CP, increased sputum production, fever, cough, mental status changes, tachycardia, cyanosis, infiltrate on CXR

42

ASPIRATION PNEUMONIA
What are the associated CXR findings?
P143

Early—fluffy infiltrate or normal CXR Late—pneumonia, ARDS

43

ASPIRATION PNEUMONIA
Which lobes are commonly involved?
P143

Supine—RUL
Sitting/semirecumbent—RLL

44

ASPIRATION PNEUMONIA
Which organisms are commonly involved?
P143

Community acquired—gram-positive/ mixed
Hospital/ICU—gram-negative rods

45

ASPIRATION PNEUMONIA
Which diagnostic tests are indicated?
P143

CXR, sputum, Gram stain, sputum culture, bronchoalveolar lavage

46

ASPIRATION PNEUMONIA
What is the treatment?
P143

Bronchoscopy, antibiotics if pneumonia develops, intubation if respiratory failure occurs, ventilation with PEEP if ARDS
develops

47

ASPIRATION PNEUMONIA
What is Mendelson’s syndrome?
P143

Chemical pneumonitis secondary to aspiration of stomach contents (i.e., gastric acid)

48

ASPIRATION PNEUMONIA
Are prophylatic antibiotics indicated for aspiration pneumonitis?
P143

NO

49

GASTROINTESTINAL COMPLICATIONS
What are possible NGT complications?
P143

- Aspiration-pneumonia/atelectasis
(especially if NGT is clogged)
- Sinusitis
- Minor UGI bleeding
- Epistaxis
- Pharyngeal irritation, gastric irritation

50

GASTRIC DILATATION
What are the risk factors?
P143

Abdominal surgery, gastric outlet obstruction, splenectomy, narcotics

51

GASTRIC DILATATION
What are the signs/symptoms?
P143

Abdominal distension, hiccups, electrolyte abnormalities, nausea

52

GASTRIC DILATATION
What is the treatment?
P143

NGT decompression

53

GASTRIC DILATATION
What do you do if you have a patient with high NGT
output?
P144

Check high abdominal x-ray and, if the NGT is in duodenum, pull back the NGT into the stomach

54

POSTOPERATIVE PANCREATITIS
What is it?
P144

Pancreatitis resulting from manipulation of the pancreas during surgery or low blood flow during the procedure
(i.e., cardiopulmonary bypass), gallstones, hypercalcemia, medications, idiopathic

55

POSTOPERATIVE PANCREATITIS
What lab tests are performed?
P144

Amylase and lipase

56

POSTOPERATIVE PANCREATITIS
What is the initial treatment?
P144

Same as that for the other causes of pancreatitis (e.g., NPO, aggressive fluid resuscitation, NGT PRN)

57

CONSTIPATION
What are the postoperative causes?
P144

Narcotics, immobility

58

CONSTIPATION
What is the treatment?
P144

OBR

59

CONSTIPATION
What is OBR?
P144

Ortho Bowel Routine: docusate sodium (daily), dicacodyl suppository if no bowel movement occurs, Fleet® enema if
suppository is ineffective

60

SHORT BOWEL SYNDROME
What is it?
P144

Malabsorption and diarrhea resulting from extensive bowel resection (120 cm of small bowel remaining)

61

SHORT BOWEL SYNDROME
What is the initial treatment?
P144

TPN early, followed by many small meals chronically

62

POSTOPERATIVE SMALL BOWEL OBSTRUCTION (SBO)/ILEUS
What causes SBO?
P144

Adhesions (most of which resolve spontaneously), incarcerated hernia (internal or fascial/dehiscence)

63

POSTOPERATIVE SMALL BOWEL OBSTRUCTION (SBO)/ILEUS
What causes ileus?
P145

Laparotomy, hypokalemia or narcotics, intraperitoneal infection

64

POSTOPERATIVE SMALL BOWEL OBSTRUCTION (SBO)/ILEUS
What are the signs of resolving ileus/SBO?
P145

Flatus PR, stool PR

65

POSTOPERATIVE SMALL BOWEL OBSTRUCTION (SBO)/ILEUS
What is the order of recovery of bowel function after
abdominal surgery?
P145

First—small intestine
Second—stomach
Third—colon

66

POSTOPERATIVE SMALL BOWEL OBSTRUCTION (SBO)/ILEUS
When can a postoperative patient be fed through a
J-tube?
P145

