Surgery E2: Critical Care

What is the MC complication POD 0?

MI

What is the MC complication POD 1-2?

PNA

What is the MC complication POD 3?

PNA and UTI

What is the MC complication POD 4?

superficial SSI

What is the MC complication POD 5-30?

sSSI & dSSI

How often should you check on a critical care pt and do a PE?

once a day (at minimum)

What might short shallow breaths indicate?

inc pain, premature extubation, pneumothorax, anxiety

What should you do if a pt develops hypoxemic resp failure when coming off the vent?

immediate HFNC/ face mask oxygen or re-tub

When should you deliver supplement O2?

PaO2 < 70 or SaO2 < 90%

What is a normal venous blood gas?

PvO2 35-45 mmHg = Sats 60-75%

When should you get an ABG over VBG?

PaO2 > 70 and sats > 90

What is a normal arterial blood gas?

PaO2 80-100 mmHg = Sats 95-100%

What are signs of mild hypoxia?

may be asx; start nasal cannula

What are signs of moderate hypoxia?

agitation, tachycardia, tachypnea, resp distress; start face mask, venti mask, non-rebreather, HFNC

What are signs of severe hypoxia?

CNS depression, tachypnea, speech interrupted to breath, use of accessory muscles, pale or cyanotic, look bad; PaO2 < 70 on 100% oxygen

What should be used to manage severe hypoxia?

mechanical ventilation + diuretics, bronchodilators, possible transfusion

What pts need a tracheostomy?

pts requiring prolonged mechanical ventilations (> 10 days)

When should a tracheostomy be placed?

permanent neuro damage affecting resp function and will require life-long mechanical vent, chronic aspiration, radical head/neck cancer resection, upper airway obstruction where endotracheal intubation is CI

What are the benefits of Tracheostomy?

reduces oropharyngeal/laryngeal trauma, decreases airway resistance, improves amount of secretions

What are potential complications of tracheostomies?

bleeding, aspiration, pneumothorax, pneumomediastinum, hypoxia, recurrent laryngeal nerve injury

What are early signs of hypovolemia?

Tachycardia + normal-low BP

What are signs of inadequate pain control?

Tachycardia + HTN

What should you assume is causing post-op hypotension and tachycardia?

Hemorrhage until proven otherwise → needs volume replacement w/ IVF or blood products

What should urine output be in a critical care pt?

> 0.5 mL/kg/hr but < 30 cc/hr

What should you use if there is third-spacing in a post-op patient?

IV crystalloid or colloids

What is hypothermia associated with?

post-op coagulopathy

Which IVF is not a volume expander?

D5W

What do pts that are unresponsive to volume support (remain hypotensive) require?

arterial line for continuous monitoring

What do you give pts w/ a stable HR + hypotensive?

Levophed, Vasopressin, Neo-synephrine

What do you give pts w/ a slow HR + hypotensive?

Atropine, Epinephrine, Milrinone

What is considered hypertensive in the PACU?

> 160; give Lasix, cardene, esmolol, nitro, or hydralazine

What labs indicate prerenal azotemia?

urine Na < 20

FENa < 1%

What labs indicate post-renal dysfunction?

urine Na > 40

FENa > 4%

What labs indicate intrinsic renal dysfunction?

urine Na > 40

FENa > 1%

What represents the earliest sign of inadequate organ perfusion & impending acute renal failure?

Oliguria

What is oliguira?

urine output < 400-500 mL/day or < 0.5 cc/hr

What causes oliguria?

dehydration, AKI, shock, low BP, obstruction

How do you calculate FENa?

[(urine Na x serum Cr) / (urine Cr x serum Na)] x 100

What is the tx for oliguria if the pt is hypovolemic?

IVF bolus

What test needs to be done for persistent oliguria?

renal US

What are sx of bladder distention?

suprapubic pain, fullness, new onset incontinence, urge to void

What is the tx for bladder distention?

obtain bladder scan, insert foley cath if > 4hrs post-op w/o voiding

What is the tx for oliguria if the pt is fluid overloaded and has third-spacing?

diuresis (Lasix)

What post-op GI complications are pts in the ICU more likely to develop?

ileus

What are sx of ileus?

abd distention, hyperresonance to percussion, hypoactive or absent bowel sounds, ± pain

What is the tx for ileus?

NPO, NGT to low intermittent suction; clear liquid diet once bowel sounds are heard, further advance diet as tolerated

*no resolution w/in 48-72 hrs → gen surg

What should be done if the patient is still NPO after 5-7 post-op?

enteral feeding MUST begin

When do diabetic patients need their blood glucose checked?

In PACU, on arrival to floor, then q6hrs

What is used for hypoglycemia in post-op?

D50, D5W if on insulin drip d/c once pt tolerates PO

What is the tx for adrenal crisis?

isotonic fluids, obtain labs, IV hydrocortisone

How often should wounds be checked?

daily -asses for edema, erythema, induration, temp, drainage, odor, crepitus

What can improper intubation cause?

atelectasis or lobar collpase and low sats

Prolonged procedures and certain positioning are more prone to what?

DVT or PE

What might central line placement cause?

pneumothorax

What might aggressive fluid administration cause?

pulmonary edema

What should raise suspicion for airway compromise?

stridor