Pre-Op and Post-Op Care

Question 1

Ejection fraction under __% poses prohibitive cardiac risk for noncardiac operations.

Answer 1

35% (normal is 55%)

Question 2

What is the worst single finding predicting high cardiac risk in surgery?

Answer 2

Goldman’s index of cardiac risk attributes the highest amount of points to:
jugular venous distention (evidence of CHF; 11 points)
If possible, treat with ACEI, BB, digitalis, and diuretics before surgery

Question 3

What factors play into Goldman’s index of cardiac risk:

Answer 3

jugular venous distention (CHF=worst predictor), recent MI (within 6 months=next worse predictor), PVCs (5 or more per minute), non-sinus rhythm, age over 70, emergency surgery, aortic valvular stenosis/poor medical condition/surgery within chest or abdomen

Question 4

What is the most common cause of increased pulmonary risk for surgery?

Answer 4

smoking

Question 5

Cessation of smoking for ___ weeks and intensive respiratory therapy (physical therapy, expectorants, incentive spirometry, humidified air) should precede surgery

Answer 5

8 weeks

Question 6

About 40% mortality is predictable with either bilirubin above ___, albumin below ___, prothrombin time above ___, or encephalopathy. 80-85% mortality if three or more exist, or with bilirubin alone above ___, albumin alone below ___, or blood ammonia above ____

Answer 6

40%:
bilirubin >2, albumin 16

80-85%:
bilirubin >4, albumin 150 mg/dL

Question 7

Severe nutritional depletion is identified by loss of 20% body weight over a couple of months, serum albumin below ___, anergy to skin antigens, or serum transferrin less than ___.

Requires >5 days of preoperative nutritional support

Answer 7

albumin

Question 8

Malignant hyperthermia develops shortly after onset of an anesthetic like

Answer 8

halothane or succinylcholine

Question 9

Chills and temperature spike exceeding 104F 30-45 minutes into invasive procedure (such as instrumentation of the urinary tract) =

Answer 9

bacteremia. Blood cx x3 and empiric antibiotics

Question 10

What are causes of postoperative fever (101-103F)?

Answer 10

1) wind (atelectasis, pneumonia)
2) water (UTI)
3) walking/weins (PE, deep venous thrombophlebitis)
4) wound infection, deep abcesses
5) wonder drugs (drug fever)

Question 11

What is the treatment of atelectasis?

Answer 11

Improve ventilation! (deep breathing, postural drainage, incentive spirometry)

Question 12

Which cause of post-op fever occurs on:
POD 1?
POD 3?
POD 5?
POD 7?

Answer 12

POD 1: atelectasis
POD 3: PNA, UTI
POD 5: deep vein thrombophlebitis
POD 7: wound infection, PE
POD 10-15: deep abscesses

Question 13

Treatment of deep venous thrombophlebitis?

Answer 13

Anticoagulate with heparin with antibiotics

Question 14

How can you distinguish between whether there is cellulitis or an abscess in a wound infection?

Answer 14

sonogram

Question 15

What is the treatment of perioperative MI?

Answer 15

Emergency angioplasty and coronary stent; not clot busters!!!!

Question 16

What is prevention of aspiration in intubations?

Answer 16

NPO and antacids before induction

Question 17

What is the treatment of aspiration?

Answer 17

Lavage and removal of acid and particulate matter with help of bronchoscopy, followed by bronchodilators and respiratory support (steroids don’t help)

Question 18

Patients withdrawing from alcohol get confused, have hallucinations, and become combatative around which POD?

Answer 18

2-3. Treat with IV benzo

Question 19

In the case of zero urinary output, what do you do?

Answer 19

Usually a mechanical problem! Look for plugged or kinked catheter

Question 20

Paralytic ileus is prolonged by which electrolyte abnormality?

Answer 20

Hypokalemia

Question 21

What was probably assumed to be paralytic ileus not resolving after 5-7 days is most likely actually due to

Answer 21

early mechanical bowel obstruction because of adhesions

Question 22

Diagnosis of mechanical bowel obstruction with adhesions is confirmed with an abdominal CT scan showing:

What is the treatment?

Answer 22

a transition point between proximal dilated bowel and distal collapsed bowel at the site of the obstruction; surgical intervention is needed to correct the problem

Question 23

T/F: Ogilivie syndrome does not follow abdominal surgery.

Answer 23

True! Instead, it is classically seen in sedentary patients (Alzheimer, nursing home) who have become further immobilized owing to surgery elsewhere (broken hip, prostatic surgery).

Question 24

T/F: Patients with Ogilivie syndrome have a tense, but not tender, abdomen.

Answer 24

True

Question 25

What is the management of Ogilivie syndrome?

Answer 25

1) fluid and electrolyte correction
2) r/o mechanical obstruction (radiologically or by endoscopy)
3) IV neostigmine to restore colonic motility; long rectal tube is also commonly used

Question 26

What is the difference between ehiscence and evisceration?

Answer 26

Dehiscence = large amounts of pink salmon-colored fluid leave wound (peritoneal fluid); no need for emergency surgery, but reoperation will be needed to avoid or treat ventral hernia

Evisceration: skin opens up and abdominal contents rush out (not just fluid). Bowel must be covered with large sterile dressings soaked in NS; emergency abdominal closure is required

Question 27

Fistulas where in the GI tract are more dangerous: distal or proximal?

Answer 27

proximal

Question 28

Nature will close a fistula as long as there isn’t _________ to prevent it.

Answer 28

FRIENDS!

foreign body, radiation, inflammation/IBD/infection, epithelization of the tract, neoplasm, distal obstruction, steroids

Question 29

Every 3 mEq/L that serum sodium concentration is above 140 represents roughly ___ mL of water lost.

Answer 29

1000 mL! = 1 L

Question 30

Therapy for slow-developing hypernatremia requires fluid repletion with which fluid? Fast-developing hypernatremia can be corrected with…

Answer 30

slow: D5 1/2NS (rather than D5W)
acute: D5 1/3 NS or even D5W

Question 31

The safe “speed limit” of IV potassium administration is ___ mEq/h

Answer 31

10

Question 32

What provides the “quickest protection” against hyperkalemia?

Answer 32

calcium gluconate

Question 33

What is the treatment of metabolic alkalosis?

Answer 33

Abundant intake of potassium chloride will allow kidney to correct hte problem