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Surgery Clerkship > Dr. Pestana's Notes--Pre-Op & Post-Op > Flashcards

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

1
Q

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

A

35%

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2
Q

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

A

(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

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3
Q

Usually _____ is more commonly assessed for cardiovascular risk in surgery

A

functional status

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4
Q

JVD indicates ______; tx preceding surgery

A

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

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5
Q

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

A

40%; 6%

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6
Q

What do you do if pt has had recent MI?

A

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

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7
Q

MCC increased pulmonary risk due to compromised ventilation

A

smoking [COPD]

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8
Q

Compromised ventilation sxs

A

high PCO2, low FEV1

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9
Q

If pt is smoker/COPD before surgery, must ____

A

stop smoking 8 weeks before and have intense respiratory therapy

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10
Q

What does respiratory therapy consist of? (4)

A

PT, expectorants, incentive spirometry, humidified air

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11
Q

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

A

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

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12
Q

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

A

10%, 30%, 80%

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13
Q

Define severe nutritional depletion

A

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

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14
Q

Tx preop for severe nutritional depletion

A

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

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15
Q

______ is an absolute contraindication to surgery

A

Diabetic coma

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16
Q

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

A

(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]

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17
Q

Malignant hyperthermia can develop after administration of ____ or ____

A

halothane; succinylcholine

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18
Q

Sxs Malignant hyperthermia

A

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

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19
Q

Tx Malignant hyperthermia

A

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

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20
Q

Bacteremia is seen w/in _____ of invasive procedures

A

30 to 45 minutes

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21
Q

Sxs bacteremia; dx/tx

A

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

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22
Q

MCC postop fever (101-103)

A

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

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23
Q

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

A

bronchoscopy

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24
Q

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

A

3 days; CXR; sputum culture

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25
Q

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

A

day 3; UA; urinary cultures

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26
Q

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

A

day 5; Doppler studies; heparin

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27
Q

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

A

day 7; cellulitis; abscess; sonogram

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28
Q

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

A

day 10-15; CT; percutaneous radiologically guided drainage

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29
Q

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

A

hypotension; ST depression; T-wave flattening

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30
Q

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

A

within first 2-3 days; chest pain

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31
Q

Best dx for MI; Tx postop MI

A

troponin; clot busters and/or emergency angioplasty/stent

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32
Q

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

A

50 to 90%

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33
Q

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

A

day 7

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34
Q

Sxs PE

A

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

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35
Q

PE arterial blood gases show ____ and ____

A

hypoxemia; hypocapnia

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36
Q

Std dx for PE; Std tx PE

A

CT angio; heparinization

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37
Q

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

A

heparinization + IVC filter (Greenfield)

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38
Q

When can you NOT use compression devices to prevent PE?

A

pt w/ LE fracture

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39
Q

Risk factors of PE where anticoagulation is indicated (5)

A

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

40
Q

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

A

Aspiration

41
Q

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

A

lethal; chemical injury

42
Q

Prevention aspiration postop

A

NPO and antacids before induction

43
Q

Tx aspiration

A

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

44
Q

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

A

tension pneumothorax

45
Q

Sxs of intraop tension pneumothorax

A

progressively more difficult to “bag”, BP steadily declines, CVP steadily rises

46
Q

Tx of intraop tension pneumothorax

A

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

47
Q

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

A

hypoxia; sepsis

48
Q

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

A

sepsis; bilateral pulmonary infiltrates, hypoxia; congestive heart failure

49
Q

Tx ARDS

A

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

50
Q

Delirium tremens usually occurs postop _____ in alcoholics. Sxs.

A

day 2 or 3; confused, hallucinations, combative

51
Q

Tx delirium tremens

A

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

52
Q

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]

A

confusion, convulsions, coma, death

53
Q

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

A

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

54
Q

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

A

posterior pituitary; unrecognized osmotic diuresis

55
Q

Sxs hypernatremia; Tx

A

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]

56
Q

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

A

ammonium intoxication; portocaval

57
Q

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

A

In-and-out bladder catheterization; Foley

58
Q

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

A

plugged or kinked

59
Q

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

A
60
Q

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

A

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

61
Q

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 ____.

A

40 mEq/L; >1

62
Q

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

A

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

63
Q

Paralytic ileus prolonged by _______.

A

hypokalemia

64
Q

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

A

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

65
Q

Confirmatory dx of mechanical bowel obstruction. Tx.

A

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

66
Q

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

A

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

67
Q

Sxs Ogilvie syndrome

A

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

68
Q

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

A

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

69
Q

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

A

day 5; open laparotomy

70
Q

Tx wound dehiscence

A

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

71
Q

Envisceration; MCC

A

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

72
Q

Temp tx envisceration before emergency reop

A

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

73
Q

Wound infections usually occur postop ____.

A

day 7

74
Q

_____ 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.

A

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

75
Q

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.

A

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

76
Q

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

A

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

77
Q

Tx GI fistulas

A

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

78
Q

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

A

one liter

79
Q

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

A

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

80
Q

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

A

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

81
Q

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

A

ADH; isotonic

82
Q

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

A

3% or 5%

83
Q

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

A

water restriction

84
Q

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.

A

isotonic; normal saline; lactate Ringers

85
Q

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

A

slow-onset; fast-onset

86
Q

Ultimate tx hyperkalemia; tx while waiting (3)

A

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)

87
Q

DDx Metabolic acidosis

A

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]

88
Q

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

A

acids are piling up (no loss of buffers)

89
Q

Tx Metabolic acidosis

A

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

90
Q

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

A

rebound alkalosis

91
Q

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

A

renal loss of K+; K+

92
Q

Metabolic alkalosis is due to _____ or ______

A

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

93
Q

Std tx metabolic alkalosis; sometimes ____ or ___ needed.

A

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

94
Q

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

A

Respiratory acidosis; respiratory alkalosis

95
Q

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

A

PET scan

Surgery Clerkship (7 decks)

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