From 12 to 24 postoperative hours because the small intestine recovers function first in that period

67

JAUNDICE
What are the causes of the following types of postoperative jaundice:
Prehepatic
P145

Hemolysis (prosthetic valve), resolving hematoma, transfusion reaction, postcardiopulmonary bypass, blood
transfusions (decreased RBC compliance leading to cell rupture)

68

JAUNDICE
What are the causes of the following types of postoperative jaundice:
Hepatic
P145

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

69

JAUNDICE
What are the causes of the following types of postoperative jaundice:
Posthepatic
P145

Choledocholithiasis, stricture, cholangitis, cholecystitis, biliary-duct injury, pancreatitis, sclerosing cholangitis, tumors
(e.g., cholangiocarcinoma, pancreatic cancer, gallbladder cancer, metastases), biliary stasis (e.g., ceftriaxone [Rocephin®])

70

JAUNDICE
What blood test results would support the assumption that
hemolysis was causing jaundice in a patient?
P145

Decreased—Haptoglobin, Hct
Increased—LDH, reticulocytes
Also, fragmented RBCs on a peripheral smear

71

BLIND LOOP SYNDROME
What is it?
P146

Bacterial overgrowth in the small intestine

72

BLIND LOOP SYNDROME
What are the causes?
P146

Anything that disrupts the normal flow of intestinal contents (i.e., causes stasis)

73

BLIND LOOP SYNDROME
What are the surgical causes of B12 deficiency?
P146

Blind loop syndrome, gastrectomy (decreased secretion of intrinsic factor) and excision of the terminal ileum (site of
B12 absorption)

74

POSTVAGOTOMY DIARRHEA
What is it?
P146

Diarrhea after a truncal vagotomy

75

POSTVAGOTOMY DIARRHEA
What is the cause?
P146

It is thought that 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

76

DUMPING SYNDROME
What is it?
P146

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)

77

DUMPING SYNDROME
With what conditions is it associated?
P146

Any procedure that bypasses the pylorus or compromises its function (i.e., gastroenterostomies or pyloroplasty); thus,
“dumping” of chyme into small intestine

78

DUMPING SYNDROME
What are the signs/symptoms?
P146

Postprandial diaphoresis, tachycardia, abdominal pain/distention, emesis, increased flatus, dizziness, weakness

79

DUMPING SYNDROME
How is the diagnosis made?
P146

History; hyperosmolar glucose load will elicit similar symptoms

80

DUMPING SYNDROME
What is the medical treatment?
P146

Small, multiple, low-fat/carbohydrate meals that are high in protein content; also, avoidance of liquids with meals to
slow gastric emptying; surgery is a last resort

81

DUMPING SYNDROME
What is the surgical treatment?
P147

Conversion to Roux-en-Y ( ± reversed jejunal interposition loop)

82

DUMPING SYNDROME
What is a reversed jejunal interposition loop?
P147

Segment of jejunum is cut and then reversed to allow for a short segment of reversed peristalsis to slow intestinal transit

83

ENDOCRINE COMPLICATIONS
DIABETIC KETOACIDOSIS (DKA)
What is it?
P147

Deficiency of body insulin, resulting in hyperglycemia, formation of ketoacids, osmotic diuresis, and metabolic acidosis

84

ENDOCRINE COMPLICATIONS
DIABETIC KETOACIDOSIS (DKA)
What are the signs of DKA?
P147

Polyuria, tachypnea, dehydration, confusion, abdominal pain

85

ENDOCRINE COMPLICATIONS
DIABETIC KETOACIDOSIS (DKA)
What are the associated lab values?
P147

Elevated glucose, increased anion gap, hypokalemia, urine ketones, acidosis

86

ENDOCRINE COMPLICATIONS
DIABETIC KETOACIDOSIS (DKA)
What is the treatment?
P147

Insulin drip, IVF rehydration, K⁺
supplementation, ± bicarbonate IV

87

ENDOCRINE COMPLICATIONS
DIABETIC KETOACIDOSIS (DKA)
What electrolyte must be monitored closely in DKA?
P147

Potassium and HYPOkalemia (Remember correction of acidosis and GLC/insulin drive K⁺ into cells and are
treatment for HYPERkalemia!)

