Examkin

Soru

Zorluk: Çok zorPreoperative and Postoperative Care

A 7272-year-old man is evaluated on postoperative day 44 following an urgent open repair of a perforated anterior duodenal ulcer. He reports rapidly increasing shortness of breath and a cough productive of clear, frothy sputum. His medical history is significant for ischemic cardiomyopathy with a left ventricular ejection fraction of 35%35\% and severe chronic obstructive pulmonary disease. His temperature is 38.2∘C38.2^\circ\text{C} (100.8∘F100.8^\circ\text{F}), blood pressure is 158/88 mmHg158/88\text{ mmHg}, pulse is 112/min112/\text{min}, and respirations are 28/min28/\text{min}. Pulse oximetry shows 88%88\% on 4 L/min4\text{ L/min} of oxygen via nasal cannula. Physical examination reveals an elevated jugular venous pressure of 11 cm H2O11\text{ cm H}_2\text{O}. Lung auscultation demonstrates scattered expiratory wheezes and prominent bibasilar crackles. Cardiovascular examination reveals a regular tachycardia with an S3 gallop. The abdomen is soft, mildly distended, and tender only at the midline incision, with no rebound or guarding. Complete blood count shows a leukocyte count of 10,500/mm310,500/\text{mm}^3. A portable chest radiograph reveals an enlarged cardiac silhouette, bilateral perihilar haziness, and cephalization of the pulmonary vessels, without subdiaphragmatic free air. Which of the following are the most appropriate next steps in the management of this patient? (Select 2)

  1. Administration of intravenous furosemideCevap
  2. Application of noninvasive positive-pressure ventilationCevap
  3. C
    Initiation of intravenous piperacillin-tazobactam and vancomycin
  4. D
    Administration of systemic corticosteroids and inhaled bronchodilators
  5. E
    Cross-sectional imaging of the abdomen and pelvis with intravenous contrast

Cevap

The most appropriate initial steps are the administration of intravenous furosemide and the application of noninvasive positive-pressure ventilation.
The patient is presenting with acute decompensated heart failure triggered by the expected postoperative mobilization of third-spaced fluids (typically occurring on postoperative days 3-5). Patients with a history of reduced left ventricular ejection fraction are at high risk during this phase. The constellation of elevated jugular venous pressure, an S3 gallop, and characteristic chest radiograph findings points directly to volume overload. The standard initial management for acute cardiogenic pulmonary edema includes reducing preload with intravenous loop diuretics and providing respiratory support with noninvasive positive-pressure ventilation.

Adım Adım Çözüm

1
Analyze the patient's postoperative timeline and risk factors.
The patient is on postoperative day 4 with a history of heart failure with reduced ejection fraction.
Postoperative days 3 to 5 are characterized by the mobilization of third-spaced fluids back into the intravascular space, putting patients with compromised cardiac function at high risk for volume overload.
2
Interpret the physical examination and diagnostic findings.
The presence of elevated jugular venous pressure, an S3 gallop, bibasilar crackles, and chest radiograph findings of cephalization and perihilar haziness confirms acute decompensated heart failure.
These findings reliably differentiate cardiogenic pulmonary edema from other causes of postoperative hypoxia, such as pneumonia or pulmonary embolism.
3
Identify the appropriate interventions for the established diagnosis.
Intravenous loop diuretics and noninvasive positive-pressure ventilation are selected.
Diuresis addresses the underlying volume overload, while positive-pressure ventilation immediately improves oxygenation and hemodynamics.

Anahtar Kavram

Postoperative acute decompensated heart failure typically occurs on postoperative days 3-5 due to fluid mobilization. It presents with signs of volume overload and is managed with loop diuretics and noninvasive positive-pressure ventilation.
Bu soruyu puanla

Konular

Preoperative and Postoperative Care

Bu konudan daha fazla soru