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**1.Anesthesia and Surgery > 5.Perioperative Management > Flashcards

5.Perioperative Management Flashcards

1
Q

Common preoperative testing

A
  • BMP 6
  • CBC
  • UA
  • PT/PTT
  • EKG
  • Pregnancy test
  • CXR
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2
Q

When to discontinue:

Aspirin and Smoking

A

1 week prior to surgery

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3
Q

NPO status: timing

A

Adults: NPO after midnight, or minimum of 6 hours prior to sx

Pediatrics: can have clear liquids up to 4 hours before sx

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4
Q

CBC:

purpose

A

Should be used for patients with:

  • recent Hx of blood loss
  • Hx of fatigue
  • Dyspnea on exertion
  • Liver disease
  • Signs of coagulopathy
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5
Q

UA:

purpose

A
  • Used to R/O:
    • infection
    • renal dz (proteinuria)
    • diabetes
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6
Q

Coag Studies:

purpose

A

Important if patient is on blood thinners

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7
Q

EKG

purpose

A
  • Useful for identifying:
    • recent MIs
    • frequent premature ventricular contractures (PVCs)
  • *POOR indicator of ischemic heart disease
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8
Q

CXR:

pre-op indication

A

Recommended for patients with:

  • positive history of lung or heart disease
  • smokers
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9
Q

Antibiotics Prophylaxis:

timing & indications

A
  • IV 30 min prior to sx
  • Indications
    • surgery on dirty wounds
    • preexisting valvular heart disease
    • surgery lasting >2 hours
    • blood transfusion
    • preexisting infection
    • implants
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10
Q

Cefazolin (Ancef):

antibiotic prophylaxis

A

wound infxn (good Staph/Strep coverage)

  • first-generation cephalosporin
  • use: prophylaxis against wound infections during surgery.
    • good coverage against Staph aureus and Strep
  • appropriate long half-life
  • Dosage is 1 to 2 g IV pre-op
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11
Q

Vancomycin:

antibiotic prophylaxis

A

PCN-allergic pts, Implant surgery (S. Epidermidis)

  • use: prophylaxis against wound infections during surgery in penicillin-allergic patients
  • implant surgery → it covers Staphylococcus epidermis (common pathogen in implant surgery)
  • Dosage is 1 g IV
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12
Q

Amoxicillin:

Abx prophylaxis

A

bacterial endocarditis

  • Dosage is either:
    • 3 g PO before and 1.5 g PO 6 hours after, or
    • 2 g IV 30 minutes before and 1 g IV 6 hours after
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13
Q

Erythromycin:

Abx prophylaxis

A

bacterial endocarditis in penicillin-allergic patients.

  • Dosage depends on the preparation.
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14
Q

Clindamycin:

Abx prophylaxis

A

bacterial endocarditis in PCN-allergic patients.

  • Dosage:
    • 300 mg PO before and 150 mg PO 6 hours after, or
    • 300 mg IV 30 minutes before and 150 mg IV 6 hours after
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15
Q

Pregnancy tests and surgery

A
  • Test all female patients of childbearing age.
  • All elective surgery should be postponed on pregnant women.
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16
Q

Pituitary–Adrenal Suppression

A
  • Pts w/ +7.5 mg QD of corticosteroids should be tested for endogenous cortisol suppression
    • Low plasma concentrations of cortisol and ACTH indicate suppression
  • Up to 1 year for adrenal-pituitary negative feedback to recover
  • Pts on steroids often require increased dosing peri- and post-operatively
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17
Q

Steroids and Wound Healing

A
  • Steroids delay the wound healing process.
  • Topical Vitamin A may counteract this
    • Usual dose is 1,000 U applied TID to the open wound bed for 7 to 10 days.
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18
Q

Tourniquet

standard techniques

A
  • Inflate tourniquet 100 to 120 mm Hg above systolic BP
  • Maximum tourniquet pressure for the:
    • ankle: 250 mmHg
    • thigh: 500 mm Hg
  • Tourniquet must be deflated after 2 hours for at least 15–20 minutes before reinflating
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19
Q

Diabetic Patient:

perioperative management

A
  • given early morning surgical preference
  • glucose control (attached)
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20
Q

Is it preferable for DM patients to be hyper- or hypoglycemic during surgery?

