A 71-year-old man is evaluated on postoperative day 4 following an open sigmoid colectomy … — USMLE Step 2 CK

A 71-year-old man is evaluated on postoperative day 4 following an open sigmoid colectomy for recurrent diverticulitis. Over the last several hours, he has developed worsening shortness of breath and a cough productive of pink, frothy sputum. His medical history is significant for ischemic cardiomyopathy with an ejection fraction of $35\%$ and severe chronic obstructive pulmonary disease. Since the operation, he has been receiving continuous $0.9\%$ normal saline at a rate of $150\text{ mL/hr}$ and scheduled intravenous piperacillin-tazobactam.

Temperature is $38.2^\circ \text{C}$ ( $100.8^\circ \text{F}$ ), blood pressure is $168/94\text{ mmHg}$ , pulse is $112/\text{min}$ , and respiratory rate is $28/\text{min}$ . Pulse oximetry shows an oxygen saturation of $86\%$ on room air. Physical examination reveals elevated jugular venous pressure, an $S_3$ gallop, and coarse crackles over the bilateral lower and mid lung fields. Expiratory wheezing is absent. The surgical incision is clean, dry, and intact with no surrounding erythema or induration. The abdomen is soft, mildly tender near the incision, but not distended.

Laboratory studies show a leukocyte count of $12,500/\mu\text{L}$ . A portable chest radiograph reveals cardiomegaly, bilateral fluffy alveolar opacities, and small bilateral pleural effusions.

Which of the following are the most appropriate next steps in management? (Select 2)

Administer intravenous furosemideAnswer
Discontinue the continuous intravenous saline infusionAnswer
C
Administer intravenous methylprednisolone and nebulized ipratropium-albuterol
D
Escalate antimicrobial therapy to intravenous vancomycin and meropenem
E
Obtain a computed tomography scan of the abdomen and pelvis with intravenous contrast

Answer

The most appropriate next steps are to discontinue the continuous intravenous saline infusion and administer intravenous furosemide.

The correct steps address the primary pathophysiology: iatrogenic acute decompensated heart failure. Postoperative patients routinely receive large volumes of intravenous fluids. In patients with underlying left ventricular systolic dysfunction (ejection fraction of

35\%

), this aggressive fluid resuscitation can easily exceed the heart's pumping capacity, leading to elevated left ventricular end-diastolic pressure and subsequent transudation of fluid into the alveoli (pulmonary edema). The clinical diagnosis is supported by the triad of elevated jugular venous pressure, an

S_3

gallop, and bilateral pulmonary crackles. The chest radiograph confirms cardiogenic pulmonary edema with cardiomegaly and bilateral fluffy opacities. The most appropriate immediate management is twofold: remove the precipitating factor by discontinuing the continuous intravenous fluids, and actively offload the fluid excess using an intravenous loop diuretic such as furosemide.

Step-by-Step Solution

Analyze the patient's risk factors and clinical presentation.

The patient has a history of ischemic cardiomyopathy and has received large volumes of intravenous fluids (

150\text{ mL/hr}

for 4 days). He now presents with hypoxia, JVD, an

S_3

gallop, and pulmonary crackles.

Identifying the constellation of signs points toward a specific cardiopulmonary syndrome.

Interpret the diagnostic data.

The chest radiograph shows cardiomegaly, bilateral alveolar opacities, and pleural effusions, which confirm the presence of cardiogenic pulmonary edema.

Radiographic findings differentiate cardiogenic pulmonary edema from other causes of postoperative hypoxia, such as pneumonia or COPD exacerbation.

Determine the immediate therapeutic interventions.

The immediate goals are to halt further fluid accumulation by stopping the IV saline and to aggressively diurese the patient with an intravenous loop diuretic.

In acute decompensated heart failure driven by iatrogenic volume overload, reducing preload is the most critical physiological target to restore adequate oxygenation.

Key Concept

Management of postoperative acute decompensated heart failure induced by iatrogenic volume overload.

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