An 81-year-old male resident of a skilled nursing facility is assessed on postoperative da… — USMLE Step 2 CK

An 81-year-old male resident of a skilled nursing facility is assessed on postoperative day $2$ after undergoing an open cholecystectomy for acute gangrenous cholecystitis. The patient has become increasingly short of breath over the last $4$ hours. His medical history is significant for chronic obstructive pulmonary disease, hypertension, and ischemic cardiomyopathy with a left ventricular ejection fraction of $35\%$ . The operative report notes that he received $4.5$ liters of crystalloid resuscitation due to transient intraoperative hypotension. His temperature is $37.9^\circ\text{C}$ ( $100.2^\circ\text{F}$ ), blood pressure is $152/90$ mmHg, pulse is $114/\text{min}$ , and respiratory rate is $26/\text{min}$ . Pulse oximetry shows $88\%$ on room air. Physical examination reveals jugular venous distention to $11 \text{ cm } H_2O$ . Cardiac auscultation reveals a regular tachycardia and a prominent S3 gallop. Pulmonary examination demonstrates bibasilar crackles extending to the mid-lung fields without wheezing. The surgical incision is clean, dry, and intact. Which of the following is the most appropriate next step in management?

A
Computed tomography angiography of the chest
B
Intravenous piperacillin-tazobactam
Intravenous furosemideAnswer
D
Inhaled albuterol and systemic corticosteroids
E
Urinalysis and urine culture

Answer

Intravenous furosemide

The correct answer addresses the patient's acute decompensated heart failure. Patients with an underlying ischemic cardiomyopathy (ejection fraction of

35\%

) have a narrow therapeutic window for fluid balance. The administration of

4.5

liters of crystalloid intraoperatively overwhelmed his compromised left ventricle, leading to pulmonary edema. The clinical triad of an S3 gallop, jugular venous distention, and bibasilar crackles strongly confirms volume overload. Intravenous furosemide, a loop diuretic, rapidly decreases intravascular volume and cardiac preload, thereby improving pulmonary congestion and hypoxemia.

Step-by-Step Solution

Analyze the patient's medical history and intraoperative course.

The patient has a history of ischemic cardiomyopathy with a low ejection fraction (

35\%

) and received a large volume of intravenous fluids (

4.5

liters) during surgery.

Identifying risk factors for volume overload is crucial in the postoperative period.

Interpret the physical examination findings.

The presence of jugular venous distention, an S3 gallop, and bibasilar crackles without wheezing indicates left and right-sided heart failure.

These classic signs differentiate heart failure from other causes of postoperative hypoxemia such as a chronic obstructive pulmonary disease exacerbation or pneumonia.

Determine the most appropriate intervention based on the diagnosis.

Select intravenous furosemide to promote diuresis and resolve the acute volume overload.

Loop diuretics decrease preload and effectively alleviate pulmonary edema in acute decompensated heart failure.

Key Concept

Postoperative patients with a history of reduced ejection fraction are at high risk for acute decompensated heart failure following large-volume intraoperative fluid resuscitation; management requires prompt loop diuretic therapy.

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