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1 Objectives Hemodynamic Complications and in the Post Surgical Patient Debra Whitney, RN, MSN Hennepin County Medical Center Describe factors that influence hemodynamic stability in the postsurgical patient. Identify hemorrhage risk factors, common symptoms, and nursing management in the post surgical patient. Recognize symptoms associated with and management of the post operative patient with sepsis. LOTS Of fluids Hypotension Blood Loss Cardiac dysfunction B/P drop Give Fluids Fluid Overload What is current medication management? Cardiac meds before surgery Post-op order hypertension management Increase cardiac workload Goldman,

2 Interstitial Space Intravascular space Diuretics? Other contributors to HTN Goldman, Cardiac Risk 3 rd Heart Sound or JVD Recent infarct within previous 6 months >5 PVC s per minute, ever Rhythm other than sinus or PAC s on last echo Age over 70 Aortic Stenosis Poor overall general health Emergent surgery Cardiac Risk Index History of: High risk type of surgery Ischemic Heart Disease Congestive Heart Failure Cerebrovascular Disease Pre-op Tx with Insulin Pre-op Serum Creatinine >2.0 Goldman, et al., 1977 Lee, et al., 1999 Interventions Monitoring Heart rate Blood pressure: what s normal for them? Remote telemetry? Medication management AM meds prior to surgery? Diuretics, Anti-hypertensives Pain Management LOSS Of fluids 2

3 EBL NPO Insensible Water Loss Urinary output Drains Chest tubes JP Hemovac Wounds Trauma Burn Normal blood pressure Less volume = vessel restriction hypoovolemia Renal blood flow hypoperfusion DVT Hepatic blood flow Interventions Carefully Monitor Labs Vitals Surgical sites Drains I & O Replacement: blood, IVF, PO intake Fluid Balance Case Study What is Robert s Fluid status? 3

4 Pre-operative Evaluation Anti-coagulant therapy Aspirin or NSAID s Clotting disorders Age >75 Hepatic or renal dysfunction Uncontrolled HTN History of bleeding Bockwoldt, 2 Alcohol Abuse Less fibrinogen Increased fibrinolytic activity Liver impairment Diabetes Mellitus High A1c = Two-fold increased risk when compared to well controlled morrhage Colo-rectal Simple GI laparoscopic Tonsillectomy Uterine Tonneson & Kehler, 1 Marchant, et al., 200 Image Site related Pain Tenderness Hematoma Swelling Tautness Systemic Increase heart rate Tachypnea Fatigue Weakness Hypotension Narrow pulse pressure Hemorrhagic or Hypovolemic Shock demands > oxygen supply Profound hypotension Increased heart rate Extreme lethargy Anxiety Profound hypotension Increased HR Lethargic Anxiety 4

5 Case Study 1 Treatment Wait and watch Return to surgery Transfuse Disadvantages of transfusion DIC SIRS TACO TRALI Temp Heart Rate Respiratory Rate White Blood Cell Count How To Diagnose SIRS: Systemic Inflammatory Response Syndrome SOFA: Sequential (-related) Organ Failure Assessment Severe sepsis Septic shock Diagnostic Criteria 2 or more IN ICU Setting: PaO2/FiO2 Ratio <300 Acutely Altered Mental Status MAP <65mmHg persisting for at least 1 hr and unresponsive to fluid resuscitation Platelet count <100,000/microliter Creatinine level >2.0mg/dL Urine output <0.5mL/kg/hour for at least 2 hours Bilirubin level >4mg/dL 5

