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Other Postop Issues (Decreased Urinary Output (AMS we control…

- - - - PE
        
        US :loudspeaker: of LE
        
        DVT
        
        Spiral CT :radioactive_sign:
        
        Tx:
        
        Heparin bridge to Warfarin
        
        favorite test question due to initial hypercoag state
        
        Something else
        
        risk factor specific
        
        Pneumothorax
        
        not looking for these immediately
        
        MI :<3:
        
        EKG
        
        12 lead ∆'s
        
        Troponin
        
        Tx:
        
        PCI (cath)
        
        percutaneous coronary intervention
        
        indicated in STEMI
        
        or Heparin
        
        LMWH full dose
        
        elevated troponins: NSTEMI
        
        ~~tPA~~
        
        can't use in postop
    - - Hypoxemia
        
        PNA
        
        Atelectasis
        
        PE
        
        ARDS
        
        have to have a tumultuous course
        
        prolonged intubation
        
        lots of fluids/transfusion
        
        leave belly open (edematous)
        
        hypoxemic
        
        Tx: PEEP & O2
        
        intubation
        
        rare: but common on shelf/step
        
        Delirium Tremens (DT)
        
        Pt: Alcohol withdrawal
        
        day 1 NPO
        
        day 2: fine
        
        ± tachycardia :<3: & HTN
        
        looks like postop px
        
        may give px Rx
        
        no improvement
        
        progression to diaphoresis & tremors
        
        this point, can prevent seizures: BZD
        
        (48-72hr postop) : HTN, tachycardic, diaphroesis
      - Sundowning: Elderly :older_man::skin-tone-4:
        
        Alzheimer's pt
        
        expected in the elderly sx pt
        Tx: Atypical antipsychotics
        
        reorient them & get them out of the hospital
  - - - No
        
        poss. renal failure
        
        Is there any output at all?
        
        Some output
        
        actual renal disease
        
        Intrinsic or prerenal?
        
        give fluid: 500cc bolus challenge :ocean:
        
        we are controlling intake & outtake
        
        we made them NPO and caused insensible water loss
        
        is there decreased output because they are fluid down?
        
        No improvement? Intrinsic renal disease
        
        have to have really big injury to kidneys for intrinsic renal disease (IM question)
        
        Improved? Volume down
        
        most common postop fluid problem
        
        Tx: more fluid :ocean:
        
        No
        
        mechanical: kinked foley
        
        unkink or irrigate foley
      - Yes
        
        obstructive picture
        
        effectively a neurogenic bladder
        
        bladder scan
        
        nursing assessment tool for bladder volume
        
        in & out cath
        
        indwelling foley causes UTI
  - - - Ileus
        Path: Functional
        
        cut on their belly slows things down
        
        Pt: POD #1-2
        
        no stool :forbidden::poop:
        
        no flatus :forbidden::balloon:
        
        ask everyday, have you pooped/farted?
        
        Dx: KUB
        
        flat
        
        & erect
        
        metabolic cause: entire bowel affected
        
        SB dilation/ LB dilation
        
        Tx:
        
        Fluids :ocean:
        
        K :banana:
        
        OOB :forbidden:🛌
        
        getting them to move = bowel movement
      - Ogilvie's (distractor)
        Path: Functional ileus of Colon & elderly :older_man::skin-tone-4:
        Pt: Elderly colon
        Dx: KUB
        
        Distended LB
        
        importantly: no distal area is normal
        
        Tx:
        
        Rectal tube
        
        Stigmine :pill:
        
        if rectal tube fails
        
        Colonoscopy :telescope:
        
        CRC :crab: r/o
        
        :pencil2: (WISE_MD): Associated w/ Orthopedic surgeries & opioid use
      - SBO:
        
        adhesions from prior sx
        
        incarcerated hernia
        
        IBD
        
        Cancer (mets to SB) :crab:
        
        LBO:
        
        Volvulus
        
        Diverticulitis Ischemic strictures
        
        CRC :crab:
    - - Dehiscence
        Not that bad
        Path: failure of the fascia
        
        wound is not open
        
        underneath, fascial planes are not closed well
        
        Pt: Hernia (ventral)
        
        serosanguinous drainage
        
        salmon colored
        
        ± loss of integrity on abd wall
        
        Tx: prevent evisceration
        
        Binders
        
        reduced straining (no lifting)
        
        eventually: Reoperate :hocho:
        
        elective closure of the ventral hernia
        
        risk for strangulation/ encarceration
        
        nbd, urgent
        
        Evisceration
        Path: Failure of the whole wound
        
        skin & fascia breakdown
        
        Pt: loops of bowel pop out
        
        peritoneum exposed to outside
        
        Sx emergency
        
        :pencil2:how this happens: med student or PT has pt stand up way too soon
        
        Dx: Clinical
        Tx: Emergent Sx :hocho:
        
        in meantime: apply warm saline dressing
        
        so bowel stays moist
        
        keep everything out of peritoneum
        
        Never push it back in
        
        reintroduces bacteria into peritoneum = massive washout required
        
        Fistula
        Path: Epithelialized tracts from 1 to another
        
        enterocutaneous
        
        enterovesciular
        
        Foreign body :earth_asia:
        
        Epitelialization
        
        Tumor :crab:
        
        Irratiation, Inflamed, Inflammatory Bowel (Crohns)
        
        Distal obstruction
        
        Pt: Stool passing out from weird places
        Dx: Clinical
        Tx: resect fistula :hocho:
        
        may not be enough, w/o addressing underlying cause
        
        may need diversion into an -ostomy