#30764: Postoperative Complications

The assessment of Patient A was thorough and well-organized. The ABCs were evaluated upon admission to ensure the stability of the patient. The history was ascertained, and vital signs were obtained on the recommended basis. However, despite this excellent care, the patient did not demonstrate adequate improvement in his status to be discharged on the same day.

The patient's history of smoking may be the cause of the respiratory insufficiency. Whether the patient was honest in his assessment of his smoking habit could be debated; many patients do not fully and honestly report their cigarette and/or drug and alcohol use. In addition, the patient may not have reported the feelings of nasal congestion and signs of a developing "cold" to the anesthesiologist prior to surgery. Had this been shared, the surgery may have been postponed. The patient may have been instructed to cut back on cigarette use and wait until the cold symptoms subsided prior to having surgery. When patients underreport or are dishonest during the preoperative phase of care, the staff caring for the patient in the postoperative phase is put at a disadvantage.

Patient B, a woman 31 years of age, is admitted to phase I PACU after undergoing an abdominal hysterectomy. During the preoperative assessment, the patient noted that she is a nonsmoker, has a history of motion sickness, and is quite anxious concerning the surgery and her future prospects, as she will be "sterile" upon recovery. The report from the operating room is that the patient received inhalation anesthesia and a neuromuscular blocking agent during the procedure. Prior to discontinuing the anesthesia, the patient was administered 4 mg of ondansetron for PONV prophylaxis. Also noted was a period of hypotension caused by a significant amount of blood loss requiring the intraoperative infusion of two units of whole blood.

Upon awakening, Patient B is quite agitated. She is moving from side to side and is not yet oriented to place and time. When questioned, Patient B states that her pain is 7 on a scale of 10. The PACU nurse administers 2 mg hydromorphone IV per order. The narcotic appears to begin to take effect, and when questioned, Patient B's pain is now reported as a score of 4. However, she is now complaining of nausea and asking for an emesis basin as she is afraid she will vomit. The nurse asks her to take slow deep breaths through her mouth and encourages her to relax.

When Patient B's complaints of nausea do not recede, the nurse contacts the physician who orders another dose of ondansetron, which is administered. Thirty minutes after medication administration, the patient's complaints of nausea have not subsided and the nurse again requests an order for an antiemetic. At this point, the physician orders a scopolamine patch be placed on the patient. Subsequent to patch placement, Patient B notes that her nausea is resolving.

Case Study Discussion

Preoperative management of Patient B's nausea was handled well. The staff had ascertained the pertinent information; had a risk factor identification scale been utilized, the patient would have been ranked at a very severe level of risk for PONV. The anesthesiologist recognized this risk and treated Patient B with an appropriate dose of antiemetic prior to the termination of surgery.

There were omissions in care that could have reduced the risk of PONV development in this patient. Prior to the first dose of ondansetron in the operating room, a dose of dexamethasone could have been administered to enhance the effectiveness of the serotonin antagonist.

During the PACU phase of care, the nurse caring for Patient B instituted measures to manage both the patient's pain and nausea. However, there were extenuating circumstances that were not considered and could have reduced the development of this complication. It was noted in the operative report that the patient had an episode of hypotension and blood loss; this volume depletion most likely increased the risk of PONV. In addition, the patient may have remained volume-depleted into the PACU, and no note of this was made.

The physician ordered the second PACU dose of ondansetron, which was administered without benefit. The recommendation for rescue management of PONV is to change drug classes if one is not adequate; thus, another drug should have been ordered. The scopolamine patch seemed to have a beneficial response; upon further questioning of the patient, it was discovered that whenever she had previous bouts of motion sickness the patient used patches to help her manage her symptoms. Had this information been ascertained in the preoperative phase, the patch could have been applied preoperatively or in the operating room. It is critical to gather as much information as possible to reduce these types of delays in patient management.

Patient C is a high school senior. During the opening drive in the Friday night football game, Patient C is hit from behind. When he falls, he sustains open, comminuted fractures of his left tibia and fibula. Because he is unable to stand, an ambulance is brought onto the field to transport the young player to the hospital for evaluation.

Upon arrival at the emergency department, Patient C's leg is examined, x-rayed, and evaluated by the orthopedic surgeon on call. It is determined that prompt stabilization and cleansing of the wound would be optimal for the best possible outcome; thus, Patient C is prepared for surgery. His parents, who were at the game, arrive in the emergency department just moments after the ambulance and are available to give permission for the operative procedure. As Patient C has been medicated for pain, a history is obtained from the parents. There are no notable problems; Patient C is a healthy young man in excellent physical condition. He has not had previous operations and no previous exposure to anesthesia.

Patient C is transferred to the operating room. The anesthesiologist gives the patient a number of preoperative medications, including those to prevent PONV. The anesthesia of choice is enflurane (Ethrane), a volatile gas. The patient first receives succinylcholine prior to intubation, followed by the anesthetic gas. Within minutes, the anesthesiologist notes that Patient C's carbon dioxide levels are beginning to rise. Just as the surgeon is to begin, the patient sustains a cardiac arrest.

The anesthesiologist immediately stops the insufflation of the gas and begins to administer 100% oxygen. A code response is initiated by the remaining members of the operating team. The rescuer performing chest compressions notes that the patient's skin is warm. While resuscitative efforts continue, blood for laboratory evaluation is obtained. The arterial blood gas results demonstrate a pH of 6.9, partial pressure of oxygen (PaO₂) of 110 mm Hg, and a partial pressure of carbon dioxide (PaCO₂) of 55 mm Hg. At this point, the anesthesiologist's suspicions are confirmed; the patient is experiencing an episode of malignant hyperthermia.

As soon as the diagnosis is confirmed, the staff is ordered to administer dantrolene at a dose of 2 mg/kg. The operating room personnel contact the PACU to ask for assistance in drawing up and preparing the dantrolene. Only one nurse is available to leave the PACU, and she assists with mixing and administering the dantrolene as soon as it is prepared. Additionally, the patient requires repeat doses of sodium bicarbonate to combat the falling serum pH.

Within 15 minutes of administering the dantrolene, the patient begins to demonstrate a perfusing rhythm, although this is punctuated by frequent runs of premature ventricular contractions. Antiarrhythmics are administered to control cardiac complications.

Simultaneously, the patient is cooled with external cold packs applied to the groin and axilla areas. The leg wound is dressed to prevent further contamination during the resuscitative efforts. Repeat blood is obtained for laboratory analysis. The patient's potassium is elevated, and the patient is started on a glucose-insulin drip.

After the patient's cardiac condition is stabilized, the operating room staff request transfer of the patient to the PACU for further management. The patient is moved, and the PACU staff becomes responsible for managing the patient. The antiarrhythmics, the glucose-insulin drip, and the cooling measures are continued. During the first 30 minutes in the PACU, the patient's urine is noted to be a deep red color, indicative of developing rhabdomyolysis and potential renal failure. The patient is given 100 mg furosemide, and fluids are increased to 150 mL/hour. Within 20 minutes, the urine lightens in color, although it retains a reddish tinge.

Approximately three hours after the first cardiac arrest, the patient suffers a second arrest with the development of ventricular fibrillation. A second code response is called, and the patient is again resuscitated with dantrolene, antiarrhythmics, and sodium bicarbonate. Once again, the patient responds to treatment and regains a perfusing cardiac rhythm.

The patient is ordered to receive dantrolene every 4 hours for the following 48 hours to ensure that another episode of malignant hyperthermia does not develop. The patient is subsequently stabilized and transferred to the ICU, where he remains for 72 hours.

Case Study Discussion

Patient C is a perfect candidate for the development of malignant hyperthermia. He is a young male with well-developed musculature. He has had no previous exposure to anesthesia, so his history was not negative for anesthesia complications; it was incomplete. The onset of cardiac arrest was quite rapid in this patient. This devastating complication can be quick in onset, as demonstrated here, or may be delayed and occur later during the operative procedure. The first indication of the development of malignant hyperthermia in this patient was the rising carbon dioxide level. The skin temperature remained normal during the early phase of development; the first person to note the rise in body temperature was the rescuer performing chest compressions.

The patient was managed appropriately. The staff was required to perform a number of actions to save this patient's life. Administering medications, preparing those medications, cooling the patient, and monitoring blood laboratory values is only part of the picture. The additional PACU nurse pulled to the operating room to help with the resuscitation was instrumental in providing the additional hands and expertise needed in this case.

Upon arrival in the PACU, the patient continued to require extensive stabilization measures. The repeat dantrolene had been ordered but had not yet been administered when the patient sustained the second cardiac arrest. It is imperative that the administration of repeat doses of dantrolene be continued to prevent this type of occurrence. Fortunately, the patient was young and healthy and responded to the treatment.

The long-term outcome for this patient was excellent. The resuscitative efforts were exceptional, and the patient did not sustain any long-term neurologic deficits. It is important to point out that the patient did not have his fracture stabilized at this time. Subsequent surgery was delayed to ensure the stability of the patient. Once stable, the patient had the orthopedic repair performed with epidural anesthesia. Although the risk of developing malignant hyperthermia again while undergoing epidural anesthesia is small, dantrolene was used prophylactically to ensure patient stability throughout the procedure.

Aspiration in the postoperative period can carry a high mortality rate [39]. Patients can develop one of four aspiration syndromes. Most commonly, the airway is obstructed by particulate matter, which can lead to airway loss. Drowning is also a possibility if the volume of aspirated fluid is significant. Chemical pneumonitis carries a high mortality risk; damage to the airways and alveoli may be irreversible and result in subsequent respiratory failure and death. Finally, patients may develop infectious pneumonia, which can be managed successfully if treated early.

