Tutorial 39 - Sepsis

Question 1

What postoperative complications may occur at POD 1-3 (x2)

Answer 1

wind - atelectasis, pneumonia

Question 2

What postoperative complications may occur at POD 3-5

Answer 2

water - UTI

Question 3

What postoperative complications may occur at POD 5-10?

Answer 3

wound - surgical site infection

Question 4

What postoperative complications may occur at POD 5-7?

Answer 4

walking - DVT

Question 5

What postoperative complications may occur at POD > 7?

Answer 5

wonder drugs - drug induced fever.

Question 6

For patients with sepsis and septic shock, what is the recommendation with regards to fluid management?

Answer 6

IV fluids (30ml/kg) within the first hour.

Fluid boluses are preffered method of administration and should be repeated until BP and tissue perfusion are acceptable, pulmonary edema ensues, or there is no further response.

Question 7

For patients with sepsis and septic shock, fluid management should be guided using what 2 clinical targets? (specific)

Answer 7

MAP 65-70 mmHg

urine output = 0.5 mL/kg/hour.

Question 8

Following administraiton of fluids and antibiotics in a sepsis/septic shock patients, what lab values should be simultaneously obtained? (x5)

Answer 8

1. serum lactate
2. ABG
3. blood cultures from two distinct venipucture sites and any indwelling vascular access devices.
4. urinalysis
5. urine c+s

Question 9

What is the next best step in a septic/septic shock patient who remains hypotensive despite adequate fluid resuscitation (defined as 3L in first 3 hours)?

Answer 9

Vasopressors - initial agent is norepinephrine

Question 10

What is the definition of sepsis?

Answer 10

Life-threatening organ dyfunction caused by a dysregulated host repsone to infection where organ dysfunction can be measured objectively using tools such as SOFA or qSOFA.

(high yield, have been pimped on this)

Question 11

What is the definition of septic shock? (x3 criteria)

Answer 11

Persistent hypotension despite adequate fluid resuscitation

+

initiation vasopressors to maintain MAP >= 65 mmHg

+

Lactate >= 2 mmol/L in the absence of hypovolemia

Question 12

What are the five W’s of post-surgical complications?

Answer 12

Wind
Water
Walking
Wound
Wonder drugs

(see other cards for what they refer to)

Question 13

Most likely diagnosis in a 36M who develops SOB 36hrs after an ex lap d/t perforated duodenal ulcer. PMHx of asthma, treated with SABA PRN. Father died of lung cancer at 70. 14PY smoker. Social drinker. On exam, decreased breath sounds at left lung base. Bowel sounds hypoactive.

Vitals: 37.4C, 98bpm, 19RR, 122/76mmHg.

Labs: Hgb 129, WBC 10.6, PLT 223

Answer 13

Most likely diagnosis in a 36M who develops SOB 36hrs after an ex lap d/t perforated duodenal ulcer. PMHx of asthma, treated with SABA PRN. Father died of lung cancer at 70. 14PY smoker. Social drinker. On exam, decreased breath sounds at left lung base. Bowel sounds hypoactive.

Vitals: 37.4C, 98bpm, 19RR, 122/76mmHg.

Labs: Hgb 129, WBC 10.6, PLT 223

Atelectasis (SOB on POD1-3 with MILD fever and lack of crackles)

Question 14

Mild cases of atelectasis (should/should not) get imaging for definitive diagnosis.

Answer 14

Should not (per reading)

Question 15

What is the diagnostic test for atelectasis?

Answer 15

CXR OR CT (do not order for mild tho)

Question 16

What is management of post-op atelectasis?

Answer 16

Most self-resolve, however you can:

Deep breathing exersies
Chest physio
O2

(Extreme cases can require intubation/sunctioning/CPAP)

(misc note but I remember a FM doc telling me about something called incentive spirometry and how lots of patients do it incorrectly because you are supposed to blow out but everyone sucks in…)

Question 17

Most likely dx in a 59F who reports abdominal bloating and discomfort 3d after TAH. Nausea without vomitting. No appetite despite not having eaten since the surgery and only having sips of water. Pain well controlled on PCA. Cath was removed POD2 w/o issues.

On exam: mildly distended, tympanic abdomen with absent bowel sounds.

Vitals: 36.5C, 84bpm, 12RR, 132/92mmHg.

AXR shows uniform distribution of gas, with no air-fluid levels.

Answer 17

Most likely dx in a 59F who reports abdominal bloating and discomfort 3d after TAH. Nausea without vomitting. No appetite despite not having eaten since the surgery and only having sips of water. Pain well controlled on PCA. Cath was removed POD2 w/o issues.

On exam: mildly distended, tympanic abdomen with absent bowel sounds.

Vitals: 36.5C, 84bpm, 12RR, 132/92mmHg.

AXR shows uniform distribution of gas, with no air-fluid levels.

Ileus (abdominal ssx pod3, vitals stable, minimal pain, normal axr)

Question 18

What is management of postop ileus?

Answer 18

Supportive care (fluids, lytes, mag, etc.)