88

ENDOCRINE COMPLICATIONS
DIABETIC KETOACIDOSIS (DKA)
What must you rule out in a diabetic with DKA?
P147

Infection (perirectal abscess is classically missed!)

89

ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
What is it?
P147

Acute adrenal insufficiency in the face of a stressor (i.e., surgery, trauma, infection)

90

ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
How can you remember what it is?
P147

Think: ADDisonian = ADrenal Down

91

ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
What is the cause?
P147

Postoperatively, inadequate cortisol release usually results from steroid administration in the past year

92

ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
What are the signs/symptoms?
P148

Tachycardia, nausea, vomiting, diarrhea, abdominal pain,
± fever, progressive lethargy, hypotension, eventual
hypovolemic shock

93

ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
What is its clinical claim to infamy?
P148

Tachycardia and hypotension refractory to IVF and pressors!

94

ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
Which lab values are classic?
P148

Decreased Na⁺, increased K⁺ (secondary to decreased aldosterone)

95

ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
How can the electrolytes with ADDisonian = ADrenal
Down be remembered?
P148 (picture)

Think: DOWN the alphabetical electrolyte stairs

96

ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
What is the treatment?
P148

IVFs (D5 NS), hydrocortisone IV, fludrocortisone PO

97

ENDOCRINE COMPLICATIONS
ADDISONIAN CRISIS
What is fludrocortisone?
P148

Mineralocorticoid replacement
(aldosterone)

98

ENDOCRINE COMPLICATIONS
SIADH
What is it?
P148

Syndrome of Inappropriate AntiDiuretic Hormone (ADH) secretion (think of inappropriate increase in ADH secretion)

99

ENDOCRINE COMPLICATIONS
SIADH
What does ADH do?
P148

ADH increases NaCl and H(2)O resorption in the kidney, increasing intravascular volume (released from posterior
pituitary)

100

ENDOCRINE COMPLICATIONS
SIADH
What are the causes?
P149

Mainly lung/CNS: CNS trauma, oat-cell lung cancer, pancreatic cancer, duodenal cancer, pneumonia/lung abscess, increased PEEP, stroke, general anesthesia, idiopathic, postoperative, morphine

101

ENDOCRINE COMPLICATIONS
SIADH
What are the associated lab findings?
P149

Low sodium, low chloride, low serum osmolality; increased urine osmolality

102

ENDOCRINE COMPLICATIONS
SIADH
How can the serum sodium level in SIADH be remembered?
P149

Remember, SIADH = Sodium Is Always
Down Here = hyponatremia

103

ENDOCRINE COMPLICATIONS
SIADH
What is the treatment?
P149

Treat the primary cause and restrict fluid intake

104

ENDOCRINE COMPLICATIONS
DIABETES INSIPIDUS (DI)
What is it?
P149

Failure of ADH renal fluid conservation resulting in dilute urine in large amounts
(Think: DI = Decreased ADH)

105

ENDOCRINE COMPLICATIONS
DIABETES INSIPIDUS (DI)
What is the source of ADH?
P149

POSTERIOR pituitary

106

ENDOCRINE COMPLICATIONS
DIABETES INSIPIDUS (DI)
What are the two major types?
P149

1. Central (neurogenic) DI
2. Nephrogenic DI

107

ENDOCRINE COMPLICATIONS
DIABETES INSIPIDUS (DI)
What is the mechanism of the two types?
P149

1. Central DI decreased production of ADH
2. Nephrogenic DI = decreased ADH effect on kidney

108

ENDOCRINE COMPLICATIONS
DIABETES INSIPIDUS (DI)
What are the classic causes of central DI?
P149

BRAIN injury, tumor, surgery, and infection

109

ENDOCRINE COMPLICATIONS
DIABETES INSIPIDUS (DI)
What are the classic causes of nephrogenic DI?
P149

Amphotericin B, hypercalcemia, and chronic kidney infection

110

ENDOCRINE COMPLICATIONS
DIABETES INSIPIDUS (DI)
What lab values are associated with DI?
P149

HYPERnatremia, decreased urine sodium, decreased urine osmolality, and increased serum osmolality

111

ENDOCRINE COMPLICATIONS
DIABETES INSIPIDUS (DI)
What is the treatment?
P149

Fluid replacement; follow NA⁺ levels and urine output; central DI warrants vasopressin; nephrogenic DI may
respond to thiazide diuretics