Preoperative risks for aspiration include the presence of an obstructed GI tract or abnormal GI motility. Patients who undergo emergent procedures require risk reduction measures to reduce the volume of the GI contents. Obese and pregnant patients are at risk secondary to the alteration in GI function and/or anatomy. The most significant postoperative risk is early extubation accompanied by an increased level of sedation.

Risk reduction requires appropriate management during preoperative care. Ensuring that the patient complied with preoperative instructions regarding NPO status is critical [40]. While guidelines allow clear liquids up to two hours prior to surgery, many physicians will instruct their patients to be without liquids or solids for longer periods of time [41]. Administration of antacids, histamine blockers, and medications to decrease gastric contents should not be routinely administered preoperatively but should be instituted in any patient undergoing emergency surgery [40].

Treatment of aspiration includes the use of rapid sequence intubation techniques to ensure a clear airway. Management of aspiration is dependent in part upon the type of aspiration syndrome. Regardless, suctioning of the airway and ventilatory support are instituted in all patients. Antibiotic therapy is initiated, and bronchoscopy may be performed in an effort to reduce the effects of chemical pneumonitis.

Outcomes from aspiration are dependent upon a number of factors, including age, patient's response to therapy, and extent of damage to the respiratory tree. While some patients may experience sudden death due to aspiration, others may survive the initial insult only to die days later secondary to overwhelming infection.

Noncardiogenic pulmonary edema (NCPE) is an uncommon respiratory complication that can cause sudden death in patients recovering from surgery. Signs and symptoms of this complication are typical of pulmonary edema, including a decrease in oxygen saturation, frothy sputum formation, bilateral infiltrates, and the use of accessory muscles to breathe. In cardiac-induced pulmonary edema, the pulmonary wedge pressure is elevated; in NCPE, it remains normal to low.

NCPE can be precipitated by three mechanisms. The first is caused by the rapid pushing of high-dose naloxone. This form can be prevented by the judicious awareness of medication administration and proper dosing. The remaining two mechanisms are laryngospasm or pulmonary failure secondary to a transfusion reaction, known as transfusion-related acute lung injury (TRALI).

The most common cause of NCPE is the development of an acute laryngospasm or upper airway obstruction. This blockage of the airway leads to a negative intrapleural pressure generated when the patient tries to breathe in against the obstructed airway. This negative intrapleural pressure causes an increased venous return to the right ventricle and an increased pulmonary blood flow. The increased fluid in the lungs leaks out into the capillary bed and floods the accompanying alveoli, leading to pulmonary edema. Interestingly, this complication is more commonly seen in younger, healthy males who are able to generate high negative intrathoracic pressures. These patients are able to breathe deep against the obstruction, creating this cascade of events. Elderly or debilitated patients without strong respiratory effort cannot create the pressure to generate these events.

Risk factors for NCPE include obesity, a short neck, and a history of sleep apnea. It is more commonly seen in ENT patients and patients with a history of a difficult intubation [42]. In the postoperative period, early extubation can lead to the development of NCPE as the patient is unable to manage the secretions, leading to airway blockage. Suctioning the patient prior to extubation can reduce the risk of this complication. All patients with a risk factor for NCPE should be monitored for at least 60 minutes postextubation.

Management of NCPE includes performing the jaw lift maneuver and applying positive pressure ventilation in an attempt to relieve the obstruction. Lidocaine has been used to relieve the laryngospasm. Succinylcholine should be administered with assisted ventilation to manage an uncontrolled obstruction. Reintubation may be necessary for a period of 24 hours. Steroids are administered to reduce the risk of repeat laryngospasm. Supplemental oxygen should be applied to all patients experiencing respiratory difficulty.

TRALI can also cause an NCPE [43]. This complication is caused by the sequestration of white blood cells in the pulmonary vasculature, leading to an increase in vascular pressure and permeability with the subsequent development of pulmonary edema. TRALI only occurs after recent blood transfusion, developing anywhere from one to six hours post-transfusion. This is not a complication of the wrong blood type being administered; it is a reaction to type-specific blood whereby the white blood cells are incompatible with the patient's body [44]. The sign of developing pulmonary edema may occur quite early during the operative phase or may not develop until hours later when the patient is in the PACU or even in the nursing unit.

Management of TRALI includes supportive ventilatory assistance. Some patients may require mechanical ventilatory support, while others will respond to oxygen therapy and the maintenance of hemodynamic status. Resolution of TRALI usually occurs within 96 hours of onset, although reported cases of continued problems have been seen up to seven days after onset. When the patient is ready for discharge, education concerning the complication is necessary. Any future interventions requiring blood transfusions should be performed with leuko-reduced red blood cells, or "washed" blood, which is blood that has undergone additional procedures to remove the offending white blood cells [44].

Patient D is a male patient, 32 years of age, undergoing an uncomplicated bowel resection to repair damage and scarring of the bowel secondary to a traumatic automobile accident five years prior. The patient is a healthy, active male who states that he has smoked a pack of cigarettes a day off and on for the last 15 years. He had quit smoking after his auto accident but started again three years previously. His history is unremarkable for cardiovascular disease, and his anesthesia provider has reviewed his previous surgeries, performed at the time of the accident.

During surgery, the patient receives general inhalation anesthesia, intravenous narcotics, and neuromuscular blocking agents. The procedure runs approximately four hours in length. During the procedure, the patient has one short episode of hypotension that was managed with volume replacement.

Upon arrival in the PACU, the patient's vital signs are: blood pressure 118/62 mm Hg, pulse 78 beats per minute, respiratory rate 22 breaths per minute with shallow respirations, temperature 36.5°C, and oxygen saturation 91%. The patient had been extubated in the operating room just prior to transfer to the PACU. The nurse caring for the patient notes the signs and symptoms of respiratory distress, including the high respiratory rate, the shallow respirations, and the low oxygen saturation level. When the patient awakens complaining of pain, the nurse is hesitant to give too large of a dose of the narcotic that had been ordered.

After 30 minutes, the patient's respiratory rate is 18 breaths per minute, the oxygen saturation is 93%, and the patient is more alert. However, the patient continues to complain of ongoing pain, and the nurse leaves the patient's bedside to obtain the narcotics. Upon returning to the patient, the nurse finds the patient dozing. When the patient wakes, the nurse asks him to use the incentive spirometer; he had been instructed in its use in the preoperative phase of care. The patient complains of increasing abdominal pain and refuses to use the spirometer. At this point, the nurse chooses to administer 3 mg of hydromorphone as ordered for pain by the surgeon.

After receiving the hydromorphone, the patient again dozes off and appears to be comfortable. When obtaining the next set of vital signs, the nurse notices that the oxygen saturation has again dropped to 91%; however, as the patient's respiratory effort appears to be adequate, the nurse assumes this low saturation is a consequence of his smoking history. The patient has oxygen supplied by nasal prongs, and the nurse chooses not to intervene further. The patient is left sleeping while the nurse assists in the admission of another patient to the PACU.

Forty-five minutes after arrival in the PACU, Patient D experiences a respiratory arrest. The nurses immediately call a code and initiate resuscitative measures. The patient is administered naloxone, and positive pressure ventilation is initiated. However, bagging the patient is extremely difficult; the pop-off valve goes off with each ventilation, and the patient's chest is not rising as hoped.

Fortunately, the anesthesia provider responds and immediately asks for an endotracheal tube to reintubate the patient. When attempting to intubate the patient, the anesthesia provider finds it very difficult as a result of the patient developing laryngospasm. Succinylcholine is administered, and high positive-pressure oxygen is given via a jet vent. After another two attempts, the patient is successfully intubated. The patient is then placed on a mechanical ventilator with positive-end-expiratory pressure applied to help reduce the buildup of fluid in the lungs. He is started on a course of antibiotics and steroids and admitted to the ICU. After two days, the patient is extubated, moved to the surgical floor, and at day 6, is discharged from the hospital.

Case Study Discussion

Patient D is a typical postoperative patient. He was healthy and had an uncomplicated surgical event. He should have progressed through the recovery period without a problem; however, he sustained a respiratory arrest and his recovery was prolonged. Fortunately, he survived without long-term sequelae.

The nurse caring for Patient D made assumptions about his condition based upon his preoperative history. The smoking history allowed her to be lulled into a sense of security knowing that smokers have altered oxygen saturations. His appearance of ease was comforting, and she became complacent in her vigilance.

When Patient D sustained the respiratory arrest, the initial cause was unknown. He had numerous risk factors; the arrest may have been caused by the dose of narcotics, in which case, naloxone would have been a treatment of choice. This was tried but without a successful response. He was hypoxemic upon arrival in the PACU, as evidenced by his low oxygen saturations. This hypoxemic state may have precipitated the respiratory arrest. In addition, he had received neuromuscular blocking agents in the operating room and the arrest may have been secondary to residual paralytic agent. However, upon intubation he was noted to have developed laryngospasm, which may indicate that he sustained an episode of NCPE. He was a candidate for NCPE due to his age, preoperative health status, and early extubation.

Whenever a patient sustains a life-threatening event such as a respiratory arrest, it is critical that care providers work to determine the cause. Identification of the cause can lead to the appropriate choice of a resuscitative effort. In this case, the nurse acted appropriately in administering the naloxone, although it was later determined that this was not the cause of the arrest. Despite the fact that NCPE was not considered until the patient was found to have a laryngospasm, the measures undertaken were appropriate. The only error was the complacency that the nurse exhibited towards the patient's status upon arrival in the PACU and the first 45 minutes of care. Early attention to the hypoxemic state may have prevented the development of the arrest, although this does not always make a difference in cases of NCPE.

