Osteopathic Approach to the Surgical Patient

Question 1

Pre-op risk factors and management in surgical patient from respiratory-circulatory perspective

Answer 1

Risk factors: EF <35%, presence of JVD, recent MI, smoking, COPD, sleep apnea, rib SD may predispose to atelectasis and/or PNA

Management: treat CHF, OMT to diminish allostatic load, smoking cessation for 4-8 weeks prior to surgery + intensive respiratory therapy, CPAP/BiPAP, OMT to rib SD

Question 2

Pre-op risk factors and management in surgical patient from metabolic-energetic perspective

Answer 2

Risk factors: ascites, bilirubin >2, PT >16s, albumin <3, encephalopathy, weight loss, BMI >40, diabetic ketoacidosis/coma

Management: appropriate hydration and nutrition, NPO prior to surgery, some may need liver transplant, liver pump may help hepatic congestion and some of the abnormal hepatic indices, nutritional support, weight loss if BMI >50, IV fluids, IV insulin if needed, correct metabolic acidosis and BG levels

Question 3

Pre-op risk factors and management in surgical patient from behavioral perspective

Answer 3

Risk factors: illicit drug and alcohol use

Management: cessation for at least 1 week, OMT may help to control pain in pts using/abusing pain relievers

Question 4

Why perform post-op OMT?

Answer 4

Shorten hospital stay
Decrease morbidity/mortality
Decrease post op pain
Facilitate lymph flow and improve diaphragmatic mobility

Question 5

General OMT considerations in post-surgical pt

Answer 5

The sicker the pt, the lower the dose of OMT that should be done

Increase the number of treatments acutely

Consider indirect tx for acute SD, and direct tx for chronic SD

Question 6

What techniques should be avoided if pt is unstable?

Answer 6

HVLA and ME

Question 7

The parasympathetic nervous system is a craniosacral system arising from brainstem nuclei associated with CNs ________, and from the intermediate gray in the S2-4 spinal cord; it is the homeostatic reparative system

Answer 7

3, 7, 9, 10

Question 8

Contributing factors to biomechanical SDs in a postsurgical pt

Answer 8

Duration of surgery
Position in surgery
Inactivity
Prolonged bedrest

Question 9

Biomechanical management post-orthopedic surgery

Answer 9

Treat SD above and below to increase mobility

Question 10

Biomechanical management post-general surgery

Answer 10

Tx any pt complaints based on their needs; most post surgical pts develop SDs from laying in hospital bed for prolonged period of time

Question 11

What is post-op fever?

Answer 11

Fever of >100.4 occuring in about 40% of pts in major surgery as a result of pyrogenic cytokine release secondary to surgical trauma

Question 12

Post-op fever rule of Ws

Answer 12

Wind (POD 1-2): atelectasis, pneumonia

Water (POD 3): UTI, cystitis

Walking (POD 5-7): DVT/PE

Wound (POD 7-10): wound infection

Wonder drugs (POD 7+): antimicrobials, anesthetic, etc. — may see generalized maculopapular rash, bradycardia

Question 13

Contributing factors to post-op atelectasis

Answer 13

Anesthesia and mechanical ventilation
Bedrest limits excursion of ribs and diaphragm
Pain
Obesity, smoking, respiratory dz

Shallow breaths without maximal inhalation —> alveolar colalpse —> atelectasis

Question 14

Respiratory-circulatory OMT management for atelectasis

Answer 14

Rib raising
Thoracoabdominal diaphragm release (dome diaphragm)
Pectoral traction
ST and MFR to C3-5 for phrenic n. stim
Tapotement
Lymphatic pumps
Viscerosomatics (T1-6, T2-7, CNX)

Question 15

Contributing factors to pretibial edema in post-surgical pt (resp-circ model)

Answer 15

Immobility d/t bedrest
Systemic inflammation secondary to surgery
Insufficient circulation and lymph drainage

Question 16

Respiratory circulatory OMT management for pretibial edema

Answer 16

Lymphatics — open TI, petrissage and effleurage, rib raising, lymphatic pumps if allowed

Viscerosomatics (T10-L2, S2-4)

Question 17

Contributing factors to post-op ileus

Answer 17

Anesthesia 
Extensive surgical manipulation
Extended bedrest
Narcotic use
Electrolytes — hypokalemia and hypercalcemia

Question 18

Following surgery, peristalsis decreases but returns in small intestine within ____ hrs, right colon within ___ hrs, and left colon within ____ hrs

Answer 18

24; 48; 72

Question 19

metabolic-energetic OMT management for post-op ileus

Answer 19

Rib rasing at T5-L2
Mesenteric release
Paraspinal inhibition (typically T10-L2)
OA/AA and sacral rocking

Question 20

Mainstay therapy for post op pain and its side effects

Answer 20

Morphine — may cause respiratory depression, N/V, clouded sensorium, constipation

Question 21

Contributing factors to neurologic postop pain

Answer 21

Duration of operation
Degree of trauma
Incision type
Intraoperative retraction

Question 22

Neurologic OMT management for postop pain

Answer 22

Rib raising with paraspinal inhibition

ST and MFR

Viscerosomatics — T1-L2 and CNX/S2-4

Question 23

Contributing factors to anxiety/delirium from behavioral perspective in post op pt

