142 Section I / Overview and Background Surgical Information

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

When is a Greenfield filter indicated?

Oil pipeline filters!

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

What is the treatment if the patient’s condition is unstable?

What is the Trendelenburg operation?

What is a “retrievable” IVC filter?

What percentage of retrievable IVC filter are actually removed?

What prophylactic measures can be taken for DVT/PE?

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

Pulmonary artery embolectomy

IVC filter that can be removed (“retrieved”)

Only about 20%

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

ASPIRATION PNEUMONIA

What is it?	Pneumonia following aspiration of vomitus
What are the risk factors?	Intubation/extubation, impaired
	consciousness (e.g., drug or EtOH
	overdose), dysphagia (esophageal disease),
	nonfunctioning NGT, Trendelenburg
	position, emergent intubation with full
	stomach, gastric dilatation
What are the signs/	Respiratory failure, CP, increased sputum
symptoms?	production, fever, cough, mental status
	changes, tachycardia, cyanosis, infiltrate
	on CXR

	Chapter 22 / Complications 143
What are the associated	Early—fluffy infiltrate or normal CXR
CXR findings?	Late—pneumonia, ARDS
Which lobes are commonly	Supine—RUL
involved?	Sitting/semirecumbent—RLL
Which organisms are	Community acquired—gram-positive/
commonly involved?	mixed
	Hospital/ICU—gram-negative rods
Which diagnostic tests are	CXR, sputum, Gram stain, sputum
indicated?	culture, bronchoalveolar lavage
What is the treatment?	Bronchoscopy, antibiotics if pneumonia
	develops, intubation if respiratory failure
	occurs, ventilation with PEEP if ARDS
	develops
What is Mendelson’s	Chemical pneumonitis secondary to
syndrome?	aspiration of stomach contents
	(i.e., gastric acid)
Are prophylatic antibiotics	NO
indicated for aspiration
pneumonitis?
GASTROINTESTINAL COMPLICATIONS
What are possible NGT	Aspiration-pneumonia/atelectasis
complications?	(especially if NGT is clogged)
	Sinusitis
	Minor UGI bleeding
	Epistaxis
	Pharyngeal irritation, gastric irritation
GASTRIC DILATATION
What are the risk factors?	Abdominal surgery, gastric outlet
	obstruction, splenectomy, narcotics
What are the signs/	Abdominal distension, hiccups,
symptoms?	electrolyte abnormalities, nausea
What is the treatment?	NGT decompression

144 Section I / Overview and Background Surgical Information

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

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

POSTOPERATIVE PANCREATITIS

What is it?	Pancreatitis resulting from manipulation
	of the pancreas during surgery or low
	blood flow during the procedure
	(i.e., cardiopulmonary bypass), gallstones,
	hypercalcemia, medications, idiopathic
What lab tests are	Amylase and lipase
performed?
What is the initial	Same as that for the other causes of
treatment?	pancreatitis (e.g., NPO, aggressive fluid
	resuscitation, NGT PRN)
CONSTIPATION
What are the postoperative	Narcotics, immobility
causes?
What is the treatment?	OBR
What is OBR?	Ortho Bowel Routine: docusate sodium
	(daily), dicacodyl suppository if no bowel
	movement occurs, Fleet® enema if
	suppository is ineffective
SHORT BOWEL SYNDROME
What is it?	Malabsorption and diarrhea resulting from
	extensive bowel resection ( 120 cm of
	small bowel remaining)
What is the initial	TPN early, followed by many small meals
treatment?	chronically
POSTOPERATIVE SMALL BOWEL OBSTRUCTION (SBO)/ILEUS
What causes SBO?	Adhesions (most of which resolve
	spontaneously), incarcerated hernia
	(internal or fascial/dehiscence)

	Chapter 22 / Complications 145
What causes ileus?	Laparotomy, hypokalemia or narcotics,
	intraperitoneal infection
What are the signs of	Flatus PR, stool PR
resolving ileus/SBO?
What is the order of recovery	First—small intestine
of bowel function after	Second—stomach
abdominal surgery?	Third—colon
When can a postoperative	From 12 to 24 postoperative hours
patient be fed through a	because the small intestine recovers
J-tube?	function first in that period
JAUNDICE
What are the causes of the
following types of
postoperative jaundice:
Prehepatic	Hemolysis (prosthetic valve), resolving
	hematoma, transfusion reaction,
	postcardiopulmonary bypass, blood
	transfusions (decreased RBC compliance
	leading to cell rupture)
Hepatic	Drugs, hypotension, hypoxia, sepsis,
	hepatitis, “sympathetic” hepatic
	inflammation from adjacent right lower
	lobe infarction of the lung or pneumonia,
	preexisting cirrhosis, right-sided heart
	failure, hepatic abscess, pylephlebitis
	(thrombosis of portal vein), Gilbert
	syndrome, Crigler-Najjar syndrome,
	Dubin-Johnson syndrome, fatty infiltrate
	from TPN
Posthepatic	Choledocholithiasis, stricture, cholangitis,
	cholecystitis, biliary-duct injury,
	pancreatitis, sclerosing cholangitis, tumors
	(e.g., cholangiocarcinoma, pancreatic
	cancer, gallbladder cancer, metastases),
	biliary stasis (e.g., ceftriaxone [Rocephin®])
What blood test results would	Decreased—Haptoglobin, Hct
support the assumption that	Increased—LDH, reticulocytes
hemolysis was causing	Also, fragmented RBCs on a peripheral
jaundice in a patient?	smear

146 Section I / Overview and Background Surgical Information

BLIND LOOP SYNDROME

What is it?	Bacterial overgrowth in the small intestine
What are the causes?	Anything that disrupts the normal flow of
	intestinal contents (i.e., causes stasis)
What are the surgical causes	Blind loop syndrome, gastrectomy
of B12 deficiency?	(decreased secretion of intrinsic factor)
	and excision of the terminal ileum (site of
	B12 absorption)
POSTVAGOTOMY DIARRHEA
What is it?	Diarrhea after a truncal vagotomy
What is the cause?	It is thought that after truncal vagotomy,
	a rapid transport of bile salts to the colon
	results in osmotic inhibition of water
	absorption in the colon, leading to diarrhea
DUMPING SYNDROME
What is it?	Delivery of hyperosmotic chyme to the
	small intestine causing massive fluid
	shifts into the bowel (normally the
	stomach will decrease the osmolality of
	the chyme prior to its emptying)

With what conditions is it associated?

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

What are the signs/	Postprandial diaphoresis, tachycardia,
symptoms?	abdominal pain/distention, emesis,
	increased flatus, dizziness, weakness
How is the diagnosis made?	History; hyperosmolar glucose load will
	elicit similar symptoms
What is the medical	Small, multiple, low-fat/carbohydrate
treatment?	meals that are high in protein content;
	also, avoidance of liquids with meals to
	slow gastric emptying; surgery is a last
	resort