Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Surgery > Chapter 3: Pre-Op and Post-Op Care > Flashcards

Chapter 3: Pre-Op and Post-Op Care Flashcards

1
Q

Ejection Fraction that is prohibitive for noncardiac procedures?

A

<35%

  1. periop MI incidence 75-85%
  2. Post-op MI Mortality= 55-90%
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Goldman’s Index of Cardiac Risk?

A
  1. JVD= 11 pts
  2. Recent MI wi 6 months= 10 pts
  3. Premature Ventricular Contraction (5 or more per minute)= 7 pts
  4. Non-sinus rhythm= 7pts 4. age >70= 5 pts
  5. Emergency surgery = 4 pts
  6. aortic valvular stenosis= 3pts
  7. Poor medical condition= 3 pts
  8. Surgery wi the chest or abdomen= 3 pts

Score:

  1. 5 pts total= 1% cardiac complication risk
  2. 12 pts totatl= 5%
  3. 25 pts total= 11%
  4. >25pts= 22%
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Operative Mortality within 3 months of transmural or subendocardial MI?

A

40%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Post-op mortality 6 months after MI?

A

6%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Way to “optomize cardiac variables” when you must perform surgery wi 6 mths of an MI?

A

admission to the ICU the day prior to surgery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Most common cause of increased pulmonary risk?

A

smoking

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What’s the problem with smoking history in surgery?

A

Compromised ventilation:

  1. high pCO2
  2. Low FEV1 (forced expiratory volume in 1 second)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Steps in assessing pulmonary risk?

A
  1. pre-test risk: smoker? COPD?
  2. Test FEV1
  3. If abnormal, get blood gases
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Requirement for smokers seeking surgery?

A
  1. cessation of smoking for 8 weeks preceding surgery
  2. intensive respiratory therapy (physical therapy, expectorants, incentive spirometry, humidified air)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Predictors of post-op mortality based on hepatic risk?

A
  1. bilirubin
  2. serum albumin
  3. prothrombin time
  4. ascites
  5. encephalopathy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Mortality risk: Bili >2, albumin <3, PTT >16 or encephalopathy

A

>40%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Mortality Risk: 3 or more (bili >2, albumin < 3, PTT >16, encephalopathy) or one of the following:

bilirubin alone >4,

albumin alone <2,

blood ammonia concentration >150mg/dL

A

80-85% mortality

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Severe Nutritional Depletion Definition:

A
  1. loss of 20% of body weight over a couple of mths
  2. serum albumin < 3
  3. anergy to skin antigens
  4. serum transferrin level of less than 200 mg/dL
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Metabolic risk that is an absolute contraindication to surgery?

A

Diabetic Coma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Must be done before operating on a patient in diabetic coma?

A
  1. rehydration
  2. return of urinary output
  3. partial correction of acidosis and hyperglycemia

–can’t completely correct these if a septic process is happening–

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Post-op Malignant Hyperthermia?

A
  1. develops shortly after giving anesthetic (halothane or succinylcholine)
  2. temp exceeds 104F
    • metabolic acidosis
    • hypercalcemia
  5. may have a family history
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Look out for this in malignant hyperthermia:

A
  1. myoglobinuria
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Length of time it take bacteremia to occur after invasive procedures (instrumentation of urinary tract ie.)?

A

30-45 minutes after

  1. temp spike >104F
  2. chills
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Mgmt for bacteremia?

A
  1. blood cultures x 3
  2. start empiric antibiotics
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

4 elements of trmt for malignant hyperthermia?

A
  1. IV dantrolene
  2. 100% oxygen
  3. correction of acidosis
  4. cooling blankets
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Severe wound pain and very high fevers w/i hours of surgery?

A

gas gangrene of surgical wound

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

6 Causes of postop fever (101-103F)

A
  1. atelectasis –> usuale on POD 1–> listen to lungs, Cxr, improve ventilation (deep breathing, coughing, postural drainage, incentive spirometry)..ultimate treatment if needed: bronchoscopy
  2. Pneumonia –> POD 3: persistent fever, infiltrates on Cxr–> do sputum culture, treat with appropriate antibiotics
  3. UTI–> POD 3–> urinalysis, urinary cultures to diagnose–> treat with appropriate antibiotics
  4. Deep thrombophlebitis–> POD 5 or thereabouts–> doppler studies of deep leg and pelvic veins–> anticoagulate with heparin
  5. Wound infection–> POD 7 fever–> erythema, warmth, tenderness–> give abx if there’s only cellulitis, open and drain wound if an abscess is present (use sonogram to diagnose if not sure)
  6. Deep abscess (subphrenic, pelvic, subhepatic)–> POD 10-15–> CT scan is diagnostic–> percutaneous radiologically guided drainage is therapeutic
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Most commoon trigger for perioperative MI?

A
  1. hypotension (detected by ST depression, T-wave flattening on EKG)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Post-op MI

A
  1. usually POD 2-3
  2. only 1/3 present with chest pain
  3. Troponins are the most sensitive test
  4. VERY high mortality: 50-90% , higher than MI w/o surgery
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Trmt for PO MI?

