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Surgery > Approach to a surgical patient > Flashcards

Approach to a surgical patient Flashcards

1
Q

What can you use to practice suturing?

A

Chicken breast or pigs feet

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2
Q

What are the three phases of surgical management?

A
  1. Pre op
  2. operative
  3. post op
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3
Q

What makes up preop care?

A

H&P
Diagnostic work up
Pre op prep including education

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4
Q

What is the goal of general health assessment

A

identify risk factors
identifies conditions that should be treated before surgery

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5
Q

MC presenting symptom for general surgery

A

Pain / Claudication
N/V/hematemesis
Change in bowel habits / blood in stool
Lump or mass
Injury / Trauma
Numbness / Weakness

Pain
Vomiting
Change in Bowel Habits
Hematemesis or Hematochezia
Trauma

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6
Q

What type of surgery is smoking often CI in?

A

Plastic
no smoking for 8+ weeks
Need to draw a nicotine level often

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7
Q

What can lead to malignant hyperthermia

A

inhaled anesthesia gases
familial inherited

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8
Q

What does a PE depend on?

A

Whether it is elective or emergent

Emergent = more focused

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9
Q

What PE do you always do prior to surgery?

A

Airway assessment
Heart
Lungs
Abdomen

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10
Q

What is obturator and psoas used for?

A

Any inflammation of the peritoneum
peritonitis

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11
Q

Pulsatile abdominal mass is

A

AAA until proven otherwise!!!

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12
Q

What completes an abdominal exam unfortunately

A

A rectal exam

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13
Q

What are the three different ways that the breast is assessed

A
  1. Sitting or standing with both arms down
  2. Sitting or standing with both arms up
  3. Laying flat on back with arm overhead
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14
Q

MC area of cancer for breast?

A

Left upper outer quadrant

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15
Q

Why is it important to evaluate extremities in preop surgical candidates

A

CYA medicine
Also to make sure they are candidates and get overall health

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16
Q

What ABI do you need to refer to vascular specialist prior to surgery?

A

Moderate or worse (=<0.8)

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17
Q

What are the 4 reasons you do preop testing?

A
  1. Screening for asymptomatic disease that may affect the surgical result (eg, unsuspected anemia or diabetes)
  2. Appraisal of diseases that may contraindicate elective surgery or require treatment before surgery (eg, diabetes or heart failure)
  3. Diagnosis of disorders that require surgery (eg, hyperparathyroidism or pheochromocytoma)
  4. Evaluation of the nature and extent of metabolic or septic complications
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18
Q

What does INR need to be for elective surgery?

A

<1.5

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19
Q

When do you get a CXR before surgery?

A

Old
>50
AAA
Abdominal/thoracic surgery

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20
Q

How long are labs useful for prior to surgery?

A

4 months

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21
Q

What labs/diagnostic work-up is needed?

An otherwise healthy child undergoing Adenoidectomy?

A

no labs/imaging

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22
Q

An otherwise healthy 30 y/o female undergoing a lap chole?

A

BHCG (preggo)

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23
Q

A 30 y/o female with a history of diabetes and a recent DVT requiring Coumadin use undergoing a lap chole?

A

PT/INR
BHCG

24
Q

A 56 y/o male who denies any medical conditions and “never has to go to the doctor” undergoing AAA repair?

A

Everything lol

EKG
LAB work

25
Q

What is physiological age determined

A

1 MET: basic ADLs, eat, dress, go to bathroom
4 METs: can walk up small incline, single flight of stairs, walks at 3-4mph on level ground
5-10 METs: heavy house work, scrubbing floors, climbing stairs
>10 METs: participates in sports, swimming, skiing

older patients can still have a higher METs score!!

26
Q

What questions do you ask for nutritional assessment?

A

Question about weight loss
Question about diet and eating habits
Labwork: CBC with diff, serum albumin/prealbumin, vitamin B12

27
Q

What weight loss is of greatest risk for poor surgical outcomes?

A

> 10% from baseline

28
Q

If you have poor immune system, what precautions need to be taken?

A

Antiseptic (although all patients get this) + wound care (d/t delayed wound healing)

29
Q

What hemostasis assessment is used for surgery

A

Ask nose bleed frequency
easy bruising
excessive bleeding w/ previous surgery
family history of bleeding
drug history (ASA, NSAIDS, clopidegrel, warfarin, pradaxa, xarelto)

Can screen with: PT/INR PTT and CBC if suspect hemostasis issues

30
Q

Thromboembolism assessment RF

A

DVT
A fib
OCP
Smokers
Sedentary lifestyle
Clotting disorders

31
Q

Pulmonary function assessment RF

A

smoking
SOB/DOE
COPD
asthma
sleep apnea

PE findings: wheezing, rhonchi, crackles, prolonged expiration, ,ow O2 sat, obesity, advanced age

PFTs
CXR
ECG
ABG for poor controlled COPD
COPD/asthma not at baseline

32
Q

What is the questionnaire for sleep apnea?

