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158 Cards in this Set

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What is atelectasis
Collapse of the alveoli
What is the etiology of atelectasis?
Inadequate alveolar expansion (e.g., poor ventilation of lungs during surgery, inability to fully inspire secondary to pain), high levels of inspired oxygen
What are the signs of atelectasis?
Fever, decreased breath sounds with rales, tachypnea, tachycardia, and increased density on CXR
What are the risk factors for atelectasis?
Chronic obstructive pulmonary disease (COPD), smoking, abdominal or thoracic surgery, oversedation, poor pain control (patient cannot breathe deeply secondary to pain on inspiration)
What is atelectasis' claim to fame?
Most common cause of fever during postoperative days 1 to 2
What prophylactic measures can be taken for atelectasis?
Preoperative smoking cessation, incentive spirometry, good pain control
What is the treatment?
Postoperative incentive spirometry, deep breathing, coughing, early ambulation, postural drainage, suctioning, and chest PT
What is postoperative respiratory failure?
Respiratory impairment with increased respiratory rate, shortness of breath, dyspnea
What is the differential diagnosis for postoperative respiratory failure?
Hypovolemia, pulmonary embolism, administration of supplemental O2 to a patient with COPD, atelectasis, pneumonia, aspiration, pulmonary edema, abdominal compartment syndrome, pneumothorax, chylothorax, hemothorax, narcotic overdose, mucus plug
What is the treatment for postoperative respiratory failure?
Supplemental O2, chest PT; suctioning, intubation, and ventilation if necessary
What is the initial workup for postoperative respiratory failure?
ABG, CXR, EKG, Sat monitor, PE
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
What are the possible causes of postoperative pleural effusion?
Diaphragmatic inflammation with possible subphrenic abscess formation, fluid overload, pneumonia
What is the treatment of postoperative wheezing?
Albuterol nebulizer
Why may it be dangerous to give a patient with chronic COPD supplemental oxygen?
This patient uses relative hypoxia for respiratory drive, and supplemental O2 may remove this drive!
What is a pulmonary embolism (PE)?
DVT that embolizes to the pulmonary arterial system
What is DVT?
Deep Venous Thrombosis—a clot forming in the pelvic or lower extremity veins
Is DVT more common in the right or left iliac vein?
Left is more common (4 to 1) because the aortic bifurcation crosses and possibly compresses the left iliac vein.
What are the signs/symptoms of DVT?
• Lower extremity pain, swelling, tenderness, Homan's sign, pulmonary embolus (PE)
• Up to 50% can be asymptomatic!
What is Homan's sign?
Calf pain with dorsiflexion of the foot seen classically with DVT, but actually found in fewer than one-third of patients with DVT
What test is used to evaluate for DVT?
Duplex ultrasonography
What is Virchow's triad?
Stasis, endothelial injury, hypercoagulable state (risk factors for thrombosis)
What are the risk factors for DVT and PE?
Postoperative status, multiple trauma, paralysis, immobility, CHF, obesity, BCP/tamoxifen, cancer, advanced age, polycythemia, MI, HIT syndrome, hypercoagulable state (protein C/protein S deficiency)
What are the signs/symptoms of DVT and PE?
Shortness of breath, tachypnea, hypotension, CP, occasionally fever, tender LE, loud pulmonic component of S2, hemoptysis with pulmonary infarct
What are the associated lab findings with PE?
ABG—decreased PO2 and PCO2 (from hyperventilation)
Which diagnostic tests are indicated for PE?
V-Q scan (ventilation-perfusion scan), pulmonary A-gram is the gold standard
What are the associated CXR findings for 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
What are the associated EKG findings for PE?
More than 50% are abnormal; classic finding is cor pulmonale (S1Q3T3 RBBB and right-axis deviation); EKG most commonly shows flipped T waves or ST depression.
What is a "saddle" embolus?
PE that "straddles" the pulmonary artery and is in the lumen of both the right and left pulmonary arteries
What is the treatment for PE if the patient is stable?
Anticoagulation (heparin followed by long-term [3–6 months] Coumadin®) or Greenfield filter
What is a Greenfield filter?
Metallic filter placed into IVC via jugular vein to catch emboli prior to lodging in the pulmonary artery
Where did Dr. Greenfield get his idea for his IVC filter?