A

Hypoglycemia is a more hazardous condition than hyperglycemia “better sweet than sour.”

  • Hyperglycemia (greater than 200 mg per dL) impairs wound healing
  • Hypoglycemia can cause organic brain damage and death
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21
Q

Anticoagulants:

preop

A
  • D/C 3 - 6 days prior to surgery
  • Resume 24 hours post-op
  • If can’t stop, stop Coumadin 3 days prior → start LMWH drip → D/C LMWH drip 2-4 hours prior to sx
22
Q

Rheumatoid Patient:

preop

A
  • cervical spine x-ray
    • predisposed to atlas/axis dislocation
  • prone to infection
    • immunosuppressive medications
23
Q

Sickle Cell Patients

pathology

A
  • recall: AA #6 changes from Glutamic Acid → Valine
    • deoxygenation → HgS aggregates into long strands (“sickle shape”)
    • can’t deform in shape to fit through small capillaries → clogging capillaries → ischemic
  • Anemia from spleen destroying all abnormal RBCs → splenomegaly
24
Q

Sickle Cell Patients:

Diagnosis

A
  • Hemoglobin electrophoresis shows hemoglobin S.
  • Peripheral smear will show the characteristic sickle cells
25
Q

Sickle Cell Patients:

Signs/Symptoms

A
  • Long bone pain (e.g., pretibial) and hand and foot pain
  • Arthritis with fever
  • Avascular necrosis of the femoral head
  • Chronic punched out lesions around the ankles
  • Abdominal pain with vomiting
26
Q

Sickle Cell Patients:

Associated Crises

A

Aplastic crisis: During acute infections (especially viral), production of marrow RBCs slows.

Painful crises: Episodes of severe abdominal pain with vomiting that are usually associated with back and joint pain

27
Q

Sickle Cell Patients:

preop considerations

A
  • prone to hypoxia
    • due to the decreased oxygen-carrying capacity of the hemoglobin.
  • Local anesthesia is preferred
  • Avoid tourniquet
  • With general anesthesia, extra precaution must be taken to avoid volume depletion and hypoxia.
  • Increased postoperative complications
    • A high index of suspicion should be maintained for sepsis postoperatively.
    • Salmonella is MC organism isolated from sickle cell patients who develop OM
28
Q

Cardiac Patients:

Top factors leading to post-op cardiac complications

A
  1. CHF - S3 gallop, or JVD (jugular venous distention)
  2. Rhythm - PACs, or >5 PVCs/min
  3. Age - >70 y/o
  4. Coronary dz - MI w/in past 6 months
  • PAC: premature atrial contractions*
  • PVC: premature ventricular contractions*
29
Q

Endocarditis prophylaxis:

indications

A
  • valvular heart disease
  • rheumatic murmur
  • prosthetic valves
30
Q

How long to postpone elective surgery after MI?

A

At least 6 months

31
Q

Endocarditis Prophylaxis:

DOC

A

IV PCN or 1st-generation cephalosporin (Ancef)

If PCN-allergic, Clindamycin 300 mg pre-op and 150 mg post-op.

32
Q

HTN and risk of MI/Stroke

A

HTN (diastolic pressure = 110) increases the chances of intraoperative and postoperative MI or stroke

33
Q

Consideration for patients on diuretics?

A

Check K+ levels

34
Q

Which CV meds to hold morning of surgery?

