!

"#$"%&'()*& ,'-#&#
uavld L. 8owLon, Mu, lCC, lCCM
rofessor and Pead, Secuon on Crlucal Care
ueparLmenL of AnesLheslology
Wake loresL School of Medlclne

.-#/0"#1'&
no ulsclosures perunenL Lo Lhls presenLauon
CranL SupporL ln pasL 2 years:
Covldlen
nlP-nlA
234&/)*&#
AL Lhe end of Lhls course, Lhe learner wlll be able Lo:

1. ulerenuaLe among Lhe poLenual causes of posLoperauve
fever based upon Lhe ume course of fever onseL
2. LlsL causes of posL-neurosurglcal alLered menLal sLaLus and
descrlbe an approach Lo Lhelr dlagnosls and LreaLmenL
3. LlsL causes of hypoLenslon followlng CA8C surgery and
descrlbe an approach Lo Lhelr dlagnosls and managemenL
4. ulscuss Lhe slgns and managemenL of abdomlnal
comparLmenL syndrome
3. ulscuss Lhe ume course of posLoperauve resplraLory
dysfuncuon and lLs relauonshlp Lo posLoperauve resplraLory
fallure
!"#$"%&'()*& ,'-#&#
Ceneral:
lever
PypoLenslon
osL Cp 8esplraLory lallure
neurosurglcal crlses
AMS
PyponaLremla
ul
Alrway emergencles
C1
PypoLenslon
8leedlng/coagulopaLhy
ArrhyLhmlas
Cv
Surgery and coronary sLenLs
Anemla
!"#$ 2%&'()*& 5&*&'
23 of posLop pauenLs develop fever (Lemp > 38.2C)
Slmllar lncldence ln crlucally lll and non-crlucally lll
!"#$ 2%&'()*& 5&*&'
CaLegorlze by umlng:
lmmedlaLely posL op
llrsL 48 hours posL op
AcuLe (2 - 7 days posL op)
SubacuLe (aer 1 week)
!"#$ 2%&'()*& 5&*&'
CaLegorlze by umlng
1lme of onseL and euology ln crlucally lll posL op pLs
Lmergency Surgery (n= 484) Llecuve Surgery (n=142)
8arrle S eL al. Surglcal lnfecuons 2004, 3:143
!"#$ 2%&'()*& 5&*&'
lmmedlaLely posL op
MallgnanL hyperLhermla
llrsL 48 hours posL op
AcuLe (2 - 7 days posL op)
SubacuLe (aer 1 week)
6(0-78(8$ 9:%&'$;&'<-(
Cccurs ~ 1 ln 30,000 general anesLheucs
Ceneuc predlsposluon + Lrlggerlng anesLheuc
1rlggerlng agenLs: lnhalauonal anesLheucs, succlnylchollne
(nC1 nlLrous oxlde)
AuLosomal domlnanL ~ 30
M:l 2:1, 30 < 19 years old
8ecognluon:
usually occurs wlLhln 90 mlnuLes of lnducuon
lever: > 101.8l or 38.8C
8esplraLory acldosls: aCC2 > 60 mm Pg
MeLabollc acldosls: pP< 7.23, base declL > 8 mLq
Ck elevauon: > 10,000 lu/L
lamlly PlsLory of MP: MCS1 pLs do nC1 have a lP of MP
6(0-78(8$ 9:%&'$;&'<-(
lnlual LreaLmenL:
SLop all poLenL lnhalauonal anesLheucs
SwlLch Lo lv agenL, e.g. propofol
lncrease Mv and llC2
uanLrolene: 2.3 mg/kg lv, Lhen 1 mg/kg boluses unul fever decreases, aCC2
decreases, or muscle rlgldlLy abaLes (up Lo 10 mg/kg)
Call MP hoLllne: 1-800-MP-P?L8 (644-9737)
23 wlll have recrudescence aer lnlual 8x:
uanLrolene: 1 mg/kg boluses q 6h x 48 h
