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Zorluk: OrtaPreoperative and Postoperative Care

A 74-year-old man requires evaluation in the orthopedic ward four days after undergoing a right hip hemiarthroplasty for a femoral neck fracture. Over the last 12 hours, he has experienced progressively worsening shortness of breath, chest tightness, and a new-onset cough producing small amounts of clear sputum. His past medical history is significant for hypertension and moderate chronic obstructive pulmonary disease. His home medications, which include a daily fluticasone-salmeterol inhaler, were inadvertently not restarted after the procedure. His temperature is 38.1°C (100.6°F), blood pressure is 138/86 mmHg, pulse is 108/min, and respiratory rate is 22/min. Pulse oximetry shows 91% on room air. Physical examination reveals a prolonged expiratory phase and diffuse expiratory wheezing over all lung fields. There is no jugular venous distention, and heart sounds are normal without gallops or murmurs. The surgical incision is clean, dry, and intact with no surrounding erythema. There is no unilateral lower extremity edema. A chest radiograph demonstrates hyperinflated lung fields and flattened hemidiaphragms, without focal consolidation, pleural effusion, or pulmonary vascular congestion. An electrocardiogram shows sinus tachycardia without right heart strain. Which of the following is the most appropriate next step in the management of this patient?

  1. Administer systemic glucocorticoids and nebulized bronchodilatorsCevap
  2. B
    Administer a dose of intravenous furosemide
  3. C
    Begin treatment with intravenous levofloxacin
  4. D
    Obtain computed tomography pulmonary angiography
  5. E
    Encourage hourly use of an incentive spirometer

Cevap

The correct answer is to administer systemic glucocorticoids and nebulized bronchodilators.
The correct approach is the administration of systemic glucocorticoids and nebulized bronchodilators. This patient's clinical presentation—diffuse wheezing, prolonged expiration, cough, low-grade fever, and radiographic hyperinflation—is classic for an acute exacerbation of chronic obstructive pulmonary disease (COPD). The exacerbation was likely triggered by the inadvertent discontinuation of his home maintenance inhalers (fluticasone-salmeterol) during the postoperative period. Management of an acute COPD exacerbation involves supplemental oxygen (target SpO2 88-92%), short-acting bronchodilators (e.g., albuterol and ipratropium), and systemic glucocorticoids to reduce airway inflammation.

Adım Adım Çözüm

1
Analyze the patient's postoperative timeline and clinical presentation.
The patient is on postoperative day 4 with dyspnea, tachycardia, low-grade fever, cough with clear sputum, and diffuse wheezing.
Establishing the timeline and key physical exam findings is essential to narrow the differential for postoperative respiratory distress.
2
Integrate the patient's past medical history and medication context.
The patient has known COPD and his maintenance inhalers were inadvertently discontinued after surgery.
Iatrogenic withdrawal of maintenance medications is a common trigger for exacerbations of chronic conditions in the postoperative period.
3
Evaluate the objective diagnostic data.
Chest X-ray shows hyperinflation without consolidation or vascular congestion. ECG shows no right heart strain.
These findings rule out pneumonia (no consolidation) and heart failure (no congestion), supporting airway obstruction as the primary pathology.
4
Select the appropriate therapeutic intervention.
The clinical picture strongly supports an acute COPD exacerbation. Antibiotics are not indicated due to the lack of purulent sputum.
Standard therapy for a COPD exacerbation without purulent sputum relies on short-acting bronchodilators and systemic glucocorticoids.

Anahtar Kavram

Postoperative management of chronic comorbidities and recognition of acute COPD exacerbations
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Konular

Preoperative and Postoperative Care

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