Postoperative Complications


POSTOPERATIVE COMPLICATIONS



What is the most likely diagnosis?


a. Atelectasis


b. Pneumonia


c. Urinary tract infection


d. Deep venous thrombosis


e. Wound infection


Answer b. Pneumonia


The most likely cause of fever on the first through third postoperative day is pneumonia or wind. The underlying cause of pneumonia can be bacterial infiltration or aspiration.






An incentive spirometer prevents atelectasis but does not prevent pneumonia.










Anterior hypothalamus is responsible for cooling; the posterior is responsible for heating.






What is the best next step in the management of this patient?


a. Chest radiography


b. Blood cultures


c. Start antibiotics


d. Sputum culture


e. Check for a cough


Answer a. Chest radiography


The best next step in the management of this patient is to obtain posterior-anterior and lateral chest radiographs. It is always the wrong answer to obtain a portable chest radiograph for anything other than line or tube placement. Obtaining blood cultures will not help in diagnosis pneumonia but only for bacteremia, and starting antibiotics is only after the pneumonia is confirmed. Sputum is only available in up to one third of patients with pneumonia, and therefore it is not routinely done. Cough is not necessarily seen in all patients with pneumonia and therefore is also not reliable for diagnostic purposes.







Order:


PA and lateral chest radiography


Turn the clock forward to obtain results.


CCS TIP: The exam will always tell you exactly what time the report will be available.


The chest radiography reveals a dense consolidation in the right lung base consistent with aspiration pneumonia.










Interleukin 1 (IL-1) release causes fever by stimulating the hypothalamus.











Benefits of fever:


• Increased mobility of leukocytes


• Enhanced leukocyte phagocytosis


• Decreased endotoxin effects


• Increased proliferation of T cells











Order:


Antibiotics to cover for health care–associated pneumonia (HCAP) regardless of the postoperative day.










Surgery or intubation makes HCAP possible even before the 48-hour mark.












Treating HCAP when pseudomonas is likely requires vancomycin with two of the following:


• Antipseudomonal cephalosporin (cefepime, ceftaroline)


• Carbapenem (imipenem, meropenem)


• β-Lactam/β-lactamase inhibitor (piperacillin–tazobactam, ticarcillin–clavulanic acid)


• Fluoroquinolone (levofloxacin, moxifloxacin)


• Aminoglycoside


• Monobactam (aztreonam)









What is the most likely diagnosis?


a. Atelectasis


b. Pneumonia


c. Urinary tract infection (UTI)


d. Deep venous thrombosis (DVT)


e. Wound infection


Answer c. Urinary tract infection (UTI)


The most likely diagnosis for fever on the third postoperative day is a catheter-associated urinary tract infection (CAUTI). A Foley catheter is a foreign body and therefore is a nidus for infection. The risk of a CAUTI increases with the duration of catheterization. Common misconceptions regarding prevention of CAUTI include prophylactic antibiotics, using iodine-based sterile techniques for insertion, and flushing the catheter. The only way of preventing a CAUTI is early removal of the catheter.






UTI is more common in patients who have undergone a genitourinary procedure.






What is the best next step in the management of this patient?


a. Urinalysis (UA)


b. Urine culture


c. Start antibiotics


d. Remove the Foley catheter


e. Flush the Foley line with vancomycin


Answer d. Remove the Foley catheter


The best next step in the management of this patient is the removal of the Foley catheter. The patient is able to sit in a chair, is ambulatory, and no longer requires a Foley catheter. Obtaining UA and urine culture is important for diagnostic purposes, but removing the Foley catheter is more important. Otherwise, you are not treating the true underlying cause of the UTI. After obtaining urine for analysis, it is then paramount to start antibiotics. Flushing the line with vancomycin or any antibiotic has never been shown to treat a UTI.







Orders:


Remove the Foley catheter.


Obtain UA.


Obtain urine culture.


Turn the clock forward 30 minutes to obtain the results of the UA.


The UA shows a specific gravity of 1.003, no protein, no glucose, positive leukocyte esterase, nitrates, no red blood cells, and 50 to 100 white blood cells (WBCs) in the urine. The urine is foul smelling and cloudy. Culture is still pending.











The most common organisms in CAUTI are Escherichia coli #1 and enterococci #2.


The most common organism for UTI after coitus is Staphylococcus saprophyticus.










Leukocyte esterase is surrogate marker for WBCs in the urine.






Dec 22, 2016 | Posted by in GYNECOLOGY | Comments Off on Postoperative Complications
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