112

CARDIOVASCULAR COMPLICATIONS
What are the arterial line complications?
P150

Infection; thrombosis, which can lead to finger/hand necrosis; death/hemorrhage from catheter disconnection (remember to perform and document the Allen test
before inserting an arterial line or obtaining a blood gas sample)

113

CARDIOVASCULAR COMPLICATIONS
What is an Allen test?
P150

Measures for adequate collateral blood flow to the hand via the ulnar artery:
- Patient clenches fist; clinician occludes radial and ulnar arteries; 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

114

CARDIOVASCULAR COMPLICATIONS
What are the common causes of dyspnea following
central line placement?
P150

Pneumothorax, pericardial tamponade, carotid puncture (which can cause a hematoma that compresses the trachea), air embolism

115

CARDIOVASCULAR COMPLICATIONS
What is the differential diagnosis of postoperative chest pain?
P150

MI, atelectasis, pneumonia, pleurisy, esophageal reflux, PE, musculoskeletal pain, subphrenic abscess, aortic dissection,
pneumo/chyle/hemothorax, gastritis

116

CARDIOVASCULAR COMPLICATIONS
What is the differential diagnosis of postoperative
atrial fibrillation?
P150

Fluid overload, PE, MI, pain (excess catecholamines), atelectasis, pneumonia, digoxin toxicity, hypoxemia, thyrotoxicosis, hypercapnia, idiopathic, acidosis,
electrolyte abnormalities

117

CARDIOVASCULAR COMPLICATIONS
MYOCARDIAL INFARCTION (MI)
What is the most dangerous period for a postoperative
MI following a previous MI?
P150

Six months after an MI

118

CARDIOVASCULAR COMPLICATIONS
MYOCARDIAL INFARCTION (MI)
What are the risk factors for postoperative MI?
P150

History of MI, angina, Qs on EKG, S3, JVD, CHF, aortic stenosis, advanced age, extensive surgical procedure, MI within 6 months, EKG changes

119

CARDIOVASCULAR COMPLICATIONS
MYOCARDIAL INFARCTION (MI)
How do postoperative MIs present?
P151

- Often without chest pain
- New onset CHF, new onset cardiac dysrhythmia, hypotension, chest pain, tachypnea, tachycardia, nausea/
vomiting, bradycardia, neck pain, arm pain

120

CARDIOVASCULAR COMPLICATIONS
MYOCARDIAL INFARCTION (MI)
What EKG findings are associated with cardiac ischemia/MI?
P151

Flipped T waves, ST elevation, ST depression, dysrhythmias (e.g., new onset A fib, PVC, V tach)

121

CARDIOVASCULAR COMPLICATIONS
MYOCARDIAL INFARCTION (MI)
Which lab tests are indicated?
P151

Troponin I, cardiac isoenzymes
(elevated CK mb fraction)

122

CARDIOVASCULAR COMPLICATIONS
MYOCARDIAL INFARCTION (MI)
What is the treatment of postoperative MI?
P151

Nitrates (paste or drip), as tolerated
Aspirin
Oxygen
Pain control with IV morphine
ℬ-blocker, as tolerated
Heparin (possibly; thrombolytics are contraindicated in the
postoperative patient)
ICU monitoring

123

CARDIOVASCULAR COMPLICATIONS
MYOCARDIAL INFARCTION (MI)
How can the treatment of postoperative MI be
remembered?
P151

“BEMOAN”:
BEta-blocker (as tolerated)
Morphine
Oxygen
Aspirin
Nitrates

124

CARDIOVASCULAR COMPLICATIONS
MYOCARDIAL INFARCTION (MI)
When do postoperative MIs occur?
P151

Two thirds occur on PODs #2 to #5
(often silent and present with dyspnea or dysrhythmia)

125

CARDIOVASCULAR COMPLICATIONS
POSTOPERATIVE CVA
What is a CVA?
P151

CerebroVascular Accident (stroke)

126

CARDIOVASCULAR COMPLICATIONS
POSTOPERATIVE CVA
What are the signs/symptoms?
P151

Aphasia, motor/sensory deficits usually lateralizing

127

CARDIOVASCULAR COMPLICATIONS
POSTOPERATIVE CVA
What is the workup?
P151

Head CT scan; must rule out hemorrhage if anticoagulation is going to be used; carotid Doppler ultrasound study to
evaluate for carotid occlusive disease

