 \212 \212 \212 \212 \212 \212 \212 Practical hints \212 Some prefer to control blood sugar with a glucose-potassium-insulin (GKI) infusion. If the patient is having minor surgery and thus will definitely be able to eat postop, IV insulin may not be necessary. Some advocate giving the patient a small glucose drink early on the m orning of surgery and delaying his morning insulin dose and breakfast until after the proce dure. If in doubt, check with the anesthesiologist. \212 455 \212 Non-insulin-dependent diabetes mellitus (type 2 diabetes) \212 These patients are usually controlled on oral hypoglycemics (p. 290). If diabetes is poorly controlled, treat as for type 1 diabetes. Do not give long-acting sulfonylureas 24 h prior to surgery, as they can cause prolonged hypoglycemia on fasting. Beware of lactic acidosis in patients on biguanides (e.g., metformin). It is recommended to hold dose of metformin 2 4 h prior to surgery. If the patient can eat postoperatively, simply omit tablets on the mo rning of surgery and give postop with a meal. If the patient is having major surgery with r estrictions to eating postop, check fasting glucose on the morning of surgery and start IV or SC insulin given according to sliding scale. Postop, consult the diabetic \212 \212 \212 \212 team as the patient may need a phase of insulin to supplement his oral hypoglycemics. Diet-controlled diabetes is usually no problem although the patient may temporarily become insulin-dependent postop. Monitor finger-stick glucose before meals and bedtime. Avoid givi ng 5% dextrose IVI as a fluid replacement as blood glucose will rise. IV insulin sliding sc ale (This is only a guide; values are in mg/dL): Finger stick glucose (mg/dL) <60 60 \200\223130 131 \200\223180 181 \200\223250 251 \200 \223350 >351 IV soluble insulin Alternative SC insulin None (50% glucose IV) No insulin 1 U/h 2 U/h 3 U/h 6 U/h None (50% glucose IV) No insulin 2 U SC 4 U SC 6 U SC 8 U SC Blood transfusion and blood products Blood should only be given if strictly necessary, and a preoperative discus- sion regarding its use should be always undertaken. \212 Know right patient at the right time. Take blood for cross-matching from only one patient a t a time. Label immediately. This minimizes risk of wrong labeling of samples. When giving blood, monitor temperature and BP every h. and use local procedures to ensure that the right blood gets to the \212 \212 Type and screen requests Find your local guidelines for elective surgery. Obtaining c ross-matched blood is easier if the patient has already been typed and screened. No units a re set up for the patient when only a type and screen is requested. Furthermore, blood typi ng and screening may identify antibodies in a patient \200\231s blood that may require addi tional testing. Whole blood (rarely used) Indications: Exchange transfusion; grave exsangui nation: Use cross-matched blood if possible, but if not, use \200\234universal donor \200 \235 group O Rh -ve blood, changing to cross-matched blood as soon as possible. Blood >2 da ys old has no effective platelets. Red cells (packed to make hematocrit 70%) Use to correc t anemia or blood loss. 1 U \206\221 Hb by 1 \200\2231.5 g/dL. In anemia, transfuse until Hb 8 g/dL. Platelet transfusion (p. 632) not usually needed if not bleeding or count is >2 0 \227 10 9 /L. If surgery is planned, get advice if <60 \227 10 9 /L. Fresh frozen plasm a (ffp) Use to correct clotting defects; e.g., DIC (p. 625), warfarin overdosage, liver dis ease. It is expensive and carries all the risks of blood transfusion. Do not use as a simpl e volume expander. Human albumin solution (plasma protein fraction) is produced as 4.5% or 20% protein solution and is basically albumin to use for protein replacement. Both the solu tions have much the same Na + content, and 20% albumin can be used temporarily in the hypop roteinemic patient (e.g., liver disease; nephrotic) who is fluid overloaded without giving an excessive salt load. Others Cryoprecipitate (a source of fibrinogen); coagulation concen trates (self-injected in hemophilia); immunoglobulin (anti-D). 456 Complications of transfusion Management of acute reactions (see Table 13.11): \212 y r e g r u S Acute hemolytic reactions (e.g., ABO or Rhesus incom- Early (within 24 h): patibility), ana phylaxis, bacterial contamination, febrile reactions (e.g., from HLA antibodies), allergic reactions (e.g., itch, urticaria, mild fever), fluid overload, transfusion-related acute lu ng injury (TRALI) \200\224basically ARDS due to anti-leukocyte antibodies in donor plasma. Infections (e.g., viruses [hepatitis B/C, HIV], bac- Delayed (after 24 h): teria, protozoa, prions), iron overload (treatable with desferrioxamine), graft-versus-host disease, and po sttransfusion purpura , potentially lethal fall in platelet count 5 \200\2237 d post \200 \223transfusion requiring specialist treatment with IV immuno-globulin and platelet transfu sions. \212 Massive blood transfusion This is defined as replacement of an individual \200\231s entire blood volume (>10 U) within 24 h. Complications: Table 13.11 Transfusion reactions A rapid spike of temperature (>40 C) at the start indicates that the transfusion should be stopped (suggests intravascular hemolysis or bac- terial contamination). For a slowly risi ng temperature (<40 C), slow the IVI \200\224this is most frequently due to antibodies aga inst white cells. Acute transfusion Action reactions Acute hemolytic reaction (e.g., ABO incompatibility) Agitation, T \206\221 (rapid onset) , \206\223 BP, flushing, abdominal/chest pain, oozing venopuncture sites, DIC STOP transfusion. Check identity and name on unit; tell hematologist; send unit + CBC and e lectrolytes, PT, PTT, cultures and urine (hemoglobinuria) to lab. Keep IV line open with 0. 9% saline. Treat DIC. Anaphylaxis Bronchospasm, cyanosis, BP, soft-tissue swelling SLOW or STOP the transfusion. Maintain airway and give oxygen. Transfer to ICU and contact code team for intubation. Bacterial contamination T \206\221 (rapid onset), \206\223 BP, STOP the transfusion. Check identity against name on unit; tell hematolo- gist and send uni t +CBC, electrolytes, clotting, cultures, and urine to lab. Start broad-spectrum antibiotic s. and rigors TRALI (transfer related acute lung injury) Dyspnea, cough ; CXR STOP the transfusion. Give 100% O 2 . Treat as acute respiratory distress syndrome (ARDS, p . 174). Donor should be removed from donor panel. 457 \200\234white out \200\235 Nonhemolytic febrile SLOW or STOP the transfusion. Give an antipyretic (e.g., Tylenol 1 g). Monitor closely. If recurrent, use leukocyte-depleted blood or white blood cell (WBC) filter. transfusion reaction Shivering and fever usually 30 \200\22360 min after starting transfusi on Allergic reactions Urticaria and itch SLOW or STOP the transfusion; give diphenhydramine 25 \200\22350 mg IV/PO q6 \200\2238h. Monitor closely. SLOW or STOP the transfusion. Give oxy- gen and a diuretic (e.g., furosemide 40 mg) IV init ially. Consider CVP line and exchange transfusion. Fluid overload Dyspnea, hypoxia, tachy- cardia, \206\221 JVP, and basal crepitations Platelets \206\223 , Ca 2+ \206\223 , clotting factors \206\223 , K + \206\221 , hypoth ermia. Current guidelines recommend transfusing fresh frozen plasma (FFP) to packed red blo od cells (PRBCs) at a 1:1 or 1:2 ratio. Transfusing patients with heart failure If Hb 5 g/d L with heart failure, transfusion with packed red cells is vital to restore Hb to safe leve l (e.g., 6 \200\2238 g/dL) but must be done with great care. Give each unit over 4 h with ( furosemide, e.g., 40 mg slow IV/PO; do not mix with blood) with alternate units. Check for \206\221 JVP and basal lung crackles; consider CVP line. There is a role for patients havi ng their own blood stored preop for later use; however, the lifespan of autologous blood wi ll be less than that of fresh blood (autologous transfusion). Erythropoietin (EPO) can be u sed to increase the yield of autologous blood in normal individuals. See Table 13.12. Table 13.12 Blood transfusion and Jehovah \200\231s witnesses These patients are likely to refuse even vital transfusions on religious grounds. These vie ws must be respected, but complex issues can arise, especially if the patient is a child. A lternative methods of hemocon- centration should be offered to these patients. These method s include preoperative erythropoietin and iron and intraoperative normovolemic hemodilution . Consultation with hematology and anesthesiology preop- eratively is recommended. Nutritional support >25% of hospital inpatients may be malnourished. Weight loss of >10% of normal body mass may compromise the host by altering the ability to heal wounds or develop an immune response to infection. Operative mortality is increased in patients with weight loss of >20 \200\22325% of total body weight. In contrast, patients with normal body compos ition who are not hypermeta- bolic do not require nutritional intervention for up to a peri od of 5 \200\2237 d of inadequate intake. Why are so many hospital patients malnourished? 1 Increased nutritional requirements (e.g., sepsis, burns, surgery) 2 Increased nutritional losses (e.g., malabsorption, output from stoma) 3 Poor intake (e.g., dysphagia, sedation, c oma) 4 Effect of treatment (e.g., nausea, diarrhea) 5 Enforced starvation (e.g., prolonged npo periods) Identifying the malnourished patient History: Recent weight change; recent red uced intake; diet change (e.g., re- cent change in consistency of food); nausea, vomiting, pain, diarrhea that might have led to reduced intake. Examination: Examine for state of hyd ration; dehydration can go hand-in- hand with malnutrition, and overhydration can mask the appearance of mal- nutrition. Evidence of malnutrition: Poor skin turgor (e.g., over biceps ); no fat between folds of skin; hair rough and wiry; pressure sores; sores at cor- ner of mouth. Body mass index (BMI) <19 kg/m 2 suggests malnourishment. Investigations: Low albumi n, prealbumin, and transferring levels are sugges- tive of poor nutritional status. 