Post op cea - Nursing Case Study

Pathophysiology

• Primary mechanism: Post-operative Carotid Endarterectomy (CEA) complications primarily arise from surgical trauma to the carotid artery. The procedure, aimed at removing plaque build-up, can inadvertently cause intimal injury leading to platelet aggregation, thrombus formation and potential stroke.

• Secondary mechanism: Impaired cerebral perfusion due to clamping of the carotid artery during surgery is another crucial factor. This may lead to cerebral ischemia, hypoperfusion injuries and possibly result in neurological complications post-surgery.

• Key complication: Cranial nerve injury is a significant post-operative complication. The proximity of cranial nerves to the carotid artery puts them at risk during surgery, potentially causing dysphagia, hoarseness, and Horner's syndrome.

Patient Profile

Demographics:

68-year-old male, retired construction worker

History:

• Key past medical history: Hypertension, Type 2 Diabetes, previous smoker (20 years)

• Current medications: Metformin, Lisinopril, Aspirin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Experiencing discomfort and swelling at the surgery site post Carotid Endarterectomy (CEA) surgery.

• Key symptoms: Fever, pain, redness and swelling at the incision site, difficulty swallowing, shortness of breath, episodes of confusion.

• Vital signs: Elevated temperature at 100.4°F, Pulse rate 110 bpm, Blood pressure 130/85 mmHg, Respiratory rate 22 breaths per minute, Oxygen saturation 93% on room air.

Section 1

New Diagnostic Results:

The patient's labs returned and showed an increased white blood cell count of 13,000/uL, indicating a possible infection. The C-reactive protein (CRP) levels were also elevated at 15mg/L, suggesting inflammation. The patient's blood glucose levels were slightly elevated at 195mg/dL, most likely secondary to the stress of surgery and possible infection. Despite these concerning results, the patient's HbA1c was 7.0%, reflecting relatively good long-term blood sugar control.

A duplex ultrasound of the neck revealed a patent carotid artery with no evidence of thrombus or significant stenosis. However, a small hematoma was noted at the surgical site, which could be contributing to the patient's pain and swelling. A chest X-ray was ordered due to the patient's increased shortness of breath and revealed mild pulmonary edema, likely due to fluid overload or possibly heart failure exacerbation.

These diagnostic results suggest that the patient may be developing a post-operative infection and hematoma at the surgical site. The elevated blood glucose levels and pulmonary edema further complicate the patient's clinical picture, requiring careful management to prevent further deterioration. The patient's elevated respiratory rate and lower oxygen saturation on room air may be due to the pulmonary edema, and his episodes of confusion could be a result of hypoxia, hyperglycemia, or a combination of both. The healthcare team now needs to focus on managing these complications while also monitoring for signs of further neurological complications.

Section 2

Change in Patient Status:

Over the next 24 hours, the patient's condition deteriorated marginally. His respiratory rate increased to 24 breaths per minute, with further decrease in oxygen saturation to 88% on room air, necessitating supplemental oxygen via nasal cannula. The patient's confusion also worsened, and he displayed signs of restlessness and agitation. His blood glucose levels continued to rise, with a recorded level of 230mg/dL, despite corrective sliding scale insulin being administered.

The patient also reported increasing pain and swelling at the surgical site, with the area appearing red and warm on examination. The patient's temperature spiked to 38.5 degrees Celsius (101.3 F), and his heart rate increased to 110 beats per minute, both potential signs of sepsis. Consequently, the healthcare team decided to initiate broad-spectrum antibiotics and further monitor the patient's response to the treatment.

These changes indicate a possible worsening of the patient's post-operative infection and the development of sepsis. The increase in pain and swelling at the surgical site suggests that the hematoma may be expanding or becoming infected. The elevated blood glucose levels, despite insulin administration, could be a response to the stress of infection or an indication of inadequate insulin dosing. These changes in the patient's status require prompt intervention to prevent further complications and deterioration. The healthcare team will need to continue closely monitoring the patient's vital signs, blood glucose levels, and neurological status.

Section 3

Change in Patient Status:

Over the next few hours, the patient's status continued to decline. The supplemental oxygen via nasal cannula was insufficient in maintaining his oxygen saturation levels, which further decreased to 85%. His respiratory rate increased to 28 breaths per minute and he began to exhibit signs of respiratory distress such as the use of accessory muscles and increased work of breathing. His blood glucose levels remained elevated at 240mg/dL, indicating a lack of response to the sliding scale insulin regimen.

New Complications:

More troublingly, the patient's confusion escalated to delirium, and he became disoriented to time and place. His agitation also increased, necessitating the use of soft restraints to prevent self-harm. Additionally, the surgical site showed signs of worsening infection, with increased redness, swelling and purulent discharge. His temperature rose to 39.1 degrees Celsius (102.4 F) and his heart rate accelerated to 120 beats per minute, indicating possible progression of sepsis. These new developments suggest that the patient is potentially developing respiratory failure and acute delirium, both severe complications that could be linked to the underlying sepsis and uncontrolled hyperglycemia. The healthcare team will need to reassess the patient's condition and intervene immediately to prevent further deterioration.

Section 4

Response to Interventions:

Despite aggressive fluid resuscitation and broad-spectrum antibiotics, the patient's clinical status did not improve. His oxygen saturation levels remained at 85%, indicating persistent hypoxia. Furthermore, the patient's blood glucose levels remained stubbornly high at 250 mg/dL, despite an increased dose of sliding scale insulin. The healthcare team also administered haloperidol to manage his acute delirium, but the patient continued to be disoriented and agitated, further complicating his respiratory distress.

The patient's worsening condition necessitated transfer to the Intensive Care Unit (ICU) for closer monitoring and advanced interventions. In the ICU, he was intubated and mechanically ventilated to improve his oxygenation and reduce his work of breathing. The team also started him on an insulin infusion to achieve better control of his blood glucose levels. Additionally, the wound cultures from the surgical site returned positive for methicillin-resistant Staphylococcus aureus (MRSA), prompting a change in antibiotic therapy to vancomycin. The healthcare team will continue to monitor the patient closely, looking for any signs of improvement or further deterioration. This complex case requires careful clinical reasoning and vigilant monitoring to ensure the best possible outcome for the patient.

Section 5

New Complications:

Unfortunately, despite the intensive care measures, the patient developed a new complication; acute renal failure as evidenced by a rapid increase in his serum creatinine levels from 1.2 mg/dL to 3.6 mg/dL and a decrease in urine output to less than 400 ml per 24 hours. His blood urea nitrogen (BUN) also rose to 45 mg/dL, and the patient exhibited signs of fluid overload with an increase in weight and bilateral lower extremity edema. His electrolyte levels also suggested a shift towards metabolic acidosis with a blood pH of 7.28, bicarbonate levels of 18 mEq/L, and a pCO2 of 38 mmHg.

The ICU team swiftly initiated continuous renal replacement therapy (CRRT) to manage the patient's acute renal failure and fluid overload. In addition, the team re-evaluated the patient's insulin infusion, taking into account his decreased kidney function and the potential for insulin to accumulate. The patient's fluid and electrolyte imbalances also required careful correction, taking into account his changing renal function. This complicated clinical scenario will require meticulous monitoring and clinical reasoning to stabilize the patient and prevent further complications.