AvClu calclum channel blockers (lncrease k
+
)
MonlLor elecLrolyLes (k
+
) and Ck
MorLallLy 1 - 13 (1.7 ln reglsLry)
Counsel pauenL/famlly
!"#$ 2%&'()*& 5&*&'
lmmedlaLely posL op
llrsL 48 hours posL op
Surglcal lnammaLory response
AcuLe (2 - 7 days posL op)
SubacuLe (aer 1 week)
=1'7-/(0 >8?(<<($"': @&#%"8#&
osLop lnammaLory response oen underesumaLed
1lssue ln[ury releases fever-assoclaLed cyLoklnes
lL-6, lL-1, 1nl-!, lln-"
AmounL of ussue ln[ury (e.g. choly vs lap choly)
Ceneucally deLermlned response Lo ln[ury
lever due Lo ussue ln[ury usually resolves by 72 hrs
Lxcepuon - head ln[ury
Aer 48-72 hrs should prlorluze oLher causes hlgher
Llakopoulos C!, eL al. Ann 1horaclc Surg. 2007, 84:110
=1'7-/(0 >8?(<<($"': @&#%"8#&
osL lmplanLauon syndrome ln AAA sLenL gras
lever, leukocyLosls + neg culLures ln 30 - 60
ArnaouLoglou L, eL al. lnLeracuve Cardlovasc 1horaclc Surgery. 2011. 12:609
velazquez CC, eL al. Am ! Surg. 1999, 178:183
!"#$ 2%&'()*& 5&*&'
lmmedlaLely posL op
llrsL 48 hours posL op
AcuLe (2 - 7 days posL op)
SubacuLe (aer 1 week)
!"#$ 2%&'()*& 5&*&'
AcuLe (2 - 7 days posL op)
Sepsls
uead bowel
AnasLomouc leak
Abscess
neumonla
C88Sl
u1l
ALelecLasls (?)
uv1
urugs
WlLhdrawal: alcohol
1oxlclLy: seroLonln syndrome
SensluvlLy: anublouc/drug fever
30+
< 23
A3B"<-8(0 =&%#-#
vlLals: fever, Lachycardla, Lachypnea, hypoLenslon
Abd exam: Lenderness, bowel sounds, dlsLenslon,
paln, lnclslon appearance (look under Lhe covers!)
lmaglng sLudles - uld collecuons (blood, uld,
abscess?) - dlerenuauon may be dlmculL
8eexplorauon oen needed: Loo oen delayed
Llderly, or lmmunocompromlsed, or chronlcally lll pL,
may presenL aLyplcally - wlLhouL one or more:
lever, paln, W8C, or abd. Lenderness
uon'L forgeL C. dlmclle - especlally lf dlarrhea presenL
C1&#)"8
A 32 year old woman underwenL a laparoscoplc
cholecysLecLomy 3 days ago. She has Lenderness around
Lhe Lrochar slLes and also ln her rlghL lower quadranL.
1here ls no eryLhema around her lnclslons. Pe hearL raLe ls
118, her LemperaLure ls 101.1 and her 8 ls 124/72.

1he mosL llkely cause of her elevaLed LemperaLure ls:
a) 1lssue ln[ury and posLoperauve cyLoklnes (l.e. Sl8S)
b) lnLra-abdomlnal lnfecuon
c) Surglcal slLe lnfecuon
d) ulmonary embollsm
e) MallgnanL hyperLhermla
9:%"$&8#-"8
Aer ma[or abdomlnal surgery:
lmmedlaLe:
Pypovolemla
1hlrd-spaclng / surglcal lnammaLory response
8leedlng
Adrenal lnsumclency
LaLer (24-48 hrs)
Sepuc shock
necrouc bowel
AnasLomouc leak
9:%"$&8#-"8 .1& $" 9:%"*"0&<-(
ln pauenL wlLh ma[or lnLra-abdomlnal caLasLrophe (e.g.