128

CARDIOVASCULAR COMPLICATIONS
POSTOPERATIVE CVA
What is the treatment?
P152

ASA, ± heparin if feasible postoperatively Thrombolytic therapy is not usually postoperative option

129

CARDIOVASCULAR COMPLICATIONS
POSTOPERATIVE CVA
What is the perioperative prevention?
P152

Avoid hypotension; continue aspirin therapy preoperatively in high-risk patients if feasible; preoperative carotid Doppler
study in high-risk patients

130

MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
What is it?
P152

Increase in serum creatinine and decrease in creatinine clearance; usually associated with decreased urine output

131

MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
Define the following terms:
Anuria
P152

50 cc urine output in 24 hours

132

MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
Define the following terms:
Oliguria
P152

Between 50 cc and 400 cc of urine output in 24 hours

133

MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
What is the differential diagnosis?
Prerenal
P152

Inadequate blood perfusing kidney: inadequate fluids, hypotension, cardiac pump failure (CHF)

134

MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
What is the differential diagnosis?
Renal
P152

Kidney parenchymal dysfunction: acute tubular necrosis, nephrotoxic contrast or drugs

135

MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
What is the differential diagnosis?
Postrenal
P152

Obstruction to outflow of urine from kidney: Foley catheter obstruction/stone, ureteral/urethral injury, BPH, bladder
dysfunction (e.g., medications, spinal anesthesia)

136

MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
What is the workup?
P152

Lab tests: electrolytes, BUN, Cr, urine lytes/Cr, FENa, urinalysis, renal ultrasound

137

MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
What is FENa?
P152

Fractional Excretion of Na (sodium)

138

MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
What is the formula for FENa?
P153

“YOU NEED PEE” = UNP
(UNa x Pcr / PNa x Ucr) x 100
(U = urine, cr = creatinine, Na⁺ = sodium, P = plasma)

139

MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
Define the lab results with prerenal vs renal failure:
BUN/Cr ratio
P153

Prerenal: >20:1
Renal:

140

MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
Define the lab results with prerenal vs renal failure:
Specific gravity
P153

Prerenal: >1.020 (as the body tries to hold on to fluid)
Renal: 1.020 (kidney has decreased ability to concentrate
urine)

141

MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
Define the lab results with prerenal vs renal failure:
FENa
P153

Prerenal: 2%

142

MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
Define the lab results with prerenal vs renal failure:
Urine Na⁺ (sodium)
P153

Prerenal: 40

143

MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
Define the lab results with prerenal vs renal failure:
Urine osmolality
P153

Prerenal: >450
Renal:

144

MISCELLANEOUS
POSTOPERATIVE RENAL FAILURE
What are the indications for dialysis?
P153

Fluid overload, refractory hyperkalemia,
BUN >130, acidosis, uremic complication
(encephalopathy, pericardial effusion)

145

MISCELLANEOUS
DIC
What is it?
P153

Activation of the coagulation cascade leading to thrombosis and consumption of clotting factors and platelets and
activation of fibrinolytic system (fibrinolysis), resulting in bleeding

146

MISCELLANEOUS
DIC
What are the causes?
P153

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

147

MISCELLANEOUS
DIC
What are the signs/symptoms?
P154

Acrocyanosis or other signs of thrombosis, then diffuse bleeding from incision sites, venipuncture sites, catheter sites, or mucous membranes

148

MISCELLANEOUS
DIC
What are the associated lab findings?
P154

Increased fibrin-degradation products, elevated PT/PTT, decreased platelets, decreased fibrinogen (level correlates well with bleeding), presence of schistocytes
(fragmented RBCs), increased D-dimer

149

MISCELLANEOUS
DIC
What is the treatment?
P154

- Removal of the cause; otherwise supportive: IVFs, O(2), platelets, FFP, cryoprecipitate (fibrin), Epsilonaminocaproic
acid, as needed in predominantly thrombotic cases
- Use of heparin is indicated in cases that are predominantly thrombotic with antithrombin III supplementation as needed

150

MISCELLANEOUS
ABDOMINAL COMPARTMENT SYNDROME
What is it?
P154

Increased intra-abdominal pressure usually seen after laparotomy or after massive IVF resuscitation (e.g., burn
patients)

