Postoperative patients, treatment

Promethazine Promethazine also is indicated for preoperative, postoperative, or obstetric sedation prevention and control of nausea and vomiting associated with certain types of anesthesia and surgery an adjunct to analgesics for control of postoperative pain sedation and relief of apprehension, and to produce light sleep antiemetic effect in postoperative patients active and prophylactic treatment of motion sickness (oral and rectal only). 

The most efficient topical medications to reduce lOP in postoperative patients are those whose mechanism involves aqueous suppression. These agents would include topical carbonic anhydrase inhibitors, apracloni-dine, brimonidine, beta-blockers, and oral carbonic anhydrase inhibitors. Prostaglandin analogues and miotics are effective in lowering the lOP postoperatively however, they may cause increased inflammation and should not be considered a first-line treatment. 

Postoperative patients who are found to have symptomatic tears or frank retinal detachment should be referred immediately to a vitreoretinal surgeon for treatment. Repair of a rhegmatogenous retinal detachment involves locating retinal breaks, draining subretinal fluid, and sealing the breaks with cryotherapy, endolaser, or diathermy in conjunction with application of a scleral buckle or sponge or pneumatic retinopexy. 

A randomized, double-blind, placebo-controlled study of oral dextromethorphan and PCA morphine has been performed in 66 patients undergoing knee surgery (9). The study was in two parts. The first was a dose escalation study in 25 postoperative patients to determine the maximum tolerated oral dose of dextromethorphan. The second involved giving less than the maximum tolerated dose divided into three increments at 8-hour intervals. The maximum tolerated dose of dextromethorphan was 750 mg. One patient, who was given 800 mg of dextromethorphan, had adverse effects, including severe slurred speech and light-headedness followed by deep sedation. In the second part of the study 66 patients were intended to receive dextromethorphan 800 mg in three doses of 400, 200, and 200 mg. The treatment group was subsequently reduced to 22 patients, compared with 34 in the... 

Although the basic pathophysiology is similar for the various causes of hypovolemic shock, there are unique considerations relative to each. For example, whereas isolated head injuries associated with trauma typically do not result in substantial blood loss or shock, pelvic fractures may sequester several liters of blood as hematoma formation. Patients with traumatic or thermal injuries, as well as postoperative patients, may have substantial fluid accumulation in sites where it cannot be readily transferred back into blood vessels (i.e., third-spaced fluid) for maintaining pressure. With these types of injuries, prompt control of compressible bleeding sources with rapid patient transfer to the hospital for definitive treatment may preclude the cascade of events leading to shock. Indeed, with trauma patients, a scoop and run approach is used in most urban hospitals that places a priority on rapid transport to a hospital. ... 

Iron deficiency is the most common cause of resistance to erythropoietic therapy. Evaluation and treatment of iron deficiency should occur prior to initiation of erythropoietic therapy as previously discussed (see Figs. 44—1 and 44—2). Inflammation (localized or systemic infection, active inflammatory disease, or surgical trauma) is associated with defective iron utilization known as reticuloendothelial block. Reticuloendothelial block is characterized by a reduction in iron delivery from body stores to the bone marrow, and is generally refractory to iron therapy. Failure to respond to erythropoietic therapy requires evaluation of other factors causing resistance, such as infection, inflammation, chronic blood loss, aluminum toxicity, hemoglobinopathies, malnutrition, and hyperparathyroidism. Erythropoietic therapy may be continued in the infected or postoperative patient, although increased doses are often required to maintain or slow the rate of decline in Hgb/Hct. Deficiencies in folate and vitamin Bi2 should also be considered as potential causes of resistance to erythropoietic therapy, as both are essential for optimal erythropoiesis. Patients on hemodialysis or peritoneal dialysis should be routinely... 