458 Calculations of needs: To estimate caloric needs, the basal metabolic rate is estimated bas ed on height, weight, age, and gender. A stress factor is added to account for the increase d demands in hospitalized patients, and 1,000 kcal should be added per day when weight gain is desired. Protein requirements: 1 \200\2232 g/kg/d will maintain a positive nitrogen (N ) bal- ance. The optimal N-to-calorie ratio is 1:150. Divide total kcal necessary by 150 to get grams of N. Then multiply the grams of N by 6.25 to calculate grams of protein needed per day. The remainder of requirements is based on the kcals needed. y r e g r u S Remember: Carbohydrates 3.4 kcal/g Protein 4 kcal/g Fat 9 kcal/g Most patients are well-nourished with 2,000 \200\2232,500 kcal (20 \200\22340 kcal/kg) and 7 \200\22314 g nitrogen every 24 h. Even catabolic patients rarely need >2,500 kcal. Very h igh calorie diets (e.g., 4,000 kcal/24 h) can lead to fatty liver. If a patient requires nu tritional support, seek help from dietician. Prevention of malnutrition Assess nutrition st ate and weight on admission and possibly weekly thereafter. Identify those at risk (see abo ve). Nutritional supplements high in caloric count will assist with improving nutritional s tatus. Enteral nutrition (i.e., nutrition given into gastrointestinal tract). If at all pos sible, give nutrition by mouth. An all-fluid diet can meet requirements (but get advice fro m dietitian). If a patient has a limited capacity to swallow but has passed a swallowing st udy (e.g., after stroke), consider a pureed diet before abandoning food by mouth. Tube feed ing: This is giving liquid nutrition via a tube (e.g., placed endoscopi- cally, radiologica lly, or surgically directly into stomach; i.e., gastrostomy or into the jejunum). Use nutri tionally complete, commercially prepared feeds. Standard feeds (e.g., Nutrison standard , Osmolite ) normally contain 1 kcal/ML and 4 \200\2236 g protein per 100 mL. Most people \200\231s requirements are met in 2 L/24 h. Specialist advice from a dietitian is essential . Nausea and vomit- ing is less of a problem if feeds are given continuously via pump, but these may have disadvantages compared with intermittent nutrition. For various methods of t ube feedin, see Figure 13.2. Guidelines for success \212 \212 \212 \212 Use jejunal tube feeding when possible. Keep height of bed at 30 degrees to avoid aspiratio n risk. Build up feeds gradually to avoid diarrhea and distension. Weigh weekly, check bloo d glucose and plasma electrolytes (including phosphate, zinc, and magnesium, if previously malnourished). Working closely with a dietitian is essential. 459 \212 Figure 13.2 Parenteral (IV) nutrition Do not undertake parenteral feeding lightly: It has risks. Specia list advice is vital. Only consider it if the patient is likely to become malnourished with out it. This normally means that the gastrointestinal tract is not func- tioning or is not available (e.g., bowel obstruction or fistula) and is unlikely to function for at least 7 d . Parenteral feeding may supplement other forms of nutrition (e.g., in active Crohn \200 \231s disease when insufficient nutrition can be absorbed in the gut) or be used alone (tot al parenteral nutrition \200\224TPN). Even if there is GI disease (e.g., pancreatitis), stu dies show that enteral nutri- tion is safer, cheaper, and at least as efficacious. Administ ration Nutrition is normally given through a central venous line as this usually lasts long er than if given into a peripheral vein. A peripherally inserted central catheter (PICC lin e) is another option. Insert under strictly sterile conditions and check its position on x- ray. This line is then dedicated for the administration of nutrition only. Requirements The re are many different regimens for parenteral feeding. Most provide 2,000 kcal and 10 \200 \22314 g nitrogen in 2 \200\2233 L; this usually meets a patient \200\231s daily requiremen ts of 20 \200\22340 kcal/kg and 0.2 g nitrogen/kg. 50% of calories are provided by fat and 50% by carbohydrate. Regimens comprise vitamins, minerals, trace elements, and electrolyte s; these will normally be included by the pharmacist. Complications Sepsis: E.g., Staphyloc occus epidermidis and Staphylococcus aureus , Candida , Pseudomonas , infective endocarditi s.) Look for spiking pyrexia and examine 460 wound at tube insertion point. If central venous line-related sepsis is sus- pected, the sa fest course of action is