Preoperative and Postoperative Care

A 62-year-old male is evaluated in the surgical intensive care unit on postoperative day 8 following an open appendectomy for a perforated appendix. After an initially uncomplicated recovery with return of bowel function on day 4, he developed severe, constant abdominal pain, nausea, and bilious vomiting over the past 24 hours. He has not passed flatus since the onset of these symptoms.

His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), heart rate is $125/\text{min}$, respiratory rate is $24/\text{min}$, and blood pressure is $88/55\text{ mmHg}$.

Physical examination reveals a distended, rigid abdomen with diffuse rebound tenderness and involuntary guarding. Bowel sounds are absent.

Laboratory studies show a leukocyte count of $19,500/\text{mm}^3$ with $85\%$ neutrophils, and a serum lactate of $4.6 \text{ mmol/L}$.

Supine and upright abdominal radiographs demonstrate multiple dilated loops of small bowel with prominent air-fluid levels and a paucity of colonic gas.

Which of the following is the most appropriate next step in management?

A 74-year-old man is evaluated on postoperative day 3 following an open partial colectomy for colon cancer. He reports new-onset shortness of breath and a cough productive of yellowish sputum that started this morning. His medical history is significant for ischemic cardiomyopathy with an ejection fraction of 40% and chronic obstructive pulmonary disease. His temperature is 38.9°C (102.0°F), blood pressure is 118/74 mmHg, heart rate is 112/min, and respiratory rate is 24/min. Oxygen saturation is 90% on room air. Physical examination reveals a patient in mild respiratory distress. Jugular venous pressure is not elevated. Auscultation of the lungs reveals bronchial breath sounds and crackles over the right lower lung field. The surgical incision is clean, dry, and intact. There is no lower extremity edema. Based on the most likely diagnosis, which of the following are the most appropriate next steps in this patient's management? (Select 2)

A 68-year-old man is evaluated in the intensive care unit on postoperative day 14 following an emergency open repair of a ruptured abdominal aortic aneurysm. His postoperative course has been complicated by prolonged mechanical ventilation and the need for a continuous norepinephrine infusion to maintain adequate perfusion. Over the past 24 hours, his temperature has increased to $39.2$ °C ($102.6$ °F). His abdomen is distended, but deep sedation prevents a reliable assessment of tenderness. Laboratory studies show a leukocyte count of $19,500/mm^3$, a total bilirubin of $3.2$ mg/dL, and an alkaline phosphatase of $350$ U/L. A bedside right upper quadrant ultrasound demonstrates a markedly distended gallbladder with a wall thickness of $5$ mm and the presence of pericholecystic fluid. No echogenic structures with acoustic shadowing are seen within the gallbladder lumen, and the common bile duct measures $4$ mm in diameter. Which of the following is the most appropriate next step in the management of this patient?

A 42-year-old woman is evaluated in the post-anesthesia care unit $2$ hours after undergoing a total thyroidectomy for a multinodular goiter. The nursing staff calls urgently because the patient has developed acute respiratory distress. She is agitated, diaphoretic, and exhibits pronounced inspiratory stridor. Her oxygen saturation is $84\%$ on room air. Physical examination reveals a tense, rapidly expanding swelling beneath the cervical incision. Arrange the following management steps in the most appropriate chronological sequence for this patient's life-threatening complication, assuming each step is performed if the previous intervention fails to completely resolve the airway compromise.

A $68$-year-old male is evaluated in the intensive care unit on postoperative day $2$ following an emergent open repair of a ruptured abdominal aortic aneurysm. During the procedure, he received $8\text{ L}$ of crystalloid and $6$ units of packed red blood cells. The patient remains intubated and mechanically ventilated. Over the past $4$ hours, his urine output has dropped to $5\text{ mL/hr}$. Current vital signs include a temperature of $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure of $82/50\text{ mmHg}$, and heart rate of $124/\text{min}$. The ventilator is alarming for high peak airway pressures, which have increased from $24\text{ cm H}_2\text{O}$ to $48\text{ cm H}_2\text{O}$ since the morning. Central venous pressure is $19\text{ mmHg}$. Physical examination reveals a tightly distended, firm abdomen and bilateral basilar crackles. Laboratory studies demonstrate a serum creatinine of $2.7\text{ mg/dL}$ (baseline $1.0\text{ mg/dL}$) and a leukocyte count of $15,500/\mu\text{L}$. Which of the following is the most appropriate next step in management?

