Intro to Surgery Flashcards
What are preop diagnostics that patients need to obtain?
- EKG - >50 years old, vascular sx, hx of HTN/CAD/Respiratory dysfunction/DM
- CXR >50 years old, significant underlying pulmonary disease, malignancy
- PFTs
- Echo- assess pump function
- cardiac stress test
- ABG baseline
7.Carotid U/S
American Society of Anesthesiologists classification system (ASA)
stratifies how patients may tolerate an operation
ASA PS1-6
1 normal healthy patient
2 patients with mild systemic disease
3 patients with severe systemic disease
4 patients with severe systemic disease that is a constant threat to life
5 moribund patients who are not expected to survive without the operation
6 brain dead pts who organs are being removed for donor purposes
When do you want to perform a stress test?
- unstable angina, severe valvular disease, recent MI, significant arrythmias
- vascular operations in patients who have risk factors and poor functional capacity (METS <4)
- Abnormal EKG
When do you want to perform a cardiac cath/revascularization?
for those with Left Main CAD, stable angina with 2V-3V disease, proximal LAD, EF <50%, ischemia on stress test, NSTEMI, acute STEMI.
No routine revascularization for asymptomatic ischemia or stable angina
What is the preop protocol for patients on cardiac medications?
- Betablockers- continue, those having vascular surgery have a high cardiac risk
- ASA must weight risk/benefit
- Plavix held 5 days before sx-RISK
- oral anticoagulants: depending on agent, 1/2 life and urgency of sx
What are post op pulmonary complications that you want to avoid?
ATX/PNA
ventilator dependence
PE
How do you prevent pulmonary complications?
” I COUGH”
I: incentive spironometry
C: cough/deep breathing
O: oral hygeine, tooth brushing and mouth care
U: understanding- patient and family education
G: getting out of bed-mobilization
H: head of bed elevation
Venous thromboembolism prevention
- Hypercoagulability
-estrogen therapy
-inflammation
-dehydration - Vascular Damage
-physical trauma, strain, injury
-microtrauma to vessel wall - Circulatory stasis
-congenital abnormalities affecting venous anatomy(e.g. may- thurner and paget schroetter syndrome)
-low HR (brady) and low BP
slide 33,34
What is the serum glucose recommendation for pts with diabetes?
120-180
What is a red flags for a patient with diabetes
pre-op glucose > 300, assess for ketones/acidosis
What do you want to use if you need to quickly treat hyperglycemia peri op?
IV insulin vs bolus (rapid onset, short half life, immediate availability)
How can we prevent surgical site infections (SSI)?
- antibiotic ppx within 1 hour of incision vs scheduled antibiotics
- Glycemic control
- Surgical technique (limit blood loss, tissue trauma)
- Tissue oxygenation
- Change instruments including PPE to close wounds
6*** CLEAN WOUND Ancef vs Ancef + Flagyl (Ancef+ flagyl: colorectal/GYN, Urology involving urinary tract/intestine) ** - **CONTAMINATED: Rocephin (ceftriaxone) + Flagyl **
- If PCN allergic: Clinda and Gentamycin***
- MRSA: Vancomycin
Blood and Fluids can minimize cardiac and renal complications. Goal directed therapy minimizes risk for …….
pulmonary edema, ileus, wound infections, anastomosis, shorter hospital stay
Inadequate pre op steroids can result in ______________ with ____________ instability and death.
addisonian crisis, HD
You want to consider a supplemental steroid if…..
- current regimen is 5-20 mg prednisone for 3 weeks or longer
- Hx of >3 week course of 20mg
- significant history of chronic topical steroid use >2g/day on large area of skin
Thyrotoxicosis must be corrected to avoid _____________. Significant hypothyroid can induce __________ and ___________ collapse(IV doses may be higher to replete).
thyroid storm, hypothermia, CV
You want to be cautious with CT with IV contrast in patients with significant goiter because it may cause ____________
thyrotoxicosis
________________ increases the risk for surgical site infections by 5x
hypoalbuminemia (alb <3.0 mg/dl)
What meds do you want to use for the acute treatment of prevention/treatment of withdrawl for alcohol?
ativan/lorazepam
What is the pre op protocol for a patient with cancer
tumors have to be restaged before resection
certain chemo agents may affect wound perfusion/healing(best to wait 4-6 weeks before surgery)
Preop instructions: Medications with Sips
Beta blockers, CCB, nitrates, statins, hormones, cardiac rythmic drugs, COPD, GERD
ACE/ARBS held due to refractory HYPOtension risk
Diuretics held the morning of surgery
Continue chronic narcotics- methadone
Caution with MAO inhibitors
Aspirin held 1 week (unless needed for CV reasons)
Elective: coumadin held 5 days prior- do they need a bridge?
What are the 3 phases of post op?
- immediate, post anesthetic phase
- intermediate-hospitalization
- convalescent phase-post d/c
What are the primary causes of early complications and death following major surgery?
acute pulmonary, cardiovascular, fluid derangements
What are the 5 W’s of post op fever?
- Wind- respiratory infection if they have pneumonia, low grade temp from atelectasis(alveoli from lungs collapsed on themselves and can see evidence of it on chest XR)
- Wound- look at surgical wound- bowel smell, make sure skin is intact
- Water- urination, could fever come from UTI- place catheter so risk for infection
- Wonder Drug- side affects of these drugs are a fever (e.g. phenytoin which is an anti seizure med, cephalosporins, procinimide which is an anti arrythmic, drug for TB and malaria (quinidine)
- Walking- DVT or PE could cause fever.
When is a fever concerning? If _______ or more are present: nearly 100% sensitive for bacterial infection.
- pre-op trauma
- ASA > class 2
- FEVER >48 HRS POST OP
- Initial temp above 38.6C (101.4F)
- Post op WBC >10k
- Post op BUN>15mg/dl
3
What can a post op fever <48 hours indicate?
atelectasis
What can a day 2 post op fever indicate?
phlebitis
pneumonia
UTI
> 5 days post op: fever is rare without infection. What do you want to consider?
wound infection, anastomosis breakdown, intra abd abscess/leak
consideration for CT E/P +/- chest CT
What are the 3 classifications of surgical site infections and what are the risks?
- superficial incisional
- deep incisional
- organ space
age, nutritional status, DM, smoking, obesity, co-existing infection/colonization, altered immune response, duration of stay, steroid use, operative technique
Seroma (wound complication)
localized fluid not containing pus/blood. fills space under the skin.
-delay healing and increase risk of infection
-self limiting vs aspiration
compression dressing prevents reaccumulating
Hematoma(wound complication)
collection of blood or pus adjacent to incision
-common after hemotosis isnt fully achieved
-swelling and ecchymosis adjacent to wound edges +/- bloody drainage
-at risk pts include those on asa/OACs
-self resolving vs I/D
-CAUTION THE NECK
Dehiscence (wound complication)
partial or complete disruption of any or all layers of wound
most common POD#5-8
eviscertion- rupture of ALL layers of the abdominal wall and extrusion of abd contents SX EMERGENCY
What are the risk factors associated with dehiscence and what are ways to prevent it?
risks: inadequate closure, increased intra-abdominal pressure, deficiency wound healing.
prevention: abd binder, pillow, retention sutures, stool softeners, avoid coughing, straining avoid other wound healing complications