Oil pipeline filters!
When is a Greenfield filter indicated?
If anticoagulation is contraindicated or patient has further PE on adequate anticoagulation
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.
What is the Trendelenburg operation?
Pulmonary artery embolectomy
What prophylactic measures can be taken for DVT/PE?
LMWH (Lovenox®) 40 mg SQ QD; or 30 mg SQ b.i.d.; sub-Q heparin (5,000 units sub-Q every 8 hrs; must be started preoperatively), sequential compression device BOOTS beginning in OR (often used with sub-Q heparin), early ambulation
What is aspiration pneumonia?
Pneumonia following aspiration of vomitus
What are the risk factors for aspiration pneumonia?
Intubation/extubation, impaired consciousness (e.g., drug or ETOH overdose), dysphagia (esophageal disease), nonfunctioning NGT, Trendelenburg position, OR emergent intubation with full stomach
What are the signs/symptoms of aspiration pneumonia?
Respiratory failure, CP, increased sputum production, fever, cough, mental status changes, tachycardia, cyanosis, infiltrate on CXR
What are the associated CXR findings for aspiration pneumonia?
Early—fluffy infiltrate or normal CXR
Late—pneumonia, ARDS
Which lobes are commonly involved in aspiration pneumonia?
Supine—RUL
Sitting/semirecumbent—RLL
Which organisms are commonly involved in aspiration pneumonia?
Community acquired—gram-positive/mixed
Hospital/ICU—gram-negative rods
Which diagnostic tests are indicated for aspiration pneumonia?
CXR, sputum, Gram stain, sputum culture, bronchoalveolar lavage
What is the treatment for aspiration pneumonia?
Bronchoscopy, antibiotics if pneumonia develops, intubation if respiratory failure occurs, ventilation with PEEP if ARDS develops
What is Mendelson's syndrome?
Chemical pneumonitis secondary to aspiration of stomach contents (i.e., gastric acid)
What are possible NGT complications?
Aspiration-pneumonia/atelectasis (especially if NGT is clogged)
Sinusitis
Minor UGI bleeding
Epistaxis
Pharyngeal irritation
What are the risk factors for gastric dilation?
Abdominal surgery, gastric outlet obstruction, splenectomy
What are the signs/symptoms of gastric dilation?
Abdominal distension, hiccups, electrolyte abnormalities, nausea
What is the treatment for gastric dilation?
NGT decompression
What do you do if you have a patient with high NGT output?
Check high abdominal x-ray and, if the NGT is in duodenum, pull back the NGT into the stomach.
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
What lab tests are performed for postoperative pancreatitis?
Amylase and lipase
What is the initial treatment for postoperative pancreatitis?
Same as that for the other causes of pancreatitis (e.g., NPO, aggressive fluid resuscitation, ± NGT)
What are the postoperative causes of constipation?
Narcotics, immobility
What is the treatment for postoperative constipation?
Ortho Bowel Routine: docusate sodium (daily), dicacodyl suppository if no bowel movement occurs, Fleet® enema if suppository is ineffective
What is short bowel syndrome
Malabsorption and diarrhea resulting from extensive bowel resection (approximately <120 cm of small bowel remaining)
What is the initial treatment for short bowel syndrome?
TPN early, followed by many small meals chronically
What causes are related to SBO?
Adhesions (most of which resolve spontaneously), incarcerated hernia (internal or fascial/dehiscence)
What causes ileus?
Laparotomy, hypokalemia or narcotics, intraperitoneal infection
What are the signs of resolving ileus/SBO?
Flatus PR, stool PR
What is the order of recovery of bowel function after abdominal surgery?
First—small intestine
Second—stomach
Third—colon
When can a postoperative patient be fed through a J tube?
From 12 to 24 postoperative hours because the small intestine recovers function first in that period
What are the causes of the following types of postoperative jaundice: › Prehepatic?
Hemolysis (prosthetic valve), resolving hematoma, transfusion reaction, postcardiopulmonary bypass, blood transfusions (decreased RBC compliance leading to cell rupture)
What are the causes of the following types of postoperative jaundice: › Hepatic?
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
What are the causes of the following types of postoperative jaundice: › Posthepatic?