A $62$-year-old man is evaluated on postoperative day $5$ following an elective anterior resection of the rectum for a malignant mass. Over the past $6$ hours, he has developed progressively worsening, severe abdominal pain and altered mental status. His medical history is significant for type 2 diabetes mellitus and hypertension. His current temperature is $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure is $86/52\text{ mm Hg}$, pulse is $128/\text{min}$, and respiratory rate is $26/\text{min}$. Physical examination reveals an ill-appearing, diaphoretic patient. The abdomen is distended, tense, and diffusely tender to palpation with involuntary guarding and pronounced rebound tenderness. Bowel sounds are absent. The surgical incision shows no signs of erythema or purulent discharge. Laboratory studies demonstrate a leukocyte count of $19,400/\text{mm}^3$ with $14\%$ band forms, and a serum lactate level of $4.2\text{ mmol/L}$. Intravenous fluid resuscitation and broad-spectrum antibiotics are initiated immediately. Which of the following is the most appropriate next step in management?

A surgical rapid response is called for a patient experiencing acute deterioration on the surgical ward. The patient, a $68$-year-old male, underwent an uncomplicated laparoscopic repair of a large type III paraesophageal hernia $48$ hours ago. His medical history is significant for hypertension, type $2$ diabetes mellitus, and polymyalgia rheumatica. He has been taking amlodipine, metformin, and prednisone ($15$ mg daily) for the past year. Due to severe postoperative nausea and emesis, he has been strictly nil per os (NPO) since the surgery and has only received intravenous lactated Ringer solution and prochlorperazine. Currently, he appears lethargic. Vital signs reveal a temperature of $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), heart rate of $128$/min, respiratory rate of $22$/min, and blood pressure of $78/48$ mmHg. Physical examination shows dry mucous membranes and a non-distended, soft, and non-tender abdomen. His surgical port sites are clean without erythema. An electrocardiogram demonstrates sinus tachycardia. Laboratory studies are returned as follows:

* Sodium: $126$ mEq/L
* Potassium: $5.6$ mEq/L
* Chloride: $94$ mEq/L
* Bicarbonate: $18$ mEq/L
* Blood urea nitrogen: $32$ mg/dL
* Creatinine: $1.4$ mg/dL
* Glucose: $52$ mg/dL

Which of the following is the most appropriate initial step in the management of this patient?

During morning rounds, a physician evaluates a 54-year-old female recovering on the surgical unit. It is her seventh day recovering from an open myomectomy for large symptomatic uterine leiomyomas. For the past 48 hours, she has been unable to pass flatus or stool and has experienced progressive, crampy abdominal pain. This morning, she had two episodes of dark green, bilious emesis. Vital signs reveal a temperature of $38.7^{\circ}\text{C}$ ($101.7^{\circ}\text{F}$), heart rate of $122/\text{min}$, respiratory rate of $20/\text{min}$, and blood pressure of $94/60\text{ mmHg}$. On physical examination, the abdomen is markedly distended. Auscultation reveals high-pitched, hyperactive bowel sounds. Palpation demonstrates significant guarding and rebound tenderness in all four quadrants. Laboratory evaluation shows a leukocyte count of $18,500/\text{mm}^3$ and a serum lactate level of $4.2\text{ mmol/L}$ (normal: $0.5$-$1.0\text{ mmol/L}$). Which of the following is the most appropriate next step in management?

A 61-year-old man is evaluated in the surgical ward for new-onset right-sided back pain. He is currently on postoperative day $7$ following an open radical retropubic prostatectomy for localized prostate adenocarcinoma. His early postoperative recovery was routine, and he is tolerating a regular diet. Over the past $12$ hours, he has developed a fever and constant, dull pain in his right flank. He has a suprapubic catheter in place that is draining clear yellow urine. His temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $130/82$ mmHg, pulse is $105$/min, and respiratory rate is $16$/min. Physical examination demonstrates a soft, non-tender abdomen and a clean lower midline incision. There is pronounced right-sided costovertebral angle tenderness. Laboratory evaluation reveals a leukocyte count of $14,800/\text{mm}^3$. Analysis of the urine from the suprapubic catheter is negative for leukocyte esterase and nitrites, and shows $1$-$2$ leukocytes/hpf. Which of the following is the most appropriate next step in management?