A
  • Diuretics
  • ACEi and ARBs
35
Q

Post-Op Complications

A
  • Fever (5 W’s)
  • Ischemic toe: Blue, White, DVT
  • Post-op infxn
  • Pain
  • Hematoma
36
Q

Intra-operative causes of fever

A
  • Transfusion reaction
  • Malignant hyperthermia
  • Preexisting sepsis
37
Q

0-6 Hours Post-op Fever:

causes

A
  • Pain
  • Rebound from cold operating room
  • Anesthesia reaction
  • Endocrine cause (thyroid crisis, adrenal insufficiency)
38
Q

24-48 Hours Post-op Fever:

causes

A
  • Atelectasis
  • Aspiration pneumonia (after general)
  • Dehydration
  • Constipation
39
Q

+72 Hours Post-op Fever:

causes

A
  • Infection (3 to 7 days)
  • DVT
  • Thrombophlebitis from IV
  • UTI (especially if catheterized)
  • Drug allergy
40
Q

5 W’s:

post-op fever

A
  • Wind: Atelectasis, aspiration pneumonia, PE
  • Wound: Infection, thrombophlebitis (IV site), pain
  • Water: UTI, dehydration, constipation
  • Walking: DVT
  • Wonder drugs: Virtually any drug can cause fever (patient appears less ill than fever suggests)
41
Q

White Toe (Arterial Problem)

management

A
  • Place foot in dependent position.
  • Apply heat to small of back.
  • PT block.
  • Loosen bandages.
  • Twist the K-wire.
  • Remove K-wire.
  • Remove dressing, consider opening wound.

*Bold ones can only be used for arterial problems

42
Q

Blue Toe (Venous Problem)

management

A
  • Elevate foot.
  • Loosen bandage.
  • Twist K-wire.
  • Remove K-wire.
  • Remove dressing, consider opening wound.
43
Q

DVT:

risk factors

A

Surgical patients have additional risk factors for DVTs.

  • Bed rest
  • Tourniquet
  • Surgical trauma
  • Infection
  • Dehydration (due to NPO status)
  • Change in medication (i.e., d/c ASA)
44
Q

Post-op infxn:

timing and sxs

A

timing: 3-7 days post-op (group A strep can occur earlier

sxs:

  • Increased throbbing pain
  • Edema
  • Drainage
  • Dehydration
  • Erythema
  • Fever

If systemic sxs (fever/chills) → admit to hospital

45
Q

Post-op Infxn:

risk factors

A
  • Surgery longer than 2 hours
  • Blood transfusion
  • Preexisting infection
  • Implants
46
Q

Post-Op Pain:

causes if unresponsive to narcotic analgesics

A
  • Infection
  • Hematoma
  • Dressing pressure
47
Q

Causes of severe post-op pain w/in 48 hours of sx

A
  • Sutures too tight
  • Dressing too tight
  • Hematoma
  • Edema (foot in dependent position)
  • Vasospasm (from K-wire)
  • Compartment syndrome
48
Q

Hematoma

definition

A
  • collection of blood within a closed tissue space
  • can lead to infection and may result in long-term swelling and disability
  • often mimics an infection with intense pain and inflammation, but occurs sooner than infection
    • (occurs w/in 24 hours after surgery).
49
Q

Hematoma

etiology

A
  • Traumatic surgical dissection
  • Poor hemostasis
  • Creating a dead space and not using a drain
  • Exposed cancellous bone
  • Anticoagulants
  • Hypertension
  • Improper bandaging
50
Q

Sequelae of Untreated Hematoma

A

A hematoma that has walled itself off from surrounding tissue from pressure will ultimately clot and undergo fibroplasia into a dense scar.

A hematoma that is more diffusely located within the tissue will tend to resorb itself.

51
Q

Hematoma:

treatment

A

EARLY (before all the hematoma has clotted)

  • Extravasation: Pop a stitch or two, and squeeze out the fluid.
  • Aspiration: Aspirate the hematoma using a large-bore needle.
  • Steroid injection: Decrease inflammation and pain, and interfere with fibroplasia and clotting.
  • Wound Reentry: The patient is taken back to the OR and the wound is reopened, drained, and irrigated, ligate bleeders, and insert a drain.

LATE

  • Gentle heat: In an attempt to accelerate enzymatic degradation of the hematoma.
  • Physical therapy: Exercise, ROM, massage, and ultrasound. All serve to break up the hematoma and encourage resorption.

**1.Anesthesia and Surgery (7 decks)

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