Obstruction (stone), cholangitis, cholecystitis, biliary-duct injury, pancreatitis, sclerosing cholangitis, tumors (e.g., cholangiocarcinoma, pancreatic cancer, gallbladder cancer, metastases), biliary stasis (e.g., ceftriaxone [Rocephin®])
What blood tests 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
What is blind loop syndrome?
Bacterial overgrowth in the small intestine
What are the causes of blind loop syndrome?
Anything that disrupts the normal flow of intestinal contents (i.e., causes stasis)
What are the surgical causes of B12 deficiency?
Gastrectomy (decreased secretion of intrinsic factor) and excision of the terminal ileum (site of B12 absorption)
What is postvagotomy diarrhea?
Diarrhea after a truncal vagotomy
What is the cause of postvagotomy diarrhea?
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.
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)
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 small intestine
What are the signs/symptoms of dumping syndrome?
Postprandial diaphoresis, tachycardia, abdominal pain/distention, emesis, increased flatus, dizziness, weakness
How is the diagnosis of dumping syndrome made?
History; hyperosmolar glucose load will elicit similar symptoms
What is the medical treatment for dumping syndrome?
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
What is the surgical treatment for dumping syndrome?
Conversion to Roux-en-Y (± reversed jejunal interposition loop)
What is a reversed jejunal interposition loop?
A segment of jejunum is cut and then reversed to allow for a short segment of reversed peristalsis to slow intestinal transit.
What is diabetic ketoacidosis?
Deficiency of body insulin, resulting in hyperglycemia, formation of ketoacids, osmotic diuresis, and metabolic acidosis
What are the signs of DKA?
Polyuria, tachypnea, dehydration, confusion, abdominal pain
What are the associated lab values of DKA?
Elevated glucose, increased anion gap, hypokalemia, urine ketones, acidosis
What is the treatment for DKA?
Insulin drip, IVF rehydration, K+ supplementation ± bicarbonate IV
What electrolyte must be monitored closely in DKA?
Potassium and HYPOkalemia (Remember correction of acidosis and GLC/insulin drive K+ into cells and are treatment for HYPERkalemia!)
What must you rule out in a diabetic with DKA?
Infection (perirectal abscess is classically missed!)
What is Addisonian crisis?
Acute adrenal insufficiency in the face of a stressor (i.e., surgery, trauma, infection)
What is the cause of Addisonian crisis?
Postoperatively, inadequate cortisol release usually results from steroid administration in the past year.
What are the signs/symptoms of Addisonian crisis?
Tachycardia, nausea, vomiting, diarrhea, abdominal pain, ± fever, progressive lethargy, hypotension, eventual hypovolemic shock
What is Addisonian crisis' clinical claim to infamy?
Tachycardia and hypotension refractory to IVF and pressors!
Which lab values are classic in Addisonian crisis?
Decreased sodium, increased K+ (secondary to decreased aldosterone)
What is the treatment for Addisonian crisis?
IVFs (D5 NS), hydrocortisone IV, fludrocortisone PO
What is fludrocortisone?
Mineralocorticoid replacement (aldosterone)
What is SIADH?
Syndrome of Inappropriate Anti Diuretic Hormone (ADH) secretion (think of inappropriate increase in ADH secretion)
What does ADH do?
ADH increases NaCl and H2O resorption in the kidney, increasing intravascular volume (released from posterior pituitary).
What are the causes of SIADH?
Mainly lung/CNS: CNS trauma, oat-cell lung cancer, pancreatic cancer, duodenal cancer, pneumonia/lung abscess, increased PEEP, stroke, general anesthesia, idiopathic, postoperative, morphine
What are the associated lab findings in SIADH?
Low sodium, chloride, and serum osmolality; increased urine osmolality
What is the treatment for SIADH?
Treat the primary cause and restrict fluid intake.
What is DI?
Decreased release of ADH, resulting in massive I's and O's (think: Diabetes = Decreased ADH)
What are the risk factors for DI?
Central DI—head trauma, intracranial disorder
Nephrogenic DI—renal disease, electrolyte disorders, medications
What is the treatment for DI?
Vasopressin (IV, SQ, or intranasal) to replace the deficiency and massive quantities of IV fluids
What are the arterial line complications?