Patient D should be educated prior to discharge regarding the development of this side effect. If further surgeries are needed, it is imperative that he be able to relate this information so that measures can be instituted to reduce the risk of respiratory compromise.

Hypotension in the early phases of recovery is often mistaken for hypovolemia. While hypovolemia is one of the most common causes of hypotension, it is not the only consideration when assessing a patient with low blood pressure. Preoperative holding of medications, food, and fluids can cause a period of postoperative hypotension; however, anesthesiologists commonly correct this volume deficit while the patient is under anesthesia. Therefore, when a patient presents with hypotension this cause should be considered and ruled in or out quickly.

Another cause of hypotension is the use of volatile anesthetics, which have a vasodilator effect. These anesthetics also depress the myocardial function; thus, the circulating volume is often low and presents as hypotension. The position of patients in the operating room can cause compression of major vessels and eventual third spacing of fluids. If this is the case, the patient will present with low blood pressure, but when the patient is placed in the supine position and circulation is re-established, the patient's blood pressure will return to baseline levels.

Medications can also depress cardiac function, causing hypotension. Morphine, meperidine, and other medications that produce a histamine release can cause hypotension. Mechanical ventilation, especially with end-tidal positive pressures, causes an alteration in the cardiac return and a subsequent decrease in cardiac output. High spinal or epidural sympathetic blockade used in regional anesthesia techniques can also produce a profound vasodilation and cause a patient to appear to be hypotensive. Finally, the preoperative use of antihypertensive agents can cause postoperative hypotension. These medications are often held prior to surgery, but if they are still present systemically, the patient may experience profound hypotension as a result of the dose being compounded with the anesthetics and vasodilators being used.

Risk reduction measures begin in the preoperative phase when the patient's volume status is assessed. Any volume depletion should be noted, and the anesthesiologist should be notified. Intraoperatively, it is important to ensure adequate volume to help prevent postoperative hypotension from developing. If volume loss occurs during surgery, either as blood loss or with third spacing, the patient should have volume replacements based on these estimated losses.

Postoperatively, patients should have continued assessments of their volume status. If necessary, additional fluids can be administered at this time. Drug reversal remains an option, although this is avoided unless as a last effort. Vascular support with dopamine or dobutamine is rarely needed in these patients. Most cases of postoperative hypotension will resolve as the patient's own compensatory responses return the blood pressure to baseline values.

Postoperative hypertension is of significant concern due to the associated consequences of the complication, including the risk of stroke. Approximately one in three Americans is hypertensive; therefore, it is expected that many patients undergoing surgery will be hypertensive during the baseline measurement of their vital signs [46]. If hypertensive medications are held during the preoperative phase of care, it is expected that the patient will be slightly hypertensive in the recovery phase. The biggest concern is if the patient's diastolic pressure exceeds 120 mm Hg. If this is accompanied by headache, blurred vision, or changes in level of conscious, immediate intervention should be undertaken.

Hypertension can be caused by a number of factors [47]. Patients in pain who are anxious and tense may have an elevated blood pressure. Bladder and/or gastric distension can also cause a rise in blood pressure. Shivering with hypothermia can cause the pressure to rise. Some medications, such as anticholinergics, can cause a period of hypertension. Hypoglycemia produces a reflex sympathetic response, raising systolic pressure. The use of irrigating fluids may cause a hypervolemic state if they are absorbed into the vascular system.

Risk reduction is based on the cause of the hypertension. If the patient is cold and shivering, warming measures should be instituted. If the patient is in pain, pain medications may be administered. Patients who are uncomfortable due to bladder distension can have a Foley catheter placed. Management is directed at the cause, so determining the etiology is key [47]. If the blood pressure remains elevated, antihypertensive agents may be considered. However, their use is often delayed, and initial treatment should be aimed at resolving the causal condition. If the blood pressure remains significantly above baseline, medication therapy may be considered.

There are a number of antihypertensive drugs available. Diuretics may be used in cases of hypervolemia. Beta blockers are often the first-line choice when antihypertensive therapy is considered. The advantage of these drugs is their relatively short length of action; if the patient's blood pressure falls precipitously, the effects will be short-lived. Peripheral vasodilators are also available; however, these drugs are usually one of the last choices due to the significant drop in pressure experienced with their use. One rule when choosing an antihypertensive agent is to use a drug in the same class that the patient has been using for long-term management. For example, if the patient's blood pressure has been continuously managed with diuretics, administer a diuretic such as furosemide.

Dysrhythmias can develop at any point in the management of the patient but occur most commonly in the first four days after surgery. The presence of other complications (e.g., sepsis) should be considered in patients who develop postoperative dysrhythmia [47,48].

It is not uncommon to see dysrhythmia development after thoracic and cardiovascular surgeries. In many cases, atrial flutter and atrial fibrillation are seen; these will often convert to normal sinus rhythm without aggressive treatment. In 20% to 30% of patients, no therapeutic intervention is required [47,48]. Ventricular dysrhythmias are of greater concern, and the precipitating factors should be determined. The most common cause of ventricular dysrhythmias is hypoxia. All patients should be monitored with a pulse oximeter to allow for easy recognition of oxygen saturation values. When saturation percentages are in the low 90s or below, supplemental oxygen and respiratory exercises should be initiated. If improvement is not seen, additional therapies are needed to ensure adequate oxygenation.

Electrolyte imbalances are another common cause of postoperative dysrhythmias. Large fluid losses often result in hypokalemia, which can induce ventricular aberrations. Obtaining and monitoring laboratory values when appropriate will prevent these imbalances from becoming significant. If proactive, healthcare professionals can recognize these dangers and request orders for interventions prior to the problem becoming greater than necessary.

Vascular compression and venous stasis that occur during surgery are major factors in the formation of DVT. Many studies have demonstrated the extent of this problem, and guidelines for prophylaxis have been issued [49]. All caregivers in the PACU should be aware of these guidelines to ensure that all at-risk patients receive appropriate prophylaxis. The American College of Chest Physicians (ACCP) guidelines for the prevention of venous thromboembolism (VTE) outline the risks and recommendations for the management of DVT [50,116].

In acutely ill medical patients, the American Society of Hematology suggests using unfractionated heparin, low-molecular-weight heparin, or fondaparinux rather than no parenteral anticoagulant.

(https://ashpublications.org/bloodadvances/article/2/22/3198/16115/American-Society-of-Hematology-2018-guidelines-for Last Accessed: January 9, 2024)

Level of Evidence: ⊕⊕◯◯ (Conditional recommendation, low certainty in the evidence of effects)

The type of surgery is the primary factor in determining a patient's risk of DVT. Additional factors that affect the risk of DVT in general surgery patients include [50,116]:

Patients who are mobile and are undergoing an uncomplicated, minor surgical procedure are considered to be at low risk. The highest risk patients are those undergoing major lower extremity orthopedic surgeries, including hip and knee replacements (Table 4). The ACCP recommends the routine use of thromboprophylaxis following major general surgical procedures. Both low-dose unfractionated heparin (LDUH) and low-molecular-weight heparin (LMWH) have been shown to reduce the risk of asymptomatic DVT and symptomatic VTE by at least 60% in general surgery compared with no thromboprophylaxis[51].

Signs of developing DVT include swelling, redness, tenderness, and a feeling of warmth over the developing clot. Homans' sign, pain upon dorsiflexion of the foot, is present. The extremity may become swollen; however, this is a late sign [116]. When signs appear, the clot has already formed and the risk is high for pulmonary emboli formation.

Risk reduction is based on a multimodal approach to management. The use of medication therapy and mechanical methods of prophylaxis are recommended for this patient group. Medications include fondaparinux, apixaban, dabigatran, rivaroxaban, LMWH, LDUH, or vitamin K antagonist. Mechanical methods include graduated compression stockings, intermittent pneumatic compression devices, and venous foot pumps. Combination therapy is also recommended for some moderate-risk patients [50].

Management of cardiovascular complications requires vigilance and astute assessment. These complications occur unexpectedly and cause rapid deterioration in the patient. Cardiac monitoring is a necessity for all at-risk patients to allow for early detection of compromise.

Patient E, a man 74 years of age, is undergoing surgery for a blockage in his left femoral artery. The patient has a history of significant vascular compromise of his left leg secondary to the blockage. A stent is placed during surgery, and the patient is subsequently transferred to the PACU. Upon arrival in the PACU, his vital signs are: blood pressure 162/86 mm Hg, pulse 80 beats per minute, respiratory rate 16 breaths per minute, core temperature 34.5°C, and oxygen saturation 90%. The patient was extubated prior to arrival in the PACU. After the patient is stabilized and an assessment is completed, he is warmed using a warm air convection device. To combat his low oxygen saturations, his oxygen flow is increased to 6 liters per nasal cannula.

Fifteen minutes after arrival, the patient complains of severe pain in his left leg. His peripheral pulses are good, and his color is pink. However, as this was the surgical site, the nurse immediately contacts the surgeon. The surgeon speculates that the pain is secondary to new perfusion in this leg and the removal of sequestered by-products of circulation. He orders the patient to receive 3 mg hydromorphone for pain, which helps resolve the patient's complaints.

