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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
What is physiological age determined
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
What questions do you ask for nutritional assessment?
Question about weight loss Question about diet and eating habits Labwork: CBC with diff, serum albumin/prealbumin, vitamin B12
27
What weight loss is of greatest risk for poor surgical outcomes?
>10% from baseline
28
If you have poor immune system, what precautions need to be taken?
Antiseptic (although all patients get this) + wound care (d/t delayed wound healing)
29
What hemostasis assessment is used for surgery
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
Thromboembolism assessment RF
DVT A fib OCP Smokers Sedentary lifestyle Clotting disorders
31
Pulmonary function assessment RF
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
What is the questionnaire for sleep apnea?
STOP-Bang can bring CPAP to surgery to decrease risk of pulm complications
33
What is the ARISCAT calculator
Used to determine risk of POSToperative pulmonary complications low to high risk
34
Preoperative Preparation for compromised pulmonary function:
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
What does everyone before surgery get for their airway?
Babies to elders ALL patients are given O2 before surgery to decrease the risk of surgical site infections
36
What are common Postoperative Pulmonary Complications?
Atelectasis Hypoxia Pneumonia Respiratory Failure PE
37
major predictors of CV risks
Recent MI (within 6 months) Unstable angina Recent PCI Active CHF V. Tach, AV Blocks
38
minor predictors of CV risk
A. fib Age > 70 Abnormal EKG findings LVH, LBBB Poorly controlled HTN
39
What calculator allows risk stratification for survival of surgery?
NSQIP
40
What does a cardiovascular risk assessment do?
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
What is used to assess patient prior to anesthesia?
PreAnesthesia Testing (PAT) or PreAnesthesia Care (PAC) Allows you to see what risk of surgery the patient has
42
What are the 6 ASA classification?
1-6 6 = brain dead (organ harvesting)
43
How does anesthesia do an airway assessment
Neck ROM Neck circumference Mouth opening/jaw protrusion Dentition Mallampati Classification oropharyngeal assessment used to predict ease of intubation
44
Mallampati Classifications
1-4 visualization 1 = soft palate + uvula 2 = uvula 3 = only base of uvula 4 = no visualization
45
Why should you not chew gum prior to surgery?
Increases gastric motility leading to higher likelihood of aspiration
46
What meds can you continue for the day of surgery?
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
What meds can you take the day BEFORE surgery
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
What meds need to be stopped 5-7 days before surgery
anticoagulants (2 days for pradaxa though) NSAIDS Vit E Herbals Steroids typically a taper reversal if an emergent surgery
49
What DM risks of surgery
Delayed wound healing CV events infections hyper/hypoglycemia check fingerstick in the AM of surgery and immediately prior to surgery
50
What thyroid storm risks of surgery
thyrotoxicosis HTN cardiac arrythmias gouter affects airway
51
What do you take for hyperthyroid prior to surgery? Hypo?
PTU + propanolol Hypothyroid = levothyroxine
52
adrenal insufficiency complications of surgery
Addisonian Crisis should get cortisol
53
why do you see hypercapnia in COPD
difficulty blowing off CO2
54
What is the MCC of perioperative death?
Heart attack MI should always ask exercise tolerance
55
If a patient has a PCI, when is it safe to have an elective procedure?
Angioplasty alone: 2-4 wks Angioplasty with metal stents: 4-6 wks Angioplasty with drug-eluting stent: 1 year
56
Questions about prior surgical experiences
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
MCC of spontaneous bacteremia
gingivitis

Surgery (4 decks)

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