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)
What is an Allen test?
Measures for adequate collateral blood flow to the hand via the ulnar artery: patient clenches fist, then both radial and ulnar arteries are occluded; patient opens the blanched hand. The ulnar artery is released. If the palm has an immediate strong blush, the ulnar artery should be adequate collateral flow if the radial artery thromboses.
What are the common causes of dyspnea following central line placement?
Pneumothorax, pericardial tamponade, carotid puncture (which can cause a hematoma that compresses the trachea), air embolism
What is the differential diagnosis of postoperative chest pain?
MI, atelectasis, pneumonia, pleurisy, esophageal reflux, PE, musculoskeletal pain, subphrenic abscess, aortic dissection, pneumo/chyle/hemothorax, gastritis
What is the differential diagnosis of postoperative atrial fibrillation?
Fluid overload, PE, MI, pain (excess catecholamines), atelectasis, pneumonia, digoxin toxicity, hypoxemia, thyrotoxicosis, hypercapnia, idiopathic, acidosis, electrolyte abnormalities
What is the most dangerous period for a postoperative MI following a previous MI?
Six months after an MI
What are the risk factors for postoperative MI?
History of MI, angina, Q's on EKG, S3, JVD, CHF, aortic stenosis, advanced age, extensive surgical procedure, MI within 6 months, EKG changes
How do postoperative MIs present?
Often without chest pain
New onset CHF, new onset cardiac dysrhythmia, hypotension, chest pain, tachypnea, tachycardia, nausea/vomiting, bradycardia, neck pain, arm pain
What EKG findings are associated with cardiac ischemia/MI?
Flipped T waves, ST elevation, ST depression, Q waves (usually late), dysrhythmias (e.g., new onset a fib, PVC, V tach)
Which lab tests are indicated for cardiac ischemia/MI?
Cardiac isoenzymes (elevated CK mb fraction), troponin I
What is the treatment of postoperative MI?
Nitrates (paste or drip), as tolerated
Aspirin
Oxygen
Pain control with IV morphine
β-blocker, as tolerated
Heparin (possibly; thrombolytics are contraindicated in the postoperative patient)
ICU monitoring
How can you remember the treatment of postoperative MI?
"BEMOAN":
BEta-blocker (as tolerated)
Morphine
Oxygen
Aspirin
Nitrates
When do postoperative MIs occur?
Two-thirds occur on postoperative days 2 to 5 (often silent and present with dyspnea or dysrhythmia).
What is the first thing to do if a patient is found unresponsive after a cardiac event?
Establish an AIRWAY! Always remember A, B, C first!
What is a CVA?
Cerebro Vascular Accident (stroke)
What are the signs/symptoms of CVA?
Aphasia, motor/sensory deficits usually lateralizing
What is the workup for CVA?
Head CT; must rule out hemorrhage if anticoagulation is going to be used; carotid Doppler ultrasound study to evaluate for carotid occlusive disease
What is the treatment for CVA?
ASA, ± heparin if thrombotic as feasible postoperatively
Thrombolytic therapy is not usually postoperative option.
What is the perioperative prevention for CVA?
Avoid hypotension; continue aspirin therapy preoperatively in high-risk patients if feasible.
What is postoperative renal failure?
Urine output less than 25 mL/hr (30 mL/hr is minimum adult output), increased creatinine and BUN
What is the differential diagnosis for postoperative renal failure? › Prerenal?
Inadequate blood perfusing kidney: inadequate fluids, hypotension, cardiac pump failure (CHF)
What is the differential diagnosis for postoperative renal failure? › Renal?
Kidney parenchymal dysfunction: acute tubular necrosis, nephrotoxic dyes or drugs
What is the differential diagnosis for postoperative renal failure? › Postrenal?
Obstruction to outflow of urine from kidney: Foley catheter obstruction/stone, ureteral/urethral injury, BPH, bladder dysfunction (e.g., medications, spinal anesthesia)
What is the work up for postoperative renal failure?
Lab tests: electrolytes, BUN, Cr, urine lytes/Cr, FENa, urinalysis, renal ultrasound
What is FENa?
Fractional Excretion of Na+ (sodium)
What is the formula for FENa?