One hour after admission, the patient's vital signs return to preoperative values; his body temperature is now 36°C. At this point, he complains of pain in both lower extremities. Upon assessment, it is found that his peripheral pulses are weak in the right leg and the color of this extremity is dusky and cool to touch. His left leg remains warm, pink, and with good peripheral pulses. The patient's legs are elevated on a pillow to improve blood return to the heart, and he is again administered hydromorphone. After the second dose of hydromorphone, the patient drifts off to sleep. When he wakes, he continues to complain of pain in both extremities. The right leg remains cool, dusky, and with poor peripheral perfusion. The nurse again contacts the surgeon, who determines that the patient is possibly developing a DVT in the right calf. The patient has graduated compression stockings applied to the right leg to reduce the risk of further clot formation. As the patient had been heparinized in the operating room, no further anticoagulants are ordered.

The patient is discharged from the PACU to the surgical ward. At day 3, when he is ambulating in the hall, Patient E suffers a cardiac arrest and is not able to be resuscitated. He most likely sustained a pulmonary embolus secondary to the DVT in the right leg. The ambulation may have caused the clot to be knocked loose, allowing it to travel to the pulmonary vasculature.

Case Study Discussion

This patient was at high risk for DVT formation both due to the type and extent of surgery as well as his history of peripheral vascular disease. As he was anticoagulated in the operating room, no further interventions were instituted. However, the guidelines for management and prophylaxis of this type of patient recommend the institution of graduated compression stockings or intermittent pneumatic compression devices in addition to anticoagulation [50]. It can be speculated that this may have reduced his incidence of DVT formation; however, due to his extensive vascular history, he was at high risk prior to, during, and after surgery. It would be speculation to determine if this event may have been preventable.

The nurse caring for the patient performed her job according to policy. The only change that may have been recommended is the placement of the graduated compression stockings on the right leg prior to surgery or after the patient was stabilized in the PACU.

Regaining consciousness and awareness following anesthesia is impacted by many factors. When a patient does not awaken within 60 to 90 minutes following anesthesia, this is referred to as delayed awakening. The medications administered to achieve anesthesia are common culprits of delayed awakening. When a patient has received inhaled gases, awakening is directly related to alveolar ventilation. With poor ventilation, the gases remain in the pulmonary tree, prolonging arousal. Premedications that have a longer length of action than the procedure can cause the patient to remain somnolent during this period. Midazolam, with its short length of action, is commonly used as a premedicant to prevent this occurrence.

The half-life of medications administered in the operating suite may be long. Clearance through the typical metabolic pathways may be prolonged due to pre-existing physiologic complications. For instance, lipid-soluble drugs become sequestered in the adipose tissue and their release is slow, leading to prolonged length of action. The more adipose tissue that is present, the greater the risk of delayed metabolism and, by extension, delayed awakening. Medications may also have delayed onset and/or metabolism secondary to a slowing of circulation. Common in the elderly, this slow circulation results in delayed clearance by the kidneys, which leads to the drug remaining in the system longer and the drug effects continuing until the drug is cleared.

While the most common causes of delayed awakening include residual anesthetic or hypoventilation, other causes should be considered [52]. Both hypoxia and hypothermia can affect patient arousal. Electrolyte imbalances, hypoglycemia, or hyperglycemia can prolong awakening. These types of imbalances can produce metabolic problems that mimic delayed awakening. Although rare, drug overdose should be considered as a potential cause.

When a patient fails to awaken as expected, a treatment plan should include determination of cause, and reversal, if necessary. Reversal agents such as naloxone, flumazenil, and physostigmine may be used. These reversal agents may work for patients with residual medication; however, the awakening is often abrupt and uncomfortable, particularly when naloxone is used [16]. For patients who do not respond to these interventions, consideration of an intraoperative catastrophe should be considered. The patient may have suffered an episode of cerebral hypoxia or an intracerebral event, such as a clot or hemorrhage, leading to a stroke. These events will lead to life-long disability and/or death.

While many patients awaken as expected, some patients' arousals are neither smooth nor uneventful. Emergence excitement or delirium has been noted in 10% of the general surgical population [53,117]. Emergence excitement is defined as a state of restlessness and disorientation during arousal. Patients may be confused and unable to process their thoughts in a normal pattern. Emergence delirium is an extreme form of excitement in which the patient is shouting, agitated, and thrashing about and may be at risk for harming himself/herself or others. Patients also generally do not respond appropriately to commands [53,117].

According to the American Geriatrics Society, healthcare professionals should perform a medical evaluation, make medication and/or environmental adjustments, and order appropriate diagnostic tests and clinical consultations after an older adult has been diagnosed with postoperative delirium to identify and manage underlying contributors to delirium.

(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5901697 Last Accessed: January 9, 2024)

Strength of Recommendation/Level of Evidence: Strong/low

Patients at risk for emergence excitement or delirium can be identified in the preoperative, intraoperative, and postoperative phases. Age and cognitive function are both predisposing factors to this complication. Emergence excitement and delirium are more common in the young and old patient populations [54,55,118]. Patients with an inability to process cognitive thoughts in an orderly fashion are also at increased risk. Preoperative fears and anxiety can increase the chance that the patient will not awaken in a smooth fashion [53,117].

Intraoperative risk factors include the type of surgery, an episode of hypoperfusion, the use of certain medications, and the combination of multiple medications [55]. Patients undergoing hip and knee replacements have an increased incidence of an agitated or confused arousal. Abdominal wall surgical patients, including women undergoing abdominal hysterectomy, and women undergoing breast surgery have a greater chance of developing this complication as well [56,119]. Children undergoing tonsillectomy and adenoidectomy are known to be at increased risk. The administration of certain medications, such as meperidine, ketamine, atropine, scopolamine, and droperidol, has been associated with emergence excitement [53,117]. When multiple medications are used, the risk increases.

During the postoperative phase, there are certain possible causes that should be ruled out. The primary cause, until proven otherwise, is a state of postoperative hypoxia [53,117]. This is easily identified by monitoring for low oxygen saturation levels. All patients with lower-than-expected saturations should have supplemental oxygen provided until their values return to the preoperative levels. Other causes that may be identified in the postoperative phase of care include hypocapnia, dehydration, hypothermia, or hypoglycemia [53]. Patients may be experiencing a full bladder or pain but have yet to develop enough awareness to communicate this. Other patients may be experiencing the effects of withdrawal from drugs and/or alcohol; these patients may not have reported substance use or dependence during the preoperative assessment. The incomplete reversal of medications may also be a precipitating factor [53].

The priority of those caring for a patient exhibiting signs of emergence excitement or delirium is to ensure that the patient and other staff members are safe from harm. Violent movements may cause the patient to hit his or her arms, legs, or head against the side rails, so pillows should be placed to pad these areas. While restraints may be considered, their use may only increase the agitation.

The second step is to determine the cause of the agitation. Each of the possible causes should be considered one by one until etiology is determined. First and foremost, hypoxia should be investigated and oxygen saturations assessed. While oxygen therapy may be beneficial, the application of an oxygen therapy device, such as a nasal cannula or a face mask, may agitate the patient further. In this case, blowing oxygen at the patient's face and mouth may be the only method of ensuring oxygen delivery. When a patient is screaming, the PACU may be disrupted, but it demonstrates that the patient is achieving maximum pulmonary ventilation, which is a good method for clearing residual anesthetic. The loudest patients will usually return to a normal state faster than those who are hypoventilating.

Nonpharmacologic interventions are preferred over medication administration. Reorientation of the patient may be of help. Removing indwelling tubes and catheters, when appropriate, may reduce the sense of fear in the patient. If a patient normally uses reading glasses or hearing aids, these should be obtained and given to the patient. For children, having a parent at the bedside can help diminish the sense of fear. However, prior to bringing parents into the unit to visit a child who is experiencing emergence behaviors, it is critical that parents are fully informed of the child's state and are comfortable with assisting in managing their child. Often, a parent who sees a child who is uncomfortable will become anxious, and this can have the negative effect of agitating the child further.

When patients are truly at risk of harming themselves, the use of pharmacologic intervention should be considered. Midazolam has been used; however, it may also be the precipitating factor. Elderly patients may develop emergence excitement in response to midazolam administered in the preoperative phase of care [16]. In this case, an additional dose of the drug will only potentiate the problem rather than resolve it. In cases of anticholinergic-induced delirium, physostigmine can be administered [16].

Most cases of emergence excitement or delirium last less than 15 minutes. While this may seem like an eternity when caring for the patient, the complication passes quickly and generally without consequence.

The Society of Critical Care Medicine and the American Society of Health-System Pharmacists recommend that optimal clinical practice requires administering analgesic and sedative drugs prior to and during neuromuscular blockade, with the goal of achieving deep sedation.

(https://journals.lww.com/ccmjournal/Fulltext/2016/11000/Clinical_Practice_Guidelines_for_Sustained.16.aspx Last Accessed: January 9, 2024)

Level of Evidence: Good practice statement (consensus statement)

Prolonged paralysis is commonly a complication caused by the residual effect of paralytic agents used during the operative phase of care. Neuromuscular blocking agents are used during surgery to prevent patient movement, produce adequate muscle relaxation, and facilitate intubation while preventing laryngospasm. In addition, these blocking agents have a potentiating effect on inhaled gases; therefore, the anesthesiologist may choose to use these agents in an effort to reduce the amount of gas required to achieve the desired depth of anesthesia. Normally, paralytic agents are given during the procedure depending on their need. By the time the surgical intervention is complete and the patient has been moved to the PACU, the effects of these medications have usually worn off. However, in cases of prolonged drug effect, the paralysis may last into this recovery phase.

