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Surgery Two > 8 - Post-op > Flashcards

8 - Post-op Flashcards

1
Q

Asepcts of ensuring patient safety:

A 
QA/QI
Communication (hand-off, time-out, consents)
Documentation of care 
Reporting complications (M/M)
Patient feedback (surveys)
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2
Q

Retained foreign body

A

2/3 sponges

1/3 instruments

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3
Q

How to prevent retained foreign bodies

A

Increased communication
X-ray and wand prior to leaving OR
Ensure accurate instrument / sponge count
Radiopaque line on sponges

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4
Q

Post-op complications at 0-48 hrs

A

Resp and card issues

  • Failure of ventilation
  • Aspiration
  • Sudden cardiac event
  • HOTN
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5
Q

Post-op complications 48hrs to 30 days

A

Localized - UTI, pneumonia
Systemic - SIRS, MODS (multi-organ sys failure)

PROBABLE TEST QUESTION

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6
Q

What is atelectasis?

A

Collapsed alveoli -> decreased gas exchange -> one of the MC complications of general anesthesia

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7
Q

Causes of atelectasis

A

Pain inhibits cough, deep breath
hypoventilation
Retained secretions
Low tidal volume

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8
Q

Presentation of atelectasis

A

Low-grade fever
Decreased breath sounds
Basilar rales
Seen on CXR

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9
Q

How to prevent atelectasis

A

Stop smoking prior to surgery >2wk

Post-op - incentive spirometry, deep breathing, ambulate, pain management

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10
Q

Txt for atelectasis

A

Chest physiotherapy (percussion, postural drainage)
Naso-tracheal suctioning
Therapeutic bronchoscopy

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11
Q

Presentation of pneumonia

A

Fever
Cough (productive)
Leukocytosis
CXR - infiltrate, consolidation

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12
Q

Txt for pneumonia

A

ABX
Aggressive pulm toilet
Intubation (maintain PCO2 35-45, SpO2 > 95%)

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13
Q

Prevention of VAP

A 
Elevate head of the bed (30-45)
Ventilator liberation trials (daily) - see how they do off 
Don’t over-sedate
PUD/DVT prophylaxis
Aggressive oral hygiene
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14
Q

Causes of aspiration pneumonia

A

Vomiting 2/2 anesthesia, narcs, ileus/obstruction, meals before surgery, obese/pregnant, AMS

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15
Q

Prevention of aspiration pneumonia

A

NPO at least 6 hrs prior to surgery
NG decompression
Cricoid pressure / avoid insufflating the stomach

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16
Q

Management of aspiration pneumonia

A

Suction immediately
Bronchial hygiene
ABX
Mechanical ventilation

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17
Q

Causes of pulmonary edema

A

Volume overload
CHF
Renal failure

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18
Q

Management of pulmonary edema

A 
Close monitoring of fluid status 
Sit up
Diuretics PRN
Consider / rule out PE and MI
Low threshold for intubation/mechanical ventilation
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19
Q

ARDS

A

Non-cardiogenic pulmonary edema
Interstitial - doesn’t respond to diuretics
Not 2/2 HF or fluid overload
Inflammatory process - 3rd-spaced fluid

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20
Q

Txt of ARDS?

A

Mechanical ventilation
Moderate PEEP settings 10-15cm (>15cm high)
Low tidal volumes 5-7ml/kg IBW vs NL 10-15ml/kg IBW
Maintain FiO2 <60% to avoid O2 toxicity
Increase the expiration time (more alveoli open)
Airway pressure release ventilation - full inspirations, little pulsing expirations (possibly works better than prone)

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21
Q

Central lines good for:

A

More caustic meds, ABX, blood
Monitoring hemodynamics (Swan Ganz, Vigeleo)
Easy to draw blood
Easy access

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22
Q

Complications of central line

A

Infection
PTX
Hematoma
Sterile technique critical

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23
Q

Fat emboli associated with:

A 
Long bone / pelvic fx 
Fat globules move into pulmonary capillary bed
Petechial rash
Normal d-dimer
Supportive care 
Don’t forget to r/o PE / MI
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24
Q