always to remove the line. Do not attempt to salvage a line when S . aureus or Candida infection has been identified. Thrombosis: Central vein thrombosis may occur, resulting in pulmonary embolus or superior vena caval obstruction. Heparin in the nu trient solu- tion may be useful for prophylaxis in high-risk patients. Metabolic imbalance: Electrolyte abnormalities (including K + , calcium, phos- phate, zinc, magnesium), plasma glucose, deficiency syndromes. Mechanical: Pneumothorax; embolism from CVP tip. Guidelines for success \212 \212 y r e g r u S Work closely with nutrition team and pharmacist. Practice meticulous sterility. Do not use central venous lines other than for nutrition. Remove the line if you suspect infection. Cu lture the line on removal. Review fluid balance at least twice daily and requirements for e nergy and electrolytes daily. Check weight, fluid balance, and urine glucose daily througho ut period of parenteral nutrition. Check plasma glucose, creatinine, and electrolytes (incl uding calcium and phosphate), and take full blood count daily until stable and then three t imes a week. Check LFT and lipid clearance three times a week until stable and then weekly. Check zinc and magnesium weekly throughout. Do not rush. Achieve the maintenance regimen i n small steps. \212 \212 \212 Drains, wounds, and stoma care Drains Surgical drains: Abdominal drains placed in surgery a re usually closed suc- tion drains (Jackson \200\223Pratt). These drains can also be open d rains such, as a Penrose. Open drains are more commonly associated with infection. Surgical drains should always be brought out of an incision separately from the primary incision be cause of the risk of infection to the primary incision. The purpose of an abdominal drain i s to collect fluid that may accumulate after surgery. Common sites to drain include the pel vis, the lateral gutters, and any surgery performed around the pancreas. Drains are also pl aced above the fascia to drain the subcutaneous tissue, especially if skin flaps have been mobilized. Drains are usually removed when the output has dropped. Routine drain care inclu des drain site care and drain stripping. To strip a drain, the fluid in the drain is squeez ed through the tubing using the fingertips to push the fluid into the drain reservoir. Seve ral studies have been performed looking at the benefit of drains in the abdomen and very fe w have demonstrated a benefit; however, individual surgeons continue to use drains. Another important point about drain management: When cracking or advancing a drain, the drain is r emoved from the body in incre- ments of 1 \200\2232 inches a day. The drain must then be re secured. External drains: Drainage tubes may also be placed radiographically to drain colle ction. In general, these drains are not closed suction drains. Care of these drains include s flushing with sterile saline 2 \200\2233 times a day. Tube thoracostomy: Performed to eva cuate an ongoing production of air/ fluid into the pleural space or fluid that is too visco us to be aspirated by thoracentesis. If there is a question of a tension pneumothorax, a 14 - or 16-g angiocath- eter should immediately be placed in the second or third intercostal s pace in the mid-clavicular line on the affected side. 461 Posterior thoracostomy: To drain hemothorax, pneumothorax (also anterior thoracostomy), per sistent pleural effusion, and empyema. After application of local anesthesia, the incision is placed in the sixth intercostal space along the anterior axillary line. Placement of the tube occurs by entering the pleu- ral in the fifth intercostal space and directing the tip posteriorly. Anterior thoracostomy: For an anterior approach, the tube is placed over the fourth rib along the mid-clavicular line. Avoid injury to the intercostal artery and vein b y entering the pleural space above the rib. The tube thoracostomy is then connected to a Pl euravac . Tube thoracostomy removal: When the drainage is low and there is no longer a p neumothorax or air leak, the chest tube can be removed. The patient is asked to take a deep breath and perform a Valsalva. An airtight dressing is placed over the site once the tube has been removed. Wounds All surgical procedures involve the creation of a wound. Factors t hat pre- vent wounds from healing include lack of good blood supply (smoking and micro-vasc ular damage), infection, malnutrition, immunosuppression (diabetes, HIV), radiation, and ag e. Clean wounds created at the time of elective surgery can be closed primarily. Sutures us ed for wound closure should be placed in tissue with good tensile strength, such as the der mis or fascia. Contaminated wounds: Emergent surgery with free intra-abdominal contaminatio n is best closed by secondary intention. Healing by secondary intention involves closure of a wound by the