5.Perioperative Management Flashcards
1
Q
Common preoperative testing
A
- BMP 6
- CBC
- UA
- PT/PTT
- EKG
- Pregnancy test
- CXR
2
Q
When to discontinue:
Aspirin and Smoking
A
1 week prior to surgery
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
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
5
Q
UA:
purpose
A
- Used to R/O:
- infection
- renal dz (proteinuria)
- diabetes
6
Q
Coag Studies:
purpose
A
Important if patient is on blood thinners
7
Q
EKG
purpose
A
- Useful for identifying:
- recent MIs
- frequent premature ventricular contractures (PVCs)
- *POOR indicator of ischemic heart disease
8
Q
CXR:
pre-op indication
A
Recommended for patients with:
- positive history of lung or heart disease
- smokers
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
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
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
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
13
Q
Erythromycin:
Abx prophylaxis
A
bacterial endocarditis in penicillin-allergic patients.
- Dosage depends on the preparation.
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
15
Q
Pregnancy tests and surgery
A
- Test all female patients of childbearing age.
- All elective surgery should be postponed on pregnant women.
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
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.
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
19
Q
Diabetic Patient:
perioperative management
A
- given early morning surgical preference
- glucose control (attached)
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
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
Sickle Cell Patients:
Signs/Symptoms
* 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
Sickle Cell Patients:
Associated Crises
**_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
Sickle Cell Patients:
preop considerations
* **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
Cardiac Patients:
Top factors leading to post-op cardiac complications
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
Endocarditis prophylaxis:
indications
* valvular heart disease
* rheumatic murmur
* prosthetic valves
30
How long to postpone elective surgery after MI?
At least **6 months**
31
Endocarditis Prophylaxis:
DOC
**IV PCN** or 1st-generation cephalosporin (**Ancef**)
## Footnote
If PCN-allergic, **Clindamycin** 300 mg pre-op and 150 mg post-op.
32
HTN and risk of MI/Stroke
HTN (diastolic pressure = 110) **increases** the chances of intraoperative and postoperative **MI or stroke**
33
Consideration for patients on **diuretics**?
Check K+ levels
34
Which CV meds to **hold morning of surgery**?
* Diuretics
* ACEi and ARBs
35
Post-Op Complications
* *Fever (5 W’s)*
* *Ischemic toe: Blue, White, DVT*
* *Post-op infxn*
* *Pain*
* *Hematoma*
36
**Intra-operative** causes of fever
* Transfusion reaction
* Malignant hyperthermia
* Preexisting sepsis
37
**0-6 Hours Post-op** Fever:
causes
* Pain
* Rebound from cold operating room
* Anesthesia reaction
* Endocrine cause (thyroid crisis, adrenal insufficiency)
38
**24-48 Hours Post-op** Fever:
causes
* Atelectasis
* Aspiration pneumonia (after general)
* Dehydration
* Constipation
39
**+72 Hours Post-op** Fever:
causes
* Infection (3 to 7 days)
* DVT
* Thrombophlebitis from IV
* UTI (especially if catheterized)
* Drug allergy
40
5 W's:
post-op fever
* ***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
White Toe (Arterial Problem)
management
* **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
Blue Toe (Venous Problem)
management
* Elevate foot.
* Loosen bandage.
* Twist K-wire.
* Remove K-wire.
* Remove dressing, consider opening wound.
43
DVT:
risk factors
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
Post-op infxn:
timing and sxs
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
Post-op Infxn:
risk factors
* Surgery longer than 2 hours
* Blood transfusion
* Preexisting infection
* Implants
46
Post-Op Pain:
causes if **unresponsive to narcotic analgesics**
* Infection
* Hematoma
* Dressing pressure
47
Causes of **severe post-op pain w/in 48 hours** of sx
* Sutures too tight
* Dressing too tight
* Hematoma
* Edema (foot in dependent position)
* Vasospasm (from K-wire)
* Compartment syndrome
48
Hematoma
definition
* **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
Hematoma
etiology
* **Traumatic surgical dissectio**n
* **Poor hemostasis**
* Creating a **dead space and not using a drain**
* Exposed cancellous bone
* Anticoagulants
* Hypertension
* Improper bandaging
50
Sequelae of Untreated Hematoma
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
Hematoma:
treatment
**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.*