"YOU NEED PEE"
(UNa+ × Pcr / PNa+ × Ucr) × 100
(U = urine, cr = creatinine, Na+ = sodium, P = plasma)
Define the lab results with prerenal vs renal failure: › BUN/Cr ratio
Prerenal: > 20:1
Renal: < 20:1
Define the lab results with prerenal vs renal failure: › Specific gravity
Prerenal: > 1.020 (as the body tries to hold on to fluid)
Renal: < 1.020 (kidney has decreased ability to concentrate urine)
Define the lab results with prerenal vs renal failure: › FENA
Prerenal FENa: < 1
Renal: > 1
Define the lab results with prerenal vs renal failure: › Urine Na+ (sodium)
Prerenal: < 20
Renal: < 40
Define the lab results with prerenal vs renal failure: › Urine osmolality
Prerenal: < 500
Renal: < 350 mOsm/Kg
What are the indications for dialysis?
Fluid overload, refractory hyperkalemia, BUN > 130, acidosis, uremic complication (encephalopathy, pericardial effusion)
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
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
What are the signs/symptoms of DIC?
Acrocyanosis or other signs of thrombosis, then diffuse bleeding from incision sites, venipuncture sites, catheter sites, or mucous membranes
What are the associated lab findings of DIC?
Increased fibrin-degradation products, elevated PT/PTT, decreased platelets, decreased fibrinogen (level correlates well with bleeding), presence of schistocytes (fragmented RBCs), increased D-dimer
What is the treatment for DIC?
Removal of the cause; otherwise supportive: IVFs, O2, platelets, FFP, cryoprecipitate (fibrin), Epsilon-aminocaproic acid, as needed in predominantly thrombotic cases
Use of heparin is indicated in cases that are predominantly thrombotic with anti-thrombin III supplementation as needed.
What is abdominal compartment syndrome?
Increased intra-abdominal pressure usually seen after laparotomy
What are the signs/symptoms of abdominal compartment syndrome?
Tight distended abdomen, decreased urine output, increased airway pressure, increased intra-abdominal pressure
How do you measure intraabdominal pressure?
Read intrabladder pressure (Foley catheter hooked up to manometry after instillation of 50–100 cc of water).
What is normal intraabdominal pressure?
< 15 mm Hg
What intra-abdominal pressure indicates need for treatment?
25 mm Hg especially if signs of compromise
What is the treatment for abdominal compartment syndrome?
Release the pressure by opening the abdomen and place a sheet of synthetic material to the skin to allow for more intra-abdominal volume.
What is a "Bogata Bag"?
A sheet of plastic (empty urology irrigation bag or IV bag) used to temporarily close the abdomen to allow for more intraabdominal volume
What is urinary retention?
Enlarged urinary bladder resulting from medications or spinal anesthesia
How is urinary retention diagnosed?
Physical exam (palpable bladder), bladder residual volume upon placement of a Foley catheter
What is the treatment for urinary retention?
Foley catheter
What are the signs/symptoms of wound infection?
Erythema, swelling, pain, heat, (rubor, tumor, calor, dolor)
What is the treatment for wound infection?
Open wound, leave open with wet to dry dressing changes, antibiotics if cellulitis present
How should one treat abdominal wound dehiscence?
Emergently to OR for fascial reclosure
What is a wound hematoma?
Collection of blood (blood clot) in operative wound
What is the treatment of a wound hematoma?
Acute: remove with hemostasis Subacute: observe (heat helps resorption)
What is a wound seroma?
Postoperative collection of lymph and serum in the operative wound
What is the treatment for a wound seroma?
Needle aspiration, repeat if necessary (prevent with closed drain)
What is pseudomembranous colitis also called?
Antibiotic-associated diarrhea
What are the signs/symptoms of pseudomembranous colitis?
Diarrhea, fever, hypotension/tachycardia
What classic antibiotic causes C. diff?
Clindamycin (but almost all antibiotics can cause it)
How is pseudomembranous colitis diagnosed?
C. difficile toxin in stool, fecal WBC, flex sig (see a mucus pseudomembrane in lumen of colon = hence the name)
What is the treatment for pseumomembranous colitis?
1. Flagyl (PO or IV)
2. Vancomycin if refractory to Flagyl