natural biologic forces of wound contraction. These wounds are dressed with antiseptic gauze moistened with saline. Once the wound has granulated with pink healthy ti ssue, other forms of dressing can applied to accelerate healing. Stomas A stoma is an artif icial union made between two conduits (e.g., a choledo- chojejunostomy) or, more commonly, between a conduit and the outside of the body (e.g., a colostomy, in which feces are made t o pass through a hole in the abdominal wall into an adherent plastic pouch). When choosing the site for a colostomy, avoid areas in scars, the area around the waistline, and creases. The patient should be sitting at the time of stoma marking. The stoma nurse is expert in f itting secure, odorless devices. Ensure patients have their nurse \200\231s phone number fo r use before and after surgery. Nurse visits are more useful than any doctor \200\231s in e xplaining what is going to hap- pen and what the colostomy will be like, and in troubleshoo ting postop problems. 1 Loop colostomy: A loop of colon is exteriorized, opened, and sewn t o the skin. A rod under the loop prevents retraction and may be removed after 5 \200\2237 d . This is often called a defunctioning colostomy, but this is not strictly true as feces ma y pass beyond the loop. A loop colostomy is used to protect a distal anastomosis or to reli eve distal obstruction. It is often temporary and is more prone to complications than end c olostomies. A colostomy does not need to protrude very far from the skin because the efflux is not as irritating as in more proximal stomas, such as in ileostomy. 462 2 End colostomy: The bowel is divided; the proximal end is brought out as a stoma. The dist al end may be resected (e.g., abdominoperineal excision of the rectum), left in the abdomen (Hartman \200\231s procedure), or exteriorized, forming a \200\234mucous fistula. \200 \235 3 Double-barrelled (Paul \200\223Mikulicz) colostomy: The colon is brought out as two openings (similar to a mucus fistula). Ileostomies protrude from the skin and emit fluids that contain active enzymes (so skin nee ds protecting). These stoma are made to protrude (Brooke) more than a colostomy stoma becau se of the risk of skin irritation. Furthermore, because the colon is not in continuity, the risk of dehydration is great. Patients must be instructed on careful fluid management. End ileostomy usually follows proctocolectomy, typically for IBD. Loop ileostomy can be used t o temporarily protect distal anastomoses. Most stomal complications do not require emergent surgery. Work closely with your stoma therapist. See Table 13.13. y r e g r u S Table 13.13 Complication Management Early: \212 \212 \212 Early: 1. More commonly seen in cirrhotic patients; may require suture ligation of subcutan eous vessel 2. Monitor bowel below the fascia for ischemia. 3. Replace with normal saline ( NS). Delayed: 1. IV support 2. Product change 3. Topical or systemic immunosuppression 4. S ugar to stomal prolapse to assist in reduction 5. Stoma belt 6. Monitor output to determine course. 7. Stoma dilation and possible revision 8. Stoma support group 1. Hemorrhage at stoma site 2. Stoma ischemia 3. High output (especially ileostomies \200 \224can lead to \206\221 K + and dehydration) Delayed: \212 1. Obstruction (failure at operation to close lateral space around stoma) 2. Dermatitis aro und stoma site 3. Pyoderma 4. Stoma prolapse 5. Parastomal hernia 6. Fistula 7. Stoma retra ction/stenosis 8. Psychological problems \212 \212 \212 \212 \212 \212 \212 Thyroid disease, hepatic failure, steroids, anticoagulation, and surgery Thyroid hormone ex erts primary influences on growth and metabolism. It is not a primary mediator of the host response to injury and infection. Frequently, thyroid hormones levels are low in severe ill ness. Thyroid surgery for hyperthyroidism Life-threatening thyrotoxicosis may be precipitat ed by any operation but especially after thyroidectomy for hyperthyroidism. It is best to b ring hyperthyroid patients into a euthyroid state before surgery. If severe, give propylthi ouracil 50 \200\223200 mg q4h for 1 wk followed by 200 \200\223400 mg/d for an additional 5 wks prior to surgery or until euthyroid. Aqueous iodine oral solution (Lugol \200\231s sol ution), 0.1 \200\2230.3 mL/8 h PO, well-diluted with milk or water, can also be started pri or to surgery. Mild hyperthyroidism Start propranolol 80 mg/8 h PO and Lugol \200\231s solu tion as above at the first consultation. Stop Lugol \200\231s solution on the day of surger y but continue propranolol for 5 d postop. Thyroid storm Severe thyrotoxicosis may result f rom surgical stress or trauma. The patient may be tachycardic, febrile, and have an altered mental status. Supplemental oxygen should be given to the patient, as well as propanolol a nd hydrocortisone. There is a 10 \200\22320% mortality rate associated with thyroid storm. 