A

NO clot busters

  1. emergency angioplasty
  2. coronary stent
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

PO Pulmonary Embolism

A
  1. typically POD 7
  2. in elderly
  3. in immobilized pts
  4. pleuritic pain of sudden onset
  5. accompanied by SOB
  6. anxiety + diaphoresis + tachycardia
  7. distended neck vein of neck and forehead (low CVP rules it out)
  8. ABG: hypoxemia and hypocapnia
  9. CTA is standard diagnostic test
  10. pulmonary angiogram is “gold standard”
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Treatment for PE

A
  1. heparinization
  2. inferior vena cava filter (Greenfield) if PEs recur while anticoagulated or if anticoagulation is contraindicated
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Prevention of thromboembolism?

A
  1. compression devices in people who dont have a lower extremitiy fracture
  2. anticoags in high-risk people
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Risk factors for PE:

A
  1. age >40
  2. pelvic or leg fracture
  3. venous injury
  4. femoral venous cath
  5. anticipated prolonged immobilization
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Can you perform surgery if patient is in diabetic coma?

A

NO

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

What must you correct for in diabetic coma pt before you do surgery?

A
  1. rehydration
  2. return of urinary output
  3. partial correction of acidosis and hyperglycemia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

When can you not 1. rehydrate 2. return urinary output 3. partially correct acidosis and hyperglycemia in a diabetic coma pt?

A

if the indication for surgery is a septic process ( can’t completely correct as long as septic process is present)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Signs of malignant hyperthermia?

A
  1. temp >104
  2. metabolic acidosis
  3. hypercalcemia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

What type of pts are likely to aspirate during intubations?

A
  1. awake
  2. combative
    • full stomach
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Prevention strategies for aspiration?

A

(…before intubation..)

1 .NPO

  1. avoid antacids
36
Q

Morbidity caused by aspiration?

A
  1. death right away
  2. chemical injury of tracheobronchial tree
  3. pulmonary failure
  4. secondary pneumonia
37
Q

Therapy for aspiration?

A
  1. lavage
  2. removal of acid and particulate matter (using bronchoscopy as guide)
  3. bronchodilators
  4. respiratory support
38
Q

What therapy is useless in treating aspiration?

A

steroids

39
Q

Who is vulnerable to intraop tension pneumothorax?

A

pts with traumatized lungs (recent blunt trauma with punctures by broken ribs)

40
Q

what can precipitate a tension pneumo intraoperativily in traumatizedlung pts?

A

inducing positive-pressure breathing

41
Q

signs of tension pneumo intraop

A

“progressively more difficult to bag”

bp decline

CVP rise

42
Q

how to fix intraop tension pneumo?

A

–if abdomen is open, quick decompression throught the diaphragm

–if abdomen not open–> insert through anterior chest wall into the pleural space (under the drapes)–> place formal chest tube later

43
Q

First thing you suspect when post-op pt gets confused or disoriented

A

hypoxia (secondary to sepsis)

—> check blood gases + provide respiratory support

44
Q

Who gets ARDS?

A

pts w stormy, complicated post-op course ….usually includes sepsis as precipitating event

45
Q

signs of ARDS?

A
  1. bilateral pulmonary infiltrates
  2. hypoxia
  3. no evidence of congesive heartfailure
46
Q

treatment for ARDS?

A
  1. PEEP

* be careful not to use too much volume!* –> can cause barotrauma

  1. correct the sepsis
47
Q

When does delerium tremens occur?

A

2nd or 3rd PO day

Sx: confusion, hallucination, and become combative

48
Q

Trtmt for delerioum tremens?

A

intravenous benzos

intravenous alcohol (5% in 5% dextrose)

49
Q

what can cause hyponatremia?

A

administering Na-free IV fluids (like D5W) in postoperative pt with high levels of ADH ..triggered by the response to trauma )

50
Q

How can you figure out if a pt got a large fluid intake?

A
  1. chart review
  2. quick weight gain
  3. rapidly lowering serum Na concentration (in a matter of hours)
51
Q

Therapy for hyponatremia?

A
  1. therapy is controversial and mortality is very high (young women especially)
  2. use small amts of hypertonic saline (aliquots of 100 ml of 5%, or 500 ml 3%)
  3. also add osmotic diuretics
52
Q

Causes of hypernatremia?

A
  1. large, unreplaced water loss
  2. surgical damage to posterior pituatary w unrecognized diabetes insepidus
  3. unrecognized osmotic diuresis
53
Q

Signs of hypernatremia?

A

`. 1. chare shows large, unreplaces urinary outpus

  1. rapid weight loss
  2. rapid rise in sodium
54
Q

Treating hypernatremia?

A
  1. rapid replacement of the fluid deficit
  2. use D5 (1/2) or D5(1/3) normal salin rather than D5 W
55
Q

Treatment for post-op urinary retention?