Between 20% and 40% of patients arrive in the PACU with objective evidence of residual neuromuscular blocking agents. Multiple investigations have demonstrated that residual neuromuscular blocking agent is an important patient safety issue, and numerous clinical studies have documented that incomplete neuromuscular recovery is associated with a variety of adverse events (e.g., airway obstruction, hypoxemic episodes) in the early postoperative period [57]. Despite the evidence documenting the importance of perioperative neuromuscular monitoring, surveys indicate that subjective assessment using nerve stimulators is performed in less than 40% of patients, while objective monitoring is even rarer (17% of patients) [57]. Failure to monitor occurs not only in adult patients but also in pediatric patients who are even more vulnerable to the sequelae of incomplete reversal [57]. PACU nurses report that residual neuromuscular blocking agent is one of the most critical events that they may face requiring emergency intervention [58].

Recovery can be tested by evaluating the following parameters: ability to open eyes wide, sustained protrusion of the tongue, sustained hand grip for at least five seconds, sustained head lift for at least five seconds, and the ability to cough effectively [59]. Achievement of certain respiratory parameters, including a tidal volume of at least 5 mL/kg, a vital capacity of at least 15–20 mL/kg, and/or an inspiratory force of 20–25 cm, may also indicate recovery. However, in many settings, evaluation using these parameters has had limited success in preventing the occurrence of residual paralysis [57].

To guide appropriate perioperative management, assessment of residual paralysis with a peripheral nerve stimulator is mandatory [57]. As the effects of paralytic agents begin to wear off, muscle recovery is noted. The order of muscle recovery is as follows: diaphragm, intercostal muscles, large muscle groups (i.e., shoulders, abdominal muscles), medium muscle groups (i.e., extremities, tongue), and finally small muscle groups (i.e., eyes, mouth, face, fingers). The peripheral nerve stimulator is used to test the responses of the small muscles in the hand and fingers demonstrating the return of function of the last muscle group.

The peripheral nerve stimulator is usually applied to the ulnar nerve at the wrist or elbow. Other sites of electrode placement include the facial nerve, the peroneal nerve, or the posterior tibialis nerve. The electrodes are applied to the skin and attached to the peripheral nerve stimulator. Commonly, the train-of-four method of testing is used [57,59]. Four rapid stimuli are applied through the electrode, stimulating the ulnar nerve, causing the small muscles of the hand and thumb to twitch. When the fourth twitch is not present, the amount of residual blockade at the motor end plates is estimated at 75%; when both the 3rd and 4th twitches are abolished, the blockade is estimated at 80%. If the second twitch is not seen, the block is estimated at 90%, and if no twitching is seen, there is 100% blockade. As the patient recovers, the amount of blockade will decrease and all twitches will be seen [59,60]. Consensus guidelines for the use of muscle relaxants in critically ill children call for the assessment of the depth of the block at least once every 24 hours with train-of-four monitoring [57,61,120].

If the patient remains in a state of paralysis, agents are available to reverse the effects of the nondepolarizing blocking agents. Reversal agents include neostigmine and pyridostigmine [16,59]. The newest reversal agent, sugammadex, was approved by the U.S. Food and Drug Administration (FDA) in 2015 [16]. Sugammadex is a modified gamma cyclodextrin (a selective relaxant binding agent) that reverses neuromuscular blockade induced by rocuronium or vecuronium in adults undergoing surgery. These reversal agents can be administered intravenously, and the effects occur within 5 to 15 minutes after administration (or in less than 3 minutes with sugammadex) [16]. When the patient begins to regain motor function, the peripheral nerve stimulator is no longer used. While return of function occurs within minutes, the patient remains weak and should be monitored throughout the recovery period for return of developing weakness or paralysis. If the patient was administered succinylcholine, a depolarizing blocking agent, the drug cannot be reversed and the return of motor function will be dependent upon clearance of the drug through normal metabolic channels [16,59].

There are a large number of factors that potentiate the development of neuromuscular blockade. It is important to assess for these factors and develop a plan of care based on these interactions. Medications and conditions potentiating the development of neuromuscular blockade include:

When these factors are present, paralysis may linger into the recovery phase, but with time and clearance of the drugs, the patient will regain function, often without the need for reversal agents.

Compartment syndrome is another neurovascular complication that can lead to lifelong disability if not recognized and treated early. Most commonly affecting the lower extremities, compartment syndrome develops when fluid and blood accumulate within the fascia surrounding the muscles. The fascia does not expand; thus, the increasing fluid accumulation causes an increase in the intracompartmental pressure. This increased pressure causes a decrease in circulation within the compartment and subsequent cellular death due to anoxia [62]. The most common cause of compartment syndrome after surgery is compression of tissue during surgical positioning. If the extremity is not positioned for drainage and circulatory flow, this pressure can increase, leading to compartment syndrome.

The most common sign of compartment syndrome is pain out of proportion to the injury [62,63]. There may be evidence of swelling, tenseness, and redness around the affected area; however, these may be late signs, and recognition at this point may be too late to achieve a normal outcome. Loss of peripheral pulses has often been considered a sign of impending compartment syndrome, yet pulses may be present even in the acute stages of this complication. As an example, the lower leg has four compartments [63]. If one is developing compartment syndrome, the other three may be providing adequate circulation to the lower extremities, allowing pulses to remain intact despite the lack of circulation in the one affected compartment. Comparing extremity circumference from the normal to the affected side may also be used; however, due to the fact that the fascia is nondistensible, this difference is often minimal.

If unrecognized, the pain and paralysis will continue to the point of loss of function. After cellular demise begins, reversal is difficult; necrotic tissue develops, requiring surgical removal. Time of onset to the development of necrosis after ischemia is approximately six to eight hours [62]. Measuring intracompartmental pressure remains the standard for the diagnosis of compartment syndrome and can be performed using commercial or "self-made" systems. Often, evaluation by an orthopedic surgeon is all that is required. Once recognized, the surgeon performs a fasciotomy regardless of the compartmental pressure. The sooner the fasciotomy is performed, the earlier blood flow can return to the affected area and cellular repair can begin [62].

Recognition of compartment syndrome is critical to successful outcomes. It is important to be aware of the possibility of compartment syndrome development in any patient, especially those who were positioned for a lengthy surgery. Preceding trauma may also increase the risk of development; a thorough preoperative history will alert caregivers to this risk. Despite the lack of predisposing factors, any time a patient complains of pain that is considered out of proportion to the expected, compartment syndrome should be considered.

Patient F, a woman 47 years of age, has sustained a comminuted fracture of her left tibia and fibula after falling on wet grass. Patient F is transferred to the emergency department, where the determination is made to take her to the operating room for internal fixation and subsequent casting.

Following surgery, Patient F is admitted to the PACU with a cast on her left leg. The leg is elevated on top of pillows to ensure adequate drainage. Upon awakening, the patient complains of pain of 9 on a 10-point scale. She is medicated with hydromorphone and falls back to sleep. Forty-five minutes later, she again complains of continued pain. At this point, she receives 3 mg of intravenous morphine. While reviewing the patient's chart and medication orders, the PACU nurse discovers that the patient has a history of frequent narcotic use and is labeled a "complainer" who is frequently seen in the emergency department or physician's office with vague complaints of pain and requests for refills of her narcotics.

After two hours in the PACU, the patient is transferred to the orthopedic floor for continued recovery. Other than her complaints of pain, her PACU stay is uneventful. When giving report to the nurses on the floor, the PACU nurse relays her findings regarding the patient's complaints of pain and repeat requests for pain medications.

During the remainder of the day and into the evening shift, the patient is monitored every four hours. She is medicated as ordered, but within one to two hours after receiving her medications she calls the nurse for additional analgesia. She continues to complain of pain, stating that she feels a burning sensation in her left leg. Her cast is checked and appears to be intact, without peripheral swelling of her leg, and peripheral pulses are present but weak.

At midnight, the patient calls the nurse with continued complaints of pain. The nurse notes that the cast is tight; the patient is no longer keeping it elevated as instructed. The orthopedist on call is contacted, and the decision is made over the telephone to bivalve the patient's cast to ensure adequate circulation. This is accomplished, and the patient appears more comfortable, although her reported pain score remains at 6.

The following morning the patient is seen by the orthopedic surgeon, who notes the bivalved cast and continued complaints of pain. The surgeon orders the cast to be replaced, which is accomplished. That evening the patient again complains of pain, this time giving a score report of 10. The physician is again contacted by telephone, and additional pain medications are ordered. Throughout the night, the patient continues to complain of pain despite frequent doses of narcotics.

The patient is scheduled for discharge in the morning. When seen by the surgeon prior to discharge, it is noted that the patient's foot is cool to touch and peripheral pulses remain weak. She has continued complaints of pain and does not want to be discharged at this time. At this point, the surgeon considers the possibility that the patient may be developing a case of compartment syndrome. The cast is removed, and the extremity is tense and cool, with poor color. The patient is immediately taken to the operating room, where a fasciotomy was performed. Upon opening the compartment, it is noted that there is extensive necrotic tissue that requires debridement. The remaining amount of muscle is minimal. The patient eventually recovers but with severe disability in her ambulatory capabilities.

Case Study Discussion

This patient sustained a long-term disability secondary to rapidly developing compartment syndrome. As discussed, rapid assessment and intervention is required to prevent this type of sequelae. The classic sign of compartment syndrome is pain that is out of proportion to the injury. This patient had continued complaints of pain; however, due to her history as someone who was always complaining of pain, her complaints were not taken seriously. All patient complaints should be addressed and believed; the lack of attention to these complaints led to a long-term disability in this patient.