Ketorolac (administered as the tromethamine salt Toradol, Ultram) has been used as a short-term alternative (less than 5 days) to opioids for the treatment of moderate to severe pain and is administered intramnscnlarly, intravenously, or orally. Unlike opioids, tolerance, withdrawal, and respiratory depression do not occur. Like other NSAIDs, aspirin sensitivity is a contraindication to the nse of ketorolac. Typical doses are 30 to 60 mg (intramnscnlar), 15 to 30 mg (intravenous), and 5 to 30 mg (oral). Ketorolac is used widely in postoperative patients, but it should not be used for routine obstetric analgesia. Topical (ophthalmic) ketorolac is FDA approved for the treatment of seasonal allergic conjunctivitis and postoperative ocular inflammation after cataract extraction. 

Ketorolac exerts typical NSAID effects. It prolongs the bleeding time and can impair renal function, especially in a patient with preexisting renal disease. Ketorolac is not available over-the-counter. Its piimaiy use is as a parenteral agent for pain management, especially for treatment of postoperative patients. The answer is (D). 

Treatment of adverse events for co-administration of clonidine with other agents, one or both doses should be reduced as necessary to avoid adverse events. Treatment of these adverse events is typically supportive, though it should be noted that intrathecal neostigmine appears to counteract clonidine-induced spinal hypotension and that yohimbine has been used to coimteract clonidine-induced sedation in postoperative patients. Hemodialysis is not likely to be effective for complications from neuraxial clonidine administration. 

Empirical therapy for postoperative infections in neurosurgical patients (including patients with CSF shunts) should include vancomycin in combination with either cefepime, ceftazidime, or meropenem. Linezolid has been reported to reach adequate CSF concentrations and resolve cases of meningitis refractory to vancomycin.35 However, data with linezolid are limited. The addition of rifampin should be considered for treatment of shunt infections. When culture and sensitivity data are available, pathogen-directed antibiotic therapy should be administered. Removal of infected devices is desirable aggressive antibiotic therapy (including high-dose intravenous antibiotic therapy plus intraventricular vancomycin and/or tobramycin) may be effective for patients in whom hardware removal is not possible.36... 

Patients must be monitored to assess their response to treatment and to detect recurrent diseases. PSA as a specific marker for prostate cancer is most useful in monitoring patients who have been treated with radical prostatectomy, radiation therapy, or endocrine therapy. The concentration of PSA falls to undetectable levels following a radical prostatectomy because all prostate tissue has been removed. Generally, PSA is measured at periodic intervals. In studies, the extent of disease at the time of surgery correlated well with the postoperative PSA concentration. A significant measurable PSA concentration after prostatectomy indicates that residual tumor may be present. PSA concentrations decline gradually after radiation therapy (36). 

An increasing number of both clinical and laboratory-derived observations support the importance of luminal components in driving the inflammatory response in ulcerative colitis and Crohn s disease. Although its role is unclear, antibiotic therapy is commonly used in clinical practice for the treatment of moderately to severely active ulcerative colitis. Metronidazole and/or ciprofloxacin are currently employed in active Crohn s disease, particularly in patients with colonic involvement and with perianal disease. Rifaximin, a rifamycin-derived antibiotic, is characterized by a wide range of antibacterial activity and a very low systemic absorption. Some preliminary data show its efficacy in severe active ulcerative colitis, pouchitis and prevention of postoperative recurrence in Crohn s disease. 

More recently, Campieri et al. [51] performed a randomized trial to evaluate the efficacy in the prevention of postoperative recurrence with rifaximin 1.8 g daily for 3 months followed by a probiotic preparation (VSL 3) 6 g daily for 9 months versus mesalazine 4 g daily for 12 months in 40 patients after curative resection for CD. After 3 months of treatment, patients on rifaximin had a significantly lower incidence of severe endoscopic recurrence compared to those on mesalazine [2/20 (10%) vs. 8/20 (40%)]. This difference was maintained since the end of the study using probiotics [4/20 (20%) vs. 8/20 (40%)]. 

---