Answer 23

Drugs —> psychosis

Electrolyte abnormalities

Delirium tremens — alcohol withdrawal seen POD 2-3

Hypoxia, sepsis, ARDS

Question 24

Behavioral OMT management for post-op anxiety/delirium

Answer 24

Calming techniques: suboccipital inhibition and CV4

Question 25

35 year old female is POD #1 from a laparoscopic Roux-en-Y gastric bypass surgery and complains of chest pain. Her medical history includes obstructive sleep apnea, GERD, hyperlipidemia, and BMI of 41. She reports a lot of pain beyond her incision sites and has been reliant on IV pain medication. Physical exams reveals decreased breaths sounds bilaterally at the bases. What is the sympathetic innervation of the lungs?

a. C3-5
b. T1-6
c. T4-8
d. T5-9
e. T1-9

Answer 25

b. T1-6

Question 26

A 64 year old female with a history of CHF presents to the ER in a very anxious state with complaints of shortness of breath and leg swelling. PE reveals bi-basilar rales and bilateral pretibial edema among various somatic dysfunctions. You initiate appropriate medical management and OMT. After a thoracic inlet release, which of the following is the most appropriate next step in a lymphatic drainage treatment?

a. pedal pump
b. pectoral lift
c. abdominal pump
d. doming the diaphragm
e. rib raising

Answer 26

d. doming the diaphragm

Question 27

52 year old female is POD #2 from open laparotomy for ruptured sigmoid diverticulum with abscess formation with c/o constipation, abdominal bloating and discomfort. Patient is afebrile, NPO, surgical drain from abdominal midline, and no bowel sounds in all four quadrants. Abdominal X-ray shows dilated loops of bowel. What is the sympathetic innervation of the colon that will regain its peristaltic activity first?

a. T1-4
b. T2-7
c. T5-9
d. T10-11
e. T12-L2

Answer 27

d. T10-11

Question 28

65 year old male is POD #3 from CABG (coronary artery bypass graft) surgery c/o chest pain and constipation. He admits that he has zero pain tolerance and has been dependent on his pain medication. He has been begging the nurses for more pain medications. The nurse informs you that he hasn’t been able to drink much fluids and that he has yet to pass a bowel movement s/p surgery. Which of the following OMT techniques in addition to medical management (eg. stool softener & laxative) would most directly address the nurse’s primary concern?

a. sacral inhibition
b. BLT for C3 F RLSL
c. mesenteric release
d. LE petrissage
e. MET for T7 E RRSR

Answer 28

c. mesenteric release

Question 29

72 year old female is POD #2 from an inguinal hernia repair surgery and the hospitalist is called by the nurse noting mental status changes. Her past medical history includes HTN, SLE (systemic lupus erythematous), COPD, and stress incontinence. Admission H&P states a normal mental status exam, but today her attentiveness comes and goes. The patient describes long wavy green and red ribbons dancing on the walls. Vitals are within normal limits. Which of the following is the first step in management?

a. obtain a psych consult
b. treat her cranial torsion strain pattern
c. give her an anxiolytic
d. review her current meds
e. increase her IV fluids maintenance dose

Answer 29

d. review her current meds

Question 30

Your attending surgeon asks you to perform OMT on the patient to hasten recovery of his normal bowel function. Which of the following techniques is most appropriate in this setting?

a. HVLA to thoracic and lumbar region
b. manual milking of bowel via anterior approach
c. pedal lymphatic pump
d. rib raising with paraspinal inhibition
e. thoracic lymphatic pump

Answer 30

d. rib raising with paraspinal inhibition

Question 31

The most common manipulative method to modify sympathetic activity in the upper GI tract and small intestine is…

a. OA release
b. rib raising to T5-11
c. sacral rocking
d. MET to T1-6
e. CS tender point

Answer 31

b. rib raising to T5-11

Question 32

Regarding the osteopathic treatment of this patient, which of the following structures most likely plays a role in the maintenance of ileus in his post-abdominal surgery period?

a. facial n.
b. L5 nerve root
c. phrenic n.
d. spinal accessory n.
e. vagus n.

Answer 32

e. vagus n.

Question 33

Current treatment for post-abdominal surgery patient often indicates the use of intermittent compression stockings (SCD) for prophylaxis of DVT. What manipulative technique may also be beneficial?

a. cervical HVLA
b. ME for L/R ST
c. gentle effleurage
d. mid-thoracic paraspinal ST
e. paraspinal inhibition

Answer 33

c. gentle effleurage

Question 34

Your attending has ordered rib raising (with paraspinal inhibition) for your patient. What is the rationale for this treatment?

a. it will normalize CSF flow
b. it will increase PNS activity to intestinal tract
c. it will inhibit rib motion to decrease pain
d. it will reduce SNS hypertonicity to intestinal tract
e. it should not be ordered bc it is contraindicated in a pt with acute abdominal pain

Answer 34

d. it will reduce SNS hypertonicity to intestinal tract