Compartment syndrome is a common complication following fracture, and the possibility of this complication should have been recognized earlier. In fact, the first evening, when the first cast was bivalved, compartment syndrome should have been considered. It was more than 36 hours before the diagnosis of compartment syndrome was made, enough time for severe tissue necrosis to develop. Had the patient undergone a fasciotomy rather than bivalving the cast, the outcome may have been different.

This case demonstrates the need for prompt recognition of patient's complaints and consideration of all potential complications, regardless of the patient's previous history. The nurses and physicians in this case neglected the patient's pain complaints because of her prior history. The patient should have been given the benefit of the doubt, which may have allowed for earlier intervention.

This case subsequently went to litigation. The physicians involved in her care admitted to malpractice in neglecting to recognize and diagnose the development of the compartment syndrome earlier in her care when the potential for complications may have been decreased. The nurses admitted to malpractice as they chose to disregard the patient's complaints when further investigation should have been undertaken. It is a sad outcome, especially as it was a preventable complication.

Patient G is a man, 83 years of age, who is undergoing colon resection for removal of cancerous nodes. The operative procedure proceeds without complication, and the patient is transferred to the PACU without incident.

During the first postoperative hour, the patient is noted to be hypotensive, with a systolic blood pressure of 80 mm Hg. A review of the patient's history indicates that his normal systolic pressure on admission was 160 mm Hg. The patient is noted to take furosemide, hydrochloride thiazide, metoprolol, and lisinopril for blood pressure control. With this information in mind, it is obvious that the patient's systolic pressure is significantly lower than anticipated.

Upon awakening, the patient is confused and disoriented. He needs continual reminders to help orient to person, place, and time. He is not compliant with postoperative instructions and tries to remove the dressing from his abdomen. He complains of pain when asked but is not able to rate the pain on a scale of 1 to 10. He requires wrist restraints to prevent him from disrupting the surgical site.

The patient is also noted to have a history of congestive heart failure following a myocardial infarction many years ago. While fluid resuscitation would be the first step in supporting the patient's blood pressure, the risk of developing further cardiac failure should be considered. Prior to instituting further management, the patient's history and medication use is reviewed.

The patient stated upon admission that he had been NPO after midnight, as instructed. He was told to take his medications in the morning with a small sip of water prior to arriving at the hospital, to which he complied. His wife told the nurses that he did not eat the food recommended on his bowel prep program the evening before surgery; he was anxious and wanted to ensure that his colon had been cleaned out sufficiently. His wife also noted that he had complied with the bowel prep cleansing as instructed.

The patient is administered additional intravenous fluids at a rate of 75 mL/hour. He is finally discharged from the PACU five hours after surgery and transferred to the surgical ward. On the surgical ward, his blood pressure remains low, with an average systolic pressure of 90–100 mm Hg. The patient is discharged on day 3 with a blood pressure of 102/86 mm Hg.

Case Study Discussion

This case presents the typical complication of under-resuscitation and subsequent volume depletion. The patient's response to this complication was the development of a prolonged hypotensive episode, complicated by confusion and disorientation upon awakening.

Further history should have been ascertained from the patient and the patient's wife prior to surgery. The staff was unaware that the patient had been NPO for such a length of time. When asked if he complied with the bowel cleansing as ordered, the patient replied yes; no further questions were asked to ensure how he complied, when he last ate, etc. This assumption increased the risk of compromise.

In addition, the patient took his normal blood pressure control medications prior to surgery. While holding of these medications is often done on the day of surgery, the nurses needed to recognize the potential risk this offered. Ensuring adequate resuscitation and volume status in the preoperative and operative phases of care should have been instituted.

Anesthetic agents are vasodilators. This combined with the administration of blood pressure reducing agents caused a significant drop in the patient's systolic pressure. The patient's systolic pressure remained low even at the time of discharge; it is critical to alert this patient to this development and ensure that the patient follow up with either the surgeon or the cardiologist. As the drugs cleared from the patient's body, the normal systolic pressure should have been achieved.

The confusion and disorientation that developed in the PACU was most likely a consequence of low perfusion pressure within the cranial cavity of this patient. There are several reasons for postoperative confusion in the elderly; those reasons should be identified and treated. In this case, had the patient received fluid resuscitation earlier in the course of care, this neurologic development may have been avoided.

Managing an elderly patient with a history of multiple disease processes, medication use, and anesthetic administration is challenging. Further in-depth evaluation and history taking is critical to ensure safe care delivery throughout the operative period.

The absence of bowel motility after surgery is known as a postoperative ileus. There is no bowel obstruction causing this hypomotility; it is a physiologic response to surgical intervention on the abdominal tract. Postoperative ileus occurs most commonly following intraperitoneal surgery, but it may also be identified after retroperitoneal and extra-abdominal surgeries. The lack of motility leads to the accumulation of fluid and gas in the GI tract, causing bloating, pain, discomfort, and nausea with or without vomiting, and can extend the hospital stay of postoperative patients [68].

The most common symptoms of postoperative ileus are lack of bowel movement and absence of bowel sounds. Unlike an obstruction, in which bowel tones are present, this is an adynamic state in which there is no bowel motility and no movement of gastric contents. After surgery, the bowel regains function; the small bowel will regain function within hours. The stomach will resume function at one to two days postoperatively, and the colon will eventually regain motility at three to five days after surgery. This pattern of recovery is typically seen in patients without comorbid conditions. Complications such as sepsis, metabolic disorders, pneumonia, and trauma can significantly delay recovery times. In addition, medications commonly used in the recovery phase of care, including narcotics, anticoagulants, and antacids, can alter recovery.

When caring for a patient with an ileus, it is vital to recognize its development. The patient may be uncomfortable, often trying to move and change positions frequently to relieve the pressure in the abdomen. The patient may complain of nausea and may vomit, and the abdomen may be distended and tympanic. The size and shape of the patient's abdomen should be monitored regularly. While the ileus may resolve on its own within a couple of hours, increasing intravenous fluids may help to speed recovery. Judicious use of narcotics, which slow GI peristalsis, may be considered. When choosing medication for pain, the use of nonsteroidal agents may help to reduce the need for additional narcotics and to reduce the swelling of the bowel wall.

It is important that patients do not begin feedings until resolution of the ileus. Should the bowel remain immobile and food intake started, this food will remain in the GI tract and may increase the risk of mechanical obstruction. Beginning a diet with liquids and advancing to soft foods should be recommended for all patients upon resolution of the ileus.

Nasogastric tubes offer no benefit to the patient with an ileus in terms of recovery; however, they may provide discomfort relief if they help remove some of the accumulated gases. One study demonstrated that gum chewing helped speed up the return of peristalsis [68]. Other recommendations have encouraged early ambulation to reduce the risk of other complications, such as DVT and atelectasis. Although early ambulation has generally not been found to be harmful to the patient, it does not appear to prevent or ameliorate postoperative ileus [50,51,69,70]. While most ileus formations resolve quickly and without intervention, many patients complain that this complication is a very uncomfortable aspect of their recovery.

Genitourinary complications in the postoperative phase include the development of renal insufficiency, which can lead to acute renal failure (i.e., acute kidney injury) if undetected and untreated. Some of the more common causes of renal insufficiency include: dehydration and/or hypovolemia preventing adequate renal blood flow; the use of intravenous dyes; and the use of certain medications. Furthermore, development is more common in certain patient populations, including patients undergoing coronary artery bypass [68].

Although the occurrence is rare (i.e., risk of 0.8%), several factors accurately predict the development of postoperative acute renal failure [68,71,72]:

Recognition of increased risk can decrease the associated mortality; following cardiac surgery, the development of acute renal failure requiring dialysis is associated with a mortality rate as high as 40% to 70% [73,74]. Infection and cardiorespiratory complications are the most common causes of death in patients with acute renal failure [72]. One sign of impending renal failure is a low urine output with rising serum creatinine levels. Hyperkalemia is a common complication of acute renal failure [72].

Management of renal insufficiency begins with fluid challenges [72]. Based on the age, weight, and medical condition of the patient, fluids are infused to challenge the kidneys to begin normal functioning. Furosemide may be used to correct volume overload if the patient is still responsive. All nephrotoxic agents should be avoided or used with extreme caution. All medications cleared by renal excretion should also be avoided or their doses adjusted [75].

Early recognition of renal compromise and postoperative ileus is imperative to maintaining homeostasis of the GI and GU systems following surgery. While an ileus is a common development, prompt resuscitation with fluid is important to prevent it from progressing to a more significant complication. Renal insufficiency in the early postoperative phase can be treated with fluid resuscitation with good success at preventing the more life-threatening complication of acute renal failure and the need for dialysis. Reviewing the patient's intake and output record is an important place to start the assessment of volume status, keeping in mind that the patient may have arrived at the facility in a state of dehydration and volume depletion. Ensuring adequate circulating volume is the one parameter that can prevent these two rare complications.

Patient H, a man 34 years of age, is admitted to the PACU following abdominal surgery for colitis. In the operating room, the patient's disease was found to be extensive, and he now has an ileostomy for stool drainage. He had a large mid-line incision reaching from the pubis to the distal sternum.

Upon admission, his vital signs are: blood pressure 102/60 mm Hg, pulse 72 beats per minute, respiratory rate 16 breaths per minute, oxygen saturation 94%, and core temperature 35°C. He is somnolent but opens his eyes upon repeated commands. The formation of the stoma was discussed with the patient prior to surgery as a last choice option; however, he was unaware at that point in his care of the extent of his disease and the need for the ileostomy.

