High-Yield Surgery Flashcards
What to monitor with Toradol? Tylenol?
NSAID
- SCr, Hgb
- 15mg IV q 6hr
Tylenol - LFTs
Surgery progress note
24hr interval: fever, chills, SOB, CP, eating, NGT output, BMs, foley
Plan:
- pain mgmt
- I&Os
- DVT ppx
- pulm toilet
- labs
- functional status
- PO status
- diet
Post Op Infection
PNA, UTI, wound infection (cellulitis, central line infection)
5-7d out –> abscess
Causes of fever
Wind: atelectasis, PNA (POD 1-2)
Water: UTI, esp w/foley (POD 2-3)
Wound: incision site, cellulitis, abscess (after 72hr, POD 5-7)
Walking: DVT, PE, thrombophlebitis (after 72hr)
Wonder drug: drug reaction
Whole blood: transfusion reaction
Work up:
- <48hr postop does not need workup
- > 48hr postop: CXR, blood culture x2, urine culture
- fever >1wk is a serious complication unless drug allergy
Fluids
Resuscitative fluid (postop) = lactated ringer Maintenance: D5 1/2NS + KCl IV Fluids + TPN + Lipids = 100cc/hr
Electrolyte goals for surgery
K+5
- tablet KCl is C.I. w/SBO
- if dumping, liquid >tablet
Phos 3
Mg 2
- if 1.5 give 2mg Mg sulfate; 1.2 give 4mg Mg sulfate
Preop abx
Flagyl + Neomycin
Pancreatitis Etiologies
I GET SMASHED
Idiopathic Gallstones EtOH Trauma/Trigs Steroids Mumps Autoimmune Scorpion bite Hyperlipidemia/HyperCa ERCP Drugs
Voiding trial
Give 8hr to void after removing foley
Bladder scan if no void; if >600 = straight cath
Diagnostic imaging first lines
Appendicitis: abd CT (US in kids, pregnancy) Chronic pancreatitis: ERCP Gallbladder: US Diverticulosis: barium enema Diverticulitis: CT scan Achalasia: barium swallow Zenker's diverticulum: barium swallow UGIB: endoscopy PE: pulmonary angiogram
Courvisier’s sign
palpable, nontender gallbladder
indicates compression or obstruction of distal CBD d/t mass = pancreatic cancer
Trosseau’s sign
hypercoagulable state created by malignancy
migratory thrombophlebitis throughout body
Whipple procedure
Pancreatic cancer
Pancreatoduodenectomy
Most common kinds of cancer
Colon: Adenocarcinoma
Gallbladder: Adenocarcinoma
Pancreas: Adenocarcinoma (ductal) - CA 19-9
Prostate: Adenocarcinoma (MC cancer in men U.S.)
Liver HCC (AFP levels)
Renal: renal cell carcinoma
Small bowel: carcinoid tumors (ileum)
Esophageal: SCC
Anal: SCC
Vulvar: SCC (risk - lichen sclerosis)
Bladder cancer: transitional cell carcinoma (smoking)
Breast: IDC
Carcinoid tumors tend to be in appendix
Thyroid: papillary carcinoma (radiation = risk)
Coagulation cascade
common pathway: II, V, X
PT: coumadin
- extrinsic, common pathways (VII)
PTT: heparin
- intrinsic pathway (VIII, IX, XI, XII)
Bowel obstruction
1 = adhesions (western nations)
Worldwide - hernias
Other: malignancy
Ogilvie’s syndrome
Idiopathic pseudo-obstruction
Enormous dilation of right colon w/out obstruction
Mgmt:
- bowel rest
- IVF
- rectal decompression tube via scope
MC Vascular procedure
CEA
Renal cell carcinoma triad
MC solid renal tumor
Flank pain
Hematuria
Palpable mass
Sutures
Vicryl: absorbable
Nylon: non-absorbable
Malignant hyperthermia
IV dantrolene
Gastric ulcers should…
undergo bx for risk of carcinoma
Ileus causes
laparotomy
hypoK
narcotics
intraperitonal infection
Virchow’s node
Left supraclavicular
Sister mary joseph node
Umbilical
Necrotizing fascitis
Renal impairment - hallmark
- WBC > 14
- BUN > 15
- HypoNa < 135
Pressure ulcers
Stage I: intact skin w/blanching erythema
Stage II: partial-thickness skin loss - breakdown of dermis from abrasion, blister, shallow ulcer crater
Stage III: full thickness skin loss extending SubQ but not beyond fascia
Stage IV: full thickness, SubQ loss, extending to muscle tendon, bones, joint
Factors affecting perioperative mortality (Goldman’s index)
- CHF (EF <35% - no surgery)
- MI w/in 6mo (Check ECG, stress test, cath, reperfusion)
- Arrhythmia
- Age > 70
- Emergent surgery
- AS, poor medical condition, surgery in chest/abd
- always check for AS murmur [late systolic, crescendo, decrescendo murmur radiating to carotids, increased w/squatting]
Meds to stop prior to surgery
Aspirin, NSAIDs, Vit E: 2wk
Warfarin: 5d, drop INR to 1.5 (use Vit K if needed)
1/2 AM dose of insulin if diabetic [lactic acid risk w/metformin]
CKD on dialysis: dialyze 24hr preop
BUN>100: increased risk of postop bleed secondary to uremic platelet dysfunction
Ventilation Settings
Assist control: set tidal volume and rate but if pt takes a breath vent gives the volume
Pressure support: pt rules rate but a boost of pressure is given; important for weaning
CPAP: pt must breathe on own but positive pressure given at all times
PEEP: pressure given at end of cycle to keep alveoli open; used w/ARDS and CHF
Ventilation - best tests to evaluate management
ABG
PaO2 low: increase FiO2
PaO2 high: decrease FiO2
PaCO2 low (high pH): decrease rate or TV
PaCO2 high (low pH): increase rate or TV
TV is more efficient to change
- more air goes into function space vs. increasing rate is getting more air into dead space
Fluids & Nutrition
Maintenance IVF: D5 1/2NS + 20KCl
4:2:1 rule when calculating cc/hr
Daily requirements: 100mL/kg/d for first 10kg, 50mL/kg/d for next 10kg, 20mL/kg/d for all kg above 20
Enteral feeds are best: keep gut mucosa intact and prevent bacterial translocation
TPN indication:
- gut cannot absorb nutrients secondary to physical or functional loss
- risks: acalculus cholecystitis, zinc deficiency, hyperglycemia, liver dysfunction, electrolyte problems
HIT
postop, decreased Plt, clots
Tx: agatroban (synthetic heparin)
DIC
low Plt, increased PT/PTT, low fibrogen, high d-dimer, schistocytes
Lung Cancer
Low PTH –> hypercalcemia –> SCC
[SIADH from small cell carcinoma]
Peripheral: adenocarcinoma, large cell
Central: squamous, small cell
Small cell = no surgery -> chemo, radio-sensitive
Non-small cell = surgery - adenocarcinoma, squamous, large cell
Right-sided murmurs get louder with
inspiration