Risk factors for PE

A 
Malignancy 
Pregnancy
Immobilization
Nephrotic syndrome
Blood dyscrasia (hypercoagulable)
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25
Presentation of PE
Hypoxia Tachypnea Signs of DVT
26
PE workup
``` Low pulse ox Hypoxemia Hypocarbia D-dimer Cardiac isoenzymes and BNP to r/o MI and CHF ```
27
Imaging for PE workup
CXR limited Spiral CT with PE protocol VQ if pregnant or renal problems Pulmonary angiogram - good but requires a central line
28
Txt for PE:
O2, IV access Anticoag - heparin or SQ LMWH Oral warfarin x 3-6 mos (INR 2-3) Oral Xa inhibitors to replace warfarin Inferior Vena Cava Filter - Christmas ornament
29
Virchow’s triad
Venous stasis Endothelial injury Hypercoagulability
30
Risk factors for DVT
``` Malignancy Elderly Pregnancy OCP use Post-partum Prolonged immobility Surgery stuff ```
31
DVT presentation
Swollen Warm Pitting edema Homan’s sign
32
Txt for DVT
Elastic stockings Early ambulation Compression devices Anticoag - heparin, LMWH, Anti-Xa, warfarin
33
Compartment syndrome
Normally from long bone fx Fascia surrounds muscle Muscle belly inflames or bleeds with intact fascia Pressure causes impaired perfusion -> ischemia -> necrosis
34
S/s of compartment syndrome
Pain out of proportion (early) Loss of function / distal pulses (late)
35
Prevention / treatment of compartment syndrome
Incise from skin through fascia Fasciotomy - allows muscle to swell without compressing vessels
36
Rusk factors for decubitus ulcer
Immobility (sedated, on vent, SCI)
37
Prevention of decubitus ulcer
``` Adequate nutrition Frequent turning Pad pressure points Special beds Daily skin inspections Good skin hygiene ```
38
Parotiditis
Inadequate oral hygiene | Dehydration
39
Epistaxis
Unhumidified O2
40
Ototoxicity
Aminoglycosides | Vancomycin
41
A-fib
Rule out MI and PE first | Check electrolytes and volume status
42
Cardiogenic shock
Decreased forward flow from the heart
43
Neurogenic shock
Loss of neurogenic tone
44
Distributive shock
Loss of vascular tone
45
Ileus complications
Hypovolemia Abd surgery Mitigate with preop Entereg (alvimopan) and minimizing bowel manipulation
46
Mitigate GI bleed risk with:
PPI | H2 blockers
47
Pancreatitis can occur after
ERCP | Biliary surgery
48
C dif is the MCC of:
ABX-associated diarrhea
49
Suspect c diff in pts with:
>3 loose stools in 24 hrs
50
Most c diff pts respond to:
Oral vanc or metronidazole
51
Drastic c diff measures
Fecal transplant Subtotal colectomy
52
Prevention of c diff
Hand washing Judicious use of ABX Contact precautions Avoid gastric acid suppression
53
Pre-renal dehydration / hypovolemia
Can lead to oliguria Consider first in post-operative patient Higher insensible losses
54
Intra-renal oliguria
Consider in pts who received IV contrast, ABX, and diuretics Crush, electrical injuries - myoglobin obstructs glomerulus - push IVF to flush it out - can alkalinize IVF to enhance myoglobin solubility
55
Post-renal oliguria
Prostate hypertrophy - restart alpha blockers in pts with BPH Obstructed bladder catheter DOPE the catheter - Displaced-Obstructed-Positional-Equipment failure Neurogenic bladder - DM, narcs, antihistamines / cold medicine
56
MC complication of bladder catheterization
UTI
57
Minimize catheter UTI by:
Using sterile technique Removing ASAP when no longer needed
58
Hernia repair can impact which nerve
Ilio-inguinal Leads to skin numbness
59
Mastectomy can impact which nerve
Long thoracic nerve Leads to winged scapula
60
Thyroid / parathyroid surg can impact which nerve
Recurrent laryngeal Leads to hoarseness
61
Carotid endarterectomy can impact which nerve
Hypoglossal nerve Leads to deviated tongue
62
DIC
Initially prothrombotic condition which results in multi-vascular thrombi and MODS • Progresses to consumption of all coagulation proteins and results in severe bleeding
63
Transfusion related complications
Hypocalcemia- serum Ca binds to the citrate in banked blood • Transfusion reaction • TRALI- Transfusion Ralated Acute Lung Injury • Metabolic acidosis- hyperkalemia of banked blood 2/2 hemolysis • Hypothermia during transfusion
64
Hypothermia leads to decrease in
SpO2 Oxy-hemoglobin dissociation curve Lethal triad - metabolic acidosis, coagulopathy, hypothermia
65
Abdominal compartment syndrome
Usually after long abdominal case with manipulation or trauma which required massive fluid resuscitation
66
Ways to mitigate abdominal compartment syndrome
Abdomen not closed and converted to wound vac Allows for tissue expansion to minimize tissue ischemia and dehiscence
67
Wound complications
Hematoma / seroma: small - resolve on their own....larger - aspirate or open to decompress
68
Salmon colored fluid?
Early fascial dehiscence It’s peritoneal fluid
69
Late fascial dehiscence leads to
Incisional hernia
70
If surgical site infection
Open, irrigate, pack Avoid temptation to reclose
71
MC nosocomial infection is:
A surgical site infection Test question! Other causes: c. diff, catheter UTI, central line infx, VAP
72
Fever workup
H and P Atelectasis, pneumonia UTI SSI Cultures CXR Inspect IV sites DC invasive stuff you don’t need
73
Keeping your patient alive
Round on the sickest patients first If the nurse calls: see the patient, note GCS, assess ABC’s, always consider MI and PE Anaphylaxis? Epi, diphenhydramine, solumedrol Keep in touch with senior resident
74
SIRS criteria
Temp Tachycardia Tachypnea Leukocytosis
75
There are 2 kinds of Subaru owners
Pre-op and post-op

Surgery Two (9 decks)

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