138 Section I / Overview and Background Surgical Information

What is the danger of prolonged use of Demerol?

Accumulation of metabolite normeperidine (especially with renal/hepatic dysfunction), which may result in oversedation, hallucinations, and seizures!

What medication reverses	Naloxone (Narcan®), 0.4 mg IV
the effects of narcotic
overdose?
Narcotic used to decrease	Demerol®
postoperative shivering?
MISCELLANEOUS
What reverses the effects of	Flumazenil (Romazicon®), 0.2 mg IV
benzodiazepines?
What is Toradol®?	Ketorolac IV NSAID
What are the risks of	GI bleed, renal injury, platelet
Toradol®?	dysfunction
Why give patients IV Cipro	No reason—500 mg of Cipro PO gives
if they are eating a regular	the same serum level as 400 mg Cipro
diet?	IV! And PO is much cheaper!
What is clonidine	Abruptly stopping clonidine can cause
“rebound”?	the patient to have severe “rebound”
	hypertension (also seen with -blockers)

C h a p t e r 22	Complications
ATELECTASIS
What is it?	Collapse of the alveoli
What is the etiology?	Inadequate alveolar expansion (e.g., poor
	ventilation of lungs during surgery,
	inability to fully inspire secondary to
	pain), high levels of inspired oxygen

Chapter 22 / Complications 139

What are the signs? Fever, decreased breath sounds with rales, tachypnea, tachycardia, and increased density on CXR

What are the risk factors? Chronic obstructive pulmonary disease (COPD), smoking, abdominal or thoracic surgery, oversedation, poor pain control

(patient cannot breathe deeply secondary to pain on inspiration)

What is its claim to fame? Most common cause of fever during PODs #1 to #2

What prophylactic measures Preoperative smoking cessation, incentive can be taken? spirometry, good pain control

What is the treatment? Postoperative incentive spirometry, deep breathing, coughing, early ambulation, NT suctioning, and chest PT

POSTOPERATIVE RESPIRATORY FAILURE

What is it?	Respiratory impairment with increased
	respiratory rate, shortness of breath,
	dyspnea
What is the differential	Hypovolemia, pulmonary embolism,
diagnosis?	administration of supplemental O2 to
	a patient with COPD, atelectasis,
	pneumonia, aspiration, pulmonary
	edema, abdominal compartment syndrome,
	pneumothorax, chylothorax, hemothorax,
	narcotic overdose, mucous plug
What is the treatment?	Supplemental O2, chest PT; suctioning,
	intubation, and ventilation if necessary
What is the initial workup?	ABG, CXR, EKG, pulse oximetry, and
	auscultation
What are the indications for	Cannot protect airway (unconscious),
intubation and ventilation?	excessive work of breathing, progressive
	hypoxemia (PaO2 55 despite
	supplemental O2), progressive acidosis
	(pH 7.3 and PCO2 50), RR 35

140 Section I / Overview and Background Surgical Information

What are the possible causes of postoperative pleural effusion?

What is the treatment of postoperative wheezing?

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

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

Albuterol nebulizer

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

PULMONARY EMBOLISM

What is a pulmonary	DVT that embolizes to the pulmonary
embolism (PE)?	arterial system
What is DVT?	Deep Venous Thrombosis—a clot forming
	in the pelvic or lower extremity veins

Is DVT more common in the Left is more common (4:1) because the

right or left iliac vein?	aortic bifurcation crosses and possibly
	compresses the left iliac vein
What are the signs/symptoms	Lower extremity pain, swelling, tenderness,
of DVT?		Homan’s sign, PE
	Up to 50% can be asymptomatic!
What is Homan’s sign?	Calf pain with dorsiflexion of the foot
	seen classically with DVT, but actually
	found in fewer than one third of patients
	with DVT
What test is used to evaluate	Duplex ultrasonography
for DVT?
What is Virchow’s triad?	1.	Stasis
	2.	Endothelial injury
	3. Hypercoagulable state (risk factors for
		thrombosis)

What are the risk factors for DVT and PE?

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

	Chapter 22 / Complications 141
What are the signs/symptoms	Shortness of breath, tachypnea,
of PE?	hypotension, CP, occasionally fever, loud
	pulmonic component of S2, hemoptysis
	with pulmonary infarct

What are the associated lab findings?

Which diagnostic tests are indicated?

What are the associated CXR findings?

What are the associated EKG findings?

ABG—decreased PO2 and PCO2 (from hyperventilation)

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

1.Westermark’s sign (wedge-shaped area of decreased pulmonary vasculature resulting in hyperlucency)

2.Opacity with base at pleural edge from pulmonary infarction

50% are abnormal; classic finding is cor pulmonale (S1Q3T3 RBBB and right-axis deviation); EKG most commonly shows flipped T waves or ST depression

What is a “saddle” embolus? PE that “straddles” the pulmonary artery and is in the lumen of both the right and left pulmonary arteries

What is the treatment if the patient is stable?

What is a Greenfield filter?

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

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