463 Hepatic failure and surgery Patients with hepatic failure are particularly prone to develop ing oliguria after surgery. The cause of this can be multifactorial and includes prerenal a zotemia, acute renal failure, and the hepatorenal syndrome. The cause of the hepatorenal sy ndrome is unknown but may be related to intrahepatic blood flow redistribution, cortical is chemia, and inappropriate activation of the renin-angiotensin system. Development of this s yndrome is suggestive of a grim outcome. Preoperative preparation \212 Consider arterial line and CVP line to ensure an adequate intravascular volume intra- and p ostoperatively. Insert a urinary catheter. Check clotting and give prophylactic vitamin K ( p. 621). \212 \212 During surgery \212 \212 Measure urine output. Alert anesthesiologist to the removal of large quantities of ascites, which may lead to hypovolemia. Consider giving 0.9% saline IV to match the urine output. M easure urine output and urine and serum electrolytes and follow closely. Low urine sodium c oncentration (<10 mEq/L) with normal urine osmola- lity may suggest prerenal azotemia or th e hepatorenal syndrome. Give 0.9% saline at rate to match fluid lost through NGT, as well a s maintenance fluid. Intraoperative ascites drains may be placed to help with anastomotic h ealing and wound closure. Drain output should be matched cc per CC output with 0.9% norm al saline. Spironolactone (50 \200\223100 mg q6 \200\2238h) may be used to assist in treati ng ascites. Give furosemide if urine output is poor despite adequate intravascular volume. \212 \212 \212 \212 Surgery in those on steroids or anticoagulants Steroids: Patients with a history of steroid use in the 6 months prior to surgery may need extra exogenous steroids to cope with the ad ded stress of surgery and the potential for adrenal insufficiency. The amount needed depend s on the extent of the surgery and the preop dose of steroids. Major surgery: Typically, gi ve hydrocortisone 50 \200\223100 mg IV with the pre-med and then q8h IV/IM for 2 d. Then re turn to previous medication. Minor surgery: Prepare as for major surgery except that hydroc ortisone is given for 24 h only. Adrenal insufficiency results in hypotension. If this is e ncountered without an obvious cause, it may be worthwhile giving a dose of 50 mg hydrocorti sone IV. Those on stable long-term anticoagulants (warfarin and aspirin): All long-term ant icoagulants should be stopped 5 \200\2237 d prior to surgery. Presently, there are enough a lternatives that no patient should be on a long-term antico- agulant at the time of surgery . Discuss these issues when arranging consent. Vitamin K or FFP may be needed in emergency surgery. Patients with arti- ficial valves requiring anticoagulation (particularly mitral) and newly placed cardiac stents should be placed on an alternative shorter acting antico- a gulant prior to surgery, such as SQ fractionated heparin (Lovenox) or IV unfractionated hep arin. 464 Postoperative care Postoperative complications and management Fever: Mild fever in the firs t 24 h is typically from atelectasis (needs prompt respiratory therapy, not antibiotics), t issue damage, or necrosis but an ele- vated in temperature >24 h postop should stimulate an infection evaluation. Check the CXR for pneumonia, the wound, the urine, and the abdomen f or signs of peritonitis (e.g., anastomotic leakage). Examine sites of IV cannula and central v enous access for signs of infection. Check the legs for DVT. Send blood for CBC, electrolyt es, and culture. Send the urine for analysis. Consider CXR, abdominal CT, and lower extremi ty duplex depending on the clinical findings. Confusion: This may manifest as agitation, di sorientation, and attempts to leave hospital, especially at night. Gently reassure the pati ent in well-lit sur- roundings (p. 354). The common causes are: y r e g r u S \212Hypoxia (pneumonia, atelectasis, CHF, PE) \212Infection (see above) \212Drugs (opiat es, sedatives, and many others) \212Alcohol withdrawal \212Urinary retention; MI or strok e \212Liver/renal failure Occasionally, sedation is necessary to examine the patient; consider mida- zolam (antidote: Flumazenil) or haloperidol 0.5 \200\2232 mg IM. Reassure relatives that postop confusion i s common and reversible. Shortness of breath or hypoxia Any previous lung disease? Have pat ient sit up. Give oxygen, monitoring peripheral O 2 saturation by pulse oximetry. Examine f or evidence of: \212 \212 \212 \212 Pneumonia/pulmonary collapse/aspiration Pulmonary edema (MI or fluid overload) Pulmonary em bolism (p. 188) Pneumothorax (p. 189; due to CVP line or intercostal anesthetic block). Do CBC, arterial blood gasses, CXR, and ECG. Manage according to findings. BP \206\223 If severe, tilt bed head down and give O 2 . Check pulse