necrouc bowel, anasLomouc leak) uld shls can be huge
- volume resusclLauon
? 1argeL: Cl, Cv, SvC2, Svv
lnadequaLe daLa for LargeL-speclc quesuon
!ammer l, eL al. AnesLheslology 2010, 113:1072
AB'&8(0 >8#1D/-&8/: EA>F
Preoperative glucocorticoid Rx major risk factor
Not seen with prednisone equivalent ! 5 mg/day; < 3 weeks
Etomidate suppresses 11 #-hydroxylase ~24 72 h
Hypotension or manifestations of AI very uncommon in
surgical patients (as opposed to septic shock)
Doses of hydrocortisone ~50 mg IV q8h PLENTY
Maximal stress response of adrenals < 300 mg/day
High dose (250 mcg) ACTH stimulation testing
underestimates incidence of HPA axis suppression
But no demonstrably superior alternative
Cortisol assays highly variable
Critical illness reduces degradation of cortisol
?ong SL, eL al. Cochrane uaLabase of SysLemauc 8evlews. 2009, lssue 4
Annane u, eL al. Am ! 8esplr CrlL Care Med. 2006, 174:1319
Cohen !, eL al. lnLenslve Care Med. 2006, 32:1901
A3B"<-8(0 ,"<%('$<&8$ =:8B'"<&
Semng: posL resusclLauon or ma[or abd. surgery
8ladder pressure > 12 mm Pg denes lAP
> 20 mm Pg wlLh organ dysfuncuon denes ACS
Crgan fallures:
8enal - prlmarlly due Lo renal veln compresslon
ulmonary - Lhoraclc compllance reduced
CnS - lncreased lC 2 Lo lmpalred venous dralnage
CuL - mesenLerlc and mucosal blood ow reduced
Pepauc - lacLaLe clearance reduced
Surglcal decompresslon for ACS and lAP>23
aracenLesls or escharoLomy may be approprlaLe
?1emporlze wlLh nC sucuon, sedauon, paralysls
CheaLham ML, eL al. lnLenslve Care Med. 2007, 931
A ,(#& "G 9:%"$&8#-"8
A 72 year old man underwenL 3-vessel coronary
arLery bypass gralng 24 hours ago. Pe has been on
a neosynephrlne lnfuslon aL 73 mcg/mln Lo malnLaln
hls MA > 63 mm Pg. Whlch of one of Lhe followlng
ls nC1 a llkely cause of hypoLenslon ln Lhls pauenL?
a) vasoplegla
b) Myocardlal dysfuncuon
c) Cardlac Lamponade
d) ulmonary embollsm
9:%"$&8#-"8 AH&' ,I =1'7&':
vasodllauon
8leedlng
1amponade
Myocardlal dysfuncuon
uysrhyLhmlas
9:%"$&8#-"8 AH&' ,I =1'7&':
vasodllauon (hours Lo days)
CyLoklnes (esp lL-1) (C8)
Low preop Ll (< 33)
AssoclaLed wlLh depressed vasopressln levels
reop ACL lnhlblLors
uepressed arglnlne vasopressln levels
8x wlLh vasopressors (neosynephrlne or norepl)
Conslder vaspressln lnfuslon (0.03 u/mln)
Argenzlano M, eL al. ! 1horac Cardlovasc Surg. 1998, 116:973
9:%"$&8#-"8 AH&' ,I =1'7&':
8leedlng ~ 3 of pLs severe
lncreased rlsk: age, clopldogrel, reoperauon
Commonly manlfesLed as excess dralnage from
medlasunal and/or pleural dralns (> 200 cc/hr)
8esldual heparln eecL (AC1 > 120 sec)
PypoLhermla (Lemp)
laLeleL dysfuncuon (preop Lhlenopyrldlnes)
1hrombocyLopenla (plaLeleL counL)
Clomng facLor depleuon (prolonged 1 or a11)
lnadequaLe surglcal hemosLasls (excluslon)
Choong Ck, eL al. Lur ! CardloLhorac Surg. 2007, 31:834