After 15 minutes, the repeat vital signs are unchanged except for the blood pressure, which is 90/58 mm Hg. His body temperature remains at 35°C. Measures to rewarm the patient are undertaken. He continues to sleep, although he is arousable. After 30 minutes, the patient's blood pressure drops to 84/48 mm Hg. It is also noted that urine output is only 5–10 mL of dark yellow urine in the Foley catheter tubing. The physician is notified, and she orders a fluid challenge of 100 mL.

After the fluid challenge, the patient's blood pressure rises to 92/60 mm Hg. Although this is below baseline, it does show improvement. However, urine output remains the same; there is no recognizable response to this fluid challenge. The ostomy drainage does increase and is measured at 100 mL of very light yellow liquid.

Two hours after admission, the patient remains in the PACU. His core body temperature remains low, and his blood pressure is below baseline. Little urine output has been noted, but ostomy output is at 250 mL since surgery. Bowel tones are heard as high-pitched squeaks. Additionally, the patient remains significantly sleepy and slow to respond to commands.

After three hours, the patient is transferred to the surgical inpatient unit. His blood pressure is 98/60 mm Hg, pulse 70 beats per minute, respiratory rate 16 breaths per minute, core body temperature 35°C, and oxygen saturation 96%. Urine output totals 30 mL since the end of surgery; ostomy drainage totals 350 mL. The patient is arousable but sleeping when not stimulated.

That same evening, approximately seven hours after surgery, the patient is awake and complaining of severe abdominal pain. His abdomen is distended; ostomy drainage now measures an additional 300 mL, and urine output is 150 mL. The surgeon is notified, and the patient is evaluated. At this point, the surgeon speculates that there may be leakage at the stoma site. The patient is prepped for the operating room for further evaluation.

While waiting for the surgical team to arrive, the patient begins passing a significant amount of gas into the ostomy bag. The amount of drainage remains high, but with the passing of the gas the distension begins to resolve and the patient notes that his pain has diminished. It is determined that the surgery will be delayed pending resolution of the abdominal distension.

The patient remains in the hospital for another four days. He receives instructions on how to manage his stoma and ostomy. His stoma drainage remains high for the first two days. He tries solid foods on day 3 but develops severe abdominal cramping and distension yet again. His diet is changed to soft foods, and over the course of the next week, he is eventually able to tolerate a normal diet.

Case Study Discussion

This patient was admitted following an extensive abdominal procedure. Upon arrival in the PACU, his core body temperature was low; however, this is common in patients undergoing an open abdominal procedure of extended length. The only error in care was the delay in beginning to warm the patient. Rewarming measures, using forced air warming, should be the standard of practice for this type of patient.

The patient developed hypovolemia, as evidenced by his low blood pressure. This period of decreased circulating volume could have potentiated the risk of subsequent ileus formation. The fluid challenge of 100 mL was ordered without awareness of the ostomy output. This output should be included in the volume assessment of the patient prior to reporting his vital signs. Most likely, a large fluid challenge would have benefited the patient and could have helped to prevent the ileus formation.

When the patient complained of severe pain while in the nursing unit, it was appropriate to consider the risk of failure of the stoma sutures. This is not an uncommon complication in this type of surgery, especially with the distended abdomen. However, the patient required a more detailed evaluation prior to being prepped for surgery. Ileus formation was not considered because the patient had audible bowel tones. While most patients with postoperative ileus do not exhibit bowel tones, these tones are not uncommon for patients with a stoma and significant changes in their GI tract. One procedure that may be beneficial for these patients is the insertion of a tube into the stoma. However, with the concern of disruption of the sutures, this was not an appropriate course of action for Patient H and was not performed.

While the patient did exhibit postoperative complications, the development was not unexpected. The assessment of the patient could have been better; assessing the intake and output beginning before surgery may have alerted the staff to the hypovolemic state. If this had been recognized and treated earlier, the ileus formation may have been averted. However, it is not uncommon for this patient type to develop an ileus, so it is difficult to determine whether it was a controllable complication. The patient's ultimate outcome was not affected by these complications, but his recovery period could have been more comfortable and without risk had certain assessment parameters been monitored more closely.

Patient I is a girl, 5 years of age, undergoing a surgical intervention to correct a congenital cleft lip and palate. She is small for her age and has had multiple difficulties with food intake. During the first year of life, it was nearly impossible for her to suck either at the nipple or on a bottle due to the shape and size of the defect. Despite multiple attempts and alternative methods of feeding, her growth has been slowed due to malnourishment. As she became able to ingest solid foods, she had difficulty with swallowing and had multiple bouts of sinus infections due to food particles being forced into the open sinuses.

In the preoperative phase of care, Patient I is noted to be quite anxious, crying in her mother's arms and shying away from the caregivers. She does not want an IV line started and throws a tantrum when this is attempted. Despite her young age, she is well aware of the multitude of interventions that occur in a hospital setting and she is determined to maintain some control over these developments. Her mother comforts her and does not appear to have much control over Patient I's behavior.

The corrective repair progresses without complication, although the surgery is long, more than six hours in length. When Patient I is transferred to the PACU, she is intubated and asleep. The surgeons do not want her to awaken abruptly and risk dislodgement of the endotracheal tube and/or damage to the surgical site. Her vital signs are stable compared to those obtained during the preoperative phase of care. She has an IV line in her right forearm, a Foley catheter, and cardiac monitoring electrodes on her chest, along with the endotracheal tube.

After Patient I is stabilized in the PACU, her mother is allowed in to see her and sit at the bedside. The mother is instructed to watch the patient and notify the nurses if she starts to awaken and reach for the tubes. The mother is overwhelmed by the change in her daughter's appearance, something she has dreamed about for the last five years.

After 30 minutes in the PACU, Patient I begins to move in bed. Her eyes remain closed but she appears to be awakening and somewhat agitated. The orders are to administer narcotics to the patient for pain; however, the patient is unable to use any type of pain scale due to the decrease in cognition. The mother is holding the child's hand when the child pulls her hand away and starts to reach for her mouth. The nurse sees this happening and is able to grasp the child's wrist and prevent her from reaching the tube and surgical site. Wrist restraints are applied to ensure that the patient is not able to repeat this potentially life-threatening action.

At 60 minutes, the patient begins to open her eyes and starts to move from side to side. She is pulling against the restraints and trying to sit up so she can reach the endotracheal tube to remove it. The nurse instructs the patient that she must lie still and that the tube must remain in place. The nurse attempts to use an illustrated pain scale, but the patient refuses to cooperate, continuing to pull at the restraints.

During this combative period, the patient's blood pressure and pulse rate continue to rise and blood is noted on the dressing around her mouth. It is imperative that something be done to reduce the risk of damage; the nurse decides to medicate the patient with the narcotic ordered to help control the agitation and allow the child to relax and perhaps fall asleep. This objective is achieved, and the patient falls asleep and appears relaxed. Her vital signs again return to preoperative values.

Ninety minutes after surgery, the surgeon enters the PACU to examine the patient. While touching the patient's dressing, the patient's eyes open; she grasps the hand of the surgeon and tries to grasp the endotracheal tube. She is shaking her head violently from side to side, and the dressing on her face begins to loosen. The physician yells for assistance, and the nurse holds the head of the child still so the tube and dressing can be re-stabilized and secured. The look in the eyes of the child is one of pure terror. By now the only way the patient is able to lash out is to kick her legs, and she is thrashing about in the bed. Her mother is trying to calm her, but the child does not appear to recognize her mother or at least does not respond to the mother's efforts.

The surgeon orders a dose of midazolam in an effort to calm the child and ensure the safety of the tube and surgical site. After administration, the child does calm down and is no longer struggling; however, she does not appear to fall asleep. She continues to have a very scared look in her eyes, and she does not appear to be fully aware of what is going on around her. Within 20 minutes, the child is dozing quietly and appears to be much more comfortable.

Two hours after surgery, the patient again awakens and is calm and cooperative. She is responding to her mother and is receiving comfort from her mother's presence. She is again instructed as to the need for the restraints and is not pulling against them. She tries to talk and begins coughing against the endotracheal tube. The surgeon has ordered that the patient remain intubated for at least the first 48 hours post-surgery to ensure adequate time for the wound healing to begin. This is going to be a challenge with this patient as she is trying continually to either remove or talk around the tube.

The patient is stable at three hours and is transferred to the ICU, as she remains intubated. Report is given to the staff. While the patient is being moved to the ICU bed and her hands are free, she grabs the endotracheal tube and pulls. Fortunately, she is prevented from removing the tube, although the tube is checked to ensure proper placement. At 48 hours, she is extubated and transferred to the pediatric floor. Within four days she is discharged home without further complication.

Case Study Discussion

This child presents a number of challenges to the PACU staff. Airway management is always the first step in stabilizing a patient who has arrived from the operating suite, and this patient did have a secure airway at the time of transfer. The concern developed when the patient began to awaken and tried to remove the tube. Had she been successful at pulling the tube, this could have been a life-threatening complication. Attempting to mask ventilate the child would be challenging with the surgical repair site preventing the achievement of a good seal with the mask. Re-intubation would have to be performed with extreme caution to prevent damage to the surgical repair.

The child was initially stable, and the recovery appeared to be without incident. However, after the child started to awaken she demonstrated many of the signs of emergence delirium, which is more common in children than adults. She was thrashing about, pulling on her restraints, and uncooperative with instructions. Her mother did not appear to be able to calm her, indicating the possibility that she was disoriented and confused.

