During morning rounds, a 74-year-old male is evaluated in the surgical intensive care unit… — USMLE Step 2 CK

During morning rounds, a 74-year-old male is evaluated in the surgical intensive care unit due to progressive dyspnea and mild confusion. The patient is 72 hours status post an uncomplicated Billroth II subtotal gastrectomy for a refractory peptic ulcer. His past medical history is significant for essential hypertension and osteoarthritis. He has received a total of $7.5\text{ L}$ of isotonic crystalloid since the operation and has had a cumulative urine output of $1.8\text{ L}$ . Vital signs demonstrate a temperature of $37.9^\circ\text{C}$ ( $100.2^\circ\text{F}$ ), blood pressure of $162/94\text{ mm Hg}$ , pulse of $118/\text{min}$ , and respiratory rate of $28/\text{min}$ . Pulse oximetry shows an oxygen saturation of $87\%$ on room air. Physical examination reveals elevated jugular venous pressure. Lung auscultation demonstrates bilateral basilar crackles and diffuse expiratory wheezing. The abdomen is soft, mildly tender at the incision site, and non-distended, with intact surgical dressings and no erythema. Which of the following are the most appropriate immediate steps in the management of this patient? (Select exactly two options)

Administer intravenous furosemideCevap
Initiate noninvasive positive-pressure ventilationCevap
C
Administer inhaled ipratropium-albuterol and systemic corticosteroids
D
Obtain a computed tomography scan of the abdomen and pelvis
E
Commence empiric intravenous piperacillin-tazobactam

Cevap

The correct management steps are to administer intravenous furosemide and initiate noninvasive positive-pressure ventilation.

The patient is experiencing acute decompensated heart failure due to fluid overload, a classic postoperative complication occurring around days 3 to 4 as third-spaced fluids mobilize back into the intravascular space. The massive positive fluid balance, hypoxia, jugular venous distention, basilar crackles, and wheezing (cardiac asthma) strongly point to cardiogenic pulmonary edema. Initial management includes reducing preload with loop diuretics and providing respiratory support with noninvasive positive-pressure ventilation to immediately improve oxygenation and decrease the work of breathing.

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Analyze the patient's fluid balance and timeline.

The patient received

7.5\text{ L}

of fluids with only

1.8\text{ L}

of output and is currently on postoperative day 3.

Third-spaced fluids characteristically mobilize back into the intravascular compartment between postoperative days 3 and 4, greatly increasing the risk of hypervolemia and volume overload.

Interpret the physical examination and vital sign findings.

Hypoxia, elevated jugular venous pressure, basilar crackles, and wheezing are identified.

These signs collectively indicate increased right-sided heart pressures and pulmonary edema, confirming a diagnosis of acute decompensated heart failure rather than an infectious or primary pulmonary process.

Determine the immediate management for postoperative pulmonary edema.

Select interventions that reduce preload and improve oxygenation.

Intravenous loop diuretics (furosemide) reduce intravascular volume, while noninvasive positive-pressure ventilation improves alveolar gas exchange and reduces the work of breathing.

Anahtar Kavram

Postoperative fluid overload and the mobilization of third-spaced fluids (typically occurring on postoperative days 3-4) can precipitate acute decompensated heart failure, requiring acute management with loop diuretics and noninvasive respiratory support.

Soru

Cevap

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Anahtar Kavram

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