Dr. Pestana's Notes--Pre-Op & Post-Op

Question 1

Ejection fraction under ____ is preop risk for noncardiac operations because perioperative MI risk his high.

Answer 1

35%

Question 2

Goldman’s index of cardiac risk lists the findings that predict trouble in surgery. Name them in order of importance (8)

Answer 2

(1) JVD (2) recent MI (3) premature ventricular contractions/arrhythmias (4) age >70yo (5) emergecy surgery (6) aortic valvular stenosis (7) poor medical condition (8) surgery w/in chest/abdomen

Question 3

Usually _____ is more commonly assessed for cardiovascular risk in surgery

Answer 3

functional status

Question 4

JVD indicates ______; tx preceding surgery

Answer 4

congestive heart failure; ACEIs, ß blockers, digitalis, diuretics

Question 5

Risk of mortality due to recent transmural or subendocardial MI is ____ in first 3 months then _____ after 6 months

Answer 5

40%; 6%

Question 6

What do you do if pt has had recent MI?

Answer 6

defer surgery until after 6months if possible; if you cant’, admit to ICU a day before surgery to “optimize cardiac variables”

Question 7

MCC increased pulmonary risk due to compromised ventilation

Answer 7

smoking [COPD]

Question 8

Compromised ventilation sxs

Answer 8

high PCO2, low FEV1

Question 9

If pt is smoker/COPD before surgery, must ____

Answer 9

stop smoking 8 weeks before and have intense respiratory therapy

Question 10

What does respiratory therapy consist of? (4)

Answer 10

PT, expectorants, incentive spirometry, humidified air

Question 11

(A) Which 2 clinical findings are used to predict operative mortality in pts w/ liver dz? (B) Laboratory findings?

Answer 11

(A) encephalopathy, ascites (B) serum albumin, INR, bilirubin

Question 12

Child class looks at presence and severity of liver disease pre-op. Class A has ___ mortality risk, Class B has ____ and Class C has ____

Answer 12

10%, 30%, 80%

Question 13

Define severe nutritional depletion

Answer 13

loss of 20% obdy wt over couple of months, serum albumin

Question 14

Tx preop for severe nutritional depletion

Answer 14

4 or 5 days preop nutritional support (preferably via gut)

Question 15

______ is an absolute contraindication to surgery

Answer 15

Diabetic coma

Question 16

(3) things must be achieved before operating on someone w/ diabetic coma

Answer 16

(1) rehydration (2) return UOP (3) at least partial correction of acidosis and hyperglycemia [must treat sepsis if have it!! otherwise can’t operate at all]

Question 17

Malignant hyperthermia can develop after administration of ____ or ____

Answer 17

halothane; succinylcholine

Question 18

Sxs Malignant hyperthermia

Answer 18

Temp >104, metabolic acidosis, hypercalcemia; may have family hx

Question 19

Tx Malignant hyperthermia

Answer 19

dantrolene, 100% O2, correction of acidosis, cooling blankets; MUST watch for dev of myoglobinuria!!

Question 20

Bacteremia is seen w/in _____ of invasive procedures

Answer 20

30 to 45 minutes

Question 21

Sxs bacteremia; dx/tx

Answer 21

chills, fever spike >104; blood culture x 3 and start empiric abx

Question 22

MCC postop fever (101-103)

Answer 22

atelectasis, pneumonia, UTI, DVT, wound infection, deep abscess [in descending order]

Question 23

If deep breathing, coughing, postural drainage and incentive spirometry fails to fix atelectasis postop, tx w/ ____

Answer 23

bronchoscopy

Question 24

Pneumonia will occur about ____ postop if ateclectasis not resolved. Dx includes ____ and ___. Tx w/ abx

Answer 24

3 days; CXR; sputum culture

Question 25

UTI produces fever on postop _____. Dx includes ___ and ____. Tx w/ abx

Answer 25

day 3; UA; urinary cultures

Question 26

DVT produces fever on postop _____. Dx includes ___ of deep leg/pelvic veins. Tx w/ ____