While the nurse was aware of the need to protect the child, she chose to administer the narcotics as ordered rather than receive an order for a different medication. It may have been that the narcotic was the right choice; the patient could have been in pain, although this was not assessed due to her behavior. On the other hand, the narcotic could have caused the second bout of combativeness noted upon the surgeon's arrival. When the patient was able to grasp the endotracheal tube, it was determined that the mother had released the restraint while holding her daughter's hand. This could have been another life-threatening complication; the nurse needed to not only ensure that the mother understood the need for the restraints but also check for proper placement of the restraints when her vital signs were obtained.

Midazolam was the drug that was able to allow the child to fall asleep and awaken in a more controlled state. Although midazolam may be a cause of emergence delirium and confusion in children, it is also one of the first drugs considered in its management. For this patient, it was the right drug, although the right time may have been during the first episode of combativeness. Not all children must be medicated; however, with the risks of tube dislodgement and surgical site disruption being quite high in this child, the administration of midazolam in the earlier phase of care may have been a better choice.

This case demonstrates the multitude of issues in dealing with pediatric patients. Although patients are educated prior to the surgical intervention, this education is not fully understood and the child may not follow instructions as directed. The mother was an excellent source of comfort to her child but also put her child at huge risk by untying the restraints. Parents should have continual reminders of their place in the care of their child.

The risk of postextubation croup was not addressed but could have presented a significant challenge to this patient either in the ICU or once on the pediatric unit. The risk of this form of croup increases when the patient has remained intubated for a length of time and/or when the child fights against the tube, both risk factors in this case. Fortunately, this did not occur and the patient was eventually discharged without further incident.

Children present challenges regularly in the PACU. Their risk of compromise is greater, and the complications are different. Astute care will allow for safe recovery during this period.

Patient J is a man, 87 years of age, undergoing surgical repair of a fractured hip. He was living at home independently when he slipped and fell in the bathroom, fracturing his right femoral neck. He was on the floor for an indeterminate amount of time prior to being found by a neighbor who checked on him when he had not been seen for a number of hours. Emergency service personnel were called. They found the patient on the bathroom floor in a confused state. He was unable to accurately note the date or time, and he had no recollection of how he ended up on the floor. During the head-to-toe assessment, it was noted that Patient J had sustained a small scalp laceration over his right temporal region, which was clotted by the time the ambulance personnel arrived. His leg was in a displaced position, and a fractured hip was suspected. He was also noted to have a healed scar on his sternum, indicative of a previous open-heart procedure.

Upon arrival in the emergency department, the patient is evaluated by orthopedic, cardiology, and neurology specialists. His history is reviewed and reveals a previous open-heart procedure eight years prior to admission, a long history of smoking prior to the cardiac procedure, and a history of lifelong obesity. The patient's skin condition is poor; he has multiple bruises in varying stages of healing. He has multiple folds of fatty skin, and between these folds, the skin is quite dirty and foul smelling, indicating a poor hygienic state. He has a list of medications in his wallet, which identifies the following drugs: digoxin, simvastatin, furosemide, potassium chloride, amlodipine, and lisinopril. Due to his current state of confusion, the accuracy of this list and the last time the patient took his prescribed medications are unable to be determined.

Patient J's greatest immediate need is stabilization of the fractured femur. The neurologist deems that it is appropriate to perform the surgery under general anesthesia and that postoperative neurologic assessment should be initiated. The cardiologist agrees that the patient is stable from a cardiac standpoint and that he will most likely be able to tolerate the effects of anesthesia. The orthopedic surgeon performs the fractured hip repair.

Upon transfer to the PACU, the patient is still asleep; he was extubated in the operating room, has a cardiac monitor on and a Foley catheter in place, and his hip is positioned for optimum healing. His vital signs are: blood pressure 162/100 mm Hg, pulse 80 beats per minute, respiratory rate 22 breaths per minute, oxygen saturation 89% on 4 liters nasal prongs, and core temperature 34.5°C. No urine is noted in the Foley catheter. The greatest initial concern is the lower oxygen saturation; the nasal prongs are replaced by a face mask at a flow rate of 6 liters per minute. Within 15 minutes of switching the oxygen delivery device, the oxygen saturation increases to 91%.

Thirty minutes after arrival in the PACU, the patient remains asleep. His vital signs are stable; however, his body temperature remains at 35°C despite forced air warming. He is not moving nor does he appear to be in any discomfort. His skin condition does not appear to have improved. His lower extremities are cool to touch, and peripheral perfusion is poor.

At approximately 40 minutes after arrival in the PACU, the patient sustains a cardiac arrest. Resuscitation efforts continue for approximately 20 minutes without success, and the physician in charge pronounces the patient dead.

Case Study Discussion

This patient is representative of the typical postoperative geriatric patient. He has multiple health issues and takes many medications. His physical status is compromised by his nutritional status, in this case, obesity. He was living independently prior to this event; he did not have family close by, and his history was only ascertained by the information that his neighbor and the first care responders were able to locate. Even with that, the accuracy of this information was questioned. Prior to the fall, the patient had been happily living his life, which was subsequently lost after the surgery.

After the patient was pronounced dead, it was speculated that he had developed a clot that occluded his pulmonary vasculature. If this was indeed the case, the outcome would not have changed despite the resuscitation efforts. However, due to his advanced age and condition, a postmortem exam was not performed and the cause of death was never confirmed.

The patient's condition was compromised by numerous factors. He had a positive cardiac and smoking history and may have sustained a neurologic event at the time of the fall, or a neurologic event may have precipitated the fall. His obesity presented a number of issues. His skin condition was quite poor, and his apparent lack of hygiene would increase his risk of postoperative infection. While he was considered to be independent, his current health state was definitely not optimal.

Had this patient survived, in all likelihood, he would not have been able to return to an independent living environment. He would have required care in a rehabilitation facility to learn to ambulate post-surgery. Whether he would be strong enough to recover to a fully independent state was questionable.

This case demonstrates the many issues and challenges in managing the elderly patient. The lack of concrete information in the preoperative stage can impact the decisions that are made in the operating suite. Patient J's poor health status put him at increased risk for complication development. Even if the patient had survived, his long-term outcome would have been significantly different than the lifestyle he had prior to the injury. Preparing the patient and family for these less-than-optimum outcomes should be considered part of the preoperative care measures.

Patient K is a woman, 42 years of age, who weighs 432 pounds. She has a BMI of 62 and is scheduled to undergo a restrictive bariatric procedure. Her history is positive for hypertension, diabetes controlled with two to three insulin injections daily, gastroesophageal reflux disease, and obstructive sleep apnea. She is nervous prior to surgery, yet anxiously awaiting the new life that she sees in her future.

The operative course of care is unremarkable. The patient has a gastric band placed, creating a small pouch. She is transferred to the PACU having been extubated. Her vital signs upon admission are: blood pressure 182/112 mm Hg, pulse 82 beats per minute, respiratory rate 24 breaths per minute, core temperature 35°C, and oxygen saturation 91%. She remains very somnolent but opens her eyes with loud verbal stimulus.

Upon admission, the concern for this patient is the low oxygen saturation. She maintained a saturation of 94% during the procedure but the postoperative saturation remains 90% to 91%. Oxygen is being delivered by nasal cannula at 4 liters/minute. The nurse caring for the patient is unsuccessful at awakening her for more than a few seconds. The oxygen delivery system is changed to a face mask with a liter flow of 6 liters/minute. Little improvement in the patient's status is seen with this change.

It would be optimal to awaken the patient to have her participate in respiratory exercises; however, she remains quite sleepy while in the unit. Elevating the head of the bed may help her oxygenation but does little to increase her oxygen saturation values. Arterial blood gas analysis is obtained; the results are pH of 7.34, PaO₂ of 74, and PaCO₂ of 47. With these results it is obvious that the patient is hypoventilating, most likely secondary to pressure on the diaphragm limiting her respiratory excursion effort.

The patient remains somnolent for the next four hours. Her oxygen saturation values remain around 91% despite the efforts of the staff. After four hours in the PACU, she is transferred to the inpatient unit for an overnight stay. She remains hypoxic until the following afternoon.

Case Study Discussion

The patient in this case study demonstrated one of the more common complications following bariatric surgery: hypoventilation. The upward displacement of Patient K's diaphragm prevented full expansion of her lungs, causing carbon dioxide levels to rise while oxygenation values remained low. Although the levels were low, they were not to the point of being life-threatening.

One measure that may be used to improve oxygenation in patients following surgery is respiratory exercises to help expand the lungs and encourage the patient to expel secretions. To accomplish this goal, the patient should be cooperative and have an appropriate cognitive level to follow the commands. As this patient remained somnolent for a lengthy period, efforts at obtaining her cooperation were unsuccessful. It is not uncommon for obese patients to experience a delay in awakening following anesthesia. The drugs are absorbed into the fatty tissue, and release occurs over an extended period. One measure that may have been successful in arousing the patient more quickly is a fluid challenge. This extra fluid can often help circulate the remaining anesthetic and speed the metabolism of the medication, allowing the patient to awaken more quickly. While this may not always be the answer to delayed awakening, it is often successful in obese patients.

Fortunately, this patient did not experience any of the other postoperative complications that are common following bariatric surgery. After her respiratory status improved, she was able to meet the criteria for discharge and was sent home the next day.

In follow-up with this patient, she lost more than 100 pounds in the first year following surgery. She started an exercise regimen and is determined to continue with her weight loss. While 100 pounds is quite a bit of weight to lose, her weight is now 330 pounds; therefore, she remains at risk for the complications of obesity. Her diabetes has not resolved, yet she remains hopeful that with continued weight loss, she will one day be free of insulin injections. Morbidly obese patients have a long and often arduous path ahead of them and should not expect miracles to happen overnight.