Diagnosis and correction of thrombohemorrhagic complications in cardiosurgical patients in the early postoperative period

The methods of the prevention, diagnosis, and correction of hemostatic disorders are discussed in cardiosurgical patients. Prevention of hemorrhages requires hemostatic history data collection that allows identification of patients with concomitant hemophilia and those, taking antithrombotic drugs. The benefits of an extended study of blood coagulation disorders are shown in neonates and babies of the first year of life due to the physiological features of the hemostatic system and the pattern of heart disease. Algorithms are proposed for the diagnosis and treatment of hemorrhagic diathesis in the early postoperative period; a complex of minor signs of surgical hemorrhage is formulated, which makes it possible to timely perform rethoracotomy and to reduce blood transfusion. Efficiency evaluation and exclusion criteria for the use of recombinant factor VIIa are given. The efficiency of using the Russian drug tranexam versus epsilon-aminocapronic acid and aprotinin in the perioperative period was evaluated. The blood coagulative system was monitored in the treatment of disseminated intravascular coagulation in multiple organ dysfunction and sepsis, which promoted the timely use of recombinant human activated protein C and human antithrombin III. A diagnostic and treatment algorithm for replacement therapy of congenital heart disease concurrent with hemophilia A is given.     

Structural changes in metabolism in the early postoperative period and the methods for their correction

Surgery and general anesthesia involve changes in adaptive compensatory mechanisms manifesting by homeostasis disturbances, specifically metabolic disorders. This report describes the dynamic characteristics of structural metabolic disorders and the external respiratory function during the immediate and early postoperative period after surgery of different duration under different anesthesias and metabolic infusions. The results indicate that general anesthesia and any surgery involve structural disorders in energy expenditures during the early postoperative period. The duration of anesthesia and surgery and methods of anesthesia determine the metabolic disturbances and external respiratory changes during the postoperative period. Addition of opioids and hypertensive glucose infusions to general anesthesia and postoperative period decreases the severity of structural metabolic disorders and external respiratory function during the early postoperative period.     

High thoracic epidural analgesia in the postoperative period after correction of congenital heart defects in children

The effects and side effects of thoracic epidural analgesia on the respiratory response, awakening time, and cooperation with nurses were studied. Forty children received epidural analgesia after open-heart surgery. Lidocaine was injected in a dose of 1.5-2 mg/kg every 1.5-2 h. Controls (16 pts) received intravenous fentanyl + diazepam analgesia. Respiratory response and awakening were significantly earlier (p < 0.001) in the epidural group. Cooperation with nurses was much better in this group, too. No side effects were observed in the epidural group. Therefore, thoracic epidural analgesia is a safe and effective method of postoperative analgesia for children subjected to open-heart surgery.     

Stroke in the postoperative period

Stroke in the postoperative period requires a certain level of sophistication in dealing not only with the patient, but also with the family and significant others. The consultant who is called in to assess the patient must deal with the delicate matter of addressing a presumably unforeseen complication; this often requires political deftness when the surgeon is reluctant to acknowledge that anything possibly could go awry. It is the ultimate hope of all involved that the patient will have a speedy and full recovery. It is important for the patient to be evaluated properly and thoroughly in an effort to prevent a minor, reversible deficit from becoming a major, irreversible neurologic disability. Family members should have all findings and the implications of such findings thoroughly explained to them. Efforts to minimize the potential ramifications of a postoperative stroke generally are not well received and can lead to questions about the integrity of the surgical team as well as the quality of care.     

Nutritional support in the postoperative period

Nutritional support is used frequently as a treatment modality in the postoperative patient. Indications for nutrition support, patient selection, mode of administration, contents of solutions and complications of therapy are issues that the consulting internist must address. The role of a nutrition support team and optimal communication between the consultant and members of the surgical staff are emphasized.     

Acute gastric necrosis in the postoperative period

In this report we have described three patients with upper GI bleeding who were found to have acute gastric necrosis. We have demonstrated the usefulness of esophago-gastroduodenoscopy and CT scan in further evaluation of such cases.     

Anxiety in the postoperative period following cardiac surgery

Among the patients treated in the Intensive Care Unit at the Virgen del Rocio University Hospital, two sample group studies, one immediately following the other, were carried out. In the first study, the investigative methods used were participants' observations and non-participants' observations. The second study used interviews. Data analysis was based on categorization. The main anxiety-causing factors which stand out are thirst during the first 24 post operative hours and the need to defecate in a bedpan or similar device when this need is not indicated as a procedure to follow during the post operative period. Bear in mind that these definitive results were drawn after carrying out 12 interviews. The low number of interviews does not allow one to draw categorical conclusions but one can consider these as a take off point in further investigations.     

The problem of adequate analgesia in the postoperative period

Despite numerous methods of drug and non-drug analgesia, acute pain relief remains a pressing problem, particularly for the postoperative period. Individual protocols of analgesia are still to be developed. Standard doses of analgesics, administered in some intensive care wards, may be inadequate in some patients. An increase of an opioid dose may lead to untoward reactions. Therefore, we consider therapy with nonsteroid antiinflammatory drugs (ketorolac) justified. An important trend in improvement of the efficacy of drug analgesia is evaluation of a sufficient analgesic dose. Patient-controlled analgesia (PCA), administered in accordance with the patient's request, is an alternative to the traditional analgesia administered according to indications (planned analgesia). The main advantage of PCS in comparison with traditional administration of analgesics are effective analgesia meeting the individual requirements of a patient, rapid desired effect, a shorter period without analgesia, stable concentration of the analgesic in the plasma, time saving for the staff, and a lower incidence of side effects. PCA has been used in 227 patients in intensive care wards of Research Center of Surgery. The majority of patients appreciate this method high, which results in adequate analgesia in 82-95% cases.     

Nursing diagnosis of the patient in the immediate postoperative period

The aim of this study was to identify the nursing diagnoses that are more frequent in patients in immediate post-operative period. Data were collected and recorded on specially cards, through evaluation of 28 patients in the first two hours after the admission of the patient. The nursing diagnoses were set by one of the authors, based on Taxonomy I, proposed by North American Nursing Diagnosis Association--NANDA. The diagnoses that occurred mostly were: Risk for injury (100.0%), Risk for infection (92.8%), Sensory perceptual alterations (89.2%), Risk for aspiration (82.1%), Impaired physical mobility (71.4%), Impaired tissue integrity (82.1%) and Hypothermia (67.8%).     

Obstruction of the small bowel in the early postoperative period

To analyze factors related to etiology, diagnosis, and outcome, we reviewed the records of 26 patients in whom a clinical picture of small bowel obstruction developed within one month after abdominal surgery. The initial operation was an emergency procedure in 20 cases and an exploratory laparotomy after trauma in 11. The colon was the organ most commonly operated upon initially, being involved in ten procedures (38%), all of which were emergencies. The clinical diagnosis of bowel obstruction was made within ten days postoperatively in most cases. Surgical reexploration was required in 15 patients (58%), whereas the obstructive symptoms resolved with nasogastric suction in 11. Two patients, both of whom survived, required resection of strangulated bowel; in both a treatment delay of at least 72 hours was documented. There were two deaths (8%), neither of which was directly related to the bowel obstruction. Diagnosis of this clinical entity requires a high index of suspicion, especially after emergency procedures that involve the colon. Optimal survival is achieved by prompt recognition and early intervention when a mechanical bowel obstruction is suspected in the early postoperative period.