6 Diagnostic Criteria 2 or more OUT of ICU Setting: T > 38.3 C or < 36 C HR > 90 BPM Altered Mental Status Systolic blood pressure <100 mmhg Respiratory rate > 20/min WBC > 12,000 cells/microliters Septic Shock Diagnostic Criteria: Persistent hypotension requiring vasopressors to maintain MAP >65mmHg Serum lactate level >18 mg/dl Case Study 2 Elderly 4.21% for 80 versus 1.75% for 50 Men 1.17% over women Diabetics However, no difference in mortality Stegenga, et al., 2010 References Bachman, L. (1955). The antidiuretic effects of anesthetic agents. Anesthesiology, 16, Bockwoldt, D. (2009). Antithrombosis management in community-dwelling elderly: Improving safety. Geriatric Nursing, 31, Dunne, J. R., Malone, D. L., Tracy, J. K., & Napolitano, L. M. (2004). Allogenic blood transfusion in the first 24 hours after trauma is associated with increased systemic inflammatory response syndrome (SIRS) and death. Surgical Infections, 5, Epocrates. (2016): Fry, D.E. (1995). Surgical Infections. Little, Brown, & Co: Boston/New York/Toronto/London. Goldman, L (1983). Cardiac Risks and Complications of Noncardiac Surgery. Annals of Surgery, 198, Goldman, L., Caldera, D. L., Nussbaum, S. R., Southwick, F. S., Krogstad, D., Murray, et. al. (1977) Multifactorial index of cardiac risk in noncardiac surgical procedures. New England Journal of Medicine, 297, Hammond, K.;, & Margolin, D. (2006). Surgical hemorrhage, damage control and the abdominal compartment syndrome. Clinical Colon Rectal Surgery. 19 (4): Lee, TH, et al. (1999). Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation, 100, Marchant, M. H., Viens, N. A., & Bolognesi, M. P. (2009). The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty. Journal of Bone and Joint Surgery, 91, References Hammond, K.;, & Margolin, D. (2006). Surgical hemorrhage, damage control and the abdominal compartment syndrome. Clinical Colon Rectal Surgery. 19 (4): Lee, TH, et al. (1999). Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation, 100, Marchant, M. H., Viens, N. A., & Bolognesi, M. P. (2009). The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty. Journal of Bone and Joint Surgery, 91, Murphy, M. M., Shah, S. A., Simons, J. P., Csikesz, N. G., McDade, T. P., Bodnari, A., et. al. (2009). Predicting Major Complications after Laparoscopic Cholecystectomy: A Simple Risk Score. Journal of Gastrointestinal Surgery, 13, Poldermans, D., et al. (2009). Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. European Heart Journal, 30, Raghunathan, K., Murray, P. T, Beattie, W. S., Lobo, D. N., Myburgh, J., Sladen, R., Kellum, J. A., Mythen, M. G. and Shaw, A. D. (2014). Choice of fluid in acute illness: what should be given? An international consensus. British Journal of Anaesthesia 113, Skeate, R. & Eastlund, T. (2007). Distinguishing between transfusion related acute lung injury and transfusion associated circulatory overload. Current Opionion in Hematology. 14:

7 References Skeate, R. & Eastlund, T. (2007). Distinguishing between transfusion related acute lung injury and transfusion associated circulatory overload. Current Opionion in Hematology. 14: Stegenga, M. E., Vincent, J. L., Vail, G. M., Xie J., Haney D. J., Williams M. D., et al. (2010). Diabetes does not alter mortality or hemostatic and inflammatory responses in patients with severe sepsis. Critical Care Medicine, 38, Tonneson, H. & Kehler, H. (1999). Preoperative alcoholism and postoperative morbidity. British Journal of Surgery, 86, Troy, P. & Lowell, C. (2007). TRALI Definiton, mechanism, incidence and clinical relevance. Best Practice & Research Clinical Anaesthesiology. 21 (2): Urden. L. D. (2010). Critical Care Nursing: Diagnosis and Management, 6th ed. Mosby: St. Louis. Vogel, T.R., Dombrovskiy, V.Y., & Lowry, S.F. (2009). Trends in postoperative sepsis: Are we improving outcomes? Surgical Infections, 10, Walker, P. & Giles, D. (2007). Post-tonsillectomy hemorrhage rates: are they technique-dependent? Otolaryngology Head Neck Surgery. 136(4): Questions 7