rate and mea- sure BP yourself; compa re it with that prior to surgery. Postop \206\223 BP is com- monly due to hypovolemia resu lting from inadequate fluid input so check fluid chart and replace losses, usually with col loid initially. Monitor urine output; consider catheterization. A CVP line may be useful to monitor fluid resuscitation. Hypovolemia may also be caused by hemorrhage so review wounds and abdomen. If severe, return to operating room for hemostasis. Beware cardiogenic causes and look for evidence of MI and PE. Consider sepsis and anaphylaxis. Urine output \206 \223 (oliguria) Aim for output of >30 mL/h in adults ( mL/ kg/h). Anuria frequently means a blocked or obstructed catheter. Flush or replace catheter. Oliguria is usually due to in adequate replacement of lost fluid. Treat by increasing fluid input. Acute renal failure ma y follow shock, nephrotoxic drugs, transfusion, or trauma. \212 \212 \212 465 Review fluid chart and examine for signs of volume depletion. Urinary retention is also com mon, so examine for a palpable bladder. Establish normovolemia (a CVP line may help here; n ormal is 0 \200\2235 cm H relative to sternal angle); patient may need 1 L/h IVI for 2 \200 \2233 h. If intrinsic renal failure is suspected, refer to a nephrologist early. 2 O \212 Nausea/vomiting Any mechanical obstruction, paralytic ileus, or emetic drugs (opiates , digoxin, anesthetics)? Consider abdominal x-ray (AXR), NGT, and antiemetic. Other postop complications Pain (p. 452), DVT (p. 453), PE (p. 188), wound dehiscence, bleeding (see Tab le 13.14). Follow-up for surgical patients 1 Prior to discharge, all patient should be give n instructions for follow-up. Determine what further care is needed for the patient. 2 If patients have skin staples, these are usually removed 10 \200\22314 d after surgery. Table 13.14 Postoperative bleeding \212Primary hemorrhage : I.e., continuous bleeding, starting during surgery. Replace blood loss. If severe, return to the operating room for ade- quate hemostasis. Treat shock vigor ously (p. 745). \212Reactive hemorrhage : Hemostasis appears secure until BP rises and bleeding starts. Replace blood and reexplore wound. \212Secondary hemorrhage occurs 1 \200\2232 wks postop and is the result of infection. Table 13.15 Discharging patients after day-case surgery After day-case surgery, don \200\231t discharge until \200\234LEAP-FROG \200\235 establish ed: L ucid, not vomiting, and cough reflex established E asy breathing; easy urination A mb ulating P ain relief + postop drugs dispensed + given. Do they understand doses? F ollow-up arranged R hythm, pulse rate, and BP checked one last time. Is trend satisfactory? O perat ion site checked and explained to patient G ive the primary care provider a call is 3 If a patient has a stoma, this should be attended to by a stoma thera- pist by at least 4 wks after surgery because the size of the stoma often changes. 4 If patient is being treated for a cancer and requires further adjuvant ther- apy, the onc ologist appreciates a check from the surgeon prior to initiat- ing therapy. For day-case surgery, see Table 13.15. The acute abdomen An acute abdomen refers to any sudden manifestation of a nontraumatic dis order involving pain in the abdominal area for which urgent surgical exploration may be nec essary and repeated examination is essential. Begin by obtaining a careful history of the p ain Ask about the location of the pain, any spreading or shifting, duration, mode of onset, progression, character (dull, sharp, crampy), and any other associated symptoms including nausea, vomiting, diarrhea, obstipation, constipation, hematuria, etc. Types of pain Viscer al pain is mediated by the afferent C fiber and usually is felt in the midline. It is slow in onset and dull. It can be elicited by distension, inflam- mation, or ischemia. Parietal pain is mediated by both C fibers and A delta nerve fibers. Abdominal parietal pain is more focused as a result of direct irritation of the somatically innervated parietal peritoneum by pus, bile, GI secretions, etc. It is conventionally described as occurring in four abdo minal quadrants (see Figure 13.4). 