151

MISCELLANEOUS
ABDOMINAL COMPARTMENT SYNDROME
What are the signs/symptoms?
P154

Tight distended abdomen, decreased urine output, increased airway pressure, increased intra-abdominal pressure

152

MISCELLANEOUS
ABDOMINAL COMPARTMENT SYNDROME
How to measure intra-abdominal pressure?
P154

Read intrabladder pressure (Foley catheter hooked up to manometry after instillation of 50–100 cc of water)

153

MISCELLANEOUS
ABDOMINAL COMPARTMENT SYNDROME
What is normal intra-abdominal pressure?
P154

15 mm Hg

154

MISCELLANEOUS
ABDOMINAL COMPARTMENT SYNDROME
What intra-abdominal pressure indicates need for
treatment?
P154

≥25 mm Hg, especially if signs of
compromise

155

MISCELLANEOUS
ABDOMINAL COMPARTMENT SYNDROME
What is the treatment?
P154

Release the pressure by placing drain and/or decompressive laparotomy (leaving fascia open)

156

MISCELLANEOUS
ABDOMINAL COMPARTMENT SYNDROME
What is a “Bogata Bag”?
P155

Sheet of plastic (empty urology irrigation bag or IV bag) used to temporarily close the abdomen to allow for more intraabdominal volume

157

MISCELLANEOUS
URINARY RETENTION
What is it?
P155

Enlarged urinary bladder resulting from medications or spinal anesthesia

158

MISCELLANEOUS
URINARY RETENTION
How is it diagnosed?
P155

Physical exam (palpable bladder), bladder residual volume upon placement of a Foley catheter

159

MISCELLANEOUS
URINARY RETENTION
What is the treatment?
P155

Foley catheter

160

MISCELLANEOUS
URINARY RETENTION
With massive bladder distention, how much urine can be drained immediately?
P155

Most would clamp after 1 L and then drain the rest over time to avoid a vasovagal reaction

161

MISCELLANEOUS
URINARY RETENTION
What is the classic sign of urinary retention in an elderly patient?
P155

Confusion

162

MISCELLANEOUS
WOUND INFECTION
What are the signs/symptoms?
P155

Erythema, swelling, pain, heat (rubor, tumor, dolor, calor)

163

MISCELLANEOUS
WOUND INFECTION
What is the treatment?
P155

Open wound, leave open with wet to dry dressing changes, antibiotics if cellulitis present

164

MISCELLANEOUS
WOUND INFECTION
What is fascial dehiscence?
P155

Acute separation of fascia that has been sutured closed

165

MISCELLANEOUS
WOUND INFECTION
What is the treatment?
P155

Bring back to the O.R. emergently for reclosure of the fascia

166

MISCELLANEOUS
WOUND HEMATOMA
What is it?
P155

Collection of blood (blood clot) in operative wound

167

MISCELLANEOUS
WOUND HEMATOMA
What is the treatment?
P155

Acute: Remove with hemostasis
Subacute: Observe (heat helps resorption)

168

MISCELLANEOUS
WOUND SEROMA
What is it?
P156

Postoperative collection of lymph and serum in the operative wound

169

MISCELLANEOUS
WOUND SEROMA
What is the treatment?
P156

Needle aspiration, repeat if necessary
(prevent with closed drain)

170

MISCELLANEOUS
PSEUDOMEMBRANOUS COLITIS
What are the signs/symptoms?
P156

Diarrhea, fever, hypotension/tachycardia

171

MISCELLANEOUS
PSEUDOMEMBRANOUS COLITIS
What is the incidence of bloody diarrhea?
P156

10%

172

MISCELLANEOUS
PSEUDOMEMBRANOUS COLITIS
What classic antibiotic causes C. difficile?
P156

Clindamycin (but almost all antibiotics can cause it)

173

MISCELLANEOUS
PSEUDOMEMBRANOUS COLITIS
How is it diagnosed?
P156

C. diff toxin in stool, fecal WBC, flex sig (see a mucous pseudomembrane in lumen of colon = hence the name)

174

MISCELLANEOUS
PSEUDOMEMBRANOUS COLITIS
What is the treatment?
P156

1. Flagyl (PO or IV)
2. PO vancomycin if refractory to Flagyl

175

MISCELLANEOUS
PSEUDOMEMBRANOUS COLITIS
What is the indication for emergent colectomy?
P156

Toxic megacolon