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Difficulty: MediumPreoperative and Postoperative Care

A physician is called to the bedside to evaluate a 68-year-old male who developed acute shortness of breath. The patient underwent an uncomplicated partial bowel resection three days ago. His past medical history includes essential hypertension, hyperlipidemia, and a myocardial infarction four years ago. During the first two postoperative days, he received a total of 5 liters of isotonic crystalloid due to transient episodes of hypotension. Current vital signs show a temperature of 37.4°C (99.3°F), blood pressure of 162/95 mmHg, heart rate of 108/min, and a respiratory rate of 26/min. Pulse oximetry is 89% on room air. On physical examination, the jugular venous pressure is elevated. Lung auscultation reveals bilateral basilar crackles, and cardiac auscultation demonstrates a third heart sound (S3). The surgical incision is intact without erythema or drainage. Which of the following is the most appropriate next step in management?

  1. A
    Administer intravenous piperacillin-tazobactam
  2. B
    Administer inhaled albuterol and ipratropium
  3. Administer intravenous furosemideAnswer
  4. D
    Encourage targeted use of an incentive spirometer
  5. E
    Perform computed tomography pulmonary angiography

Answer

Administer intravenous furosemide
The correct answer is administering intravenous furosemide. This patient is presenting with acute decompensated heart failure (ADHF) characterized by cardiogenic pulmonary edema. The diagnosis is supported by the triad of an S3 gallop, elevated jugular venous pressure (JVP), and bilateral basilar crackles in the setting of acute hypoxia. Patients with a history of cardiac disease (such as a prior myocardial infarction) are at high risk for ADHF in the postoperative period, particularly after receiving aggressive intravenous fluid resuscitation. As the administered crystalloids begin to mobilize from the extravascular space back into the intravascular compartment around postoperative day 3, the compromised left ventricle cannot handle the increased preload, leading to pulmonary congestion. The immediate next best step is to administer an intravenous loop diuretic like furosemide to decrease preload and resolve the pulmonary edema.

Step-by-Step Solution

1
Identify the primary clinical problem from the physical examination and vital signs.
The patient has acute dyspnea, hypoxia, an elevated jugular venous pressure, bilateral crackles, and an S3 gallop on postoperative day 3.
Recognizing this specific constellation of signs is essential to differentiate between various causes of postoperative respiratory distress.
2
Correlate the physical findings with the patient's recent medical history and interventions.
The patient has a history of a myocardial infarction and received large volumes of intravenous fluids (5 liters) over the past 48 hours.
Prior structural heart disease predisposes to ventricular dysfunction, and aggressive fluid resuscitation often precipitates volume overload in these patients once third-spaced fluid begins to mobilize.
3
Determine the diagnosis and select the appropriate therapeutic intervention.
The diagnosis is acute decompensated heart failure presenting as cardiogenic pulmonary edema. Intravenous loop diuretics (like furosemide) are the most appropriate next step.
Diuresis effectively reduces intravascular volume and preload, which relieves pulmonary congestion and improves oxygenation.

Key Concept

Postoperative acute decompensated heart failure frequently occurs following aggressive intravenous fluid resuscitation in patients with underlying cardiac disease, presenting with hypoxia, crackles, elevated JVP, and an S3 gallop.
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Topics

Preoperative and Postoperative Care

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