Common Postoperative Problems

Generally, an elevated temperature ⱖ38.5°C requires workup. Timing is important, as postoperative fever within the first 24 hours suggests atelectasis, possibly an early wound infection, or a urinary tract infection. Other considerations for fevers, especially after 24 hours postoperatively, include drug reactions, wound abscess, sepsis, pneumonia, or an IV or central line infection. Also, a possible transfusion reaction, a deep vein thrombosis, or an infected decubitus ulcer should be considered.

Workup

A bedside examination includes taking vitals with pulse oximetry and check- ing the wound for erythema, edema, fluctuance, drainage, and warmth. You should auscultate for rales or diminished breath sounds, examine IV sites for redness, and check the patient’s legs for calf tenderness. If the patient has a tracheotomy, look for increased and discolored sputum. Consider possible sepsis if the patient has tachypnea, tachycardia, or hypotension. Consider or- dering a chest x-ray, blood cultures, sputum cultures, and/or a urinalysis with cultures. For atelectasis/pneumonia, empiric treatment may include a chest physical exam, supplemental oxygen, and respiratory therapy with incentive spirometry, mucolytics, nebulized bronchodilators, and empiric antibiotics (determined after the results of culture specimens have been received). For the treatment of pneumonia, cephalosporin and clindamycin are recom- mended and for a suspected urinary tract infection (UTI), treat the patient with sulfa or fluoroquinolone. Adjust antibiotics based on culture results.

Gentle IV hydration may be useful. Treat with an antipyretic such as Tylenol (Ortho-McNeil-Jansson Pharmaceuticals, Titusville, NJ), a 650-mg dose for adults (15 mg/kg/dose for children). A wound abscess will require opening the wound, draining it, initiating a gram stain with culture, and changing the packing. If other vital signs are abnormal, you may want to transfer to the patient to a monitored bed, with continuous pulse oximetry and arterial blood gas assessment.

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Confusion (Mental Status Change)

This is one of the most common calls in otolaryngology–head and neck surgery regarding postoperative patients. Although the possible causes for a mental status change are many, it is prudent to consider the cause to be hypoxia until proven otherwise.

Resist the request for benzodiazepine to “calm him or her down”;

instead instruct the nurse to obtain a full set of vitals, including pulse oximetry. Personally visit the patient.

The differential diagnosis includes hypoxia (can be due to tracheostoma occlusion, crusting, mucus plugging, underlying severe chronic obstructive pulmonary disease [COPD]—common in heavy smokers—atelectasis, pneumonia, aspiration, overmedication with narcotics, pneumothorax, pulmonary embolism, or acute postoperative pulmonary edema), cardiac arrhythmia, alcohol withdrawal, delirium from medications, stroke, meningitis, hypoglycemia or severe hyperglycemia, sepsis, anxiety, or psychosis.

Workup

The bedside exam should include taking a full set of vitals with pulse oximetry; auscultation; an examination of the tracheostoma, if present; and a quick neurologic exam looking for focal deficits, and the patient’s orienta- tion to person, place, and time. For ancillary tests, start with arterial blood gases (ABGs), a 12-lead ECG, a fingerstick glucose test, and a portable chest

x-ray. Acute respiratory insufficiency in the head and neck patient often presents with a low PaO ₂ and elevated PCO ₂ ; however, a PCO ₂ below 40 may be seen with compensatory overventilation. Typically, the patient has an underlying chronic lung disease and has had inadequate tracheopulmonary toilet, allowing for accumulation of secretions and mucus plugging. Thus, treat with humidified supplemental oxygen and aggressive suctioning. If there is an inadequate response and other tests are normal, consider testing the patient for a pulmonary embolism (PE).

Pulmonary Embolism

In the case of a possible PE, currently a spiral CT is commonly obtained, although ventilation/perfusion (V/Q) scans can be performed and labora- tory testing for D -dimer may be useful. Patients with proven PE and an otherwise stable cardiovascular status are often managed with supplemental oxygen and anticoagulation, using an IV heparin bolus of 10,000 units, with a drip at 800 to 1200 units per hour maintaining an activated partial throm- boplastin time (aPTT) at 1.5 to 2.0 times normal. The patient is transferred to the ICU with continuous monitoring; if the patient becomes unstable with cyanosis, low PaO ₂ , cardiac arrhythmia, hypotension, and low urine output, consider intubation with ventilatory support as well as prescribing an inotropic agent.

Acute Postobstructive Pulmonary Edema

Acute postobstructive pulmonary edema (APOPE) should be suspected in patients with postoperative acute respiratory failure. The development of hypoxia, bradycardia, and pink frothy sputum is characteristic in patients with APOPE. Type I APOPE occurs with acute airway compromise usually following extubation. This develops from inspiration against a closed glottis due to laryngospasm or other obstruction. Type II APOPE develops after relief of chronic upper airway obstruction. This may occur in children or adults following surgery to correct severe obstructive sleep apnea. In both cases, a sudden decrease in intrathoracic pressure leads to increased pulmonary venous return and transudation from the capillary bed into the interstitium.

The treatment of APOPE includes intensive care monitoring and a low threshold for immediate reintubation. Positive end expiratory pressure may be necessary for adequate ventilation. Diuretics and steroids may be considered. In patients who are stable, medical management with oxygen supplementation, diuretics, and close observation may be appropriate.

Careful restriction of intravenous crystalloids may also be an option.

Other Causes of Mental Status Change

If the hypoxia workup is normal, other testing may reveal an obvious cause.

The ECG should rule out the possibility of cardiac arrhythmia, ST changes, or signs of cardiac ischemia or infarction. If the ECG is positive, transfer of the patient to the ICU and a consult with cardiology is mandatory. The fingerstick glucose test is a rapid way to exclude a common cause for mental

status change, especially in known diabetics. Glucose below 40 should be treated with an ampule of IV D50 and repeated. If the neurologic exam suggests focal deficit, a brain CT scan to screen for stroke should be considered, although an MRI scan is much more sensitive. Mental status change in a patient with a high fever should prompt consideration of meningitis, especially if the patient has had skull base or otologic surgery. Workup includes a lumbar puncture, then treatment with empiric antibiotics followed by the transfer of the patient to an ICU setting (see Chapter 2.2.3 for further details regarding meningitis).

Alcohol Withdrawal

Many head and neck patients have a history of alcohol abuse, often under- reported. Thus, in the absence of other obvious causes for mental status change, attempting to obtain an honest alcohol use history is important.

Unrecognized delirium tremens can have up to an 8% mortality rate. Thus, the postoperative alcoholic patient must be handled properly. Typically, di- azepam 5 to 10 mg every 4 hours may be needed. IV fluids may contain D10, instead of the typical D5, and also should be supplemented with a 10 mL multivitamin solution per bag. The patient should also be given thiamine daily. Check serum magnesium levels, which are typically low, and replete.

Psychiatric Disorders

Severe anxiety, delirium, or psychosis can be seen in the postoperative patient. There are many predisposing factors, such as sleep deprivation, elderly state, ICU stay, drug dependency, or metabolic alterations. It is important to exclude hypoxia or other obvious medical causes for mental status change or agitation. Psychiatric consultation, if available, may be helpful. Haldol (Ortho-McNeil-Jansson Pharmaceuticals, Titusville, NJ) 5 mg IV as needed is a reasonably safe drug to use short term, as it will decrease agitation while having little to no influence on cardiovascular status.

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Wound Problems

A variety of wound problems can arise following head and neck surgery, including hematoma, seroma, infection, dehiscence, development of a pharyngocutaneous fistula, exposure of the carotid artery leading to rupture or “carotid blowout,” chyle leak, or reconstructive flap complications such as venous edema or arterial ischemia. As with most situations, prevention is helpful: proper preoperative assessment, management of identified risk factors such as malnutrition or coagulopathy, and meticulous surgical technique. Preoperative radiation therapy is a common issue that greatly increases the risk of healing problems.

Assessment and Management of Wound Problems Hematoma and Seroma

In cases of hematoma and seroma, the wound will be swollen, usually fluctuant but possibly tense or discolored. A fluid collection can lead to

infection, dehiscence, or decrease skin flap viability. A small fluid collection may resorb, or it may be simply aspirated. With a rapidly expanding or large fluid collection, the patient should be taken to the OR, the wound should be opened, irrigated, and explored to maintain hemostasis.

A hematoma following thyroid surgery is an emergency. Most commonly, this is seen the day of surgery and presents with an expanding mass and discomfort, which may progress to dyspnea, stridor, and severe airway compromise. This is due to venous back-pressure causing the rapid development of laryngeal edema. The wound is opened immediately at the bedside and the patient is then taken to the OR to wash out the wound and establish hemostasis. Intubation may be difficult, but opening the wound should facilitate intubation. If this remains difficult, a tracheotomy should be simple to perform because the thyroidectomy has exposed the subglottic trachea.

Wound Infection

An infected neck wound is typically warm, red, swollen, and tender; it may present with purulent drainage, a fluctuant collection, or abscess formation. Complications may lead to fistula, flap necrosis, or carotid exposure. Management includes opening the wound, culture of drainage, appropriate antibiotics, and packing change. Empiric antibiotic coverage should be broad spectrum, such as Unasyn (Pfizer Pharmaceuticals, New York, NY), or cefuroxime and clindamycin. Simple wet to dry saline gauze changes twice a day may be sufficient. Clorpactin or acetic acid gauze packing have antimicrobial properties and promote granulation tissue formation. However, if there is carotid exposure, it is prudent to perform surgery to cover the carotid with vascularized tissue, such as a pectoralis flap.

Pharyngocutaneous Fistula

Salivary drainage increasing in suction drains or draining via an incision indicates development of a fistula. One can test drainage for amylase to confirm. Most commonly, poor wound healing leads to a fistula following salvage surgery in a patient with persistent or recurrent disease after radiation therapy. Again, this is managed with packing changes, antibiotics, and consideration of surgery to bring in vascularized tissue if this fails to heal. One should check prealbumin and thyroid-stimulating hormone (TSH) levels to assess for malnutrition and hypothyroidism, and correct. Using the gut when it works is a sound principle, so the patient who must be kept NPO to reduce fistula output should be fed via an NG tube or PEG. Only if this cannot be accomplished should one use TPN.

Chylous Fistula

The incidence of chylous fistula after neck dissection is reported to be between 1 and 5.8%. Chylous fistula results from injury to the thoracic duct, which is encountered in level 4 on the left. However, 25% of chyle

leaks occur on the right. This complication is best treated if recognized intraoperatively with suture ligature or oversewing local muscle flaps.

Chylous fistula is suspected postoperatively in the face of increased drain outputs. The quality of output may change from serosanguineous to a more milky/turbid consistency. This may occur with the onset of PO intake.

High-output chyle loss may lead to electrolyte disturbances, hypovolemia, hypoalbuminemia, immunosuppression, chylothorax, peripheral edema, and local skin breakdown. If there is a question about the diagnosis of a chylous fistula, obtain a drain output analysis for triglycerides and chylo- microns. First-line treatment involves conservative management. This is aimed at reducing chyle flow. The patient may be started on a medium- chain fatty acid diet. If there is no improvement, a trial of NPO with TPN should be considered. Local pressure dressing should be placed. Surgical management is indicated if chylous drainage is in excess of 600 mL per day, persistent low-output drainage for an extended period of time, and electrolyte disturbances. Treatment involves wound reexploration and ligation of lymphatic channels. Alternatively, thorascopic ligation or per- cutaneous lymphangiography-guided embolization of the thoracic duct may be useful.

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Carotid Artery Blowout

A carotid artery blowout is a devastating complication and efforts are aimed at prevention. If postoperative wound problems result in exposure of the carotid, it can rapidly desiccate and then rupture, either externally or into the trachea, depending upon the wound situation. Maintaining healthy vascularized tissue between the carotid and the external environment can generally prevent the problem. Preoperatively, correcting malnutrition, hypothyroidism, and stopping tobacco use are important, especially in the previously irradiated neck. Surgically, if the sternocleidomastoid muscle can be preserved, without oncologic compromise, this will help cover and protect the carotid. Avoiding placement of an incision trifurcation directly over the carotid is best. If there is postoperative wound breakdown that may threaten the carotid, prompt management with packing and prevention of desiccation is critical. It is prudent to consider “carotid precautions”: maintain large-bore IV access, have a type and cross order in place with the blood bank, and keep an emergency instrument kit in the room. Moreover, if there appears to be any evidence of carotid exposure, one should proceed with surgery to bring in vascularized tissue coverage, rather than hope for healing. A pectoralis flap is ideal; a microvascular free flap is another option.

If a carotid blowout occurs, this can present first with a relatively minor sentinel bleed, which stops. Again, one should proceed with flap coverage if there has been a sentinel bleed. If there is a true blowout, there will be a profuse hemorrhage. One should establish direct firm pressure, treat with bolus IV fluids and proceed directly to the OR for hemostasis. This will involve establishment of proximal and distal control of the vessel, with a risk of stroke. Transfusion will likely be necessary,

and if the patient can be saved, wound coverage should be performed. If the blowout occurs into a tracheotomy stoma in a laryngectomee, one may use an endotracheal tube to intubate a mainstem bronchus distal to the site of rupture, tightly inflate the cuff, and then tightly pack the stoma opening to achieve tamponade while ventilating on one lung on the way to the OR.

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Gastrointestinal and Genitourinary Problems

Renal Failure

Low urine output is a common postoperative issue. The problem may be considered as prerenal, renal, or postrenal. Low urine output is generally defined as less than 30 mL per hour, for the 70 kg patient. A prerenal problem means the kidney is underperfused. Usually, this is from hypotension and/

or hypovolemia. One should treat with IV hydration. If there is no cardiac failure, give 500 mL of normal saline as an IV bolus. If cardiac failure exists, this must be treated to correct renal perfusion. Diuretics should be used carefully. Acute renal failure of parenchymal cause may be due to glom- erulonephritis, nephrotoxicities, or acute tubular necrosis. Urine may show casts; urine osmolality is equal to plasma; and urine sodium is elevated. One must follow daily fluid intake and output carefully, and follow laboratories closely. Electrolytes and creatinine will guide the need for dialysis. Postre- nal problems refer to obstructive uropathy. One must identify and correct the source of obstruction. The placement of a Foley catheter may be all that is needed; or imaging studies such as an IV pyelogram may be indicated.

In any patient with low urine output or possible renal failure, one must be cautious administering potassium. If hyperkalemia exists, watch for ECG changes. Potassium ⬎6 should be lowered. A Kayexalate (Sanofi-Aventis Pharmaceuticals, Paris, France) 15 g enema may be given; also IV glucose can be given, along with 10 units of regular insulin to rapidly lower plasma potassium.

Diarrhea

The main concern in hospitalized patients with diarrhea is the possibility of Clostridium difficile colitis, also known as pseudomembranous colitis.

This is an anaerobic spore-forming bacteria that is highly transmissible, especially by health care workers with poor hand washing. Stool samples should be sent for the C. difficile toxin assay in triplicate. Typically, colonic flora has been reduced by antibiotic use, leading to the C. difficile infection. Thus, it is important to stop antibiotics whenever possible, and to use them appropriately. Patients with C. difficile are treated with Flagyl (Pfizer Pharmaceuticals, New York, NY) 500 mg PO or IV TID. There are resistant strains, which may require the use of vancomycin given orally.

Proper handwashing is critical. New highly virulent strains of C. difficile have resulted in fatal infections, and other cases have been treated with colectomy: this is a problem to be taken seriously.

Electrolytes

Hypocalcemia may be seen on the head and neck service, following thyroid or parathyroid surgery. Inadequate parathyroid gland function rapidly results in low serum calcium. One may follow total serum calcium, correlated to albumin level, or may follow ionized calcium. As total calcium drops below

⬃7.5 to 8.0, the patient may become symptomatic with tingling hands or twitching; with severe hypocalcemia, tetany may ensue. Chvostek sign is twitching of the corner of the mouth in response to tapping over the facial nerve trunk, and tends to correlate with a calcium level lower than ⬃8.0. For mild hypocalcemia, the patient may be treated with oral calcium carbonate, 1 g TID, along with Rocaltrol 0.25–0.5 mcg PO daily. In more symptomatic patients, IV correction is necessary using 10% calcium gluconate given 20 ml IV over 15 to 30 minutes. For severe hypercalcemia, a rare condition, treat with massive IV hydration.

For further information on hypercalcemia and hypocalcemia, see Chap- ter 5.4.12.

1.8 General Otolaryngology

Dalam dokumen Handbook of Otolaryngology (Halaman 88-95)

Further Reading

8. Send patient blood sample for direct antiglobulin (Coombs) test, free Hb, haptoglobin; send urine for Hb

1.7 Common Postoperative Problems

Fever