A 52-year-old male is recovering in the intensive care unit on postoperative day 3 following an open pancreaticoduodenectomy. He has had an uneventful recovery thus far. The surgical team decides to discontinue his right internal jugular central venous catheter. The nurse removes the catheter while the patient is sitting upright in his bed. Immediately after the catheter is pulled, the patient gasps and becomes unresponsive. His blood pressure drops to $65/40 \text{ mmHg}$, heart rate increases to $138 \text{ /min}$, and oxygen saturation falls to $76\%$ on room air. Auscultation of the chest reveals a loud, churning, machinery-like murmur over the precordium. Arrange the following immediate management steps in the most appropriate chronological order.

A $28$-year-old man with no significant past medical history is undergoing an elective open reduction and internal fixation of a right femur fracture. Anesthesia is induced with propofol and succinylcholine, and maintained with sevoflurane. Approximately $45$ minutes into the surgery, the anesthesiologist notes a sudden, unexplained rise in end-tidal carbon dioxide (ETCO2) from $35$ mmHg to $68$ mmHg. The patient's heart rate increases to $142$/min, and generalized masseter muscle rigidity is observed. His core body temperature begins to rise rapidly and is currently $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$). Arrange the following steps in the most appropriate chronological sequence for the immediate management of this patient's suspected complication.

Surgical team rounds are being conducted on a 71-year-old male patient who is currently recovering six days after an elective open abdominal aortic aneurysm repair. His past medical history is notable for diet-controlled type 2 diabetes and mild chronic obstructive pulmonary disease.

Seventy-two hours after his surgery, he experienced acute tachypnea, a productive cough, and a temperature spike to 38.7°C (101.7°F). Portable chest imaging confirmed a right lower lobe consolidation. The patient was promptly started on an empiric antimicrobial regimen of intravenous piperacillin-tazobactam and vancomycin for suspected hospital-acquired pneumonia.

Today, the patient feels much better, is breathing comfortably on ambient air, and his temperature has normalized to 37.1°C (98.8°F). Leukocyte counts have trended down from a peak of 16,500/mm³ to 8,500/mm³. The microbiology laboratory reports that respiratory cultures from the initial febrile episode have finalized, revealing a heavy growth of Haemophilus influenzae. The isolate demonstrates susceptibility to ceftriaxone, levofloxacin, and amoxicillin-clavulanate.

Which of the following represent the most appropriate management decisions at this time? (Select exactly 2 answers)

During morning rounds, the surgical team evaluates a 48-year-old male patient who is currently on his second day of recovery following an open cholecystectomy for acute gangrenous cholecystitis. The patient complains of new, mild shortness of breath and right-sided abdominal discomfort when attempting to take a deep breath. Vital signs show a temperature of 38.3°C (100.9°F), pulse of 98/min, blood pressure of 128/82 mmHg, and a respiratory rate of 20/min. Pulse oximetry displays 94% on room air. Auscultation of the chest demonstrates diminished breath sounds at both lung bases without crackles or wheezing. The surgical wound appears well-approximated without drainage, induration, or erythema. The abdomen is soft with expected mild tenderness at the incision site.

Which of the following interventions are the most appropriate next steps in managing this patient's clinical presentation? (Select 2 options)

During routine evening rounds, a physician is asked to assess a patient who recently underwent abdominal surgery. The patient is a 54-year-old male who had an open partial colectomy for a large, benign colonic polyp 48 hours ago. The nursing staff reports that his temperature has increased to 38.5°C (101.3°F). Vital signs show a blood pressure of 130/80 mmHg, pulse of 96/min, and respirations of 20/min. Oxygen saturation is 96% on room air. The patient feels slightly fatigued but denies any chest pain, shortness of breath, or pain with urination. He is currently receiving patient-controlled intravenous morphine. On physical examination, the abdomen is mildly distended with hypoactive bowel sounds, and the surgical dressing is clean and dry. Auscultation of the chest reveals diminished breath sounds bilaterally at the lung bases without crackles or wheezes. There is no calf swelling or tenderness. Which of the following is the most appropriate initial intervention for this patient?

A 62-year-old man is assessed on the surgical ward 72 hours after undergoing an open sigmoid colectomy for complicated diverticulitis. He reports feeling fatigued but denies shortness of breath, chest pain, dysuria, or nausea. He is tolerating a clear liquid diet and passed flatus this morning. His medical history includes chronic obstructive pulmonary disease (COPD) and essential hypertension.

His vital signs are:
Temperature: 38.6°C (101.5°F)
Blood pressure: 132/84 mm Hg
Heart rate: 96/min
Respiratory rate: 18/min
Oxygen saturation: 94% on room air

Physical examination reveals a soft abdomen with mild, localized tenderness at the surgical incision site. There is no rebound tenderness or guarding. The midline incision is well-approximated, clean, and dry without erythema or discharge. Pulmonary auscultation reveals mild, scattered expiratory wheezes bilaterally that are unchanged from his preoperative baseline examination. There are no crackles, and jugular venous distension is absent. His indwelling urethral catheter was removed 24 hours ago, and he has voided spontaneously since then. Bilateral calf examination shows no edema or tenderness.

