Chapter 22 / Complications 147
What is the surgical	Conversion to Roux-en-Y ( reversed
treatment?	jejunal interposition loop)

What is a reversed jejunal interposition loop?

Segment of jejunum is cut and then reversed to allow for a short segment of reversed peristalsis to slow intestinal transit

ENDOCRINE COMPLICATIONS

DIABETIC KETOACIDOSIS (DKA)

What is it?	Deficiency of body insulin, resulting in
	hyperglycemia, formation of ketoacids,
	osmotic diuresis, and metabolic acidosis

What are the signs of DKA?

What are the associated lab values?

What is the treatment?

What electrolyte must be monitored closely in DKA?

Polyuria, tachypnea, dehydration, confusion, abdominal pain

Elevated glucose, increased anion gap, hypokalemia, urine ketones, acidosis

Insulin drip, IVF rehydration, K supplementation, bicarbonate IV

Potassium and HYPOkalemia (Remember correction of acidosis and GLC/insulin drive K into cells and are treatment for HYPERkalemia!)

What must you rule out in a diabetic with DKA?

Infection (perirectal abscess is classically missed!)

ADDISONIAN CRISIS

What is it?	Acute adrenal insufficiency in the face
	of a stressor (i.e., surgery, trauma,
	infection)
How can you remember	Think: ADDisonian ADrenal Down
what it is?
What is the cause?	Postoperatively, inadequate cortisol
	release usually results from steroid
	administration in the past year

148 Section I / Overview and Background Surgical Information

What are the signs/	Tachycardia, nausea, vomiting, diarrhea,
symptoms?	abdominal pain, fever, progressive
	lethargy, hypotension, eventual
	hypovolemic shock
What is its clinical claim to	Tachycardia and hypotension refractory
infamy?	to IVF and pressors!
Which lab values are classic?	Decreased Na , increased K (secondary
	to decreased aldosterone)
How can the electrolytes	Think: DOWN the alphabetical
with ADDisonian ADrenal	electrolyte stairs
Down be remembered?
	J
		K+
		L
		M
			Na+
			O
What is the treatment?	IVFs (D5 NS), hydrocortisone IV,
	fludrocortisone PO
What is fludrocortisone?	Mineralocorticoid replacement
	(aldosterone)
SIADH
What is it?	Syndrome of Inappropriate AntiDiuretic
	Hormone (ADH) secretion (think of
	inappropriate increase in ADH
	secretion)
What does ADH do?	ADH increases NaCl and H2O resorption
	in the kidney, increasing intravascular
	volume (released from posterior
	pituitary)

	Chapter 22 / Complications 149
What are the causes?	Mainly lung/CNS: CNS trauma, oat-cell
	lung cancer, pancreatic cancer, duodenal
	cancer, pneumonia/lung abscess, increased
	PEEP, stroke, general anesthesia, idio-
	pathic, postoperative, morphine

What are the associated lab findings?

How can the serum sodium level in SIADH be remembered?

What is the treatment?

DIABETES INSIPIDUS (DI)

Low sodium, low chloride, low serum osmolality; increased urine osmolality

Remember, SIADH Sodium Is Always Down Here hyponatremia

Treat the primary cause and restrict fluid intake

What is it?	Failure of ADH renal fluid conservation
	resulting in dilute urine in large amounts
	(Think: DI Decreased ADH)

What is the source of ADH?

What are the two major types?

What is the mechanism of the two types?

POSTERIOR pituitary

1.Central (neurogenic) DI

2.Nephrogenic DI

1.Central DI decreased production of ADH

2.Nephrogenic DI decreased ADH effect on kidney

What are the classic causes of central DI?

What are the classic causes of nephrogenic DI?

What lab values are associated with DI?

What is the treatment?

BRAIN injury, tumor, surgery, and infection

Amphotericin B, hypercalcemia, and chronic kidney infection

HYPERnatremia, decreased urine sodium, decreased urine osmolality, and increased serum osmolality

Fluid replacement; follow NA levels and urine output; central DI warrants vasopressin; nephrogenic DI may respond to thiazide diuretics

150 Section I / Overview and Background Surgical Information

CARDIOVASCULAR COMPLICATIONS

What are the arterial line complications?

What is an Allen test?

Infection; thrombosis, which can lead to finger/hand necrosis; death/hemorrhage from catheter disconnection (remember to perform and document the Allen test before inserting an arterial line or obtaining a blood gas sample)

Measures for adequate collateral blood flow to the hand via the ulnar artery:

Patient clenches fist; clinician occludes radial and ulnar arteries; patient opens fist and clinician releases only the ulnar artery

If the palm exhibits immediate strong blush upon release of ulnar artery, then ulnar artery can be assumed to have adequate collateral flow if the radial artery were to thrombose

What are the common causes of dyspnea following central line placement?

What is the differential diagnosis of postoperative chest pain?

What is the differential diagnosis of postoperative atrial fibrillation?

MYOCARDIAL INFARCTION (MI)

Pneumothorax, pericardial tamponade, carotid puncture (which can cause a hematoma that compresses the trachea), air embolism

MI, atelectasis, pneumonia, pleurisy, esophageal reflux, PE, musculoskeletal pain, subphrenic abscess, aortic dissection, pneumo/chyle/hemothorax, gastritis

Fluid overload, PE, MI, pain (excess catecholamines), atelectasis, pneumonia, digoxin toxicity, hypoxemia, thyrotoxicosis, hypercapnia, idiopathic, acidosis, electrolyte abnormalities

What is the most dangerous	Six months after an MI
period for a postoperative
MI following a previous MI?

What are the risk factors for postoperative MI?

History of MI, angina, Qs on EKG, S3, JVD, CHF, aortic stenosis, advanced age, extensive surgical procedure, MI within 6 months, EKG changes

	Chapter 22 / Complications 151
How do postoperative MIs	Often without chest pain
present?	New onset CHF, new onset cardiac
	dysrhythmia, hypotension, chest
	pain, tachypnea, tachycardia, nausea/
	vomiting, bradycardia, neck pain, arm
	pain
What EKG findings are	Flipped T waves, ST elevation, ST
associated with cardiac	depression, dysrhythmias (e.g., new
ischemia/MI?	onset A fib, PVC, V tach)
Which lab tests are	Troponin I, cardiac isoenzymes (elevated
indicated?	CK mb fraction)
What is the treatment of	Nitrates (paste or drip), as tolerated
postoperative MI?	Aspirin
	Oxygen
	Pain control with IV morphine
	-blocker, as tolerated
	Heparin (possibly; thrombolytics are
	contraindicated in the postoperative
	patient)
	ICU monitoring
How can the treatment of	“BEMOAN”:
postoperative MI be	BEta-blocker (as tolerated)
remembered?	Morphine
	Oxygen
	Aspirin
	Nitrates
When do postoperative MIs	Two thirds occur on PODs #2 to #5
occur?	(often silent and present with dyspnea
	or dysrhythmia)
POSTOPERATIVE CVA
What is a CVA?	CerebroVascular Accident (stroke)
What are the signs/	Aphasia, motor/sensory deficits usually
symptoms?	lateralizing
What is the workup?	Head CT scan; must rule out hemorrhage
	if anticoagulation is going to be used;
	carotid Doppler ultrasound study to
	evaluate for carotid occlusive disease