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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
Q

Presentation of PE

A

Hypoxia
Tachypnea
Signs of DVT

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26
Q

PE workup

A 
Low pulse ox
Hypoxemia
Hypocarbia
D-dimer
Cardiac isoenzymes and BNP to r/o MI and CHF
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27
Q

Imaging for PE workup

A

CXR limited
Spiral CT with PE protocol
VQ if pregnant or renal problems
Pulmonary angiogram - good but requires a central line

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28
Q

Txt for PE:

A

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

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29
Q

Virchow’s triad

A

Venous stasis
Endothelial injury
Hypercoagulability

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30
Q

Risk factors for DVT

A 
Malignancy
Elderly
Pregnancy
OCP use
Post-partum
Prolonged immobility
Surgery stuff
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31
Q

DVT presentation

A

Swollen
Warm
Pitting edema
Homan’s sign

32
Q

Txt for DVT

A

Elastic stockings
Early ambulation
Compression devices
Anticoag - heparin, LMWH, Anti-Xa, warfarin

33
Q

Compartment syndrome

A

Normally from long bone fx

Fascia surrounds muscle

Muscle belly inflames or bleeds with intact fascia

Pressure causes impaired perfusion -> ischemia -> necrosis

34
Q

S/s of compartment syndrome

A

Pain out of proportion (early)

Loss of function / distal pulses (late)

35
Q

Prevention / treatment of compartment syndrome

A

Incise from skin through fascia

Fasciotomy - allows muscle to swell without compressing vessels

36
Q

Rusk factors for decubitus ulcer

A

Immobility (sedated, on vent, SCI)

37
Q

Prevention of decubitus ulcer

A 
Adequate nutrition 
Frequent turning
Pad pressure points 
Special beds
Daily skin inspections
Good skin hygiene
38
Q

Parotiditis

A

Inadequate oral hygiene

Dehydration

39
Q

Epistaxis

A

Unhumidified O2

40
Q

Ototoxicity

A

Aminoglycosides

Vancomycin

41
Q

A-fib

A

Rule out MI and PE first

Check electrolytes and volume status

42
Q

Cardiogenic shock

A

Decreased forward flow from the heart

43
Q

Neurogenic shock

A

Loss of neurogenic tone

44
Q

Distributive shock

A

Loss of vascular tone

45
Q

Ileus complications

A

Hypovolemia
Abd surgery

Mitigate with preop Entereg (alvimopan) and minimizing bowel manipulation

46
Q

Mitigate GI bleed risk with:

A

PPI

H2 blockers

47
Q

Pancreatitis can occur after

A

ERCP

Biliary surgery

48
Q

C dif is the MCC of:

A

ABX-associated diarrhea

49
Q

Suspect c diff in pts with:

A

> 3 loose stools in 24 hrs

50
Q

Most c diff pts respond to:

A

Oral vanc or metronidazole

51
Q

Drastic c diff measures

A

Fecal transplant

Subtotal colectomy

52
Q

Prevention of c diff

A

Hand washing
Judicious use of ABX
Contact precautions
Avoid gastric acid suppression

53
Q

Pre-renal dehydration / hypovolemia

A

Can lead to oliguria

Consider first in post-operative patient

Higher insensible losses

54
Q

Intra-renal oliguria

A

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
Q

Post-renal oliguria

A

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
Q

MC complication of bladder catheterization

A

UTI

57
Q

Minimize catheter UTI by:

A

Using sterile technique

Removing ASAP when no longer needed

58
Q

Hernia repair can impact which nerve

A

Ilio-inguinal

Leads to skin numbness

59
Q

Mastectomy can impact which nerve

A

Long thoracic nerve

Leads to winged scapula

60
Q

Thyroid / parathyroid surg can impact which nerve

A

Recurrent laryngeal

Leads to hoarseness

61
Q

Carotid endarterectomy can impact which nerve

A

Hypoglossal nerve

Leads to deviated tongue

62
Q

DIC

A

Initially prothrombotic condition which results in multi-vascular thrombi and MODS
• Progresses to consumption of all coagulation proteins and results in severe bleeding

63
Q

Transfusion related complications

A

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
Q

Hypothermia leads to decrease in

A

SpO2

Oxy-hemoglobin dissociation curve

Lethal triad - metabolic acidosis, coagulopathy, hypothermia

65
Q

Abdominal compartment syndrome

A

Usually after long abdominal case with
manipulation or trauma which required massive
fluid resuscitation

66
Q

Ways to mitigate abdominal compartment syndrome

A

Abdomen not closed and converted to wound vac

Allows for tissue expansion to minimize tissue ischemia and dehiscence

67
Q

Wound complications

A

Hematoma / seroma: small - resolve on their own….larger - aspirate or open to decompress

68
Q

Salmon colored fluid?

A

Early fascial dehiscence

It’s peritoneal fluid

69
Q

Late fascial dehiscence leads to

A

Incisional hernia

70
Q

If surgical site infection

A

Open, irrigate, pack

Avoid temptation to reclose

71
Q

MC nosocomial infection is:

A

A surgical site infection

Test question!

Other causes: c. diff, catheter UTI, central line infx, VAP

72
Q

Fever workup

A

H and P
Atelectasis, pneumonia
UTI
SSI

Cultures

CXR

Inspect IV sites

DC invasive stuff you don’t need

73
Q

Keeping your patient alive

A

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
Q

SIRS criteria

A

Temp
Tachycardia
Tachypnea
Leukocytosis

75
Q

There are 2 kinds of Subaru owners

A

Pre-op and post-op

Surgery Two (9 decks)

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