Answer 26

day 5; Doppler studies; heparin

Question 27

Wound infection produces fever on postop _____. PE shows erythema, warmth, tenderness. Tx w/ abx if there is only ____, if there is ____, open and drain first. Ddx w/ ____ imaging

Answer 27

day 7; cellulitis; abscess; sonogram

Question 28

Deep abscesses produce fever on postop _____. Dx includes ___ of subphrenic, pelvic or subhepatic area. Tx usually w/ ___

Answer 28

day 10-15; CT; percutaneous radiologically guided drainage

Question 29

MC trigger of periop MI; detected by ____ or _____ on EKG

Answer 29

hypotension; ST depression; T-wave flattening

Question 30

When it happens, MI usually occurs _____ posop, showing up as ____ only in one-third of cases

Answer 30

within first 2-3 days; chest pain

Question 31

Best dx for MI; Tx postop MI

Answer 31

troponin; clot busters and/or emergency angioplasty/stent

Question 32

MI postop mortality greatly exceeds MI not associated w/ surgery by _____

Answer 32

50 to 90%

Question 33

PE typically occurs around postop _____ in the elderly and/or immobilized pts.

Answer 33

day 7

Question 34

Sxs PE

Answer 34

pleuritic pain w/ sudden onset and SOB; anxiety, diaphoresis, tachycardic w/ prominent distended veins in neck/forehead

Question 35

PE arterial blood gases show ____ and ____

Answer 35

hypoxemia; hypocapnia

Question 36

Std dx for PE; Std tx PE

Answer 36

CT angio; heparinization

Question 37

Tx of PE if PE recurs while anticoagulated or if anticoagulation is contraindicated

Answer 37

heparinization + IVC filter (Greenfield)

Question 38

When can you NOT use compression devices to prevent PE?

Answer 38

pt w/ LE fracture

Question 39

Risk factors of PE where anticoagulation is indicated (5)

Answer 39

(1) age >40 (2) pelvic/leg fractures (3) venous injury (4) femoral venous catheter (5) anticipated prolonged immobilization

Question 40

_____ is a hazard in awake intubations in combative pts w/ full stomach.

Answer 40

Aspiration

Question 41

Aspiration can be ____ immediately or lead to _____ of tracheobronchial tree subsequent to pulmonary failure or secondary pneumonia

Answer 41

lethal; chemical injury

Question 42

Prevention aspiration postop

Answer 42

NPO and antacids before induction

Question 43

Tx aspiration

Answer 43

lavage/removal of particulates/acid w/ bronchoscopy followed by bronchodilation and respiratory support

Question 44

Intraoperative _____ can develop in pt w/ traumatized lungs (punctures by broken ribs) once they are subjected to positive pressure breathing

Answer 44

tension pneumothorax

Question 45

Sxs of intraop tension pneumothorax

Answer 45

progressively more difficult to "bag", BP steadily declines, CVP steadily rises

Question 46

Tx of intraop tension pneumothorax

Answer 46

needle inserted through ant chest wall into pleural space; formal chest tube placed later

Question 47

First thing to suspect when postop pt gets confused/disoriented is ____. May be secondary to ____. Check blood gases and provide respiratory support

Answer 47

hypoxia; sepsis

Question 48

ARDS is seen in pts w/ complicated postop course, often complicated by ____. Clinical sxs. There is NO evidence of ____

Answer 48

sepsis; bilateral pulmonary infiltrates, hypoxia; congestive heart failure

Question 49

Tx ARDS

Answer 49

PEEP [extensive pressures can result in barotrauma] and tx of sepsis

Question 50

Delirium tremens usually occurs postop _____ in alcoholics. Sxs.

Answer 50

day 2 or 3; confused, hallucinations, combative

Question 51

Tx delirium tremens

Answer 51

benzodiazepines or IV alcohol (5% in 5% dextrose)

Question 52

Hyponatremia can cause ____ if quickly [in hours] induced by liberal administration of sodium-free fluids [D5W] in postop pt w/ high levels of ADH [triggered by response to trauma]

Answer 52

confusion, convulsions, coma, death

Question 53

Prevent hyponatremia postop due to increased ADH; Mortality if occurs is high. ____ are vulnerable. Tx

Answer 53

including sodium in IV; young women; hypertonic saline and osmotic diuresis (mannitol)

Question 54

Surgical damage to _____ with unrecognized DI can cause hypernatremia postop. ____ can also cause this.

Answer 54

posterior pituitary; unrecognized osmotic diuresis

Question 55

Sxs hypernatremia; Tx

Answer 55

large, unreplaced UOP, rapid wt loss, rapidly rising serum sodium; rapid fluid replacement, "cushion" it by D5-1/2 or D5-1/3 NS [not D5 only]

Question 56

______ is a common cause of coma in cirrhotic pt w/ bleeding esophageal varices who undergoes _____ shunt

Answer 56

ammonium intoxication; portocaval

Question 57

_____ should be done 6 hours postop if no spontaneous voiding occured; ____ indicated at second/third day of consecutive catheterization

Answer 57

In-and-out bladder catheterization; Foley

Question 58

Zero urinary output is usually a mechanical problem cause ed by a _____ catheter

Answer 58

plugged or kinked

Question 59

Low UOP is (defined as _____) in the presense of nml perfusing pressure represents either ____ or ____.

Question 60

Ddx low UOP uses fluid challenge, which is ____. Dehydrated pts will have _____. Acute renal failure pts will have _____.

Answer 60

bolus 500 mL IV fluid infused over 10-20 min; temporary increase in UOP; no increase UOP

Question 61

In dehydrated pt, urinary sodium will be ____ whereas in a patient with acute renal failure, it will be _____. When looking at fractional excretion of sodium (FeNa), renal failure will have FeNa ____.

Answer 61

40 mEq/L; >1

Question 62

Sxs Paralytic ileus (nml after first few days of abd surgery)

Answer 62

absent bowel sounds, no flatus, mild distension, no pain

Question 63

Paralytic ileus prolonged by _______.

Answer 63

hypokalemia

Question 64

Mechanical bowel obstruction usually dx as postop ileus is noticed on postop _____ when still no BM. Xrays will show _____.

Answer 64

days 5, 6 or 7; dilated loops of small bowel w/ air-fluid levels

Question 65

Confirmatory dx of mechanical bowel obstruction. Tx.

Answer 65

abdominal CT w/ transition pt btwn proximal dilated bowel and distal collapsed bowel at site of obstruction; sx

Question 66

"Paralytic ileus of the colon", aka ______, is poorly understood and very common. Usually seen in _____

Answer 66

Ogilvie syndrome; elderly sedentary pts who are further immobilized [post hip fracture sx, etc]

Question 67

Sxs Ogilvie syndrome

Answer 67

large abd distension (tense, nontender) w/ imaging showing massive dilated colon

Question 68

Tx Ogilvie syndrome; ____ should be avoided b/c side effects can be lethal if colon is actually obstructed

Answer 68

fluid and electrolyte correction, colonoscopy to suck out air and place long rectal tube; neostigmine

Question 69

Wound dehiscence can be seen postop _____, usually after _____. Fluid is salmon-colored (peritoneal fluid).

Answer 69

day 5; open laparotomy

Question 70

Tx wound dehiscence

Answer 70

must be taped securely until promt reop to prevent envisceration or ventral hernia can occur

Question 71

Envisceration; MCC

Answer 71

skin opens and abd contents fall out; when pt strains, coughs or gets out of bed

Question 72

Temp tx envisceration before emergency reop

Answer 72

kept in bed w/ bowel covered w/ large sterile dressings soaked w/ warm saline

Question 73

Wound infections usually occur postop ____.

Answer 73

day 7

Question 74

_____ are when bowel contents leak out through wound or drainage site. Complications include _____ (1) if they do not drain completely to outside and _____(3) if they do.

Answer 74

Fistulas of GI tract; sepsis; fluid/electrolyte loss, nutritional depletion, erosion/digestion of belly wall

Question 75

Complications of fistulas of GI tract related to location and volume of fistula. The problems are nonexistent in _____, manageable in ______ w/ low-volume (200-300 mL/day) output and awful in _____ w/ high-volume (several liters) output.

Answer 75

distal colon; high GI fistulas (stomach, duodenum, upper jejunum): high GI fistulas

Question 76

Nature will heal GI fistula if the following is absent. (Steroids will also prevent healing)

Answer 76

[FETID] foreign body, epithelialization, tumor, infection/irradiated tissue/IBD, distal obstruction

Question 77

Tx GI fistulas

Answer 77

electrolyte replacement, nutritional support, compulsive protection of abdominal wall (ostomy bags)

Question 78

Every 3 mEq/L that the serum sodium concentration is above 140 represents about _____ of water loss.

Answer 78

one liter

Question 79

If hypernatremia occurs slowly, the brain will adapt. Tx should be corrected _____ using ______

Answer 79

rapidly (in hrs); D5-1/2 NS

Question 80

If hypernatremia occurs rapidly (as in ____ or _____), CNS symptoms will develop. Tx w/ ______ or even ____

Answer 80

osmotic diuresis; DI; D5-1/3 NS; D5W

Question 81

Hyponatremia can occur when pt has too much _____, for example, in postop water intoxication or paraneoplastic condition secreted by tumors; Hyponatremia can also occur due to losing large amts _____ [tonicity] fluids from GI tract

Answer 81

ADH; isotonic

Question 82

If hyponatremia occurs rapidly, the brain cannot adapt. Tx should include _____ hypertonic saline

Answer 82

3% or 5%

Question 83

If hypernatremia occurs slowly, the brain will adapt. Tx should include ____.

Answer 83

water restriction

Question 84

If hypernatremic dehydrated pt losing GI fluids, _____ [tonicity] fluids for volume restoration should be used. ___ should be used if there is alkalosis. ____ should be used if there is acidosis or normal pH.

Answer 84

isotonic; normal saline; lactate Ringers

Question 85

Renal failure and aldosterone antagonists will cause _____ hyperkalemia, whereas crushing injuries, dead tissue and acidosis will cause ______ hyperkalemia.

Answer 85

slow-onset; fast-onset

Question 86

Ultimate tx hyperkalemia; tx while waiting (3)

Answer 86

hemodialysis; (1) 50% dextrose + insulin (pushing K into cells) (2) NG suction/exchange resins (sucking it out of GI tract) (3) IV Ca+ (neutralizing its effect on cellular membrane; quickest)

Question 87

DDx Metabolic acidosis

Answer 87

fixed acids [DKA, lactic acidosis, low-flow states], loss of buffers [loss bicarb fluids from GI tract], inability of kidney to eliminate fixed acids [CKD]

Question 88

In metabolic acidosis, an anion gap 10-15 indicates that _______.

Answer 88

acids are piling up (no loss of buffers)

Question 89

Tx Metabolic acidosis

Answer 89

tx underlying problem, can temp tx w/ admin of bicarb ONLY if that is initial prob

Question 90

If too much bicarb is administered to a metabolic acidotic pt, can cause ___

Answer 90

rebound alkalosis

Question 91

In long-standing acidosis, ______ leads to a deficit that doesn't become obvious until acidosis is corrected; therefore must be prepared to replace ____ as part of therapy of acidosis

Answer 91

renal loss of K+; K+

Question 92

Metabolic alkalosis is due to _____ or ______

Answer 92

loss of acid gastric juice; excessive admin of bicarb/precursors

Question 93

Std tx metabolic alkalosis; sometimes ____ or ___ needed.

Answer 93

abundant intake KCl (5-10 mEq/h) will correct problem; ammonium chloride; 0.1 N HCl

Question 94

____ due to impaired ventilation and ___ due to abnormal hyperventilation. Recognized by abnormal PCO2. Therapy directed at improving or reducing ventilation.

Answer 94

Respiratory acidosis; respiratory alkalosis

Question 95

What imaging is used to see if a lung lesion is an old scar or a rapidly dividing lung mets

Answer 95

PET scan