General Surgical Concepts

Question 1

You’re conducting your preoperative assessment, what are some risk factors you are looking out for?

Answer 1

• age, exercise capacity, alcohol, smoking, illicit drug use, and medication use
• bleeding
• allergies
• hx / fam hx of clotting issues
• CA, GI disease and diuretic use prone to hypovolemia
• Vascular disease (TIA, PAD, DM)

Question 2

You’re conducting your preoperative assessment, what are some things you will do/look for on PE?

Answer 2

Full PE

• neuro
• assessment of peripheral arterial pulses, adequacy of circulating blood volume via fullness of neck veins in supine and partially erect position, orthostatic BP and pulse.
• Rectal and pelvic exam based on pts disease and health maintenance schedule.

Question 3

You’re conducting your preoperative assessment, what labs will you order?

Answer 3

• If pt healthy, then routine labs have poor predictive value.
• HgB if > 65 and those with expected sig. blood loss
• Scr (>2.0 predicts post op cardiac complications): get in pt’s over 50 in PTs w/ renal disease, experiencing hypovolemia or when nephrotoxic drugs to be used.
• HCG in reproductive age females
• ECG: known CAD, arrythmia, PAD, CVD, heart disease
• CXR and PFT if >50 and getting thoracic or abd surg.

Question 4

The Doc tells you to take care of the informed consent, what will you discuss w/ the patient?

Answer 4

• PARQ, may need blood transfusion
• often discussed w/ next of kin
• needs to be charted

Question 5

What convention is used for assessing anesthesia risk?

Answer 5

The American Society of Anesthesiologists’ Classification of Physical Status

ASA 1 normal healthy PT
ASA 2 PT w/ mild systemic disease
ASA 3 PT w/ severe systemic disease that is limiting but not incapacitating
ASA 4 PT w/ incapacitating disease that is a constant life threat
ASA 5 Moribund PT not expected to live > 24 hrs
ASA 6 Declared brain dead person who’s organs are being removed for donor purposes
E designation for emergency surgeries

Question 6

Name three major categories for Surgery-related morbidity and mortality

Answer 6

cardiac, respiratory and infectious complications

Question 7

How many surgeries have at least one or more complications?

Answer 7

17%

Question 8

You find out your patient is taking ASA, Clopidogrel, Motrin, and an oral anticoagulant (warfarin, dabigatrian,etc.). How will you counsel them for each drug in regards to prepping for surgery?

Answer 8

Aspirin should be discontinued 7-10 days before surgery thienopyridines (such as clopidogrel) for 2 weeks before surgery

Selective cyclooxygenase-2 (COX-2) inhibitors do not potentiate bleeding and may be continued until surgery.

Oral anticoagulants should be stopped 4-5 days prior to invasive procedures, allowing INR to reach a level of 1.5 prior to surgery

Question 9

How do you assess bleeding risk?

Answer 9

Hx

PE

If no flags on Hx/PE then no labs needed

If flags then PT, aPTT and platelets and possibly LFT, Scr, CBC and smear.

Question 10

How do you determine the appropriate use for VTE prophylaxis?

Answer 10

• stratify risk (high if extensive surgery, lots of anesthesia and prolonged immobilization plus PT specific RF’s like age, smoker, CA, obese, coagulopathy)
• Caprini Risk assessment is often used.

-if contraindications to bleeding risk then use mechanical methods until bleeding risk low enough to use LMWH.

• low risk: early and frequent ambulation
• low mod risk: mechanical devices (SCD)
• mod risk: LMWH until discharge
• High risk: LMWH/warf until one month post discharge

Question 11

Surgery is scheduled and its time for bowel prep! What now?

Answer 11

• Rid colon of stool the night before surgery
• PEG (have to drink a lot, can cause Nausea and bloating) or mag citrate ( better tolerated, can cause electrolyte abnormalities.

Question 12

Big Bob is ready for his surgery tomorrow and wants to know why he can’t eat anything….

Answer 12

-it reduces risks for aspiration!
ASA NPO guidelines:

UNLESS OTHERWISE INSTRUCTED, BEFORE ELECTIVE PROCEDURES, THE MINIMUM DURATION OF FASTING SHOULD BE:

8 hours for a normal meal
6 hours for a light meal (toast and clear liquids)
2 hours for clear liquids

Question 13

What are the indications for NG tubes?

Answer 13

DX: upper GI bleed, poison w/ tablets
TX:
-upper GI bleed,
-prep for endoscopy,
-prevention of vomiting/asp,
-decompress GI during small bowl obstruction,
-to admin drugs for PTs post stroke/alt MS to reduce asp. risk

Question 14

What practice do many institutions maintain preoperatively in order to prepare for more than expected blood loss during surgery?

Answer 14

Blood type, cross and screen in case of urgent blood transfusion.

Question 15

Jim’s set for surgery on his abdomen, what are the routine preoperative medications given?

Answer 15

• anxiolytic like midazolam
• opiate (fentanyl)
• -or–
• thorough explanation and discussion of expectations w/ patient has similar calming effect

-H2 blockers, PPI or antacid to reduce gastric acid production and thereby decrease aspiration risk.

Question 16

Do you use presurgical ABX?

Answer 16

• only if active infection, GI surgery w/out bowel prep and colorectal surgery.
• Oh and if you are putting in prostheses (cardiovascular or orthopedic)

start at time of anesthesia and stop at end of surgery. If colorectal then start a few hours before.

Question 17

Your patient finished the operation, now where to?

Answer 17

Post operative care unit (PACU)

Question 18

What are the most common PACU issues?

Answer 18

• nausea and vomitting
• respirator problems (hypoxemia): atelectasis, pulmonary aedema, PE, narcotics, anesthesia, tec.
• other: hypo/htn, hypothermia, delirium, urinary retention

Question 19

In the PACU who is in charge of cardiopulmonary function? Surgical site care?

Answer 19

Anesthesiologist

Surgeon

Question 20

How long does it take for cardio, pulmonary and neuro fx to return to normal after surgery? What if they don’t?

Answer 20

1-3 hours, if not then ICU