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Principles of

Perioperative
Care
© Ogan Gurel, MD
Table of Contents
PREOP............................................................................................................................................................1
Communication.................................................................................................................................................2
Routine Preop preparations..............................................................................................................................4
Preop rituals.....................................................................................................................................................5
Pre-existing Cardiovascular Disease...............................................................................................................7
Pre-existing Respiratory Disease.....................................................................................................................9
Pre-existing Gastrointestinal Disease............................................................................................................11
Pre-existing Renal Disease.............................................................................................................................14
Pre-existing Hematologic Disease.................................................................................................................15
Pre-existing Endocrinological Disease..........................................................................................................18
Pre-existing Neuromuscular Disease.............................................................................................................21
Pre-existing Psychiatric Disease....................................................................................................................23
Miscellaneous pre-existing conditions...........................................................................................................25
POSTOP.........................................................................................................................................................26
Acute Pain.......................................................................................................................................................27
Pain Management: Pharmacology.................................................................................................................28
Simple Analgesic Techniques.........................................................................................................................31
Advanced Analgesic Techniques....................................................................................................................33
Nausea & Vomiting.........................................................................................................................................35
Fluids & Electrolyte Balance.........................................................................................................................38
Bleeding & Transfusion..................................................................................................................................44
Feeding...........................................................................................................................................................48
Blood Gases....................................................................................................................................................50
Monitoring Devices........................................................................................................................................54
Hypotension....................................................................................................................................................56
Dysrhythmias..................................................................................................................................................60
Hypertension...................................................................................................................................................65
Myocardial Ischemia......................................................................................................................................67
Pulmonary Edema..........................................................................................................................................69
Cardiac Arrest.................................................................................................................................................73
Respiratory Problems.....................................................................................................................................76
Oliguria & Catheters......................................................................................................................................86
Fever...............................................................................................................................................................89
Hypothermia...................................................................................................................................................92
CNS complications.........................................................................................................................................94
Thrombosis....................................................................................................................................................100
Miscellaneous Postoperative problems........................................................................................................102
Principles of Perioperative Care © Ogan Gurel, MD

Preop
A complete, systematic, open-minded H+P is
important to optimize patients for surgery
(and to optimize the surgery for the patient)

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Principles of Perioperative Care © Ogan Gurel, MD

Communication
• You will be judged more on your communications skills than on
any other aspect of your job

Talking to patients

Names
• Learn patient’s names
• Introduce yourself
• Shake hands

Dress code
• Tie, avoid wearing scrubs, daily shave

Make time
• Avoid being curt
• Shake hands & sit down (for H+P)
• Make the purpose of the visit clear at the outset (“I’m here to
place an IV, etc.)

Chaperones
• Essential

Dealing with complaints


• Apologize early (an apology is not an admission of liability)
• Explain circumstances truthfully
• Refer up the line to seniors

Talking to professionals

Seniors
• Get senior residents involved early in developing problems
• Document your discussion with senior residents
• Call senior (and have attending contacted) whenever a major
(especially an unexpected) change in patient management
occurs (e.g. an admission, discharge, ICU transfer, consult,
etc.)

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Other Specialists
• Make personal visits when possible; (use beeps sparingly)
• Visit ICU patients at least once daily
• When consulting other services ask for advice (not services)
• Document your discussions

PCPs
• Send a brief note upon DC
• D-SUM include: nature of surgery, any complications, drug
regimen and f/u arrangements
• With deaths call PCP

Nurses
• Learn their names
• Treat them with respect
• Ask their advice

Notes
• Date and time (military)
• If you put plan of action at end of note be sure to follow-
through
• If you talk to senior, be sure to record the fact
• Sign name (print last name & beeper number)

Prescriptions
• Do not put DEA number on unscheduled drugs
• For scheduled drugs use a prime number (2, 3, 5, 7, 11, 13,
17, 19, 23, 29 , 31, 37, 41, 43, 47, 53, 59, 61, 67, 71 , 73, 79,
83, 89, 97, 101)
• Use generic names
• Put full-name, address, age & date
• Write Rx for OTC meds if there is a question of compliance

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Principles of Perioperative Care © Ogan Gurel, MD

Routine Preop
preparations
H+P
• Confirm surgical lesion
• ROS (focus on CV & resp systems)
• Detailed drug history
• Allergies (always ask what happened)

Preoperative Investigations

Screening tests
• UA
• CBC
• Lytes, BUN, Cr
• EKG (> 60, younger if smoker / major surgery)
• CXR

Tests necessary due to pre-existing illness


Cross-match

BBS

T+C 2U

T+C 4U

T+C 6U

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Preop rituals
NPO
• NPO/IVF pMN (avoid solids/clrs up to 4h/2h)
• Do not withhold oral medications

Regular Medication
• Very few drugs interfere with anesthesia/surgery
• Exceptions:
1. insulin & OHAs
2. anticoagulants
3. lithium
• Definitely continue cardiac meds

Bowel Prep

DVT prophylaxis

Antibiotic prophylaxis

To reduce incidence of postop wound infection


• Biliary: cephalosporin or amoxicillin
• Colorectal: cephalosporin with metronidazole
• Vascular: cephalosporin or amoxicillin
• Amputation: Penicillin, metronidazole and cephalosporin
• Orthopedics: cephalosporin

To prevent endocarditis in susceptible individuals


• High risk: patients with prosthetic valves or previous BE
• Moderate risk: RHD, septal defects, patent ductus, MV
prolapse, aortic sclerosis, h/o RF and IVDA

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• Rx: Amoxicillin 3g po or 1g IV followed by 400mg 6h pOP (if


allergic to penicillin give clindamicin 300 mg po followed by
150 mg 6h pOP

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Pre-existing
Cardiovascular Disease
Hypertension
• Uncontrolled hypertensives subject to surgery tend to exhibit
grossly exaggerated BP responses which can lead to strokes &
MIs
• Poorly controlled HTN = DBP > 110 -> should be controlled
before surgery
• For well controlled hypertensives maintain all antihypertensive
medications
• preop EKG; evidence of LVH or “strain” suggests higher risk;
Lytes, BUN, Cr if patient is on diuretics.
• Hypertension is associated with ischemic heart disease

CHF

History
• Exercise tolerance is a sensitive measure of cardiac reserve.
• Ask about past history of MIs/hospital admissions & cardiac
medication.
• ? Orthopnea/PND

Exam
• rest tachycardia, LE edema, JVD, basilar rales.

Labs
• EKG -> look for dysrhythmias, old MI & acute ischemia
• Echo -> gives more information about fitness of the heart to
tolerate GA/Surgery than any other test. Most important: EF
which is the best predictor of outcome after major surgery. EF
<40% particularly bad.
• CBC -> lower than usual threshold for treating anemia

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Valvular Heart Disease


• Key idea is to identify those patients with fixed cardiac output
states: aortic stenosis, mitral stenosis and constrictive
pericarditis. These patients react poorly to vasodilatation
(anesthesia).
• Patients with prosthetic heart valves require heavy
anticoagulation at all times + antibiotic coverage

Ischemic Heart Disease

Recent MI (< 6 months)


• Postpone elective, non-cancer surgery

Unstable angina (angina with has recently changed in frequency


or severity).
• Increased NTG consumption is a sensitive measure of this.

Dysrhythmias
• Atrial fibrillation is the most common abnormality
• Ventricular rate in controlled AF should be 80; question the
adequacy of treatment if this is higher.
• Maintain all anti-dysrhythmics
• Beware of hypokalemia or changes in renal function in
patients on digoxin. Digoxin levels should be taken 6h after
the dose is given.

Miscellaneous
• No particular precautions for patients with pacemakers;
electrocautery risk very low.

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Pre-existing Respiratory
Disease
Fitness for Surgery

History
• Exercise tolerance
• H/O of chronic bronchitis -> purulent sputum
• Check current meds (steroids, NSAIDS)
• Ask about prior admissions, home oxygen, history of smoking

Exam
• Cyanosis, wheeze, dyspnea at rest, right heart failure,
clubbing or focal chest signs

Labs
• CBC (elevated white count in PNA)
• CXR
• ABG (baseline for major surgery/severe disease)
• PFTs (severe disease to VC, FEV1 and response to
bronchodilators)
• EKG

Smoking

(stopping for …
• 12-24hr reduces need for carbon monoxide & nicotine
elimination
• 3-4 days improves ciliary activity
• 1-2 weeks reduces sputum volume
• 6 weeks reduces pulmonary and coronary vascular resistance
and restores normal pulmonary macrophage function

Preop preparation
• stop smoking. 48hr intensive PT for sputum retainers

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Asthma

Gauging severity:
• ask about EW visits, previous admissions, courses of steroids,
ICU stays, and limitation of activities. Severe asthmatics are
rarely wheeze-free.

Medications/Prophylaxis
• Maintain all regular medications
• Avoid using bronchospastic drugs: morphine, all NSAIDs and β-
blockers.
• Humidify oxygen, treat pain adequately and avoid creating
anxiety
• Consider dose of inhaler on call to OR

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Pre-existing
Gastrointestinal
Disease
Obesity

BMI
• body mass index combines height & weight

• Obesity = BMI > 28


• Morbid obesity = BMI > 35

Cardiovascular problems
• HTN, CHF, ischemia more common
• Take history of snoring, day-time drowsiness
• Raised bicarbonate indicates carbon dioxide retention and
thus may be a contraindication to postop oxygen

Respiratory problems
• Increased work of breathing
• prone to PNA
• Nursing: upright position, mobilization, early PT, oxygen at
night

Gastrointestinal problems
• Hiatal hernias, GERD common.
• Continue H2-blockers or omeprazole / Prilosec perioperatively

Metabolic issues
• Screen for diabetes
• Temporary insulin dependence may be a possibility

Venous access
• Avoid IM injections (usually intra-adipose)
• If prolonged access required think central line

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Malnutrition

Labs
• Lytes, BUN, Cr especially with diarrhea or vomiting
• Glucose -> chronic hypoglycemia
• EKG -> weakened cardiac muscle -> CHF/dysrhythmias
• CXR -> preop PNA more common due to
immunocompromise/weakness. Pulmonary edema/pleural
effusions due to hypoalbuminemia
• LFT/clotting: hypoalbuminemia, hypoglobulinema, prolonged
PT

Management
• Prone to infection, poor healing, skin ulcers, hypothermia
• IM route is unreliable due to reduced muscle blood flow

Upper GI problems

Heartburn & Indigestion


• Continue (or start) H2 antagonists/omeprazole
• Avoid particular antacids (use sodium citrate instead)

Upper GI bleeding

Liver Problems

LFTs
• Bilirubin (yellow pigment) function is to cause renal failure
• Albumin is a protein without which you get edema & ascites
• PT/INR is a measure of clotting which is impaired in liver
disease
• Liver enzymes are not measures of liver function at all but of
liver damage

Acute jaundice (liver function is OK)


• Renal failure in jaundice is caused by toxins & precipitated by
hypovolemia; hydrate -> 1ml/kg/hr
• Clotting is deranged (because vit K is fat-soluble and requires
bile salts in the intestine for absorption). Give vit K IM (wait
24hr). Otherwise give FFP 6U.

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• Hypoxia (because of increased pulmonary shunt). Give postop


oxygen; use sat monitor & good analgesia.

Liver failure (leads to ascites, jaundice and encephalopathy)


• For clotting disorders use FFP (vit K is useless)
• Protect gastric mucosa (with H2-blockers or omeprazole)
• For renal failure maintain diuresis
• Drug metabolism unpredictable; avoid sedatives and titrate
analgesics in small IV doses
• To prevent encephalopathy order a low-protein diet; think of
oral neomycin, lactulose, and/or rectal magnesium sulfate.

Lower GI tract problems

Diarrhea
• Results in hypovolemia, hyponatremia, hypokalemia and
acidosis.
• Replace with NS with 20-40 K (depending on K results)
• Acidosis may be treated with bicarbonate

Bowel prep
• Iatrogenic hypovolemia is common
• Replace with 2 liters of NS over 24hr preoperatively

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Pre-existing Renal
Disease
Chronic Renal Failure

Associated conditions

Medications in CRF

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Pre-existing
Hematologic Disease
Anemias
• Anemia is important because it increases the risk of
perioperative ischemia. (Hb < 12 in males, < 10 in females)
• Classify according to erythrocyte size & hemoglobin content

Microcytic, hypochromic
• MCV < 75
• Most commonly due to chronic blood loss
• More rarely due to failure to absorb or utilize iron
• Rx with oral ferrous sulfate (will raise Hb by 2 g/dl in 2 weeks)
• Transfusion will raise Hb by 1 g/dl per unit
• Ideally transfuse 2 days preop to give time for stored cells to
return to normal oxygen delivery
• Transfuse patients with history of ischemic heart disease more
aggressively (keep Hb > 10).

Normocytic, normochromic
• Anemia of chronic disease (renal failure, severe connective
tissue disease and carcinoma).
• Do not require transfusion because anemia is well-
compensated by increased intracellular 2,3-DPG which
stabilizes the deoxy state allow the hemoglobin to release
oxygen more readily in the tissues.
• Transfusion in renal failure may be harmful

Macrocytic (megaloblastic)
• MCV > 96.
• Result of either folate or B12 deficiencies due to diet,
malabsorption or increased demand (pregnancy).
• Associated with heart failure; transfuse only packed cells and
consider using a diuretic,
• Important to send blood for B12 and folate assays before
treating with folate.
• Treat B12 deficits with hydroxocobalamin 1mg IM.

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Bleeding Disorders
• Usually iatrogenic (rather than pathologic)

Warfarin
• Warfarin / Coumadin therapy measured by INR (2-4.5) for DVT,
valve prophylaxis
• DC warfarin 2-3 days preop and replace with heparin (if
necessary)
• For urgent correction of coagulopathy treatment of choice is
FFP (6U FFP = 1 liter)
• In catastrophic cases may also consider vit K (5mg slowly IV)
but it is slow-acting, makes later AC difficult, and there is also
a risk of anaphylaxis.

Heparin
• Short half-life (~1hour) means that effect can be reversed by
stopping 3-4 hours preop.
• Typical dose is 1000 U / hr which will achieve a 50%
prolongation of PTT
• Check PTT at least qD
• When restarting warfarin it is necessary to overlap warfarin
and heparin for 2-3 days.

Thrombocytopenia
• Minimum acceptable count is 100,000
• Transfusing one unit will raise the platelet count by 5,000

Hemoglobinopathies

Sickle cell anemia


• Screening test
• Preoperative transfusion may be necessary
• Tourniquets can precipitate sickling
• Postoperatively prevent a crisis: pain, cold, infection, acidosis
and hypoxia are the principal causes. Should a crisis occur,
the risk of pulmonary embolus becomes very high -> AC

Polycythemia
• Polycythemia vera or secondary polycythemia
• PV patients should undergo venesection 1-2 days preop

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• Secondary polycythemia due to increase erythropoeitin


secondary to chronic hypoxia. Full pulmonary work-up,
possible venesection, and DVT prophylaxis

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Pre-existing
Endocrinological
Disease
Diabetes
• Collective term for insulin deficiency states

Principles of Management

Cardiovascular
• All diabetics are at increased risk of MI, PVD and CVA. Careful
PE & EKG.
• Ischemia is often occult

Infectious Disease
• Infection worsens diabetic control
• Diabetics are immunocompromised
• Consider preop Abx
• Rigid exclusion of URI/UTI important

Renal
• DM causes CRF
• Check Lytes, Bun, Cr preop

Neurological
• Autonomic neuropathy can cause hypotension
• On exam:
1. Pulse rate does not change on Valsalva
2. Postural hypotension

Principles of Metabolic Control


• Hyperglycemia affects CNS only indirectly and slowly through
acid-base and electrolyte disturbance, while hypoglycemia
leads to problems very rapidly

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NIDDM
• Put early on for AM operations
• Stop long-acting OHAs at least 18h preop
• Check BS in AM and just before surgery
• If hypoglycemic put in D5W; if hyperglycemic do not start
insulin

IDDM
• Omit long-acting insulins the night before; continue short-
acting insulins for the evening meal. Omit all insulins on the
morning of surgery.
• DKA: hypovolemia, acidosis, hyponatremia and hyperglycemia.
ICU admission. Correct hypovolemia with saline (~2l/hr), give
insulin bolus (20U) and replace potassium (20 meq KCl per
liter)

Thyroid problems

Hyperthyroidism

Preoperative testing
• TFTs; all cases should be euthyroid
• Surgery without medical control of hyperthyroidism risks
“thyroid storm’. Carbimazole and/or β-blockers. Iodine
sometimes given to reduce vascularity
• Indirect laryngoscopy (via ENT) to exclude a pre-existing
laryngeal nerve palsy. If the other normal nerve were to be
injured -> b/l palsy which could threaten the airway.
• CXR/thoracic inlet views/CT scan->tracheal compression,
substernal involvement
• Preoperative calcium for baseline. To compare to post-op
calcium as indicator of parathyroid injury

Postop considerations
• Airway obstruction due to hematoma, edema, nerve palsies or
cartilage erosion -> pair of scissors or staple removers at
bedside
• Acute hypoparathyroidism. Check postop calcium and signs of
tetany. IV calcium gluconate 10% 10ml slowly.

Hypothyroidism
• At risk of heart failure, hypothermia, over-sedation and
pneumonia

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Adrenocortical problems
• Addisonian crisis -> hypotension, hyponatremia,
hyperkalemia.
• Resuscitate with IV steroids and saline.
• With chronic Addison’s measure preop lytes, glucose.
• Patients on long-term steroids (or previous steroid therapy
within one year) need stress steroids (hydrocortisone 100 mg
IV at induction and 8 hr post-op x one day). Does halved each
day until preop dose is reached.
• Hydrocortisone (100 mg IV/IM) = Prednisolone (25mg PO).

Diabetes insipidus
• May follow head injury or neurosurgery
• Due to failure of production or action of ADH resulting in large
volumes of dilute urine (specific gravity < 1.010).
• Treat with intranasal DDAVP (synthetic ADH) 10-40 mcg/day.

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Pre-existing
Neuromuscular Disease
Epilepsy
• Some AEDs can cause blood dyscrasias
• Do not discontinue any AEDs
• Phenothiazines [chlorpromazine/thorazine &
prochlorperazine/compazine] lower the seizure threshold

Strokes
• Indication that there is underlying atherosclerosis or cardiac
Dz -> preop EKG
• Swallowing difficult predisposes to malnutrition & aspiration
PNA
• Immobility increases DVT risk & skin breakdown
• Higher risk of PNA & UTI
• Hypovolemia & hypoxia should be avoided

Parkinson’s disease
• Possible further respiratory compromise due to rigidity of the
thorax.
• Continue anti-Parkinsonian drugs but watch for urinary
retention + confusion (anti-cholinergic effects).
• Central dopamine antagonists [droperidol/, haloperidol/haldol,
metoclopramide/reglan] may worsen disease.

Multiple Sclerosis
• Risk of UTI/PNA (aspiration) high.
• Autonomic hyper-reflexia (full bladder of constipation) may
lead to uncontrolled autonomic reflex with severe
hypertension, sweating and bradycardia.
• Good catheter and bowel care.

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Myasthenia gravis
• Do not withdraw anticholinesterases or steroids.

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Pre-existing Psychiatric
Disease
Drugs

Benzodiazapines
• Sudden withdrawal manifests as a panic attack -> severe w/d
-> Sz.
• Sx develop within a day to week (depending on half-life of
drug).
• Continue usual medications.

Antidepressants
• Side-effects of tricyclics include urinary retention,
constipation, blood dyscrasias, electrolyte imbalance,
dysrhythmias and confusion.
• CBC, Lytes, EKG are needed preop
• SSRIs are safer than tricyclics but same studies needed.
• MAOIs. Do not discontinue. May not have sympathomimetics.

Antipsychotics
• such as the phenothiazines (thorazine) have many side
effects: Parkinsonianism, blood dyscrasias, urinary retention,
constipation, hypotension and hypothermia.
• Effects are additive with other phenothiazines
[prochlorperazine/compazine] or other dopamine antagonists
[metochlopramide/reglan].

Lithium
• Narrow therapeutic window (0.4 - 1.0). Toxic effects may
occur > 1.5.
• Toxicity: mixed cerebellar signs, confusion, coma, convulsions,
diarrhea and vomiting.
• Toxicity is precipitated by hyponatremia, dehydration, pyrexia
and loop diuretics.
• Advisable to measure serum lithium preop

Alcohol
• Prevent withdrawal: alcohol or benzodiazepines

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• Oral diazepam/valium 30mg in divided doses on first day and


reduce by 5mg/day until maintenance of 10mg/day is reached

Consent

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Miscellaneous pre-
existing conditions
Pregnancy
• Risks to fetus are teratogenesis in the first trimester and
premature labor in the third trimester. Second trimester is the
safest.
• After 16 weeks greater risk of aspiration -> H2 blocker/
• Resting respiratory rate and heart rate higher; BP lower.
Greatly increased risk of DVT/PE. Urine output and
maintenance IVF requirements are higher.
• Compression of inferior vena cava -> place on left lateral
decubitus position

Breast feeding
• Safe medications: morphine, acetaminophen, ibuprofen,
metoclopramide and heparin.
• Do not give: aspirin (risk of Reye’s), atropine (anticholinergic
effects), barbiturates (drowsiness in high doses),
chloramphenicol (bone marrow toxicity in the fetus),
ciprofloxacin (large concentrations in breast milk), tetracycline
(possibility of dental discoloration)

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Posto
p
Important to institute a servo-loop approach to
patient management: assess, therapy, reassess,
adjust therapy, etc.

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Acute Pain
What is the problem
• Pain control is poorly managed
• It is important to identify causes of pain that need a different
form of intervention (i.e. an operation).

Consequences of pain
• Psychological
• Secondary psychological
• Respiratory
• Cardiovascular
• Other

Pain measurement
• 1-10 pain score
• Important to use a series of pain scores to assess titration of
therapy with response with frequent assessment

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Pain Management:
Pharmacology
Opioids
• All opioids cause analgesia, N/V and respiratory depression

Actions

Analgesia
• there is no such thing as more potent opioid ... just different
dosages

Nausea & Vomiting


• Nausea & vomiting is common: write for anti-emetic Rx

Respiratory Depression
• Assess by RR (< 8 is bad).
• Never use a pulse oximeter (hypoxia is a late sign).
• Respiratory depression is accompanied by somnolence.
• Management of respiratory depression with naloxone / Narcan
(0.2 mg IV). Short duration of action (~10 min) so repeated
doses may be required.

Addiction
• Patients given opioids appropriately when in acute pain do
NOT become addicted.
• Dose requirements vary enormously ... depending on severity
of pain, age, prior opioid use, psychological factors and
weight.

Drugs

Morphine
• Fast onset; duration 4-6 hours. Side-effects include delayed
gastric emptying, constipation, spasm of sphincter of Oddi.
Histamine release which may cause bronchospasm in
asthmatics. Typical IM dose is 10mg q3 PRN

Demerol
• Less spasm of sphincter of Oddi

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NSAIDs

Mode of action
• Analgesic, antipyretic and anti-inflammatory actions
• Mode of action (peripheral inhibition of prostaglandin
synthesis) is completely separate from opioids so are safe to
use in combination
• Very effective in postoperative pain relief ... so should be used
in every case where contraindications do not exist

Side effects

Gastric irritation
• Hazard whatever the route of administration
• Contraindicated in patients with GU/DU or predisposition to
UGIB
• Always prescribe NSAIDs to be taken with food

Renal effects
• Reduction in blood flow, sodium & water retention
• Use with caution in anyone with renal disease, hypovolemia,
hypertension or gout
• Check chemistries frequently

Platelet inhibition
• Only becomes a postoperative problem with patients with
thrombocytopenia, dysfunctional platelets or large raw areas
to bleed from.

Bronchospasm
• Avoid NSAIDs in asthmatics or those with nasal polyps
• strongly contraindicated in the presence of active
bronchospasm

Drug interactions
• Increase in anticoagulation during warfarin therapy

Specific Drugs

Aspirin
• Doses 500-1000 mg q 4-6hr
• Absolutely contraindicated for children

Ibuprofen / Motrin
• Dose 200-400 mg q4-8hr
• Causes fewer side-effects than aspirin

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Ketorolac / Toradol
• Powerful ... equivalent to 10mg of MS
• IM form

Combination pills
• Very low risk of side-effects and high efficacy

Role of sedatives
• Benzodiazepines have a weak muscle relaxant action which
may improve pain associated with skeletal muscle contraction.
• Anxiolytic effects may be useful but only if anxiety is a major
component of the pain state.
• Treat pain with analgesics, not sedatives

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Simple Analgesic
Techniques
Non-drug analgesia
• Talk with patient
• Appropriate use of traction/splinting etc.

Enteral therapy
• Preferred route
• Bioavailability is often less than parenteral routes
• Meds per NGT require a liquid preparation

IM therapy
• Use in patients who have moderate pain and who are
expected to rapidly progress to oral pain medications

Disadvantages
• PRN basis … which is bad
• IM therapy is time-consuming and labor-intensive
• IM injections hurt … patients thus avoid them
• Can result in excessive peaks & troughs
• Variable absorption … contraindicated with patients in shock
• Also contraindicated in patients with coagulopathy

PRN vs. RTC medication


• Try to have a regular element to any pain prescription with a
PRN rescue medication
• Or … write RTC unless refused by patient

Loading doses
• Importance of loading doses
• Loading doses are given IV

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• Use an assessment-therapy-reassessment servo loop


• Start with 2 mg MS
• Have an amp of naloxone (0.4 mg) ready.

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Advanced Analgesic
Techniques
PCA
• Safe and effective
• Concentration, demand dose, lockout interval, basal rate
• Basal rate usually does not improve the quality of the
analgesia but increases the incidence of side-effects

Epidural

Formulations
• Local anesthetic
• Opioids
• Combination of opioid (fentanyl) + weak anesthetic (0.125%
bupivicaine)
• Useful for thoracotomy, major laparotomy, multiple rib Fx,
high risk patients, cancer pain & terminal care

Adverse Effects
• Respiratory depression
• Hypotension -> Rx with fluid bolus
• Pruritis -> chlorpheniramine (10 - 20 mg IM) or decrease rate
of infusion
• Urinary retention
• Nausea
• Sedation -> reduce rate
• Motor or sensory block -> reassurance

Special circumstances

Respiratory disease
• Pain is definitely more dangerous than analgesia

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CNS depression

Shock
• Shock should be treated before analgesia is given
• Fentanyl IV in increments of 25 - 50 mcg
• Do not give IM drugs of any kind to a shocked patient

Narcotic addiction
• Get advice from pain specialist

Children

Neurogenic pain
• Does not respond to opioids
• Often lancinating (shooting or electric)
• Treatment may include carbamazepine/Tegretol,
amitriptyline/Elavil, baclofen, nerve blocks, neurosurgery

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Nausea & Vomiting


Physiology of emesis
• Vomiting is a reflex involving:
1. emetic detectors,
2. central integrating area, and
3. motor outputs
• Four emetic areas:
4. CTZ
5. Vestibular system
6. Gastrointestinal afferents
7. Higher centers

Causes of emesis

Preoperative factors
• Raised ICP
• Bowel obstruction

Direct drug actions


• Opioid receptors in the CTZ
• Opioid receptors also delay gastric emptying
• Opioids sensitize the emetic response to labyrinthine stimuli
• Opioids enhance serotonin release in the gut

Indirect drug effects


• GI effects: some anesthetics reduce GI motility or inhalational
agents may diffuse to gut causing distention
• CV effects: hypotension (as with spinals) may precipitate N/V
• CNS effects: drug-induced increased ICP may worsen nausea

Patient factors: increased risk with


• Patients who have motion sickness
• Previous pOP N/V
• Females > males
• Anxiety -> orophagia and delayed gastric emptying
• obesity

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Effects of the surgery


• Intrabdominal surgery
• Laparoscopic gyn surgery
• ear surgery
• T&A

Surgical complications
• Ileus
• bowel obstruction
• pancreatitis
• Myocardial infarction (especially inferior ) may cause N/V

Complications of emesis

Fluid & electrolyte loss


• Hypokalemia
• Alkalosis

Physical effects
• Wound dehiscence
• Mallory-Weiss tear -> esophageal rupture

Physiological effects
• Hypertension & tachycardia -> myocardial infarction, CVA

Treatments

General measures
• Placement of NGT

Phenothiazines (like chlorpromazine / thorazine)


• Prochlorperazine/Compazine
• The most useful agents (block dopamine receptors on CTZ)
• Extra-pyramidal side-effects (0.3% incidence) … very low with
doses < 10 mg
• Other effects include sedation, hypotension, cholestatic
jaundice, skin sensitivity and hyperprolactinemia

Butyrophenones (like haloperidol / haldol)


• Droperidol
• Effect is less striking than with phenothiazines
• Hypotension can occur due to α-blockade

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• About 20% of patients complain later of a generalized feeling


of malaise and anxiety.

GI prokinetic agents
• Metoclopramide/Reglan
• Increases motility of the GI tract, blocks dopamine receptors
at the CTZ
• Works poorly however.

5-HT3 antagonists
• Ondansetron/Zofran
• Used in N/V of chemotherapy

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Fluids & Electrolyte


Balance
Normal
maintenance
requirements
• Potassium intracellular
• Sodium extracellular
• Water 30 ml/kg/day -> ~ 2000 cc/day
• Sodium 1-2 meq/kg/day -> ~ 60 - 120 meq / day
• Potassium 1 meq/kg/day -> ~ 60 meq /day

Deficits and losses

Normal losses
• UO 1500 cc/day.
• Insensible losses 0.5 cc/kg/hr.
• Fever, obesity increase insensible losses.

Special surgical losses


• EBL.
• Third space (injury causes increased local capillary
permeability).

Other measured losses


• Significant volumes should be recorded and replaced.
• Diarrhea -> very large potassium losses (30 -70 meq/l).

Pre-existing deficits

Stress & Fluid balance


• Stress response -> increased aldosterone & ADH
• Stressed patients therefore cannot excrete large water loads

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• ADH increases cannot be modified so use of hypotonic


solutions is not recommended

Management

IVF
• Crystalloid (small particles)
• Colloid (large molecules capable of exerting oncotic pressure)

Crystalloid
• Distribution of IVF depends primarily on sodium content
• NS/LR -> freely distributed in extracellular compartment
• D5 (sugar gets pulled into cells) thus it is like giving pure
water. Distributes in the total body water
• D5/saline; 20% stays in ECF, majority ends up in total body
water.

Colloid
• Retained within intravascular space
• With shock and injury (increase in capillary permeability)
colloid molecules reach the interstitial space thus worsening
edema

Assessment

History
• Ask about thirst, prolonged vomiting/diarrhea
• Drowsiness, headaches, dizziness, malaise, delayed
mobilization

I/Os
• Consider all information not charted: prior deficits, insensible
loss, third space loss, internal hemorrhage
• UO 0.5 - 1ml /kg /hr. Oliguria is most commonly caused by
inadequate volume, but renal impairment and urinary
obstruction must be ruled out

Exam
• Dry mucous membranes
• Edema
• Pulse rate/pressure
• warm/cold extremities
• Rales
• Skin turgor
• Daily weights

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Labs
• Serial measurements of CVP
• Hematocrit may point to hemorrhage ... may take several
hours
• Increased BUN in dehydration
• CXR -> pulmonary edema indicating overhydration

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Planning a regimen

• Aim is to produce a stable but slightly dry patient

Pre-existing deficit
• Treat there and then with a fluid challenge servo loop (give
250 cc NS and reassess HD/UO.
• Do not “speed up the drip” and leave

Maintenance
• 500 ml NS
• 1500 ml D5

Ongoing Losses
• Usually sodium - containing so replete with D5NS, NS or LR
• Potassium (20 - 40 meq/l)
• Blood (keep Hct > 30)
• GI losses (give NS with 20meq/l KCl); large losses should have
electrolyte content measured to ensure appropriate
replacement
• Nutrition
• Check daily chemistries while on IV fluids

Special situations

Cardiac failure
• Heart failure does not affect the rate of fluid loss so
maintenance fluid/electrolyte requirements are the same
• But ... cannot cope with as wide a range of filling pressures so
aggressive fluid resuscitation should only be used with good
evidence of ECF loss/deficit.
• Continue diuretics
• Changes in physical signs are important

Respiratory disease
• Small and clinically undetectable degrees of fluid overload can
dramatically worsen pulmonary function.
• Better to err on the dry side

Liver disease
• Obstructive jaundice at risk of hepatorenal syndrome ...
maintain high UO
• Decrease sodium intake

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Renal disease
• Strict I/Os; daily chemistries
• Err on the wet side .. nothing will finish off a failing kidney
quicker than hypovolemia
• Avoid potentially nephrotoxic drugs ... NSAIDs,
aminoglycosides, loop diuretics

Diabetics
• May be severely dehydrated on presentation
• Renal impairment common

Other problems

Septic Shock
• Often huge volumes are required

Hypothermia
• Repeated bolus fluid resuscitation may be required as
hypothermic patient warms up

Hormone problems

Electrolyte disturbances

Hypokalemia
• K < 3.5
• Symptoms of muscle weakness
• Causes include excessive K loss (diarrhea, vomiting),
inadequate replacement, alkalosis/hyperventilation, diuretic
therapy
• Requirements 60 meq/day

Hyperkalemia
• K > 5.0
• Acute changes more serious than chronic
• Causes: renal failure, acidosis, hypercatabolism (malignant
hypothermia)

Management
• 10% Ca-Gluconate
• Correct acidosis
• Dextrose / Insulin (50 ml D50 with 20 units insulin over 30
minutes)
• Kayexelate 30mg tid po/pr
• Arrange dialysis

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Hyponatremia
• A sign of excess water
• Causes: iatrogenic (hypotonic IVF), TUR syndrome, SIADH
• Acute dilutional: water restriction
• Acute salt-losing resuscitate with NS+K
• Diuretic-induced

Hypernatremia
• Due to lack of water
• Fluid resuscitate with D5 or D5NS

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Bleeding & Transfusion


Diagnosis of bleeding
• Heart rate: Tachycardia (loss > 15%); ST -> 120 (>30%)
• Blood pressure decreases late (> 30% blood volume); an
earlier change is decrease in pulse pressure
• Urine output < 0.5 ml/kg/hr represents a 30% loss
• Level of consciousness 15% -> anxiety, 30% to confusion,
40% to lethargy or coma
• Respiratory rate increases (? due to physiological dead
space)
• Skin signs pallor, poor capillary refill (normally < 1 sec) and
reduced skin turgor
• CVP/JVP more important as relative measures (compensatory
venoconstriction may misleadingly increase CVP)
• Hematocrit does not decrease acutely but only after dilution;
only makes sense with a separate assessment of volume
status

Causes

Surgical lesions
• Most common reason is lack of hemostasis
• A dry drain does not exclude bleeding

Bleeding disorders

Causes
• Dilution of platelets/clotting factors
• Inhibition of platelets/clotting factors
• Consumption of platelets/clotting factors by
DIC/cardiopulmonary bypass

Diagnosis
• Diagnosis is a clinical one: bleeding at venipuncture sites,
bruises, bleeding mucosa, hematuria, hemarthroses. Labs are
used to define cause & guide therapy
• PT: Warfarin, dilution, DIC or liver disease prolong PT
• PTT: dilution, DIC or heparin
• LFTs liver is major source of clotting factors

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• FDPs fibrin degradation products seen with DIC


• Chemistries: urea is a platelet inhibitor
• Ionized calcium: hypocalcemia is a rare cause of coagulopathy.
Tourniquet falsely elevates serum calcium. Best assay is the
ionized calcium

Principles of treatment

Preventing further hemorrhage


• Elevation (especially for venous bleeding)
• Direct pressure

Supportive treatment

Causes of death
• hypovolemia (1st priority)
• loss of oxygen transporting capability

Restore plasma volume


• crystalloid useful (but only 30% stays in circulation)
• colloid require less volume
• blood products to restore both volume and oxygen carriage
• Inotropes are not used

Restore oxygen carriage


• Oxygen
• Hb > 10 g/dl
• 500 ml blood loss -> 1g/dl drop in hemoglobin

Definitive treatment
• Usually exploratory surgery

Bleeding in children

Physiological differences
• Faster HR
• Lower SBP
• Higher RR
• Higher UO (1ml/kg/hr)

Volume calculations
• Simplest measure is weight
• 8% of body weight is blood

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• First fluid bolus is 20 ml/kg of salt

Transfusions

Red cell transfusions


• Two indications: acute hemorrhage & anemia
• As much as possible, anemia should be treated with
hematinics (iron, folate, vit B12). Decision to transfuse: Hct,
expectation of further blood loss, patient’s general health
(especially cardiac patients).
• Patients with renal failure should generally not be transfused
(problems with fluid overload).
• > 18 gauge IV
• Furosemide / Lasix only rarely indicated
• Avoid transfusing o/n (because of need for frequent VS checks)
• One unit of blood will increase Hb / Hct by 1 / 3.

Plasma products
• FFP -> replacement of clotting factors
• Indications
1. Massive transfusion
2. Rapid correction of warfarin / Coumadin
anticoagulation
• Ask for 2 U FFP whenever you ask for 4 or more units of PRBC

Platelets
• Depends on platelet count.
• Tx for platelets < 50,000

Preoperative cross-matching

Autotransfusion

Complications of blood transfusion

Fluid overload
• Elderly, known cardiac disease and megaloblastic anemia
• Treat chronic anemia with PRBCs & give it slowly
• Concomitant diuretic (furosemide / Lasix 20mg PO) with every
other unit of blood

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Infection

Immunological complications

ABO incompatibility

Rh incompatibility & other antibodies

Other reactions
• Coagulopathy (since stored blood contains very little clotting
factors)
• Hypothermia
• Citrate toxicity -> hypocalcemia & acidosis
• Hyperkalemia
• Impaired oxygen delivery (stored blood progressively loses
2,3-DPG)

Other complications

Jehovah’s Witnesses

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Feeding
The effects of starvation
• Liver -> 24 hr of glucose
• Afterwards glucose from gluconeogenesis (from AA)
• Decrease in BMR
• Negative nitrogen balance which can be reversed in simple
starvation but not in starvation accompanied by stress

The stress response


• Catecholamines, glucocorticoids, growth hormone, glucagon
causing increased protein catabolism, accelerated
gluconeogenesis & insulin resistance
• Aldosterone & ADH cause salt and water retention

Enteral nutrition
• Use the gut if functional
• If swallowing not possible or low PO intake use NGT (or
feeding tube); check with CXR -> below diaphragm
• For long-term feeding G-tube or J-tube
• If slow gastric emptying -> cisapride/Propulsid 10 mg po tid or
metoclopramide / reglan 10 mg po tid
• Complications of TFs: diarrhea, tube insertion, pulmonary
aspiration (tube promotes regurgitation)
• Begin with low-strength ‘starter’ solution then proceed to full
strength
• Decrease diarrhea but reduce rate of infusion, switch to iso-
osmolar solution, treat with codeine or loperamide/Lomotil)

Parenteral nutrition
• Gut dysfunction; contraindicated when gut feeding is possible
• Give through central line; nothing else in line due to infection
risk

Choice of regimen
• Daily regimen

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Monitoring
• VS/fluid balance
• LFTs, chemistries, CPM, lipids, UA

Complications
• Catheter complications
• Sepsis (C-reactive protein is a sensitive marker of line
infection)
• Fluid overload (esp. cardiac/renal/elderly patient)
• Hyperglycemia
• Electrolyte imbalance
• Trace element deficiency
• Carbon dioxide production

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Blood Gases
Acid-base physiology
• Maintenance of pH is essential
• H+ is constantly produced by the body as a product of
metabolism.
• Buffer systems attenuate fluctuations in pH by reducing the
free H+ concentration
• Most important buffer is the bicarbonate system

produced by metabolism buffer removed by ventilation

• Acid can be removed via three process:


1. Immediate taken up by bicarbonate
2. Short-term via removal of CO2
3. Long-term (definitive) via kidney & gut
• Two groups of disturbances:
Metabolic (production or excretion of acid)
Respiratory (problem with excretion of CO2)

Control mechanisms
• Recall the Henderson-Hasselbach equation:

• pH depends on the balance between bicarbonate and carbon


dioxide
• Whenever a physiological pH is perturbed, the body will
attempt to compensate for the abnormality
• Short-term compensation (minutes) via respiratory system
• Long-term compensation (days) via renal system
• The body never over-compensates for an acid-base
disturbance

Blood gas measurements


• pH most important: tells you whether you have an acidosis or
alkalosis. Normal range is 7.35 - 7.45.
• pCO2 tells you about alveolar ventilation, e.g.
hyperventilation or hypoventilation. Normal is 35 - 45 mm Hg

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• pO2 tells you about oxygenation.

Interpretation
• Basically two components: oxygenation & acid-base status

Oxygenation
• Normal range for RA is 80 - 100 mmHg; pO2 drops with age
• FIO2. You need to interpret oxygenation in the context of the
inspired oxygen concentration.
• Oxygen saturation. Unless the oxygen saturation is directly
measured ... trust the pulse oximeter result

Acid-base status
• Look at the pH and decide whether the changes are opposite
to the pH or not.
1. Is it acidosis or alkalosis
2. Is the patient hyperventilating or
hypoventilating?

Arterial vs. Venous sample


• Normal venous O2 is 40 mmHg and the normal saturation 75%
• If PaO2 is much more than 50 mmHg then it is unlikely to be
venous.
• If the pulse oximeter saturation is substantially greater than
the blood gas result than the sample is unlikely to be arterial
• If any doubt, repeat the sample

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Management of abnormalities

Metabolic acidosis

Causes
• Failure to excrete acid: renal failure
• Excessive production of acid: shock, post-MI, ketoacidosis
• Excessive loss of bicarbonate: duodenal fistulae
• Excessive absorption of bicarbonate

Management
• Directed at the cause

Bicarbonate for metabolic acidosis


• Commonest cause for acidosis is shock. Giving bicarbonate
yields CO2 which cannot be released because of poor tissue
perfusion. CO2 enters the cells an decreases the intracellular
pH, thus aggravating the acidosis.
• Metabolic acidosis without tissue hypoxia is an indication for
bicarbonate treatment.

• Give half the calculated requirement over an hour first, then


re-check gases. For renal failure with fluid overload do
dialysis.

Respiratory acidosis
• May be acute or chronic, or (acute-on-chronic … some with
COPD who decompensates)
• Acute respiratory acidosis is always serious … get senior
assistance.
• Chronic may be subjected to “hypoxic drive” and may become
apneic when administered oxygen.

Causes of acute respiratory acidosis


• Respiratory depression
• Respiratory failure

Metabolic alkalosis

Causes
• Excessive bicarbonate administration
• Chronic potassium loss
• Pyloric stenosis (loss of acid without loss of bicarbonate) ->
hypochloremic acidosis

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Management
• Give sodium & water to correct dehydration
• Give chloride to correct the deficit
• Give potassium
• NS with 40 meq /l KCl

Respiratory alkalosis
• Hyperventilation is the only cause
• Lung diseases (such as asthma, pneumonia, pulmonary
fibrosis, mild pulmonary edema)
• Anxiety which can lead to relative hypocalcemia (numbness &
tingling in the fingers, even tetany & spasm). Alkalosis
deprotonates carboxyl groups on albumin making more sites
available for binding to calcium. Treatment: breathe in and
out of a paper bag.

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Monitoring Devices
• Monitoring should never be a substitute for clinical judgment

Non-invasive blood pressure


• Pressure in various vessels varies as a result of presence of
vessel disease
• Dimensions of cuff relative to arm are important
• Narrow cuff on a fat arm will overestimate the BP and an
excessively narrow cuff may lead to an underestimate.

Automated BP machines
• Oscillometry
• Onset of pulsations = SBP
• Point at which oscillations are the greatest = MAP
• Disappearance of pulsations = DBP

Arterial lines
• Only used in an ICU
• Used for continuous BP monitoring & blood sampling
• Most important dangers are exsanguination & intra-arterial
injection

Central venous pressure monitoring


• Subclavian/IJ or femoral approaches; External jugular vein will
not give reliable reading on account of valve at proximal end
• Major complications: hemorrhage, pneumothorax and air
embolus.
• Measurements of CVP should be taken at the end of expiration
• Reference point is the anterior axillary line in the 4th interspace
• Used as an estimate of volume status

Pulse oximeters

Principle
• oxyhemoglobin & deoxyhemoglobin have different optical
absorption spectra.

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• By passing two different wavelengths and measuring the


relative absorption, the proportion of oxygenated and
deoxygenated blood can be estimated.

Limitations
• Poor signal (w/ poor perfusion)
• Other forms of hemoglobin. Carboxyhemoglobin &
methemoglobin are similar to oxyhemoglobin
• Dyes (bilirubin, methylene blue or nail varnish) will affect the
reading
• Ambient light (strong light sources confuse the photocell)
• Venous pulsation (patients in cardiac failure, tricuspid
regurgitation) may have detectable venous pulsations

Pitfalls
• Pulse oximeter should never be used as a means of detecting
airway obstruction. As the hemoglobin saturation falls, the
warning will come far too late.
• Is not sensitive to hypoventilation if the patient is breathing
oxygen.
• In comparing calculated (ABG) sats with pulse oximeter sats
use the latter as it is a measurement (unless the ABG has co-
oximetry)

EKG monitoring
• Detection of dysrhythmias and ischemia
• For any unstable patient who you feel warrants closer
monitoring use a pulse oximeter and a Dinamap.

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Hypotension
Definitions
• SBP < 90mmHg or significant drop (> 30 mmHg from
recorded baseline)
• Evidence of end-organ dysfunction, e.g. low UO, decreased
LOC

Causes

Hypovolemic
• Poor cardiac output secondary to decreased preload

Cardiogenic
• Pump problem due to poor myocardial contractility,

Septic / Anaphylactic
• Probably due to release of endotoxin from bacteria
• Early phase warm sepsis which proceeds to hypotension and
cool extremities.
• Strongly associated with MSOF with a high mortality
• Anaphylactic shock is caused by a type I hypersensitivity
reaction leading to massive release of vasoactive mediators
such as histamine

Neurogenic
• Spinal shock

Combined causes
• pOP CHF may also be hypovolemic
• Early sepsis there is relative hypovolemia and in more
advanced sepsis there is direct myocardial depression

Other causes
• Drugs -> anesthetics, analgesics, antihypertensives
• Spinal/epidural anesthesia: due to autonomic blockade
• Vasovagal responses
• Drug toxicity: digoxin / Lanoxin, tricyclics, lithium
• Pulmonary embolus

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• Measurement error
• Pregnancy: caval compression in late pregnancy. Heavily
pregnant women should not lie flat
• Hypothermia
• Metabolic disorders; acidosis, disorders of calcium/phosphate,
citrate toxicity
• Addisonian crisis: a patient with undiagnosed Addison’s or a
patient who abruptly stops taking steroids
• TUR syndrome: associate with hyponatremia following TURP

Assessment
• Aimed at deciding the cause and severity of hypotension
• Airway: Talk to the patient. If the patient is speaking then
the airway is clear.
• BreathingCheck breath sounds. Give oxygen. Check RR
• Circulation Is there a pulse. Rate & character. Is the
hypotension severe or mild
• Level of consciousness Awake & alert or comatose?
• If you have determined that a cardiac arrest is not imminent,
then you can revert to a more detailed assessment

History
• Age. PMH.
• Surgical diagnosis - any reason for active bleeding?
• Fluid history
• Onset of hypotension sudden or gradual?
• Recently administered drugs, especially pain medications
• Any specific symptoms? CP, SOB, itchy rash?

Exam
• Gen: Pallor, cyanosis; visible blood loss from
drains/wounds, skin turgor. Sweating, warm/cold extremities
• VS: pulse, measure BP manually, RR
• CV: JVP raised? Murmurs
• Chest: Lungs clear?
• Abd:

Investigations
• UO (insert catheter if necessary
• CBC
• Lytes, BUN, Cr
• BBS
• EKG/CXR if suspicious of cardiogenic component
• CVP

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Central venous pressure monitoring

Measurement
• Via central vein (subclavian, IJ or femoral) … not external
jugular
• Complications: hemorrhage, pneumothorax, air embolism
• Always get CXR after CVL insertion

Physiology

Starling hypothesis
• Contractility is a function of initial fiber length
• Stroke volume varies with EDV
• EDV varies with volume status
• EDP varies with EDV
• Right EDP varies with left EDP. True in the healthy heart …
however a variety of conditions lead to a difference in function
between the two sides of the heart including respiratory
disease, mitral stenosis, cardiac failure and pregnancy.
• CVP is the same as EDP

Interpretation
• Normal CVP is ~ 5 cm H2O
• CVP is a very indirect way of guessing left ventricular filling.
Therefore absolute values are meaningless. Do not base fluid
management decisions on a single CVP reading.
• Normal CVP does not rule out hypovolemia or fluid overload
• For patients with heart failure, there is a level of CVP which is
optimal. This “optimum” CVP is very unlikely to be within the
“normal range”
• CVP is extremely useful when monitoring trends or response
to treatment.

Management

Basic resuscitation
• Airway
• Oxygen
• Large-bore IV

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Fluid Challenge

Principle
• Once basic measures have been taken the cornerstone of
treatment is the fluid challenge.
• The principle of the fluid challenge is an example of a servo
loop.

Method
• Infuse 100 - 200 ml of fluid rapidly and monitor the effects on
heart rate, blood pressure, UO and CVP.
• Crystalloid vs. Colloid is not important; however, D5 or D5½NS
are not particularly useful as their effect on ECF and
intravascular volume is much less.
• If the fluid therapy is indicated, then a favorable effect on the
hemodynamic variables will be seen and further challenges
given. If deterioration, then hypovolemia is unlikely to be
present

Caveats
• Never diagnose “fluid overload” purely on the basis of a fluid
balance chart. Many important loss never get charted.
• Do not base decisions on a single CVP reading
• The management of hemorrhage is surgical
• Blood should always be warmed when given rapidly
• Opioids are only rarely the sole cause of hypotension.
However, when a hypovolemic patient is given MS for pain,
the blood pressure may drop dramatically. The treatment is
fluid, not naloxone / Narcan.

When the fluid challenge works


• Check hemodynamic variables: pulse, BP, UO, CVP.
• Repeat fluid boluses to rectify the situation. However, at each
stage, the patient should be re-assessed. Fluid overload,
particularly in the elderly is a hazard if fluid is given without
regular assessment.

When the fluid challenge doesn’t work


• When the patient is in true cardiogenic shock. Invasive
monitoring, inotrope therapy, treatment of dysrhythmias.
• Different etiology such as tension pneumothorax, cardiac
tamponade or Addisonian crisis.
• Profound hypovolemia such that a small fluid challenge is
inadequate to make a noticeable difference.

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Dysrhythmias
Immediate action
• Most commonly the result of pre-existing cardiac disease, but
may occur as a result of other factors such as hypoxia,
hypovolemia, drug actions, electrolyte or acid-base
disturbances or a combination of these.
• Ensure the ABCs: airway, oxygen, breathing, pulse, BP,
consciousness level. Hypotension in the presence of
dysrhythmia is an indication for urgent, expert help.
• Get a 12-lead EKG; get preop one for comparison and attempt
a diagnosis
• Exclude any underlying causes: give oxygen, establish IV
access and send Lytes, BUN, Cr and blood gases
• Treat the dysrhythmia with specific therapy … or get someone
to do it for you.

Diagnosis
• Three simple things to decide:
• Is it tachycardia or bradycardia?
• Is it broad-complex QRS (> 0.12 sec or three small squares) or
narrow-complex?
• Is it irregular or regular?

Atrial ectopic beats

Definition
• Extra beats on a background of sinus rhythm. QRS complexes
are the same and the P waves are different.

Causes
• Can be precipitated by caffeine, alcohol or stress although
occasionally a more sinister underlying cause such as
electrolyte abnormality or drug toxicity (e.g. digoxin).

Treatment
• Treatment is usually not necessary.

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Ventricular ectopic beats

Definition
• Extra beats on a background of sinus rhythm, where the QRS
complexes are different from normal beats. The QRS
complexes are wide and bizarre, and not preceded by a P
wave. They may be unifocal (where the abnormal QRS is
always the same) or multifocal, where they are different
• Must be taken seriously if they are:
1. Frequent (> 5/min)
2. Multifocal
3. Occurring in runs of two or more
4. Occurring at or just before the T wave, the so-
called R-on-T phenomenon, which can precipitate
ventricular fibrillation

Causes
• If serious, An underlying cause such as electrolyte
disturbance, ischemia or hypoxia should be sought.

Treatment
• Treatment is usually lidocaine 80 - 100 mg IV

Atrial fibrillation

Definition
• Irregular, usually narrow-complex tachycardia with absent P
waves. Most common dysrhythmia

Causes
• Long-standing AF is common in surgical patients.
• Acute AF can occur in myocardial infarction, thyrotoxicosis,
pulmonary embolism, electrolyte disturbances and hypoxia.
• A lapse in the patient’s regular digoxin dose may also cause
new acute AF in the previously well-controlled patient.

Treatment
• Treat pain, hypovolemia, hypoxia
• For an undigitalized patient, a full loading dose of digoxin can
be given IV
• For a digitalized patient, the usual problem is inadequate
levels of digoxin and a single extra dose (.5 mg orally will do
the trick. Digoxin toxicity is possible, particularly in the
presence of hypokalemia.

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• For a shocked patient use DC cardioversion


• Digoxin has a narrow therapeutic window, but undertreatment
is more common than toxicity. Almost nobody on 0.0625 or
0.125 mg qd has levels in the therapeutic range (except for
CRF patients). Loading dose is unchanged.

Paroxysmal atrial fibrillation

Definition
• Flip in and out of AF. Digoxin will not prevent paroxysms of
AF, but will reduce the ventricular response.

Treatment
• The drug of choice is sotalol 120 - 240 mg/day.

Supraventricular tachycardia

Definition
• Paroxysmal re-entrant tachycardia which on an EKG is a
regular, narrow-complex tachycardia with a rate usually
between 140 and 250 bpm.
• Abnormal P waves with a fixed relationship to the QRS
complex.

Causes
• Uncommon in postoperative period but may be seen in
otherwise healthy young patients who may have a history of
palpitations. May occur after MI

Treatment
• May respond to physiological measures which terminate the
dysrhythmia by provoking vagal activity. These include
sustained valsalva maneuver or carotid sinus massage.
• Valsalva … blow into manometer of a sphygmomanometer
and asked to maintain a pressure of 20-30 mmHg for 10 sec
and then breath out. On exhalation, there is a burst of vagal
activity that slows conduction in the AV node, and may
terminate the dysrhythmia.
• Drug treatment: adenosine 6 mg IV followed by 6 mg, then 12
mg if necessary. Adenosine is a powerful vasodilator, and
transient hypotension is common.

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Atrial flutter

Definition
• Flutter waves occur instead of P waves usually a rate of
300/min and give a sawtooth appearance to the baseline.
Normally there is a 2:1 or 3:1 block. A narrow-complex
tachycardia at a rate very close to 150 bpm is highly
suggestive of flutter with 2:1 block

Causes

Treatment
• Same management as for atrial fibrillation but primarily aimed
at controlling the ventricular rate, although amiodarone or DC
cardioversion may restore sinus rhythm

Ventricular tachycardia
• Ventricular tachycardia is a medical emergency

Definition
• Any broad-complex tachycardia is VT until proven otherwise.
• The main diagnostic difficulty occurs with other forms of
tachycardia in patients who normally have BBB, and whose
QRS complexes are always wide.
• Get 12-lead EKG and compare with previous traces.
• The diagnosis can be confirmed if independent atrial activity
can be spotted: regular P waves superimposed on the
ventricular activity.

Treatment
• Conscious patient: lidocaine 100mg (10 ml of 1%) followed by
an infusion of 1-4 mg/hr.
• Unconscious patients: same treatment as with VF

Bradycardia

Definition
• Slow heart rate

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Causes
• May be normal finding in fit individuals or during sleep as well
as with patients on β-blockers.
• May also be an ominous sign, particularly of hypoxia.

Treatment
• If no underlying cause then treat with oxygen and atropine
(0.5 mg IV)

Heart Block

Definition
• 1st degree: impulse is delayed but gets through each time. A
sign of cardiac disease but not an urgent problem.
• 2nd degree: impulses are sometimes transmitted but not
always. There are more P waves than QRS complexes. There
are two subtypes: type I in which the PR interval gets
progressively longer until a beat is dropped (the Wenckebach
phenomenon) and the more serious type II in which the ratio
of Ps to QRSs is more fixed (e.g. occurring in 2:1 or 3:1
pattern). 2nd degree heart block deserves urgent attention
from a physician.
• 3rd degree in which none of the atrial impulses are conducted.
P waves are regular but bear no relationship to the QRS
complexes. The ventricular rate is usually low. Occurs after
MI, a result of degenerative changes in the conducting system,
or congenital

Causes
• Problem with conduction of the impulse between atria and
ventricles.
• Usually a sign of significant heart disease.

Treatment
• Definitive treatment is transvenous pacing, but as a
temporary measure, the ventricular rate can be improved with
an infusion of isoprenaline.

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Hypertension
• Sustained, severe HTN is associated with MI & CVA
• Need to treat underlying cause before any antihypertensive
medication is given

Definitions
• DBP > 110 definitely abnormal
• Sustained hypertension needs to be treated

Causes

EXCLUDE
• Pain: NEVER give antihypertensives to a patient in pain
• Anxiety
• Drugs: inotropes
• Hypercapnea/hypoxia
• Full bladders (especially in elderly, confused people)
• Malignant hyperthermia
• Hormonal: pheochromocytoma, thyroid crisis, carcinoid …

ESSENTIAL HYPERTENSION
• Undiagnosed hypertension. Brought out by surgery
• Hypertension inadequately controlled before surgery
• Patient mistakenly advised not to take regular medication
preop

Treatment
• Oxygen
• Goal is short-term control

Nifedipine SL
• Sublingual nifedipine 10mg.
• Can be written PRN - 10 mg SL up to q2hr for systolic BP >
170

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Labetalol IV
• For those who cannot take sublingual medication because of
sedation, poor cognitive function on non-cooperation (consider
pain or full bladder) or for those in which nifedipine is
ineffective.
• Titrate IV dose against effect, giving 5mgto start with. After 5-
10 min if no effect, give 10mg, then 15 mg etc.
• Contraindicated in asthma and cardiac failure.

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Myocardial Ischemia
• MI is the single biggest killer in the perioperative period.
• pOP MI often does not generate the typical signs & symptoms.
Chest pain may be masked by analgesic/anesthetic
medication.
• pOP MI occurs most frequently 48-72 hr after surgery
• Needs careful monitoring just like for DVT: identify patients at
risk and employ full range of simple measures to prevent
ischemic complications.

Patients at risk
• Previous MI (especially within last 6 months) or known angina
• Hypertensives (especially those with EKG evidence of LVH)
• Diabetics
• The elderly
• Vascular surgery patients (concomitant CAD)
• Smokers
• Those with EKG evidence of “strain,” bundle branch block or
old MI

Prevention
• Avoid anything that upsets the balance of myocardial oxygen
supply and demand. Avoid tachycardia, hypotension,
hypertension and hypoxia.

Fluid Balance
• Ensure good hydration/adequate UO. Avoid anemia (Hb > 10
mg/dl)

Analgesia
• Pain is very bad for the heart

Oxygen
• Patients will have hypoxia for 3 or 4 days pOP, particularly at
night. Prescribe oxygen for at-risk patients

Hypothermia
• Treat accordingly

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Regular medication
• Continue all cardiovascular medications. Remember that NTG
can be given as a transdermal patch.

Monitoring
• The more the better. Pulse oximeter or automatic BP if
feasible

DVT prophylaxis
• SQ heparin & TEDs

Management
• Examine for evidence of hypotension, CHF or dysrhythmia
• Treat CP with increments of IV MS
• Employ preventative measures above
• Bed rest
• Get 12-lead EKG & compare to preop EKG
• Send blood for serial CKs. CK levels are normally elevated
pOP so be sure to ask for isoenzymes
• Consult medicine/cardiology.

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Pulmonary Edema
• Pulmonary edema is an abnormal accumulation of fluid in the
extravascular spaces and tissues of the lung.
• It is not an uncommon cause of respiratory distress in surgical
patients.

Physiology

Starling forces
• Starling forces describe the flow of fluid in an out of the
pulmonary capillary.

35 20 5 20

Arterial Venous

• Most of the fluid forced out at the arterial end passes back
into the capillary at the venous end; the rest drains out via the
lymphatics.
• If excessive fluid leaks from the capillary, pulmonary edema
results.

Interstitial Edema
• Characterized by engorgement of the interstitial space.
• Effects on lung function are subtle; the lungs become stiffer
and the patient usually complains of SOB.
• Some radiological changes

Alveolar Edema
• When fluid passes into the alveoli themselves.
• Dramatic clinical effects with shrinking of the alveoli, stiffer
lungs, increased work of breathing and impaired gas
exchange.
• The transition from interstitial to alveolar edema tends to
occur suddenly.

Mechanisms
• Increased hydrostatic pressure in the capillary (e.g. LV failure)
• Reduced colloid pressure (e.g. hypoproteinemia)

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• Increased capillary permeability (e.g. in aspiration


pneumonitis or ARDS)

Cardiogenic pulmonary edema

Presentation
• The diagnosis should be obvious clinically

History
• PMH: Like to occur in a patient with known ischemic,
hypertensive or rheumatic heart disease
• Associated with over-enthusiastic fluid therapy
• Sx: Patient complains of sudden, severe dyspnea
made worse by lying flat.

Exam
• Gen: sweating, cool peripheries, sputum is pink/frothy
• VS: tachycardia, tachypnea, hypertension. Hypotension
is a grave sign indicative of cardiogenic shock.
• Chest: B/L basilar rales; there may be an audible wheeze
• CV: raised JVP, gallop rhythm with an S3. Murmurs may
be present and a new murmur is a significant finding.

Investigations
• CXR: A normal-sized heart strongly suggests a non-
cardiogenic cause.
• EKG: looking for AMI or dysrhythmia
• Cardiac enzymes: for r/o MI. If the patient has had recent
surgery, be sure to ask for CK-MB (isoenzymes).
• Echo To study valve function, myocardial
contractility and EF.
• CVP not necessary for diagnosis in the acute case.
• ABG When respiratory failure is suspected.

“Borderline cardiac failure”


• Patients with chronic heart disease while not in overt failure
are at risk of developing pulmonary edema. Factors which
may tip the balance:

Fluid overload
• Patients with chronic heart failure cannot cope with a wide
range of filling pressures.
• However, fear of this complication leads to a tendency to be
excessively miserly with IVF

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Systemic vasoconstriction
• Causes a redistribution of fluid from the systemic to the
pulmonary circulations as with pain, hypothermia or the
wearing-off of anesthetic drugs.

Myocardial ischemia/infarction or dysrhythmias

Management

Initial management
• Sit up, give adequate oxygen by face mask
• If there is evidence of cardiogenic shock or oliguria get help
early
• Titrate in some IV narcotic (MS 2mg at 2 min intervals up to a
maximum of 10 mg). This reduces venous tone and alleviates
agitation and anxiety
• Furosemide / Lasix (20 - 40 mg IVP). The immediate effect of
this drug is venodilation which reduces preload. Later there is
a diuresis.
• Proceed to advanced management (with medical/ICU
consultation) in severe or refractory cases.

Advanced management
• Identify and treat dysrhythmias
• Consider vasodilators (e.g. isosorbide dinitrate IV)
• In severe cases intubate and start mechanical ventilation
• Further measures are required for cardiogenic shock
(hypotension, oliguria) or respiratory failure. These include
inotropes, invasive monitoring, ventilation, and one-to-one
nursing … ICU

Non-cardiogenic pulmonary edema


Causes
• ARDS Final common pathway for a variety of major insults
such as trauma, shock, sepsis, pancreatitis, burns, obstetric
disasters or MSOF. The basic mechanism is an increase in
capillary permeability.
• Pulmonary aspiration of gastric contents
• Pneumonias and sepsis
• Allergic reactions to drugs or blood products
• Neurogenic pulmonary edema. A rare condition in which
pulmonary edema accompanies an acute intracranial lesion
such as head injury, tumor, or hemorrhage.

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Diagnosis
• Suggested by an absence of specific features of cardiac
failure.
• Usually obvious from the history alone.
• The diagnosis can be confirmed by pulmonary edema in the
presence of a normal-sized heart, or normal PCWP.

Management
• ICU
• Specific treatment depends on the precipitating cause
• Supportive management includes ventilation, optimization of
filling pressures and maintenance of colloid oncotic pressure
by avoidance of hypoproteinemia.

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Cardiac Arrest
Who to resuscitate?
• DNR is appropriate when CPR is unlikely to succeed, where it
is contrary to the expressed wishes of a competent patient, or
where CPR is likely to be followed by a length or quality of life
which is unacceptable to the patient. DNR on the basis of age
alone is not appropriate.
• The decision for DNR rests ultimately with the responsible
attending. The decision should be taken as soon as possible
where arrest is deemed likely. The decision should be
reviewed regularly.
• When a DNR order is taken, it should be documented clearly in
the chart, and a brief rationale given.

DNR vs. Withdrawal of treatment


• It may be appropriate to continue various supportive
measures in a patient who is the subject of a DNR order.
• Treatment aimed at alleviating suffering should always be
continued.

Basic life support

Call for help

Airway
• Look for verbal response.
• Open and maintain the airway with jaw thrust/chin lift and
head extension

Breathing
• Listen at the lips while watching the chest.
• If there is no apparent respiratory effort begin mask
resuscitation.

Circulation
• Feel for a carotid pulse (for 5 sec). If absent, start external
cardiac massage at a rate of 80/min.

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• Place one hand on top of the other, on the lower sternum, and
give sharp compressions to depress the sternum by 3-4 cm
each time. If alone give 15 compressions for every two
breaths.

Advanced cardiac life support

General measures
• Intubation, mask ventilation or mechanical ventilation, and
securing of IV access should be performed.
• An EKG monitor should be connected.
• For witnessed arrests, a pre-cordial thump is recommended.
• Further treatment then depends on the heart rhythm

VF or pulseless VT
• DC shock 200J, 200J, 360 J
• Epinephrine 1mg IV
• Continue CPR
• Shock 360, 360, 360
• Consider lidocaine 100 mg (= 5 ml of 2%) or bretylium

Asystole (where VF cannot be excluded)


• Shock 200, 200, 360 then as for asystole

Asystole
• Epinephrine 1mg IV
• Continue CPR
• Atropine 3 mg IV qD
• Consider pacing

Electromechanical Dissociation
• Differential diagnosis is hypovolemia, tension pneumothorax,
pulmonary embolism or cardiac tamponade. Consider specific
therapy for each.
• Epinephrine 1mg IV
• CPR
• Repeat as required.

When to give up

If cardiac output restored


• If cardiac output is restored admit to ICU for further
management.

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• Prognosis depends on the underlying cause of the arrest and


the hypoxic interval; the longer the hypoxic interval the
greater the chance of neurological damage.
• Arterial pH correlates well with outcome. If pH > 7.20, the
outlook is reasonable. Survival where the post-arrest pH < 7.0
is poor.

If cardiac output not restored


• Decision has to be made on when to discontinue CPR.
Normally, 20 minutes of unsuccessful resuscitation is
considered enough.

Indications for prolonged resuscitation include:


• Hypothermia CPR should be continued until body
temperature is normal. Rewarming may require
cardiopulmonary bypass.
• Suspected drug overdose
• Any arrest in children who tend to have a better neurological
prognosis than adults
• During prolonged resuscitation, epinephrine 1 mg IV is given
every 5 minutes. Bicarbonate should only be given for severe
acidosis (pH < 7.0) as documented on blood gas analysis.

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Respiratory Problems
Effects of surgery and anesthesia on
respiratory function
• There are four major effects, decreased lung compliance,
ventilation/perfusion mismatch, hypoventilation and ciliary
dysfunction.

1. Decreased lung compliance


• Stiffer lungs

2. Ventilation/perfusion mismatch
• Anesthesia and surgery upset the delicate mechanisms that
usually match perfusion to ventilation

3. Hypoventilation

Central causes
• Respiratory depressant effects of anesthetic agents, opioids or
CNS pathology

Peripheral causes
• Obesity
• Abdominal distention
• Tight dressings
• Pain
• Any lung pathology which increases the work of breathing
(e.g. bronchospasm or sputum retention)

4. Ciliary dysfunction
• Giving dry gas directly to the airway has a damaging effect on
respiratory mucosa and ciliary function.

Overall effects
• Common finding after surgery is hypoxemia (worse in the
presence of chronic lung disease.
• Dips of oxygen saturation to < 50% are commonplace after
major abdominal surgery. Episodic hypoxemia occurs
especially at night, within 72 hours of the operation. It is
known that this hypoxia is associated with episodes of severe
myocardial infarction.

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Preventative measures
• Identify patients at risk: abdominal or thoracic surgery,
elderly, smokers, COPDers
• Prescribe oxygen therapy.
• Ensure good analgesia

Oxygen therapy

Methods

Standard facemask
• Cannot deliver very high concentrations of oxygen.
• The exact FIO2 depends on the pattern of breathing.
• High respiratory rates will be closer to RA while deeper
breathes will have higher oxygen concentrations.

High-flow masks
• Jet of oxygen is passed through the mask.
• Come in a selection of concentrations 28%, 28%, 35%.
• Are the preferred mode of delivery for patients with significant
chronic lung disease.
• The highest concentration is 35%.

Non-rebreather masks
• The reservoir bag fills up with oxygen during expiration.
• Can deliver up to 85% oxygen.

Nasal cannulae
• Used for comfort
• Cannot give high concentrations of oxygen and are thus not
suitable for very sick patients

Complications

Respiratory depression
• A small subset of patients with chronic lung disease have
grossly abnormal blood gases. As a result of long-standing
lung damage, they have chronically increased work of
breathing and by consequence such hypoventilation that their
central chemoreceptors are extremely tolerant of very high
levels of CO2.
• Their kidneys compensate for the respiratory acidosis by
retaining bicarbonate, so the arterial pH is near normal.
• Instead these patients rely on hypoxia for respiratory drive.
• Giving oxygen will depress the respiratory drive further
increasing the CO2 resulting in depression of consciousness

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and apnea. If the oxygen is discontinued, hypoxia will return


but the CO2 levels will be too high to be overcome and unless
the patient receives mechanical ventilation he will die.
• Hypoxic drive is rare
• Controlled oxygen delivery is the key … do not use face masks
but rather use high-flow oxygen delivery which can be
titrated.

Identifying patients with hypoxic drive


• Patients are bright blue
• History: long h/o of COPD. Shortness of breath at rest or
minimal exertion. Bronchospasm, chronic purulent cough.
Previous uneventful general anesthesia makes hypoxic drive
extremely unlikely.
• Exam: Cyanosis and asterixis (flapping tremor)
• Labs: Blood gases (low PaO2 (< 75 mmHg) and high
PaCO2 (> 55 mm Hg) and slightly low or normal pH under RA.
Be suspicious if bicarbonate is > 30 mmol/l.

Controlled oxygen therapy


• Giving progressively increased concentrations of oxygen and
at each step measuring blood gases after 10 minutes or so.
• If you see an increase in PaO2 without an increase in PaCO2 it
is safe to proceed to the next concentration up.
• If you see an increase in PaCO2, go back down to the step
before and prescribe this much oxygen.

Oxygen toxicity
• Said to occur if concentrations of > 60% are inhaled for long
periods (i.e. > 24 h).
• Hypoxia should never be tolerated because of fear of oxygen
toxicity.

Retrolental fibroplasia
• See in neonates who are ventilated with high oxygen
concentrations, causing fibrosis behind the lens of the eye,
and blindness.

Fire
• See with inveterate, chronic smokers who can’t resist one last
drag while on oxygen therapy.

Indications
• Cyanosis or documented hypoxemia (as with a pulse oximeter)
• Major surgery (24 h postoperatively and at night for 3 nights)
• Shock and severe hemorrhage. Any cause of shock results in
a reduction of oxygen delivery.
• Myocardial ischemia or those at risk of it.

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• Conditions of high metabolic rate. For example, fever, rigors,


thyroid crisis, malignant hyperthermia.
• Reduced consciousness or hypoventilation

Analgesia and respiratory dysfunction


• Any source of pain which prevents movement, deep breathing
or coughing will hamper a patient’s ability to clear secretions
from the lungs.
• The resultant immobility and sputum retention is a potent
recipe for pneumonia.
• However, excessive, or ill-chosen analgesic regimens can also
have an equally catastrophic effect.
• All opioids have respiratory-depressive properties which is
especially dangerous in decompensated patients.

Epidural analgesia
• The gold standard.
• Provides the most effective pain relief available allowing
movement and coughing without pain.
• The respiratory side-effects are comparatively trivial.

IV opioids
• Need to titrate.
• Therefore the best is PCA.
• For patients with airway disease fentanyl is preferred over
morphine because it causes less bronchospasm.

Opioids by other routes


• Intermittent injection should be avoided.
• All opioids have respiratory depressive effects. So-called
“weak opioids” also cause respiratory depression in proportion
to their analgesic effects.

Peripheral nerve blocks


• Excellent for surgery in the peripheries.
• Avoids opioids

NSAIDs
• Are an effective adjunct to postoperative pain management
and reduce the requirement for opioids.
• Significant incidence of bronchospasm; the effect is often
delayed.

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Sputum control
• Humidified oxygen
• Good general hydration.
• Pain relief
• Chest PT: including percussion and postural drainage.

Respiratory distress
• Differential diagnosis
• Asthma
• Pneumonia, collapse, consolidation
• Pulmonary edema
• Pulmonary embolus
• Pneumothorax
• Pulmonary aspiration
• Pleural effusions

Asthma and bronchospasm


• Worsening asthma is heralded by dyspnea, audible wheeze
and the use of accessory muscles.

Five important danger signs;


1. Tachycardia > 120 (although most often caused
by treatment with β-2 agonists or theophylline).
Bradycardia in acute asthma is an indication for a
code.
2. Inability to speak
3. Silent chest (signifies severe hypoventilation)
4. Cyanosis or SaO2< 93%
5. Depressed consciousness

Investigations
• CXR to exclude pneumothorax, pneumonia or aspiration
• ABGs (a PaCO2 in the normal range is bad, suggesting
impending deterioration). Patients with acute asthma who are
coping well usually hyper ventilate with a PaCO2 or 25-
30mmHg

Management
• Humidified oxygen
• salbutamol / and iptraropium / Atrovent by nebulizer
• IV steroids (hydrocortisone 200 mg q6hr for average adult)
• The quantity of nebulized bronchodilator that reaches the
lower airways in acute asthma is small, and if a single
nebulizer has limited effect, it should be immediately followed
by another, then another. Each nebulizer then becomes more

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progressively more effective. Four-hourly nebulizers are for


maintenance, not emergency management.
• Sedatives are absolutely contraindicated. Opioids should also
be avoided if at all possible. Consult pain service/anesthesia if
severe pain coexists.

Pneumonia, collapse and consolidation


• Nosocomial pneumonia occurs in 0.5 - 5% of all in-patients
and 10 - 40 % in the ICU.
• Commonest causative organism is Strep. Pneumoniae but
Gram-negative organisms are seen more often than in
community-acquired pneumonias.
• Diagnosis, suggested by cough, fever, purulent sputum and
consolidation on CXR should be confirmed by blood cultures.
• Sputum clearance is even more important than antibiotics.
Involve chest PT early.

Pulmonary edema
• Pulmonary edema is a potent cause of respiratory distress,
hypoxemia and ventilatory failure.

Pulmonary embolus
• Any patient laid up in bed after surgery is at risk.
• Of PEs, 40-60% are asymptomatic; 10% are fatal. The
common signs are non-specific, and the specific signs are rare,
though pulmonary embolus should always feature in the
differential diagnosis of respiratory distress.
• PE is a diagnosis of exclusion.

Symptoms
• Dyspnea: common. Sudden onset of SOB is the most reliable
indicator.
• Syncope: occasionally
• Pleuritic chest pain and hemoptysis: this occurs in pulmonary
infarction, which is only rarely a consequence of PE.
• Palpitations: AF can occur if there is pre-existing cardiac
disease.

Signs
• Tachycardia and tachypnea: common
• Low-grade fever: may occur
• Wheeze: sometimes
• Hypotension common in massive PE.

Investigations
• CXR minimal change. There may be some loss of
volume. Infarction (with the classic ‘wedge’ appearance) and
pleural effusion is rare.

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• EKG Sinus tachycardia is the usual finding. Acute-onset


AF may be seen. S1Q3T3, right axis deviation and RV
ischemia are rare.
• ABG may show reduced PaO2 but not always. PaCO2 is
usually low.
• Scans Perfusion scan can exclude; V/Q scan required for
definitive proof of diagnosis.

Diagnosis
• Most patients with a PE will be dyspneic, tachycardic with a
normal CXR and sinus tachycardia on the EKG with no other
signs.
• Need to decide whether to heparinize.
• Exclude other causes: pulmonary edema, pneumothorax,
pulmonary collapse, consolidation, aspiration.
• If there are no other likely causes, then a PE can be presumed
and a request for a V/Q scan made at the earliest opportunity.

Management
• Make sure there are no contraindications to anticoagulation
• If not, then give 5000 U IV followed by an infusion of 20,000 -
24000 U per day.
• Monitor the clotting times regularly. A PTT of 2-3 times control
is required. If clotting times fall below this, it is usually
necessary to give a bolus (e.g. 2000 Units) as well as
increasing the infusion rate.
• If the diagnosis is confirmed with a scan, treatment with
warfarin will be required for 3-6 months.
• Remember interactions with aspirin

Pneumothorax
• May be spontaneous, trauma-related or iatrogenic

Spontaneous
• Occur in tall, thin males, or in those with
• COPD/asthma

Trauma-related
• Rib fractures, or
• penetrating chest wounds

Iatrogenic
• Central line insertion
• Brachial plexus block
• as a result of some forms of surgery (e.g. nephrectomy)

Diagnosis
• Index of suspicion with a dyspneic patient

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• Upright CXR

Management
• Large PTX managed with chest tube drainage
• Small non-traumatic ones can sometimes be managed by
aspiration or watched with serial chest x-rays.

Pulmonary aspiration
• Results from inhalation of gastric contents

Predisposing factors
• anesthesia
• emergency surgery
• depressed consciousness
• disorders of swallowing or cough
• use of NG tubes
• pregnancy and tracheostomy

Presentation
• Dyspnea
• Wheezing
• Cough
• Rhonchi
• CXR changes include multilobar infiltrates which may be
alveolar or interstitial and may be unilateral

Management
• Supportive including humidified oxygen, hydration and
artificial ventilation.
• Antibiotics are indicated only if there is definite evidence for
infection, and are usually aimed at Gram-negative organisms.

Pleural effusions
• An effusion seen on a CXR is at least 150 ml
• An effusion picked up clinically is likely to be huge.
• Needle drainage is indicated where respiratory function is
borderline

The emergency CXR

Collapse (atelectasis)
• Increased opacity of the affected lobe
• Loss of volume where the three main changes seen are:
1. Raised hemidiaphragm
2. shift of mediastinal structures towards the lesion,
3. crowding of ribs on the affected side

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• Hyperlucency of adjacent unaffected lobes is sometimes seen,


as they hyperexpand to help fill the space left by the collapse.

Consolidation
• Ill-defined margins
• Irregular shape
• no loss of volume (no mediastinal shift, raised
hemidiaphragm, no rib crowding)
• air bronchograms are common

Pneumonia
• Classical picture of community-acquired “lobar” pneumonia
(Strep. pneumoniae) is uniform consolidation in a single lobe
with air bronchograms and no loss of volume.
• Nosocomial pneumonias (gram-negative bacteria or Staph.
aureus) may show patchy segmental consolidation which may
be bilateral and predominately affect the lower lobes. Air
bronchograms are rarely seen and there may be loss of
volume.

Pneumothorax
• Two findings which are required for the diagnosis of
pneumothorax:
1. loss of vascular markings at the apex, and
2. laterally a visible lung edge
• On a supine film the air collects anteriorly, which is more
difficult to spot, but clues are a unilaterally lucent lung, or a
translucent band parallel to the mediastinum or diaphragm.
• A tension pneumothorax is seen when mediastinal
structures are displaced to the opposite side.
• Tension pneumothorax is, however, a clinical diagnosis, which
must be treated immediately.

Pleural effusion
• A large pleural effusion (300 - 500 ml) should be easy to
detect on an erect chest film.
• Signs are a homogenous opacification of the lower chest, with
loss of costophrenic angle and hemidiaphragm. The upper
margin is concave upwards and higher laterally than medially.
• The signs of a small pleural effusion are usually loss of the
costophrenic angle.

Pulmonary edema
• An excess of fluid in the lungs that is not in the intravascular
compartment.
• Initially the fluid is in the interstitial spaces and, as it worsens,
it eventually spills into the alveolar air spaces.

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Interstitial edema
• Septal lines: fluid collects in the interlobular septa which is
visible as short, horizontal lines 3-6 cm long, known as Kerley
‘B’ lines. They are best seen in the peripheral lower zones.
• Peribronchial cuffing: On normal x-rays a few bronchi can
be seen end-on in the hilar regions. In interstitial edema their
walls appear thickened.
• Vascular changes: Vessel shadows are seen more clearly in
the upper zones than lower, referred to as cephalization.

Alveolar edema
• Irregular shadowing: Gray fluffy shadows are seen, more
frequently in the lower zones. As it progresses, the shadows
become confluent and whiter. Sometimes the hilar zones are
more affected give a “bat’s wins” appearance.
• Pleural effusions: commonly bilateral, but if unilateral more
common on the right. Fluid may be seen in the horizontal
fissure.
• Air bronchograms: common.

Respiratory failure and ventilation


• The lung has two functions: taking up oxygen and getting rid
of carbon dioxide (hypoventilation).
• The vast majority of cases, the respiratory failure results from
both poor oxygenation and hypoventilation.
• Treatment is intermittent positive pressure ventilation (IPPV).
• Provide adequate ventilation to control PaCO2 and thus
removes all work of breathing.
• Less work of breathing also decreases oxygen demand.
• High oxygen concentrations can be delivered and PEEP
applied which improves oxygenation.
• PEEP increases the functional residual capacity (FRC) and
reduces shunt (blood passing through unventilated areas of
lung).

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Oliguria & Catheters


• Low UO is an important sign of hypovolemia and may precede
ARF. Aim for a UO of at least 0.5 ml/kg/hr (1.0 ml/kg/hr in
children). The minimum excretion of sodium load requires a
volume greater than 20ml/hr.

Detection
• Catheterize all high-risk patients: diabetics, CRF, Jaundice,
Elderly, CHF, severe CT Dz.
• Catheterize all major surgeries: major trauma/crush injuries,
burns/electrocutions, hypovolemia/hypoxia, sepsis, major
abdominal/vascular/cardiac cases.
• Exam: (pulse, BP, mental status, skin turgor, eye turgor, dry
mouth).
• Always consider the possibility of urinary retention/obstruction
& examine for full bladder. Retention is a common cause of
postop confusion.
• Exclude signs of heart failure or fluid overload
• Consider furosemide / Lasix dependence

Management of Oliguria

Role of Fluids
• Correct the fluid deficit (with 250 cc of fluid challenge) -> then
reassess.
• If no initial improvement then repeat the challenge; consider
placing CL -> CVP

Role of Diuretics
• Diuretics can only be used when there is accurate knowledge
of volume status
• Consider furosemide dependence

Role of Inotropes
• Consider dopamine (2.5 mcg/kg/min) if volume status is
normalized & UO still low

General care
• Oxygen

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• Check for any nephrotoxic drugs (aminoglycosides, NSAIDs,


diuretics).

Diagnosis of ARF
• Kidney has lost ability to concentrate urine
ARF Hypovolemia
Dilute urine Concentrated urine, low
volume
Iso-osmotic with specific gravity > 1.016
plasma
High sodium content Low sodium content (< 20
meq/l)
Low urine/plasma urea High urine/plasma urea
ratio ratio
Low urine urea content High urine urea content

Catheters
• Indications
1. accurate measurement of UO
2. management of urinary retention
3. compromised micturition
4. bladder irrigation

Urethral catheters
• Use a urojet for analgesia/lubrication; takes time to work
• Antisepsis
• Take weight off bladder neck by taping to leg
• Clamp catheter distal to insertion of inflation channel
• Replace foreskin after catheterizing males

Suprapubic catheterization
• Preferred for management of acute retention
• Contraindications: no distended bladder, post-TURP, in
patients with bladder tumors

Catheter problems

Blockage
• Unblock with a bladder syringe & NS
• Bladder washout
• If unsuccessful, may need to change catheter

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Leaking around the catheter


• From blockage of lumen but mostly from detrusor instability
• Change the catheter for a size smaller

Acute retention
• Common after major surgery, particularly in males ....
associated with prostatic enlargement
• Increased with epidural analgesia
• Catheterize for painful retention only ... exception is with
epidural analgesia where pain may be masked.

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Fever
Causes

Normal postoperative fever


• Stress of surgery may cause a low-grade fever of 37 to 37.5.
It is therefore not usually necessary to work-up every fever in
the early postoperative period.

Non-septic causes
• DVT, Blood transfusion reactions, malignant hyperthermia,
drug reactions

Septic causes

Pneumonia
• Anesthesia + surgery impair sputum clearance. Common
pathogen is still Strep. pneumoniae.

Wound/Abdomen
• Staph. aureus, Gram-negative bacilli like E. coli & anaerobes.

Urine
• Especially after urine catheterization/instrumentation. Gram-
negatives such as E. coli.

Lines
• In any patient with a central line … especially > 1 week.

CNS
• After neurosurgery - especially VP shunt

Extremities
• Ischemic limbs can get infected with anaerobes. Orthopedic
implants can get infected.

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Assessment

History
• W/U only necessary for temperature > 38. Check oral, rectal
or tympanic measurements. Oscillating fevers are suggestive
of an abscess..
• Check recent microbiological history. Note special problems
such as immunocompromise, burns, splenectomy …

Exam
• Check for other signs of sepsis: tachycardia, tachypnea, warm
extremities, wide pulse pressure, rigors, hypotension
• Check clues as to focus: cough/sputum, dysuria, cloudy urine,
purulent wound drainage, peritoneal signs, meningism, long-
standing central line.

Labs
• Check WBC, C-reactive protein, CXR

Specimens
• Key to good microbiological practice.
• Take appropriate specimens before starting empirical
antibiotic therapy.

Blood cultures
• Blood cultures. Chance of catching bacteremia is about 60 -
70% with a 10ml sample. False positive (contaminants) are
common.
• Technique: prep a wide area of skin. Let alcohol dry first. Take
10 ml of blood, then discard needle. Place 5 ml in each bottle
using a fresh needle.
• The best time to take blood cultures is just before the peak of
temperature.

Urine
• Mid-stream urine specimen is useful.
• Finding of significant WBC indicates UTI
• Catheter specimen less useful as WBC may be a normal
finding

Sputum
• Sputum is always full of normal flora.
• The only truly significant result is a heavy growth of a known
respiratory pathogen

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• Blood cultures are a much more productive way to investigate


suspected pneumonia

CSF
• Collected by LP
• Send for gram stain/.microscopy immediately

Wound swabs
• Get frank pus
• Wipes of erythematous areas not useful

Treatment

Non-antibiotic treatment
• Sputum clearance: good analgesia & PT
• For wounds remove one or more sutures. All abscesses
require surgical exploration and drainage.
• For UTI remove catheter. Increase UO. Alkalinization of urine
helps alleviate dysuria.
• DC CL; send tip for Cx

Antibiotic treatment
• Take cultures first

Simple
• First choice is cefuroxime 1.5 g IV q8. Useful coverage for
Staph. aureus, E. coli and Gram-negatives and Strep.
pneumoniae.
• If you suspect anaerobes (after GI/abdominal surgery) add
metronidazole / Flagyl 500mgIV
• If patient received cefuroxime perioperatively then try
amoxicillin + clavulonate / Augmentin

Complicated -> get ID consult


• Recent course of Abx (other than prophylaxis)
• Immunosuppression / neutropenia
• Serious illness, septic shock, burns, MSOF
• Failure of treatment
• known allergy to first-line agents
• known resistant organism (MRSA, VRE)
• Unusual focus of infection

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Hypothermia
Definitions
• Mild 35 -37; Moderate 32 - 35; Severe < 32

Causes
• Anesthesia -> decreased BMR
• Temperature regulation altered
• Normal responses to hypothermia inhibited
• Loss of evaporative heat during surgery
• Use of unwarmed IVF.

Patients at risk
• Extremes of age
• Thoracic/abdominal surgery
• Prolonged surgery
• Emergency surgery
• Massive blood transfusion
• Hypothyroidism or malnutrition

Effects

Cardiovascular
• Vasoconstriction/shivering -> increased myocardial oxygen
demand
• Severe hypothermia -> dysrhythmias and VF
• Increased blood viscosity

Respiratory
• Shivering increases oxygen consumption -> hypoxemia
• Give oxygen to shivering patients
• Oxy hemoglobin curve stabilized

CNS
• Progressive depressed LOC
• Fixed & dilated below 28

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Other
• Decreased clotting function
• Renal/hepatic function decreased
• Hyperglycemia secondary to decreased glucose utilization

Technical problems
• BP measurement difficult; automatic machines misread
• Pulse oximeters may fail due to poor peripheral perfusion
• Phlebotomy difficult

Measurement of body temperature


• Never take axillary temperature
• Oral (rectal more reliable)
• Infrared tympanic membrane thermometer
• Nasopharyngeal/esophageal probes ... reliable for use in
unconscious/ventilated pt.

Management
• Oxygen
• Passive rewarming (remember to cover the scalp)
• Active surface rewarming ... may cause vasodilatation ->
hypotension; treat with fluid
• Active core rewarming (cardiopulmonary bypass or ECMO)

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CNS complications
Confusion: Definition

Delirium
• Used to describe a syndrome of acute, fluctuating disturbance
of attention, memory, sleep, orientation, perception and
psychomotor function.
• Usually occurs in the first few days post-op, often after a lucid
interval.
• It is typically worse at night.
• Not all patients will be agitated (some will be withdrawn)

Dementia
• Differs from delirium in having a gradual onset and in being
largely irreversible.
• It also shows as a global cerebral impairment.

Depression
• May co-exist or mimic delirium and/or dementia.
• Many of the symptoms overlap and may confuse the
diagnosis.

Confusion: Definition

Quick MSE
• Check with a set of simple test for memory and orientation.
• Ask for patients age, the time, the date, the name of the
hospital and the President.
• Ask about the date of a major historical event.
• Ask them to identify staff members by their uniforms
• Ask them to remember an address and repeat it back to you.
• Ask them to count backwards from 20.

Delirium vs. Dementia


• Delirium is an acute condition; dementia is chronic.
• The family can be very useful in comparing pre- vs. Post-
operative states.

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• Remember that: dementia can appear to be worse in


unfamiliar surroundings and that demented patients can suffer
delirium.

Causes of delirium

Metabolic
• Hypoglycemia, hyperglycemia, dehydration, hyponatremia,
uremia, acidosis, hypophosphatemia, hypercalcemia,
hypocalcemia, hypothyroidism, hyperthyroidism, hepatic
failure, porphyria.

Respiratory
• Hypoxia, infection, pulmonary embolus, fat embolus.

Infections
• Respiratory, urinary, wounds, intra-abdominal.

Cardiac
• Myocardial infarct, congestive heart failure, hypotension.

Neurological
• Raised ICP, brain contusion, reduced perfusion, post-ictal
state, CVA/TIA, post-cardiac bypass, infection, sensory/sleep
deprivation.

Excretory
• urinary retention, constipation

Drugs
• iatrogenic or withdrawal

Review drug chart


• Analgesics opioids
• Local anesthetics in overdose
• Psychotropics benzodiazepines, tricyclics, haloperidol /
haldol.
• Anti-emetics prochlorperazine / Compazine,
metoclopramide / Reglan, droperidol.
• Anticholinergics atropine, hyoscine.
• Steroids

Labs
• In all cases, hypoxia, electrolyte imbalance, myocardial
ischemia and infection needs to be actively excluded.
• CBC anemia, leukocytosis (2o to infection)
• Lytes, BUN, Cr Dehydration and electrolyte imbalance
• Glucose hypo/hyperglycemia

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• Urinalysis both for microbiology & chemistry


• Gases ± oximetry for hypoxia or acidosis.
• EKG ± enzymes for ischemia, infarct or dysrhythmias
• Radiology CXR, U/S, CT scans, V/Q scans
• Biochemistry thyroid function, drug screening, porphyrins.

Management of Delirium
• Treatment takes two forms:
1. Dealing with the cause of the delirium
2. Supportive care to prevent deterioration or
injury

Nursing care
• Implement measures to minimize risk of injury.
• Less experienced nurses may be inclined to rely too much on
sedation and should be politely resisted until you are sure
that it is indicated.
• Restraints are very rarely a good idea; they worsen the
agitation and increase the risks of injury.

Rehydration
• Dehydration causes delirium and delirium causes
dehydration.
• Good fluid and electrolyte control is essential and is likely to
need secure IV access, repeated investigations and
measurement of urine output.
• This can be difficult with an uncooperative patient.

Oxygen
• Hypoxia is common, especially at night.
• All patients who have had major surgery should receive
oxygen at night.
• All delirious patients should have at least a trial of oxygen,
along with serial gases or oximetry to find if they are helped
by it.
• Persistent hypoxia with delirium despite oxygen is likely to
mean a transfer to the ICU.

Nutrition & vitamins


• Adequate calories and protein intake needs to be
continued; often by the nasogastric route.
• Vitamin B-12 may be indicated if there is good evidence of
alcoholism or chronic deficiency.

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Sedatives
• Should be a last resort, not an automatic reaction to
delirium.
• Most sedatives can cause delirium and that many are
respiratory depressants.
• When sedation is essential it is best given in regular small
doses.
• Benzodiazepines are respiratory depressants, long-acting and
disturb normal cognitive function; unless they are specifically
indicated they should be avoided.
• Haloperidol /haldol is a good choice and can be given orally
in doses of 0.5 - 2.0 mg q6hrs.
• Thioridazine / Mellaril is an alternative in doses of 5 - 10 mg q
8hr. This dose can be increased to a maximum of 30 mg
q8hrs.

Withdrawal

Alcohol

Benzodiazepines

Opioid

Insomnia
• Rule-out pain, delirium, withdrawal or depression.

Benzodiazepines
• Essential to pick a short-acting agent to avoid daytime
sedation.
• Try Serax 10-15mg PO.
• Problems include respiratory depression and addiction.
• All patients must be warned that hypnotics are extremely
habit-forming and should be used infrequently, irregularly and
only in the short-term.
• Reduce the dose in the elderly and avoid benzodiazepines
altogether when respiratory function is critical.

Other sedative drugs


• Tricyclic antidepressants have sedative properties and improve
sleep in depressed patients.

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• Antihistamines
• Opioid analgesics are powerful respiratory depressants and
should only be used in the ICU.

Coma
• Coma is never a normal finding, nor is it safe to attribute it to
anesthesia.
• When there is good reason to suspect drug-induced coma a
therapeutic trial of a specific antagonist is reasonable.
• Naloxone / Narcan (0.1 to 0.2 mg) reverses opioid sedation but
also the analgesia.; short duration of action and may require
several doses.
• Flumazenil / Romazicon (200 mcg IV) reverses the effects of
benzodiazepines.
• If coma persists think about ICU.

Convulsions/Seizures

Causes

Neurological
• Brain contusion, infections, raised ICP, epilepsy, CVA

Drugs
• many agents in overdose including lithium, tricyclics,
aminophylline, NSAIDs, anti-emetics, local anesthetics

Withdrawal
• commonly alcohol

Metabolic
• hyponatremia, hypoglycemia, hypercalcemia,
hypomagnesemia

Respiratory
• hypoxia, alkalosis

Infection
• febrile convulsions in children

Pregnancy
• eclampsia

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Treatment

Supportive
• Maintain a clear airway
• Supplemental oxygen
• Prevention of injury

Medication
• Emergency drug of choice is diazepam / Valium (10 - 29 mg IV
slowly or 10 - 20 mg PR). This can be followed by phenytoin /
Dilantin (15 mg/kg IV slowly).
• Continued seizures may require general anesthesia.
• The cause of the fit must be vigorously pursued with clinical
and laboratory tests. Don’t forget a pregnancy test in
young women.

Extrapyramidal problems
• Pre-existing Parkinsonism may worsen during a surgical
admission due to difficulty in administering the medications.
• Extrapyramidal symptoms such as rigidity, tremor, dystonia,
akathisia, tardive dyskinesia and oculogyric crisis may be
precipitated by many drugs used perioperatively.
• Notably anti-emetics (droperidol, metoclopramide / Reglan,
prochlorperazine / Compazine) and antipsychotics
(chlorpromazine / Thorazine and haloperidol / Haldol).
• These should be used with caution in the elderly and avoided
whenever possible in Parkinsonian patients.
• Antimuscarinics (benztropine mesylate / Cogentin) 1-2 mg
PO/IM qD/bid are used to treat symptoms of drug-induced
Parkinsonism.

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Thrombosis
• Thrombosis is a common consequence of anesthesia and
surgery. Occurs in up to 25% of all surgical procedures.
• Arises from:
1. Abnormal blood flow,
2. Hypercoagulability,
3. Endothelial injury.

High-risk groups
• Orthopedic surgery
• Gynecological surgery
• Cardiac failure
• Malignancy
• Obesity
• Elderly, strokes & generalized immobility
• Progesterone/Estrogen therapy
• PVD/varicose veins
• h/o DVT/PE
• Unusual hypercoagulable states

Prevention
• Early mobilization (with adequate pain control).
• SQ heparin (5000 U SC x 5 days) -> thrombocytopenia occurs
in 0.3%.
• LMWH.
• TEDs (TEDs + heparin may be additive).
• Pneumoboots.
• Epidural/spinal anesthesia.
• Coumadin (especially for orthopedic surgery).

Diagnosis

DVT
• DVT is commonly asymptomatic.
• Calf pain (redness, swelling and engorged superficial veins).
Positive Homan’s sign.
• Groin pain (with iliofemoral thrombosis).
• Cyanotic discoloration of affected limb.

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Management
• Calf DVT -> PE rare.
• However, calf DVTs may extend proximally.
• Treat with heparin ... then continue anticoagulation for 3
months.

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Miscellaneous
Postoperative problems
Thyroidectomy problems

Airway obstruction

Postoperative hematoma
• May be dramatic.
• Management is to remove the skin closure clips and evacuate
the clot at the bedside.

Laryngeal edema
• Sometimes occurs on the 2nd or 3rd day and is gradual in onset.
• Severe stridor may necessitate tracheostomy.

Recurrent laryngeal nerve injury


• Not uncommon, but is usually unilateral and often transient.
• Complete, bilateral damage may result in adducted cords and
airway obstruction.
• Patients usually have cord function assessed by an ENT
surgeon before thyroidectomy.

Tracheomalacia
• A very large long-standing goiter may erode the tracheal
cartilages.
• When the enlarged gland is removed, the trachea collapses on
inspiration.

Hormonal problems

Thyroid crisis
• Now rare, as a toxic gland is rarely operated on.
• Clinical features include fever, tachycardia, dysrhythmias,
abdominal pain and diarrhea.
• Treatment is with β-blockers, iodide and steroids.
• Help from an endocrinologist/ICU should be sought.
• Mortality is extremely high.

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Hypoparathyroidism
• If all four parathyroid glands are removed, hypocalcemia will
result.
• It is important to check calcium post-operatively.
• Severe hypocalcemia causes tetany.
• Treatment initially is with 20ml of 10% calcium gluconate
given slowly IV.

TUR syndrome
• Important condition that sometimes complicates transurethral
resection of the prostate.

Causes
• Occurs as a result of absorption of large quantities of the 1.5%
glycine irrigating solution through open venous sinuses.
• Has an incidence of up to 15% of TURPs, and is not
uncommonly fatal.

Signs
• The clinical effects are mainly due to hemodilution and
hyponatremia.
• The first signs are restlessness, headache, confusion.
• Initial hemodynamic signs are a widening of the pulse
pressure and increase in SBP. This is followed by hypotension,
bradycardia, dysrhythmias and, in severe cases, cardiac
arrest.
• If severe, cerebral edema with convulsions or coma, and
pulmonary edema.

Diagnosis
• Confirmed by measurement of plasma sodium. Problems are
likely when the sodium is < 120, but any significant drop
should be taken significantly.
• The hemoglobin and hematocrit are usually depressed by the
hemodilution.

Management

Loop diuretics
• Furosemide 40 mg IV.
• Given that the majority of the patients are fluid overloaded
and the most serious complications (cerebral edema) are a
consequence of this. However, furosemide causes diuresis by
removal of sodium which is a curious way to treat
hyponatremia.

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Do nothing
• Based on the knowledge that many patients with severe
hyponatremia (as low as 104 mmol/l) may be asymptomatic
and spontaneously correct the problem.
• Rapid correction of hyponatremia is dangerous.

Active treatment with saline


• Give either NS or more controversially 1.8% hypertonic saline.
• The big danger is that there will be further volume loading in a
patient who is already overloaded.
• It has been recommended that the sodium level should not
rise more than 2 mmol/hr.

Stable patients
• Receive only the usual maintenance fluid; avoid dextrose or
dextrose-saline solutions.
• Hesitate to treat a low hematocrit with blood transfusion
unless you are sure that a heavy blood loss took place.
• Check electrolytes regularly (q6hr).

Unstable patients
• Hemodynamic instability or convulsions should be managed in
the ICU.
• The difficulties with the clinical assessment of volume status
make invasive monitoring with CVP or even Swan-Ganz
catheters justified.
• Inotropes or calcium may be indicated and coagulation studies
performed as DIC is a recognized complication.

Eye problems

Corneal abrasion
• The eye is sore and red, with a gritty feeling.
• Confirm diagnosis by placing a drop of 0.5% amethocaine,
followed by fluorescein. The abrasion will take up the stain.
• Treatment consists of an eye pad and bandage, and
chloramphenicol ointment.

Acute (closed angle) glaucoma)


• Severe pain in and around the eye along with nausea and
vomiting.
• The cornea may be cloudy and the pupil dilated.
• Call an ophthalmologist stat
• Emergency treatment is with diuretics such as acetazolamide /
Diamox 500mg or 10% mannitol.

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Acute blindness
• Rare (and often transient)
• May occur due to retinal infarction from prolonged pressure on
the eye, from basilar artery spasm, acute MS or even TUR
syndrome.
• Although there is no specific treatment advice from an
ophthalmologist should be urgently sought.
• In the case of retinal infarction, place a patch over the eye to
decrease the metabolic work and hence oxygen requirement
of the ischemic retina.

Post-intubation problems

Sore throat
• Common
• Requires only symptomatic treatment (lozenges).

Dental damage
• Teeth should be found
• early in-patient dental treatment should be offered

Damage to pharyngeal mucosa


• can lead to extensive surgical emphysema or retropharyngeal
abscess

Damage to vocal cords


• transient hoarseness

Arytenoid dislocation
• Presents with hoarseness and odynophagia
• ENT referral indicated

Recurrent laryngeal nerve damage


• may be damaged

Musculoskeletal problems

Swollen joints

Gout
• For a single joint (especially the foot), the most likely cause
postoperatively is gout.
• Measure uric acid.

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• Involve a rheumatologist
• Treat with strong NSAIDs (indomethacin 50 mg tid)

Septic arthritis
• There will be signs of infection
• Treatment is with immobilization, antibiotics and joint
aspiration.

Nerve injuries
• Occur as a result of poor positioning, injection of substances
into the nerve or use of tourniquets.
• Full documentation should be made immediately a nerve
injury is suspected.
• Recovery is usual, but may take months.

Anaphylactoid reactions

Causes
• Type 1 hypersensitivity reaction, or true anaphylaxis. In
this type, prior exposure to the drug is required. On the first
exposure, lymphocytes produce specific IgE antibodies, which
attach to the membranes of mast cells and basophils. A
second exposure leads to degranulation of mast cells on a
massive scale.
• Complement-mediated reactions. Here exposure leads to
activation of complement cascade which cause mast cell
degranulation. Prior exposure is not necessary.

Presentation
• Skin: characteristic urticarial rash or flushing usually
appears rapidly
• Cardiovascular system: hypotension to total
cardiovascular collapse. Hypotension is the result of release
of histamine and other vasoactive peptides which cause
widespread capillary vasodilation and increased capillary
permeability. Leakage of fluid may cause significant ECF loss.
Dysrhythmias may occur, most commonly supraventricular
tachycardia.
• Bronchospasm: may be life-threatening
• Glottic edema: occasionally occurs, threatening the
airway.
• Gastrointestinal: Immediately after recovery, the patient
may complain of abdominal pain, diarrhea, nausea and
vomiting.
• Miscellaneous: Other effects include conduction
defects, coagulation disorders and leukopenia.

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Management

Immediate
• Discontinue administration of suspected drugs, give oxygen
and maintain the airway.
• Call a cardiac arrest.
• Give epinephrine. The earlier the epinephrine given, the
better the outcome. Initial IV dose should be 0.1 mg (which is
1 m of 1 in 10,000) given in increments of 0.1 mg.
• Give IVF stat. 1-2 liters of saline. Good venous access is
required (14 or 16 gauge). Colloid solutions may be preferable
if available.
• Glottic edema may require intubation or cricothyroidotomy.

Second-line
• Antihistamines. The agent of choice is chlorpheniramine /
Chlor-Trimeton (10-20 mg slowly IV) or diphenhyramine /
Benadryl (25 - 50 mg IV/PO/IM q 6hr).
• Aminophylline may be required for persistent bronchospasm
particularly in the absence of hypotension; 5 mg/kg can be
given over 20 minutes.
• Steroids have no place in immediate management. They may
be given if the reaction persists, for example hydrocortisone
200 mg IV.
• Labs: it may be desirable to take blood samples to confirm the
diagnosis and identify the agent responsible. Two EDTA (red-
top) tubes should be taken immediately after the reaction and
again at 3, 6, 12 and 24 hours.
• When a drug is implicated with reasonable certainty, the
patient should be informed. Full documentation should be
made. Inform the patient’s primary care physician.

Tracheostomy

Tracheostomy Care
• Patient’s cannot speak (except with ‘fenestrated’ tubes which
are placed later in the recovery). Make sure writing materials
are available.
• Normal cough is not possible. Regular suctioning and PT are
need to prevent sputum retention.
• Dysphagia is common due to the bulk of the cuff and to poorly
coordinated swallowing. This may be partially relieved by
temporarily deflating the cuff. It is important to assess
swallowing before allowing solids. Use methylene blue, ask
the patient to swallow, observe for coughing, and then
examine the tracheal aspirate for coloration.

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• The presence of a foreign body is irritating and causes


secretions. These may form hard crusts and can obstruct the
tube. Humidification and regular suctioning are effective in
prevention.
• Pressure necrosis of the trachea is caused by a poorly
positioned tube or an overinflated cuff. This can result in
stenosis or edema which make extubation impossible. Erosion
into the anterior neck can lead to fatal hemorrhage. Always
check cuff pressure regularly and do not let it exceed 20
cmH2O.

Changing the tube


• Changing the tube can be hazardous.
• The tissue planes can shift on removing the old tube so that
the tract disappears.
• A common mistake is to place the new tube too far anteriorly
which results in cannulation of the anterior mediastinum and
no useful airway.
• To intubate the trachea direct the tube first posteriorly until it
reaches the back wall of the trachea (a depth of 3-4 cm) and
then turn it inferiorly.
• If you are faced with an obstructed tracheostomy put out a
code call.
• Check the tube for obvious blockage, then try to pass a
suction catheter through it.

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