Which of the following are the most appropriate next steps in the management of this patient? (Select 3)

A respiratory therapy consult is requested for a 64-year-old woman who has developed mild shortness of breath on her second day of recovery following an open ventral hernia repair. She has a known history of chronic obstructive pulmonary disease and diet-controlled type 2 diabetes mellitus. Current vital signs reveal a temperature of 37.8°C (100°F), a heart rate of 102/min, a respiratory rate of 22/min, and blood pressure of 138/85 mmHg. Oxygen saturation is 92% on ambient air. When questioned, the patient states that taking large breaths causes significant discomfort at the incision site. Physical examination demonstrates shallow respirations with noticeably diminished breath sounds at both pulmonary bases. The lungs are otherwise clear, without wheezes, rhonchi, or crackles. The jugular veins are flat, and cardiac auscultation shows a regular rhythm with no gallops or murmurs. The surgical wound appears clean, dry, and intact. Which of the following is the most appropriate initial intervention to manage this patient's current respiratory presentation?

A 58-year-old man is examined in the hospital one week after undergoing a laparoscopic-assisted right hemicolectomy for a ruptured appendix with a localized abscess. He was initially recovering well but has developed worsening right shoulder pain and a mild, persistent cough over the last two days. His temperature is 39.0°C (102.2°F), blood pressure is 128/82 mmHg, pulse is 112/min, and respirations are 20/min. Pulse oximetry is 96% on room air. Cardiopulmonary examination reveals diminished breath sounds over the right posterior lung base. The abdomen is soft, with moderate focal tenderness in the right upper quadrant. The surgical incisions are healing well without erythema, fluctuance, or discharge. His leukocyte count is 18,500/mm^3. A portable chest radiograph demonstrates a small right-sided pleural effusion with an elevated right hemidiaphragm.

Which of the following is the most appropriate next step in management?

While recovering on the surgical unit, a 68-year-old male is evaluated for new-onset respiratory distress and increased sputum production. The patient is currently on postoperative day 2 following an open partial colectomy for adenocarcinoma. His past medical history includes severe chronic obstructive pulmonary disease (COPD), osteoarthritis, and hypertension. He continues to smoke one pack of cigarettes daily.

Vital signs show a temperature of 38.7°C (101.6°F), pulse of 112/min, blood pressure of 138/82 mm Hg, and respirations of 26/min. Pulse oximetry reading is 88% on ambient air. Physical examination reveals a barrel-shaped chest with diffuse, bilateral expiratory wheezing and a prolonged expiratory phase. Jugular venous pressure is normal, and heart sounds are regular without any S3 gallop. The abdominal incision is clean, dry, and intact with no surrounding erythema. Both calves are soft, compressible, and nontender. A portable chest radiograph displays hyperinflated lung fields along with a newly developed dense consolidation in the left lower lobe.

Which of the following are the most appropriate next steps in the management of this patient? (Select 3)

On his sixth day of recovery following an open appendectomy for perforated appendicitis, a 65-year-old man reports progressive abdominal bloating and bilious vomiting. He has not passed flatus or stool for the past 48 hours. Vital signs show a heart rate of 110/min and blood pressure of 115/75 mmHg. Physical examination reveals a markedly distended, tympanitic abdomen with high-pitched 'tinkling' bowel sounds. There is diffuse mild tenderness but no rebound or guarding. Arrange the following management steps in the most appropriate chronological sequence for this patient's condition, progressing from initial intervention to definitive management.

A 60-year-old woman is evaluated on postoperative day 6 following a robotic-assisted total hysterectomy and bilateral salpingo-oophorectomy for endometrial cancer. Her recovery had been uncomplicated until this morning, when she developed a mild fever and sudden-onset shortness of breath. Her temperature is 38.2°C (100.8°F), blood pressure is 110/70 mm Hg, pulse is 112/min, and respirations are 24/min. Pulse oximetry shows an oxygen saturation of 92% on room air. Physical examination reveals clear breath sounds bilaterally. The abdominal surgical incisions are clean, dry, and intact with no surrounding erythema. Her right calf appears mildly swollen and is tender to palpation compared to the left. Which of the following are the most appropriate next steps in the management of this patient? (Select two)