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Emed/Surg > Intro to Surgery > Flashcards

Intro to Surgery Flashcards

1
Q

What are preop diagnostics that patients need to obtain?

A
  1. EKG - >50 years old, vascular sx, hx of HTN/CAD/Respiratory dysfunction/DM
  2. CXR >50 years old, significant underlying pulmonary disease, malignancy
  3. PFTs
  4. Echo- assess pump function
  5. cardiac stress test
  6. ABG baseline
    7.Carotid U/S
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2
Q

American Society of Anesthesiologists classification system (ASA)

A

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

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3
Q

When do you want to perform a stress test?

A
  1. unstable angina, severe valvular disease, recent MI, significant arrythmias
  2. vascular operations in patients who have risk factors and poor functional capacity (METS <4)
  3. Abnormal EKG
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4
Q

When do you want to perform a cardiac cath/revascularization?

A

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

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5
Q

What is the preop protocol for patients on cardiac medications?

A
  1. Betablockers- continue, those having vascular surgery have a high cardiac risk
  2. ASA must weight risk/benefit
  3. Plavix held 5 days before sx-RISK
  4. oral anticoagulants: depending on agent, 1/2 life and urgency of sx
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6
Q

What are post op pulmonary complications that you want to avoid?

A

ATX/PNA
ventilator dependence
PE

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7
Q

How do you prevent pulmonary complications?

A

” 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

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8
Q

Venous thromboembolism prevention

A
  1. Hypercoagulability
    -estrogen therapy
    -inflammation
    -dehydration
  2. Vascular Damage
    -physical trauma, strain, injury
    -microtrauma to vessel wall
  3. Circulatory stasis
    -congenital abnormalities affecting venous anatomy(e.g. may- thurner and paget schroetter syndrome)
    -low HR (brady) and low BP
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9
Q

slide 33,34

A
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10
Q

What is the serum glucose recommendation for pts with diabetes?

A

120-180

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11
Q

What is a red flags for a patient with diabetes

A

pre-op glucose > 300, assess for ketones/acidosis

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12
Q

What do you want to use if you need to quickly treat hyperglycemia peri op?

A

IV insulin vs bolus (rapid onset, short half life, immediate availability)

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13
Q

How can we prevent surgical site infections (SSI)?

A
  1. antibiotic ppx within 1 hour of incision vs scheduled antibiotics
  2. Glycemic control
  3. Surgical technique (limit blood loss, tissue trauma)
  4. Tissue oxygenation
  5. Change instruments including PPE to close wounds
    6*** CLEAN WOUND Ancef vs Ancef + Flagyl (Ancef+ flagyl: colorectal/GYN, Urology involving urinary tract/intestine) **
  6. **CONTAMINATED: Rocephin (ceftriaxone) + Flagyl **
  7. If PCN allergic: Clinda and Gentamycin***
  8. MRSA: Vancomycin
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14
Q

Blood and Fluids can minimize cardiac and renal complications. Goal directed therapy minimizes risk for …….

A

pulmonary edema, ileus, wound infections, anastomosis, shorter hospital stay

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15
Q

Inadequate pre op steroids can result in ______________ with ____________ instability and death.

A

addisonian crisis, HD

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16
Q

You want to consider a supplemental steroid if…..

A
  1. current regimen is 5-20 mg prednisone for 3 weeks or longer
  2. