General Surgery Flashcards
Why do we care about a patient’s EtOH/illicit drug use?
Possibility of withdrawal in OR or post op
Anesthesia interactions
When should tobacco ideally be discontinued prior to surgery?
8 weeks
Do CV medications need to be d/c before surgery?
In general, continue taking them
Hold ACE/ARBs 24 hours prior to NON-cardiac surgery
Should statins be held prior to surgery?
NO - reduced periop mortality so continue
Should Antiplatelet meds be d/c prior to surgery?
Increased risk of bleeding, so generally d/c 7-10 days prior
Why do we want to ensure tight glycemic control perioperatively?
Reduces mortality, infection, complications
When does a patient need to be NPO?
After midnight
Depends on the facility though - clear liquids up to 2 hr prior to procedure may be ok
How do we rate a procedural risk?
Mortality <1% = Low risk
Mortality ~1-5% = Intermediate risk
Mortality >5% = High risk
What are the different risk assessment tools we use in pre-op?
ACS NSQIP surgical risk calculator
Revised Cardiac Risk Index for Pre-Op risk
MELD (patients with cirrhosis)
CAPRINI (risk for DVT)
Potential causes of increased risk of complications
Pre-existing medical conditions Allergies Surgical Hx and related complications Meds Tobacco EtOH Illicit drugs
What is the best scoring system for functional capacity and therefore overall risk?
MET scores - determine’s patient’s exercise capacity
Should be applied to all surgical patients
A patient with 1 MET…
Can they... Take care of themself Eat, dress, use toilet Walk indoors around the house Walk 1 or 2 blocks on level ground at 2-3 mph
A patient with <4 METs
Can they…
Do light work around the house, such as dusting or washing dishes
A patient with ≥4 METs
Can they... Climb a flight of stairs or walk up hill Walk on level ground at 4 mph Run a short distance Do heavy house work Participate in moderate rec activities (golf, bowling etc)
A patient with ≥10 METs
Can they…
Participate in strenuous sports, such as swimming, singles tennis, football, basketball, skiing
A patient is considered to have poor functional capacity if their MET score is…
<4
Why is age a big risk factor for surgery?
Mortality increases linearly (>80yo significantly higher)
Comorbidities generally linked
Biological capacity declines with age
Nutritional status —> limited reserves
What is the most frequent cause of non surgical perioperative morbidity and mortality?
Acute MI
1/3 to 1/2 of perioperative deaths are due to cardiac events
Hx is best method of risk assessment
COPD increases perioperative risk by…
6 fold
Smoking increases perioperative risk by…
2 fold
Most common source of morbidity and mortality
Pulmonary complications
3rd most common complication of surgery
PNA - give them an incentive spirometer
Why should be perform PFTs perioperatively
Asthma optimized
SOB with unknown etiology
Lung resection surgery
WHo should get a CXR perioperatively?
New respiratory Sx
CHF
Valvular heart disease
Specific criteria for determining risk for sleep apnea
STOP BANG
What determines the level of risk for pulmonary complications from surgery?
The closer the surgery is to the diaphragm, the higher the risk
Most widely validated VTE risk assessment model in surgical patients
CAPRINI Score
Stratifies risk for VTE and provides validated recommendations for who should be d/c with continued prophylaxis
What happens to albumin levels in surgery?
Reverse acute phase reactant —> goes down with inflammation
Best way to assess patient’s nutrition status
Look at them not their labs
Thickened cystic wall, presence of pericholecystic fluid, leukocytosis, RUQ tenderness, fever, (+) Murphy’s sign
Cholelithiasis
Test of choice for cholelithiasis
US
When should you refer a patient for a cholecystectomy
After 1st episode of symptomatic cholelithiasis - don’t wait!
What are the complications of a cholecystectomy?
Bile leak
Retained CBD stone
Symptoms of diverticulitis
LLQ pain
Fever
Rectal bleeding
(Sometimes RLQ pain)
What makes diverticulitis complicated?
Abscess Phlegmon Fistula Obstruction Bleeding Perforation
Treatment for diverticulitis
NPO, abx, support
Colonoscopy to confirm Dx
Elective colectomy
Most common GI malignancy
Colon cancer
SSx of colon cancer
Iron deficiency anemia
Rectal bleeding
Change in bowel habits
Bowel obstruction
Treatment options for colon cancer
Surgical Adjuvant chemo (chemo after surgery)
Right or left hemicolectomy
LAR or APR
What are APR and LAR?
Abdominopelvic Resection vs Low Anterior Resection
Both done to remove rectal cancer
_____ is used to remove cancers well above the anus
LAR (Low Anterior Resection) - provides better quality of life as it preserves the sphincter
____ is for cancers close to the anus
APR (Abdominopelvic Resection)
Removes the sphincter and a permanent colostomy is made
When are prophylactic abx given prior to surgery?
Within 1 hour of incision time
D/c after 24 hours post op
Should you remove hair prior to surgery?
According to Burt, no
Use clippers immediately prior to preparation of surgical field
What should the patient do to prep skin at home prior to surgery?
Shower with antimicrobial soap night before surgery
Chlorhexidine solutions preferred
When should I&Os be evaluated post op and why?
Every 4-6 hours POD 1
Every 24 hours POD 2 and beyond
To monitor electrolytes and balance fluids, and prevent fluid overload
How do we prevent atelectasis in post op patients
Incentive spirometry and early mobilization
What is the order in which GI function returns and when?
Small intestine first - 24 hours
Stomach - 36 hours
Ascending colon - 48 hours
Descending colon - 72 hours
What are normal caloric needs vs ‘stressed’ patients needs
Normal:
25-30 kcal/kg/day
0.8-1g protein/kg/day
Stressed:
50 kcal/kg/day
2.5g protein/kg/day
When is pain worst?
POD 3 - varies based on type of incision and magnitude of intraoperative retraction
An inherited, autosomal dominant hypermetabolism involving skeletal muscle after exposure to succinylcholine —> Exothermic response, Rhabdomyolysis, cerebral edema, DIC
Malignant hyperthermia
What is one of the earliest signs of malignant hyperthermia?
Increased CO2
Antidote to malignant hyperthermia
Can’t role even
Procedure that connects ileum to the abdominal wall
Ileostomy
When is an End Ileostomy used?
Entire colon removed (like in UC or FAP)
Permanent procedure
What is a Loop Ileostomy?
Loop of ileum brought to the skin, efferent and afferent ends
Temporary
Procedure that connects the colon to teh abdominal wall
Colostomy
Can be either temporary or permanent
Removal of diseased rectosigmoid colon, closure of anorexia stump and end colostomy
Hartman’s Procedure
Indications: UC Recto-sigmoid cancers Sigmoid volvulus Rectal injuries
Who are SBOs usually treated
Fluid resuscitation and NG tube
To the OR if necessary
Keys to IHS SBO protocol
Insert NG tube and place on suction
2 hours after NG tube placement, give 90 ml of undiluted gastrograffin via NG tube, clamp for 1 hour then return to suction
KUB
Constant reassessment