MehLa 8P, eL al. Clrc Cardlovasc Cual CuLcomes 2009, 2:383
9:%"$&8#-"8 AH&' ,I =1'7&':
1reaLmenL of coagulopaLhy:
roLamlne 30 mg lv lf AC1 prolonged
Warm Lhe pL lf hypoLhermlc
laLeleL Lransfuslon
8x for LhrombocyLopenla, plL dysfuncuon and reduced
clomng facLors (plasma wlLh plLs)
CC (8ebulln) for severe clomng facLor depleuon
AvClu rfvll - proLhrombouc, conLalns only fvll
8ack Lo C8 lf severe (perslsLs > ~400 cc/hr)
>8B-/()"8# G"' JK%0"'()"8 G"' L0&&B-87
SL. Andre AC, eL al. CrlL Care Med. 2003, 33:2082
9:%"$&8#-"8 AH&' ,I =1'7&':
1amponade - occurs even wlLh open perlcardlum
1achycardla, low Cl, hlgh Cv and AC, hypoLenslon
1LL - lf conrmed: 8ack Lo C8 emergenLly
8lsk lncreased wlLh anucoagulanL use ln lmmedlaLe
perloperauve perlod
new ACC guldellnes:
uv1 prophylaxls wlLh CP - nC1 heparlns
Modlfy ln long-sLay/compllcaLed pauenLs
!ones Pu, eL al. Ann 1horac Surg. 2003, 80:318
Could Mk, eL al. ChesL 2012, 141:e227S
9:%"$&8#-"8 AH&' ,I =1'7&':
Myocardlal dysfuncuon - ulLrasound (1LL)
lschemlc myocardlal dysfuncuon
Cra occluslon: uncommon (klnklng more common Lhan
Lhrombosls or spasm)
Coronary embollzauon (alr durlng surgery)
lnadequaLe lnLraoperauve proLecuon
8x wlLh lnoLrope (mllrlnone or eplnephrlne)
ulmonary hyperLenslon wlLh 8v dysfuncuon
8v dysfuncuon wlLh sepLal shl lmpalrs Lv lllng/funcuon
lnhaled epoprosLenol or lnC, noL commonly needed
9:%"$&8#-"8 AH&' ,I =1'7&':
Ll - and Sv fall lmmedlaLely
aer CA8C - nadlr aL 2-4
hours posL op
Llkely myocardlal edema and
cyLoklnes (e.g. 1nl)
WlLh small, xed Sv, Cl
becomes raLe-dependenL
8oberLs A!, eL al. ! 1horac Cardlovasc Surg. 1981, 81:69
9:%"$&8#-"8 AH&' ,I =1'7&':
uysrhyLhmlas
8radycardla:
WlLh xed small Sv, P8 of 93-100 bpm oen needed
8x wlLh Lemporary paclng (rouune posLoperauvely)
1achycardla:
WlLh aLrlal brlllauon venLrlcular lllng oen lnadequaLe
Ab occurs ln 23 - 33 of CA8C/valve pLs
8eLa blocker prophylaxls (? amlodarone)
8x:
unsLable: cardloverslon
SLable: beLa blockers, dlluazem, amlodarone
MlLchell L8, eL al. Can ! Cardlol. 2011, 27:91
9:%"$&8#-"8 AH&' ,I =1'7&':
ALrlal llbrlllauon
rophylaxls:
8eLa blockers eecuve (C8 0.3 - 0.7) - 8uL:
Plghly dependenL on pre-operauve use of 88
lf used pre-op, much greaLer beneL Lo prevenL a b
Amlodarone eecuve (C8 ~ 0.3)
Lecuve lnluaLed pre or posL op
? More eecuve Lhan beLa blockers (propanolol or soLalol -
small sLudles, underpowered)
Cholce lf beLa blocker ALs a concern (asLhma, severe acuLe
reducuon ln myocardlal conLracullLy)
oLenually more serlous drug ALs Lhan beLa blockers
MlLchell L8, eL al. Can ! Cardlol. 2011, 27:91
!"#$M"%&'()*& @&#%-'($"': 5(-01'&
C8l (relnLubauon, delayed exuLbauon) occurs ~3 of pauenLs
vC reduced up Lo 40 - 30 posLoperauvely
SLernoLomy, LhoracoLomy, upper abdomlnal lnclslon
Smaller lnclslon noL helpful?
noL due (mosLly) Lo paln
1horaclc epldural llule lmpacL
vC reduced for 2 - 7 days
normal pre op $ Severe lmpalrmenL
ModeraLe pre op $ 8elnLubauon
Calderon !, eL al. ! CardloLhorac vasc AnesLh. 2009, 23:793
CupLa P, eL al. ChesL. 2011, 140:1207
mlnl"-sLernoLomy vs
sLandard sLernoLomy
,I =1'7&':N @&8(0 5(-01'& @-#O# (8B 21$/"<&
8enal fallure markedly lncreases morLallLy
Lven modesL lncrease ln serum Cr (0.3 mg/dl) assoclaLed
wlLh more Lhan doubllng of rlsk of morLallLy (Lo 3)
ulalysls: morLallLy lncreases Lo 33 (from 1 - 2)
8enal fallure rlsk lncreased lf surgery performed
soon aer dye load from cardlac caLh - especlally <
24hrs
Lvldence LhaL sodlum blcarbonaLe ls superlor Lo
sallne ls lnconslsLenL, experL oplnlon dlvlded
uopamlne ls noL eecuve as renal proLecuon
AnZlCS Cllnlcal 1rlals Croup. LanceL 2000, 336:2139
MehLa 8P, eL al. Clrculauon 2011, 124 (suppl):S149
Coleman Mu, eL al. Curr Cpln AnaesLheslol. 2011, 24:70
=1'7&': (8B ,('B-(/ =$&8$#
uual anuplaLeleL Lherapy lmporLanL (ASA + Lhlenopyrldlne)
AbouL 3 of pLs undergo ma[or non-cardlac surgery ln year aer sLenung
SLenL Lhrombosls occurs ln 2-3 of pLs wlLh 30 morLallLy - 1PuS:
osLpone unul aer mlnlmum" durauon of Lhlenopyrldlne
admlnlsLrauon:6 weeks for 8MS, 6 monLhs for uLS
Conunue 8C1P wlLhln Lhls ume frame for emergenL surgery
LxcepL CA8C and lnLracranlal surgery
Scheduled elecuve - sLop clopldorgrel 3 days before surgery,
prasugrel 7 days, even longer prlor Lo lnLracranlal surgery
Conunue ASA WPLnLvL8 feaslble (noL lnLracranlal surgery)
8eload Lhlenopyrldlne posL op (e.g. 300 mg clopldogrel)
Au AC, eL al. Am ! Med 2012, 123:87
uoukeus !u, eL al. ChesL 2012, 141(Suppl):e326S
A8&<-(
reoperauve anemla ls a rlsk facLor for posLoperauve
compllcauons
1ransfuslon does nC1 mlugaLe Lhese compllcauons
1reaung preoperauve anemla (lron, eryLhropoleun,
eLc.) MA? reduce rlsk
Llule evldence LhaL An? populauon beneLs from a
Lransfuslon Lhreshold hlgher Lhan 8 g/dl Pb
C1 Surgery, Plp surgery, 1rauma
neurosurgery unresolved
LelchLle SW, eL al. ! Am Coll Surg 2011, 212:187
Pa[[ar LA, eL al. !AMA 2010, 304:1339
,(#&N 9:%"8($'&<-( 5"00"P-87 Q&1'"#1'7&':
A 42 year old woman was admlued Lwo days ago wlLh an
aneurysmal SAP. Per aneurysm was successfully colled.

Cver Lhe pasL 48 hrs her serum na has fallen from 140 Lo 128 mLq/L.
Per urlne Csm = 610 mCsm, and serum Csm = 268 mCsm.

Per 8 ls 128/62, P8 ls 112, 8un ls 18 mg/dl, Cr 0.9 mg/dl. lv ulds
have been nS aL 130/hr, and urlne ouLpuL has averaged 120 cc/hr.

She opens her eyes Lo volce, and locallzes paln buL does noL follow
commands. 1hls has noL changed slnce admlsslon. Per neck velns
are aL aL 30, skln Lurgor ls good, and she has no edema. She
welghs 70 kg.
ln addluon Lo waLer resLrlcuon Lo less Lhan 1L/
day, Lhe mosL approprlaLe nexL sLep ls:
a) nS aL kvC (~30 cc/hr)
b)1 L nS bolus and nS aL 173 cc/hr lv
c) normal sallne aL 173 cc/hr
d) 3 sodlum chlorlde aL 73 cc/hr, nS aL 100 cc/hr
8auonale:
WlLh a urlne osmolarlLy of 610 mCsm, normal sallne ls llkely Lo worsen her
hyponaLremla. 1L of nS (osmolarlLy = 308) wlll be excreLed ln abouL 300
cc of urlne, leavlng 300cc of free waLer - resulung ln a fall ln Lhe serum
sodlum.

1he pauenL ls excreung 1737 mCsm/day or 73 mCsm/h
[(.12 L/h x 24h x 610 mCsm/L) = 1737 mCsm/24h]

3 naCl (1026 mCsm/L) aL 73 cc/hr + nS (308 mCsm/L) aL 73 cc/hr = 2392
mCsm/day - neL 833 mCsm/24h posluve (half of Lhese Csm are na)

LCl ls approxlmaLely 14 L (0.2 x 18W) so serum na should rlse abouL 1.23
mLq/hr (17.3 mLq/hr na/14 L). 1hls raLe of correcuon ls accepLable ln
acuLe hyponaLremla (for a whlle).
!"#$M"%&'()*& Q&1'"#1'7-/(0 ,'-#&#
AlLered menLal sLaLus
PyponaLremla
ulabeLes lnslpldus
Alrway emergencles
!"#$M"%&'()*& Q&1'"#1'7-/(0 ,'-#&#
AlLered menLal sLaLus - rapld decllne
Cerebral edema
AcuLe hydrocephalus
8leedlng
lnfarcuon
AlLered menLal sLaLus - slower decllne
Pypovenulauon
PyponaLremla
!"#$M"%&'()*& Q&1'"#1'7-/(0 ,'-#&#
8apld decllne ln level of consclousness or new
neuro exam ndlngs almosL always an lndlcauon
for emergenL cranlal C1 - ume ls crlucal
8leedlng - evacuauon:
8lg, superclal (LP or SuP) or posLerlor fossa
Pydrocephalus - Lvu (draln CSl)
Cerebral edema - mannlLol, hyperLonlc sallne, sLerolds
(lf Lumor resecuon or lnammauon)
lnfarcuon - malnLaln perfuslon pressure
!"#$M"%&'()*& Q&1'"#1'7-/(0 ,'-#&#
Slower decllne ln menLal sLaLus (usually wlLhouL focal
neuro exam ndlngs):
Pypovenulauon - conrm wlLh A8C
PyponaLremla - SlAuP or cerebral salL wasung
Cerebral salL wasung more common wlLh SAP
8C1P: lnapproprlaLely hlgh urlne na and osm ln semng
of low serum na and osmolarlLy
SlAuP: volume sLaLus normal or hlgh
Cerebral salL wasung: volume sLaLus low
almer 8l. 1rends Lndocrln MeLab. 2003, 14:182
!"#$M"%&'()*& Q&1'"#1'7-/(0 ,'-#&#
1reaLmenL:
SlAuP (lf mlld or pL Laklng po): waLer resLrlcuon
? 8ole of vasopressln anLagonlsLs acuLely
ConlvapLan (lv), LolvapLan (po)
Cerebral salL wasung: volume repleuon (nS)
8C1P: 3 sallne useful (noL nS ln SlAuP)
almer 8l. 1rends Lndocrln MeLab. 2003, 14:182
!"#$M"%&'()*& Q&1'"#1'7-/(0 ,'-#&#
ulabeLes lnslpldus
Commonly seen aer Lrans-sphenoldal
hypophysecLomy
10 - 60 dependlng on slze of Lumor
ComponenL of Lrlphaslc response
ul - early (0 h - 3 d) suppresslon of AuP release
due Lo hypoLhalamlc dysfuncuon (40 manlfesL)
SlAuP - laLer (3 - 10 d) due Lo AuP release from
degeneraung posLerlor plLulLary (8)
ul (delayed or permanenL) - depleuon of AuP (3)
Pensen !, eL al. Clln Lndocrlnol. 1999, 30:431
!"#$M"%&'()*& Q&1'"#1'7-/(0 ,'-#&#
ulabeLes lnslpldus ux:
Larly dlerenuaLe from posL op uld dluresls or osmouc load
Plgh urlne ouLpuL (oen 400 - 800 cc/hr)
PypernaLremla
Low urlne speclc gravlLy (< 1.003)
Low urlne osm (< 200 mCsm usually)
ulabeLes lnslpldus 8x:
Sallne Lo malnLaln volume
uuAv 1mcg lv or 0.03 mg po (half 0.1 mg Lab)
Care Lo avold hyponaLremla
!"#$M"%&'()*& Q&1'"#1'7-/(0 ,'-#&#
Alrway emergencles
Ldema/blood compresslng alrway
ComplalnLs of dlmculLy swallowlng or breaLhlng
Conslder aer anLerlor cervlcal splne surgery or CLA
8lsk facLors aer ACu - op > 3hrs, lnvolvlng C2,3,4
MosL commonly develops wlLhln 36 hours
Always assume Lo be dlmculL alrway - all Lhe help you can
geL
repare for surglcal alrway
Sagl PC, eL al. Splne 2002, 27:949
L"R"< S-8&E#F
lever - conslder Lhe ume course
Aer 48-72 h posL op fever more llkely lnfecuous or drugs (noL
[usL surglcal lnammauon)
Shock due Lo ACS: bladder pressure> 20 - 23 + organ fallure,
8x=surglcal decompresslon
PypoLenslon aer C1 surgery: caLasLrophlc - Lamponade (1LL),
more common - vasoplegla. uon'L forgeL xed Sv, may need Lo
lncrease P8 (Lo 90 - 100 wlLh pacer)
uo noL delay evaluauon (exam + C1) of posL op neuro pL wlLh
AMS
L"R"< S-8&E#F /"8)81&B
Cerebral salL wasung and SlAuP dlmculL Lo dlsungulsh, 8x ln
neuro pLs: 3 sallne 30 - 73 cc/hr
ul common posL 1SP: hlgh urlne ouLpuL, low urlne osm, hlgh na:
repleLe volume wlLh nS
Ls wlLh cardlac sLenLs should 8A8LL? noL have ASA
perloperauvely (excepuon lnLracranlal surgery).
osLpone any surgery posslble for aL leasL 6 weeks for 8MS and
6 mos for uLS Lo avold premaLure u/C of Lhlenopyrldlne
1ransfuslon Lrlggers ln C1 surglcal, 1rauma and Plp surgery pLs
should usually be 8 g Pb or less