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R9 > Chapter 34 - Postoperative management > Flashcards

Chapter 34 - Postoperative management Flashcards

1
Q

Benefits of ICU/stepdown units

A

1) decreased myocardial oxygen demand by 2) expeditious rewarming 3) effective fluid resus 4) effective analgesia 5) meticulous control of hemodynamics 6) careful monitoring 7) appropriate nursing care for diagnosis and treatment of complications

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2
Q

Reasons to consider post-op ICU/step down stay

A

1) CAD (EF < 40%, CHF, NYHA 3-4 angina) 2) COPD FEV1 < 1L 3) dialysis dependent 4) SBP < 90 or need pressor 5) intubated needing vent 6) presence of pulmonary catheter, spinal drains 7) hypothermia < 35 C 8) massive transfusion > 3L

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3
Q

What does CVP measure

A

1) right atrial pressure 2) estimate of preload inaccurate in COPD or valvular heart disease affected by high PEEP > 12 cm H2O

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4
Q

Normal CVP

A

6-12 mmHg measured at end expiration

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5
Q

Sudden change in CVP suggest

A

1) pneumothorax 2) cardiac tamponade

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6
Q

Peripheral art line positioning

A

midpoint of right atrium 5cm below sternal angle in mid axillary

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7
Q

Reasons to insert pulmonary artery catheters

A

1) measure cardiac output 2) cardiac pressure 4) mixed venous oxygen

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8
Q

How to estimate cardiac output from echo

A

1) diameter of descending aorta 2) distribution of flow to descending aorta 3) measured flow velocity of blood

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9
Q

Normal intraabdominal pressure

A

5-7 mm Hg

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10
Q

Intra-abdominal hypertension

A

IAP 12-20 mmHg

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11
Q

Abdominal perfusion pressure

A

MAP - IAP

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12
Q

Abdominal compartment syndrome

A

constellation of symptoms suggesting organ dysfunction 1) decreased CO 2) high peak airway pressure 3) oliguria 4) IAP > 20

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13
Q

Risk for abdominal compartment syndrome

A

1) Fluid resus > 10L crystalloid or >5L colloid 2) transfusion > 10 unit in 24 hr

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14
Q

Measurement of abdominal compartment syndrome

A

1) 25-50ml normal saline into catheter 2) end expiration with patient supine

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15
Q

Target post-operative BP

A

20 mmHg +/- from baseline deviation of MAP within 20% of baseline

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16
Q

Hypertensive emergency associated BP

A

SBP > 179 DBP > 109 can cause acute damage to organs (Crisis)

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17
Q

Pulse pressure to stroke volume ratio suggestive of hypovolemia

A

> 10%:15%

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18
Q

Treatment of acute hypotension

A

Phenylephrine Dopamine

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19
Q

Treatment of tachyarrhythmia in hemodynamic stable patient

A

1) Beta blocker or CCB for rate control 2) IV amiodarone 3) adenosine 4) electrical cardioversion (if unstable)

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20
Q

Treatment of torsades de pointes

A

Polymorphic VT with prolonged QT interval Magnesium

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21
Q

Loss of atrial kick will decrease left ventricular stroke volume by

A

20-35%

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22
Q

How often do people revert out of afib after bolus amiodarone

A

1/3

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23
Q

Treatment of new afib in hemodynamically stable patients

A

1) beta blocker 2) amiodarone 3) digitalis 4) cbb electrical cardioversion if unstable

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24
Q

Detecting cardiac ischemia 3 ways

A

1) symptoms 2) ECG 3) enzymes

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25
Q

STEMI definition

A

1) ECG = ST elevation 0.1 mV (1 mm) in two consecutive leads 2) CK-MB levels elevated 3-12 hours after infarction; peak 24 hour and elevate for 3 days 3) troponin detected 4-12 hours; peak 12-48 hours; elevate 1 week

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26
Q

Medical treatment for STEMI post-cath

A

1) beta blocker 2) ACEi 3) statins

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27
Q

NSTEMI definition

A

biomarker indicative of MI without ST elevation

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28
Q

Causes of NSTEMI

A

transient reduction in coronary blood flow that causes imbalance in myocardial oxygen supply and demand

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29
Q

Hemodynamic target for NSTEMI

A

block until SBP > 90 HR > 50

30
Q

Two modes of mechanical ventilation

A

1) controlled 2) supported

31
Q

Two types of ventilator settings

A

1) volume control = fixed tidal volume with varialbe pressure 2) pressure control = fixed pressure with variable tidal volume

32
Q

Tidal volume target on ventilator for protective ventilation

A

6-8 ml/kg avoid overdistention or derecruitment/atelectasis

33
Q

Two approaches to ventilation weaning

A

1) progressive reduction of support 2) spontaneous breathing trials without progressive withdrawal

34
Q

Setting of weaning

A

1) pressure support 5-8 cm H2O 2) PEEP at 5 cm H2O 3) O2 at 30 or room

35
Q

Signs of readiness to be weaned

A

LACK of distress: 1) resp rate > 35 for > 5 min 2) desat < 90% for > 30 sec 3) increase or decrease HR +/- 20% for > 5 min 4) SBP out of 90-180 range 5) other signs of agitation and distress (paradoxical breathing, accessory muscles, diaphoresis

36
Q

Rate of reintubation

A

10-15%

37
Q

Benefit of tracheostomy

A

1) decrease work of breathing 2) better oral hygiene 3) secretion management 4) improved survival in COPD 5) shorter hospital stay

38
Q

Disadvantage of tracheostomy

A

1) procedure complication 2) stomal complication 3) tracheoinnominate fistula 4) tracheoesophageal fistula

39
Q

Relative contraindication to do percutaneous tracheostomy

A

1) hypoxic 2) high PEEP 3) obese 4) short neck 5) coagulopathic 6) recent < 10 days) anterior cervical spine fixation

40
Q

Physiologic response to hypovolemia

A

1) tachycardia 2) hypotension 3) low CVP 4) decreased urine output 5) peripheral vasoconstriction

41
Q

Post-operative coagulopathy tests, problems and treatment

A

TABLE 34.1

42
Q

Why does FFP not reduce heparin effect

A

FFP has antithrombin III which is what heparin acts on

43
Q

Hemophilia type A and B

A

A = deficiency of factor 8 B = deficiency of factor 9 C = deficiency of factor 11

44
Q

Reversal for warfarin

A

Vitamin K FFP prothrombin complex concentrate

45
Q

DIC bloodwork will show

A

1) increased INR 2) increased aPTT 3) thrombocytopenia

46
Q

Treatment of DIC

A

Cryoprecipitate if fibrinogen < 100 mg/dl FFP when other factors < 25% or abnormal iNR platelet if plt < 50

47
Q

Fluid balance in shock workup and treatment

A

FIGURE 34.2

48
Q

Transfusion threshold for RBC in CAD or without CAD

A

70 without CAD 80-90 with CAD

49
Q

Transfusion of platelets in various situations

A

Cardiac surgery, bleeding - 100 coagulopathy, bleeding - 50 coagulopathy, no bleed - 20 low risk no bleed - 10

50
Q

When to give FFP

A

active bleeding and INR > 1.5

51
Q

When to give cryoprecipitate

A

active bleed and fibrinogen < 100 mg/dl (<2.9 mcmol/l)

52
Q

What’s in cryoprecipitate

A

factor 8, factor 13, vWF

53
Q

How much platelet in one unit of whole blood

A

5.5 - 10 x 10^10

54
Q

how much platelet from 1 unit of platelet pheresis

A

40 x 10^10 from 6 units of whole blood

55
Q

Amount of cryoprecipitate needed to raise fibrinogen by 0.5-1.0g/L

A

1 unit per 5-10kg body weight

56
Q

Function of recombinant activated Factor 7

A

1) control bleeding in patients with hemophilia types A + B 2) generates thrombin at site of vessel injury - coagulation

57
Q

Antifibrinolytic agents

A

1) Tranexamic acid 2) aminocaproic acid

58
Q

Effect of antifibrinolytic agents

A

1) synthetic lysine analogues 2) inhibit plasminogen and plasmin-mediated fibrinolysis

59
Q

What is aprotinin

A

Serine protease neutralizes trypsin, plasmin, kallikrein used when fibrinolysis contributes to bleeding

60
Q

Definition of massive transfusion

A

replacement of 50% patient blood in 3 hour replacement of 100% patient blood in 24 hours

61
Q

Causes of coagulopathy in massive transfusion

A

1) hemodilution 2) hypothermia 3) acidosis due to tissue hypoxia 4) DIC 5) hyperkalemia - RBC lysis 6) hypocalcemia - citrate as anticoagulat

62
Q

Nutrition goals and feeding key points in ICU

A

1) determine goal calories 2) give 50-65% goal calorie in first week 3) increase to goal rate 4) permissive underfeeding if BMI > 30 (goal to 60-70% ideal weight)

63
Q

Autonomic hyperactivity symptoms in alcohol withdrawal

A

1) tremulousness 2) sweating 3) nausea 4) vomiting 5) anxiety 6) agitation

64
Q

Timing of autonomic hyperactivity in alcohol withdrawal

A

start 24-48 hours peak 3-5 days

65
Q

Delirium tremens rate

A

5%

66
Q

Delirium tremens symptoms

A

1) fever 2) tachycardia 3) hypertension 4) tremors 5) diaphoresis 6) hallucinations 7) disorientation 8) agitation 9) urinary incontinence

67
Q

First line treatment for alcohol withdrawal syndrome

A

Benzodiazepine

68
Q

Reasons to take thiamine and multivitamin in alcoholics

A

Prevent Wernicke-Korsakoff syndrome

69
Q

Richmond agitation sedation scale

A

10 point scale from -5 to +4 -5 is unarounsable +4 is combative 0 is normal and alert

70
Q

Three types of delirium

A

1) hyperactive 2) hypoactive 3) mixed

71
Q

Non-pharmacologic methods of delirium management

A

1) minimize risk factors 2) early mobilization 3) sleep protocol 4) timely removal of catheters and lines 5) minimize noise and unnecessary stimuli

72
Q

Pharmacologic methods of delirium management

A

1) avoid benzodiazepine - exacerbates 2) haloperidol 3) risperidone 4) quetiapine 5) olanzepine

R9 (200 decks)

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