Master the board step 3

Surgery
Nutritional support should always first be given via the gut whenever possible.
Total parenteral nutrition is almost never the right answer on the exam
due to the high risk of infection, but it is needed if there is upper GI fistula.
The following table summarizes the features and management of postoperative
complications.
Postoperative
Complication Features Management
Fever
Malignant
hyperthermia
exceeding 104°F
Bacteremia
exceeding 104°F
Postoperative fever
in the usual
range (101°–
103°F)
Perioperative
myocardial
infarction
Shortly after the onset of the anesthetic
(halothane or succinylcholine)
Treat with IV dantrolene, 100 percent
oxygen, correction of the acidosis, and
cooling blankets
Within 30–45 minutes of invasive procedures
(instrumentation of the urinary tract is a
classic example)
Atelectasis (Day 1)
Pneumonia (Day 3)
Urinary tract infection (Day 3)
Deep venous thrombophlebitis (Day 5)
Wound infection (Day 7)
Deep abscesses (subphrenic, pelvic, or
subhepatic) (Days 10–15)
Precipitated by hypotension when
intraoperative
Post-op MI seldom presents with chest pain
Watch for development of myoglobinuria
Blood cultures times 3
Start empiric antibiotics
Incentive spirometry
CXR: Infiltrate
Sputum culture
Antibiotics (hospital-acquired pneumonia)
Urinalysis and urinary culture
Antibiotics
Doppler ultrasound of deep veins of legs and
pelvis
Anticoagulation
Antibiotics if only cellulitis
Incision and drainage if abscess is present
CT scan of the appropriate body cavity is
diagnostic
Percutaneous radiologically guided drainage
is therapeutic
Thrombolytics are contraindicated, even in
post-op setting
Mortality rate is higher than for nonsurgeryrelated
MI
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