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Chapter 2. Postoperative Crises

David L Bowton, MD, FCCP, FCCM
DOI: 10.1378/critcare.21.2
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Sections

Objectives 
  • Differentiate between and describe the early and late causes of postoperative fever.

  • List common causes of postoperative hyponatremia in the neurosurgical patient and discuss management and therapeutic options.

  • Describe the common causes of hypotension following cardiac surgery and discuss their treatment options.

Synopsis 

This short review will summarize the presentation and management of selected postoperative complications, including postoperative fever and shock after general surgery; postoperative neurosurgical crises, including hyponatremia; hypotension after cardiac surgery; and perioperative management of antithrombotic therapy for cardiac stents. Malignant hyperthermia is characterized by hypercarbia, fever, and metabolic acidosis intraoperatively but may continue or recur postoperatively. Treatment is the discontinuation of anesthetic agents and administration of dantrolene. Fever in the first 2 to 3 days postoperatively is often due to surgical inflammation, while after 48 to 72 h it is more likely infectious. While the initial management of hypotension postoperatively is usually volume resuscitation, the consequences of volume resuscitation include abdominal compartment syndrome defined as a bladder pressure >20 to 25 mm Hg and organ failure. Its treatment is prompt recognition and surgical decompression. Hyponatremia in the postoperative neurosurgical patient is usually due to the syndrome of inappropriate diuretic hormone secretion, but cerebral salt wasting must be in the differential diagnosis. In the symptomatic patient, both are treated with 3% saline solution. Hypotension after cardiothoracic surgery is most commonly due to vasoplegia but can represent myocardial dysfunction or cardiac tamponade. Atrial fibrillation after cardiac surgery is common and is associated with prolonged length of stay. The unstable patient should be cardioverted, while more stable patients can be treated with calcium antagonists, amiodarone, or β-blockers. The perioperative management of antiplatelet therapy in patients with cardiac stents is challenging. These patients should generally have dual antiplatelet therapy continued throughout the perioperative period, with exceptions being cardiac and intracranial surgery.

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