NEUROLOGIC COMPLICATIONS. Delirium, Cognitive Disorder, and Psychosis Seizure Disorders Stroke and Transient Ischemic Attacks.

NEUROLOGIC COMPLICATIONS

NEUROLOGIC COMPLICATIONS

• Delirium, Cognitive Disorder, and Psychosis• Seizure Disorders• Stroke and Transient Ischemic Attacks

Delirium, Cognitive Disorder, and Psychosis

common complication of surgery.• Most precipitating factors• Postoperative anemia• electrolyte imbalance• Sepsis• Malnutrition• bladder catheterization• extended duration of anesthesia• Infection• respiratory complications• Acute alcoholic withdrawal

Delirium, Cognitive Disorder, and Psychosis

• Presentation• acutely agitated, uncooperative, and confused• altered level of consciousness and changes in

cognition• reduced ability to focus• decreased levels of awareness• and difficulty with attention• Hallucinations• These changes have a tendency to fluctuate during

the course of the day and are worse at night

Delirium, Cognitive Disorder, and Psychosis

Treatment• Recognition of the disorder • Close observation and monitoring • Identification and elimination of the precipitating factor • Treatment of any associated laboratory abnormalities • Selective use of imaging or other studies to rule out an organic

brain lesion • Application of measures to protect the patient and staff • Treatment

– Haloperidol– Benzodiazepines are the drug of choice for acute alcohol withdrawal– β-blockers (to control autonomic manifestations)– clonidine (to control hypertension)

Seizure Disorders

Etiology• Primary causes : intracranial tumor,

hemorrhage, trauma, idiopathic seizure activity

• Secondary causes : metabolic derangement, sepsis, systemic disease processes, and pharmacologic agents

Seizure Disorders

Patients high risk for postoperative seizure• previous history of epilepsy • acutely withdrawing from alcohol or

medications • pharmacologic agents : antidepressants,

hypoglycemic agents, and lidocaine.

Seizure Disorders

Presentation• Convulsions• rhythmic myoclonic activity• loss of consciousness• change in mental status • fecal and urinary incontinence• lack of neurologic responsiveness• postevent amnesia

Seizure DisordersManagement

• IV benzodiazepines is essential to stop the seizure activity and is the standard for immediate care

• maintenance after seizures are carbamazepine (Tegretol) and valproic acid

• diagnostic workup for its cause is initiated– history and physical examination– medication and drug use– white blood cell count to rule out occult infection– electrolyte and metabolic assessment.– CT or MRI – electroencephalogram

Stroke and Transient Ischemic Attacks

• Ischemic strokes most commonly• Cause• perioperative hypotension • overzealous control of hypertension • cardioemboli in patients with atrial

fibrillation,MI, bacterial endocarditis• DVT and traversing a patent foramen ovale

Stroke and Transient Ischemic Attacks

• Presentation• neurologic changes• focal alteration in motor function• alteration in mental status• aphasia

Stroke and Transient Ischemic AttacksManagement

• IV line• echocardiogram to assess the heart for structural disease • Coagulation parameters• CT scan or MRI of the brain for distinguish hemorrhagic and ischemic

stroke • Therapy is dictated by the underling mechanism of the stroke

– control of the hypertensionAntihypertensive– embolic stroke anticoagulation– hemorrhagic stroke coagulopathy with protamine– Mannitol and dexamethasone reduce cerebral swelling.– Surgical intervention indicated in patients with a localized

hematoma or vascular anomaly– low-dose aspirin therapy standard for acute ischemic infarction

RENAL AND URINARY TRACT COMPLICATIONS

RENAL AND URINARY TRACT COMPLICATIONS

• Urinary Retention• Acute Renal Failure

Urinary Retention• a common postoperative complication• Most in perianal operations and hernia repair

Presentation• Most patients should not go more than 6 to 7 hours

without passing some urine• Dull pain, constant discomfort in the hypogastrium• Percussion just above the pubis reveals fullness and

tendernessTreatment

• Foley catheter• initial straight catheterization

Acute Renal Failure

• a sudden reduction in renal output that results in the systemic accumulation of nitrogenous wastes

• Etiology– Any factor that interferes with or disrupts this

mechanism results in ARF• Hypotension• nonsteroidal anti-inflammatory drugs • gram-negative sepsis

Acute Renal Failure

• more prevalent in– major vascular procedures (ruptured aneurysm)– renal transplantation– cardiopulmonary bypass procedures– major abdominal cases associated with septic shock– major urologic operations – cases in which there is major blood loss– life-threatening trauma– major burn injuries– contrast-induced nephropathy

Cause of postoperative acute renal failure

Sabiston Textbook of Surgery, 18th Edition

Diagnostic of Acute Renal Failure

Sabiston Textbook of Surgery, 18th Edition

Acute Renal Failure

Treatment• monitoring of fluid administration• avoidance of nephrotoxic agents• provision of adequate nutrition• management electrolyte imbalance• Hyperkalemia– insulin plus glucose– aerosolized b2-adrenergic agonist– calcium gluconate– ion exchange resin (Kayexalate)

• Hemodialysis

Indications for Hemodialysis

Sabiston Textbook of Surgery, 18th Edition

CARDIAC COMPLICATIONS

CARDIAC COMPLICATIONS

• Arterial line complications• Ischemia and Infarction• Cardiogenic Shock

Arterial line complications

Infection; thrombosis, which can lead to finger/hand necrosis; death/hemorrhage from catheter disconnection

Test Allen test or Blood gas

Allen test Measures for adequate collateral blood flowto the hand via the ulnar artery

Ischemia and Infarction

Cardiovascular Risk Leading to Myocardial Infarction

• Major Risk Factors –Unstable coronary syndromes –Decompensated heart failure –Significant arrhythmias –Severe valve disease

•Intermediate Risk Factors –Mild angina pectoris (Canadian class I or II) –Previous myocardial infarction identified by history or pathologic evidence –Q waves –Compensated or previous heart failure –Diabetes mellitus (particularly insulin dependent) –Renal insufficiency

Ischemia and Infarction

Presentation –greatest in the first 48 hours after surgery–chest pain radiating into the jaw and left arm region, is often not present. –shortness of breath–increased heart rate–Hypotension– respiratory failure. –EKG. non–Q wave, non–ST segment

Ischemia and Infarction

Lab Troponin I, cardiac isoenzymes (elevated CK-mb fraction)EKG Change

Treatment Nitrates (paste or drip), as toleratedAspirinOxygenPain control with IV morphineß-blocker, as toleratedHeparin (possibly; thrombolytics are contraindicated in the postoperative patient)ICU monitoring

Cardiogenic Shock• one of the most serious sequelae of acute MI• a highly lethal condition that results in the death

of up to 75% of patients • substantial reduction in cardiac output and

resultant hypoperfusion. • Other serious sequelae from acute MI include

CHF, arrhythmias, and thromboembolic complications.

• Presentation in hypotension and respiratory failure

Cardiogenic Shock

Management• hypotension and respiratory failure• mechanical ventilation with a high FIO2

• Pharmacological Tx.• intra-aortic balloon pumps and ventricular

assist devices • Cardiac transplantation