466 Other relevant aspects of history include: \212 \212 \212 \212 \212 Physical exam Obse rve patient: Lying still or writhing, pallor, sweating, feverish? Inspect the abdomen for d istension, bruising; look for gray Turner \200\231s sign for hemorrhagic pancreatitis. Ausc ultate for bowel sound: Hypoactive indicates intra-abdominal infection; hyperactive sounds are noted in bowel obstruction. Palpate in a sequential pattern with the most tender area b eing touched last. Specific signs on palpation include: \212 \212 y r e g r u S Medical and surgical history Menstrual history Drug history Family history Travel history Peritoneal inflammation causing rectus muscle rigidity. Guarding: Rebound tenderness: gentle pressure; acute appendicitis. Murphy \200\231s sign: a brupt arrest of inspiration secondary to pain; acute cholecystitis. Iliopsoas sign: psoas a bscess in Crohn \200\231s disease. Obturators sign: discomfort in the groin area; incarcera ted obturator hernia. Costovertebral angle tenderness: angle; renal colic. Discomfort is felt upon releasing your hands from \212 Palpation in the right subcostal area while inspiring causes \212 Active flexion or passive extension of the hip illicit pain; \212 Internal or external rotation of the flexed thigh may cause \212 Punch tenderness of the costovertebral Tests CBC, electrolytes, amylase, LFT, \222 -HCG, urinalysis; laparoscopy may avert open s urgery. CT can be helpful provided it is readily available and causes no delay. Preop care Anesthesia compounds shock, so resuscitate properly first, unless blood is being lost faste r than it can be replaced in ruptured ectopic pregnancy or a leaking abdominal aneurysm (p. 475). Also do the following: 1 Establish good IV access (two 18-g IVs) and begin resuscita tion with 0.9% saline. 2 Insert Foley and NGT. 3 Type and cross-match. 4 ECG, AXR, CXR 5 Begin broad-spectrum anti biotics if infection is suspected. 6 Consent and manage pain. Clinical syndromes that usual ly require urgent surgical exploration \212 Spleen, aorta, ectopic pregnancy. Shock secondary Rupture of an organ: to cardiovascular co llapse (e.g., faints or orthostatic BP \206\223 by \200\234 20 mm Hg on standing) is a le ading sign. Abdominal swelling may be seen. Delayed rupture of the spleen may occur weeks a fter trauma. Perforation of peptic ulcer, diverticulum, appendix, bowel, or Peritonitis: ga ll bladder. Signs: Prostration, shock, lying still, tenderness ( rebound/ percussion pain ), board-like abdominal rigidity, guarding, and no bowel sounds. Erect CXR may show gas und er the diaphragm on the right side usually or free intraperitoneal air (see Figure 13.3). N B: Acute pancreatitis (p. 487) may cause these signs, but does not require a laparotomy, so always check serum amylase. 467 \212 Syndromes that may not require urgent exploration \212 E.g., diverticulitis, cholecystitis, salpingitis, and appendici- Local peritonitis: tis. If abscess formation is suspected (palpable mass, fever, and WBC \206\221 ), arrange a diagn ostic US or CT. Drainage can be percutaneous (US- or CT-guided) or by laparotomy. Look for a \200\234sentinel loop \200\235 on the plain AXR. \212Colic is a regularly waxing and waning pain caused by muscular spasm in a hollow viscu s; e.g., gut, ureter, uterus, or gallbladder. (In the latter, pain is often dull and consta nt.) Colic causes restlessness, unlike peritonitis. Other causes of abdominal pain that may masquerade as an acute surgical abdomen in which su rgery is not indicated Myocardial infarction Pneumonia (p. 160) Sickle-cell crisis (p. 618) Pheochromocytoma Gastroenteritis or urinary tract infection (UTI) Tabes (p. 576) (p. 315) Diabetes mellitus (p. 268) Zoster (p. 558) Pneumococcal peritonitis Tuberculosis (p. 552) T yphoid fever (p. 590) Porphyria (p. 682) Henoch \200\223Sch nlein Thyroid storm Narcotic a ddiction Malaria (p. 549) Cholera (p. 585) Yersinia enterocolitica (p. 583) Lead colic PAN (p. 417) Accuracy in diagnosing acute abdomen is 45% so always maintain a high index of suspicion. It is better to have a negative surgical exploration than to miss a surgical emergency. Wit h newer minimally invasive techniques in surgery, patients recover quickly. These diagrams go over the causes of an acute abdomen manifested as free intra-abdominal air or peritoniti s. Intestinal ischemia Acute onset of severe abdominal pain should always suggest the idea of bowel ischemia. Etiology can be classified as the following: \212 Strangulated bowel, large-vessel embolic or thrombotic event, Occlusive: ligation of the IMA during aortic surgery Vasospastic: titis, pancreatitis, acal culous cholecystitis Inflammatory: \212 Small-vessel nonocclusive intestinal ischemia, ischemic hepa- \212 Acute intestinal ischemia The most common cause is arterial embolism. Emboli originat e from the heart in >75% of cases and lodge preferentially just distal to the origin of the superior mesenteric artery (SMA) (see Figure 13.5). Low-flow states usually reflect poor c ardiac output but there may be other factors, such as DIC. Venous thrombosis is uncommon an d tends to affect smaller lengths of bowel. The incidence of acute colonic ischemia after a ortic surgery is 5 \200\2239%. Other risk factors include atrial fibrillation, recent myoca rdial infarction, valvular heart disease, recent cardiac or vascular catheterization, ather osclerotic disease, hypercoagulable state. A classical clinical triad of occlusive ischemia : Acute severe abdominal pain, no abdominal signs, and rapid hypovolemia (causing shock). P