A
  1. in-and-out bladder cath Q6h post-op if no voiding has occurred

*indwelling cath is indicated in the 2nd or 3rd consecutive cath

56
Q

What’s the definition of low urinary output?

A

0.5 mL/kg/h

57
Q

2 causes of low urinary output in presence of normal perfusing pressure?

A
  1. fluid deficit
  2. renal failure
58
Q

How to diagnose low urinary output?

A
  1. fluid challenge: 500cc bolus of IV fluid over 10-15 mins
  2. Or measure urinary sodium: will be 10-2 mEq/L in dehydrated pt and >40 mEq/L in case of renal failure
  3. FENa exceeds 1–> renal failure
59
Q

What prolongs paralytic ileus?

Is paralytic ileus?

A

hypokalemia

no, it doesnt hurt

60
Q

When do mechanical bowel obstructions caused by adhesions occur?

A

during the post-op period

61
Q

How does mechanical bowel obstruction present?

A

paralytic ileus not resolving after 5, 6, or 7 days

62
Q

Ogilvie’s Syndrome physical exam sx?

A

abdominal distention (tense but not tender)

63
Q

What must you do for Ogilvie’s before giving neostigmine to restore colonic motility?

A
  1. fluid and electrolyte correction
  2. r/o mechanical obstruction radiologically or by endoscopy
64
Q

What is wound dehiscence?

A

Usually seen ofn POD 5 after open laparotomy

wound appears intact but evident large amounts of pink, “salmon-colored” fluid soaking dressings (this is peritoneal fluid)

65
Q

How do you manage wound dehiscence?

A
  1. tape wound securely
  2. bind abdomen
  3. avoid mobilization and coughing (do so cautiously)
  4. make arrangements for prompt reoperation to prevent evisceration now or ventral hernia later
66
Q

On what day to wound infections typically occure?

A

POD 7

67
Q

How can you recognize a fistula in the GI tract?

A

bowel content drainage through a wound or drain site

68
Q

How can fistulas of the GI tract cause harm?

A
  1. they leak into a cesspool that thenleaks out–> cause sepsis (requiring complete drainage)
  2. If they drain freely (pt is afebrile with no signs of peritoneal irritation):
    a. fluid and electrolyte loss
    b. nutritional depletion
    c. erosion and digestion of the belly wall
69
Q

What are the types of fistula?

A
  1. nonexistent volume in distal colon
  2. low-volume (200-300 ml/day) high GI fistulas (stomach, duodenum, upper jejunum)
  3. high (daunting) volumes high in the GI
70
Q

Management for Fistulas?

A
  1. fluid and electrolyte replacement
  2. nutritional support delivered beyond the fistula Copyright (c) USMLEWorld, LLC., Please do not save, print, cut, copy or paste anything while a test is active.
  3. compulsive protection of the abdominal wall (suction tubes, “ostomy” bags)

…these will help keep pt alive until nature heals fistula…

71
Q

When will a fistula NOT heal on its own?

A
  1. foreign body
  2. epitheliazation
  3. tumor
  4. infection
  5. irradiated tissue
  6. inflammatory bowel disease
  7. distal obstruction
  8. steroids
72
Q

How can you estimate the amount of water an individual has lost based on their sodium concentration?

A

For every 3 mEq/L above 140, they have lost 1 L of water

73
Q

What’s the timeline for fluid-resuscitating someone who is hypernatremic?

A

Volume repleting: should be corrected rapidly over a number of hours

Tonicity: should be nudged slowly in a matter of days

74
Q

What fluid do you use to correct hypernatremia?

A

D51/2 NS rather than D5W

75
Q

If hypernatremia rapidly develops (i.e. via osmotic diuresis or diabetes insipidus) what corrective fluids would you give?

A

D51/3NS or even D5W

76
Q
A
77
Q

How do you treat acute hyponatremia?

A

hypertonic saline (3% or 5%)

78
Q

two ways to get hyokalemia?

A
  1. lose it from GI tract
  2. lose it in the urine (loop diuretics, too much aldosterone)
79
Q

one way to get rapid hypokalemia?

A

potassium moving into cells (i.e. when diabetic ketoacidosis is corrected)

80
Q

What’s the safe speed limit of K administration?

A

10 mEq/h

81
Q

Ways to get hyperkalemia?

A
  1. kidney failure
  2. aldosterone antagonists

3 crush injuries

  1. dead tissue
  2. acidosis
82
Q

Ultimate therapy for hyperkalemia?

A

hemodialysis

83
Q

Quick therapies for hyperkalemia?

A
  1. 50% dextrose and insulin
  2. sucking out of the GI tract (NG suction, exchange resins)
  3. neutralizing its effects on the cell membrane (IV calcium)–> quickest
84
Q

Causes of metabolic acidosis?

A

**Excessive Production of Fixed Acids**

  1. diabetic ketoacidosis
  2. lactic acidosis
  3. low-flow stats

**Loss of Buffers**

  1. bicarb-rich foods from the GI

**Inability of kidney to eliminate fixed acids**

Renal failure

85
Q
A

Surgery (9 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions