Work-up

A bedside examination includes taking vitals with pulse oximetry and checking the wound for erythema, edema, fluctuance, drainage, and warmth. Auscultate for rales or diminished breath sounds, examine IV sites for redness, and check the patient′s legs for calf tenderness. If the patient has a tracheotomy, look for increased and discolored sputum. Consider ordering a chest X-ray, blood cultures, sputum cultures, and/or a urinalysis with cultures.

Fever is a prominent sign of systemic illness in the postoperative patient. Clarifying whether patients have an isolated fever versus systemic inflammation response syndrome (SIRS; Table 2.21 ) and sepsis is important in reducing morbidity and mortality. SIRS and sepsis require urgent intervention to improve patient outcome. Sepsis is defined as SIRS with a known or suspected infectious source, with evidence of end organ dysfunction (e.g., mental status change, hypotension, decreased urine output/elevated creatinine). Septic shock is sepsis which requires vasopressor agents to maintain mean arterial blood pressure > 65 mm Hg and lactate level > 2 mmol/L (18 mg/dL) despite adequate fluid resuscitation.

For atelectasis/pneumonia, empiric treatment may include a chest physical therapy, supplemental oxygen, and respiratory therapy with incentive spirometry, mucolytics, nebulized bronchodilators, and empiric antibiotics (determined after the results of culture specimens have been received). For the treatment of pneumonia, cephalosporin and clindamycin are recommended, and for a suspected UTI, treat the patient with sulfa or fluoroquinolone. Adjust antibiotics based on culture results. Gentle IV hydration may be useful. Treat with an antipyretic, such as acetaminophen 650 mg for adults (15 mg/kg for children). A wound abscess will require opening the wound, draining it, initiating a Gram stain with culture, and changing the packing. If other vital signs are abnormal, consider transferring the patient to a monitored bed, with continuous pulse oximetry and arterial blood gas assessment.

Work-up

The bedside exam should include taking a full set of vitals with pulse oximetry; lung auscultation; an examination of the tracheostoma, if present; and a focused neurologic exam looking for focal deficits and the patient′s orientation to person, place, and time. For ancillary tests, start with arterial blood gases (ABGs), a 12-lead electrocardiogram (ECG), a fingerstick glucose test, and a portable chest X-ray. A full metabolic panel may be of use to identify electrolyte aberrations or end organ dysfunction. Acute respiratory insufficiency in the head and neck patient often presents with a low PaO₂ and elevated PCO₂; however, a PCO₂ below 40 may be seen with compensatory overventilation. Typically, the patient has an underlying chronic lung disease and has had inadequate tracheopulmonary toilet, allowing secretions to accumulate and mucus plugging to form. Thus, treat with humidified supplemental oxygen and aggressive suctioning. If there is an inadequate response and other tests are normal, consider testing the patient for a pulmonary embolism (PE).

Pulmonary Embolism

In the case of a possible PE, currently spiral chest computed tomography (CT) imaging is obtained, although ventilation/perfusion (V/Q) scans can be performed and laboratory testing for D-dimer may be useful. Patients with proven PE and an otherwise stable cardiovascular status are often managed with supplemental oxygen and anticoagulation, using an IV heparin bolus of 10,000 units with a drip at 800 to 1200 units per hour, maintaining an activated partial thromboplastin time (aPTT) at 1.5 to 2.0 times normal. The patient is transferred to the intensive care unit (ICU) with continuous monitoring; if the patient becomes unstable with cyanosis, low PaO₂, cardiac arrhythmia, hypotension, and low urine output, consider intubation with ventilatory support as well as prescribing an inotropic agent. Thrombolytics may be indicated in certain cases, although they may not be feasible in the postoperative state. Consideration for consultation with pulmonary or critical care services should be considered in these cases.

Acute Postobstructive Pulmonary Edema

Acute postobstructive pulmonary edema (APOPE) should be suspected in patients with postoperative acute respiratory failure. The development of hypoxia, bradycardia, and pink frothy sputum is characteristic in patients with APOPE. Type I APOPE occurs with acute airway compromise usually following extubation. This develops from inspiration against a closed glottis due to laryngospasm or other obstruction. Type II APOPE develops after relief of chronic upper airway obstruction. This may occur in children or adults following surgery to correct severe obstructive sleep apnea, airway stenosis, or neoplasm. In both cases, a sudden decrease in intrathoracic pressure leads to increased pulmonary venous return and transudation from the capillary bed into the interstitium.

The treatment of APOPE includes intensive care monitoring and a low threshold for immediate reintubation. Positive end expiratory pressure may be necessary for adequate ventilation. Diuretics and steroids should be considered. In patients who are stable, medical management with oxygen supplementation, diuretics, and close observation may be appropriate. Careful restriction of intravenous crystalloids may also be an option.