A

STOP-Bang

can bring CPAP to surgery to decrease risk of pulm complications

33
Q

What is the ARISCAT calculator

A

Used to determine risk of POSToperative pulmonary complications

low to high risk

34
Q

Preoperative Preparation for compromised pulmonary function:

A

Abstinence from/quit smoking (ideally 8 weeks before procedure)
Optimize chronic issues
Bronchodilators (Inhalers, Nebulizers prior to surgery)
Chest physiotherapy (percussion, vibration, postural drainage)
Pre-op/post-op supplemental O2

Preoperative treatment with high flow oxygen therapy can significantly decrease incidence of surgical site infections!

35
Q

What does everyone before surgery get for their airway?

A

Babies to elders

ALL patients are given O2 before surgery to decrease the risk of surgical site infections

36
Q

What are common Postoperative Pulmonary Complications?

A

Atelectasis
Hypoxia
Pneumonia
Respiratory Failure
PE

37
Q

major predictors of CV risks

A

Recent MI (within 6 months)
Unstable angina
Recent PCI
Active CHF
V. Tach, AV Blocks

38
Q

minor predictors of CV risk

A

A. fib
Age > 70
Abnormal EKG findings
LVH, LBBB
Poorly controlled HTN

39
Q

What calculator allows risk stratification for survival of surgery?

A

NSQIP

40
Q

What does a cardiovascular risk assessment do?

A

Evaluates whether or not you need a cardiac consult

No cardiac symptoms, OR mild cardiac symptoms with good functional capacity undergoing low risk surgery - NO WORK UP NEEDED

Low risk patients (one or more minor predictors) - ECG

Intermediate risk patients (one or two intermediate predictors) and/or intermediate risk surgery – ECG, pertinent labs

High risk patients (those with 3 or more intermediate predictors) or those undergoing high risk surgery - ECG, labs, ECHO, cardiac consult

Very High risk patients (those with one or more Major predictors) - cardiac consult - surgery postponed until condition can be stabilized (unless emergency)

41
Q

What is used to assess patient prior to anesthesia?

A

PreAnesthesia Testing (PAT) or PreAnesthesia Care (PAC)

Allows you to see what risk of surgery the patient has

42
Q

What are the 6 ASA classification?

A

1-6

6 = brain dead (organ harvesting)

43
Q

How does anesthesia do an airway assessment

A

Neck ROM
Neck circumference
Mouth opening/jaw protrusion
Dentition
Mallampati Classification
oropharyngeal assessment used
to predict ease of intubation

44
Q

Mallampati Classifications

A

1-4 visualization

1 = soft palate + uvula
2 = uvula
3 = only base of uvula
4 = no visualization

45
Q

Why should you not chew gum prior to surgery?

A

Increases gastric motility leading to higher likelihood of aspiration

46
Q

What meds can you continue for the day of surgery?

A

Cardiovascular Medications - Beta Blockers, ACE, CCB, Nitrates, Clonidine, antiarrhythmics, digoxin
Anticonvulsants - Phenytoin, Tegretol
Anti-Parkinsons Drugs - Sinemet
Lithium
Asthma/COPD Medications - singulair, theophylline, inhalers
Thyroid Medications - Synthroid
OCP’s
BPH Medications - Terazosin
GERD Medications - Prilosec, Prevacid, Zantac (do not wanna increase risk of aspiration)

essential drugs should not be discontinued

47
Q

What meds can you take the day BEFORE surgery

A

Cholesterol lowering medications - Statins
Diuretics - Lasix, HCTZ
Antidepressants - SSRI’s, TCA’s
Antianxiety Medications - Benzodiazepines
Insulins - adjustments made to evening doses
Check glucose in AM - if OK - skip morning dose
If elevated, can take half usual dose of intermediate/ long acting
Do not take short acting insulin morning of surgery
Oral Hypoglycemics - Metformin, Glucotrol
Opioids - Hydrocodone, Oxycodone
*Depending on situation, may allow to take anxiety meds/opioids day of surgery

48
Q

What meds need to be stopped 5-7 days before surgery

A

anticoagulants (2 days for pradaxa though)
NSAIDS
Vit E
Herbals
Steroids typically a taper

reversal if an emergent surgery

49
Q

What DM risks of surgery

A

Delayed wound healing
CV events
infections
hyper/hypoglycemia

check fingerstick in the AM of surgery and immediately prior to surgery

50
Q

What thyroid storm risks of surgery

A

thyrotoxicosis
HTN
cardiac arrythmias
gouter affects airway

51
Q

What do you take for hyperthyroid prior to surgery? Hypo?

A

PTU + propanolol

Hypothyroid = levothyroxine

52
Q

adrenal insufficiency complications of surgery

A

Addisonian Crisis

should get cortisol

53
Q

why do you see hypercapnia in COPD

A

difficulty blowing off CO2

54
Q

What is the MCC of perioperative death?

A

Heart attack
MI

should always ask exercise tolerance

55
Q

If a patient has a PCI, when is it safe to have an elective procedure?

A

Angioplasty alone: 2-4 wks
Angioplasty with metal stents: 4-6 wks
Angioplasty with drug-eluting stent: 1 year

56
Q

Questions about prior surgical experiences

A

Personal history of reaction to anesthesia
Family history of severe reaction to anesthesia (malignant hyperthermia)
Severe post-operative N/V
Severe peri-operative anxiety

Useful to aid in the selection of anesthetics agents used

Can use “premedication” in some instances

57
Q

MCC of spontaneous bacteremia

A

gingivitis

Surgery (4 decks)

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