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KEY POINTS

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  • The initial sign that a malignant hyperthermia crisis is developing is a rise in end-tidal CO2 levels. The treatment of choice is dantrolene.

  • Twitch monitors should be utilized to ensure that neuromuscular blockade has been adequately reversed as physical examination is not generally adequate. Residual neuromuscular blockade is an important cause of postoperative respiratory failure.

  • Unfractionated heparin for DVT prophylaxis offers no benefit for trauma patients. Low-molecular-weight heparin should be used unless contraindicated.

  • Patients with systolic anterior motion (SAM) of the mitral valve or significant ventricular hypertrophy should undergo fluid resuscitation as the mainstay of post-cardiac surgery management as inotropes may cause severe obstructive cardiogenic shock.

  • Cardiac tamponade, massive hemothorax, and right heart failure are significant causes of morbidity and mortality in cardiac surgery. Their presentations can be similar and distinguishing between the different causes is imperative to ensure that proper medical and/or surgical treatment is performed.

  • Inhaled pulmonary vasodilators are important adjuncts in the treatment of acute right heart failure in the postoperative period as they do not have the systemic effects of hypotension and hypoxemia seen with intravenous agents.

  • β-Blockers and amiodarone are the main agents used for perioperative prevention of atrial fibrillation in cardiac surgery patients.

  • Augmentation of mean arterial pressure, maintenance of cardiac output, and monitoring and drainage of cerebrospinal fluid with a lumbar drain are important adjunctive therapies to reduce rates of paralysis following aortic surgery.

  • Cardiac herniation following pneumonectomy and pericardial patch breakdown is characterized by acute obstructive shock, jugular venous distention, and discoloration of the upper torso. The mortality rate is 50%; therefore, immediate recognition and surgical treatment are imperative.

  • Bilateral recurrent laryngeal nerve injury leads to acute, emergent respiratory failure requiring intubation, followed by tracheostomy.

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OVERVIEW OF POSTOPERATIVE CRITICAL CARE

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The principles of postoperative management for general care and postoperative emergencies are often discussed only in depth in large surgical texts or specialized surgical service texts. Any critical care provider who cares for general surgical, cardiothoracic, neurosurgical, and trauma patients should have a basic understanding of routine postoperative care, including understanding of surgical drains, chest tubes, and wound care. As with all aspects of patient care, communication with nursing, ancillary personnel, and other health care providers is essential to appropriate recognition and care for the emergencies. Communication with the anesthesia and surgical teams bringing the patient to the ICU should occur to ensure that the critical care provider understands what surgical procedure occurred, what events are expected, and what potential complications to watch for. The critical care unit should furthermore have appropriate equipment to assist in recognition and, when appropriate, treatment of these emergencies. Much of the critical care management of postoperative and trauma patients is similar to nonsurgical critically ill patients. This chapter is designed to assist in specific postoperative and trauma situations not covered elsewhere in this textbook.

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IMMEDIATE POSTANESTHESIA CARE

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EMERGENCE
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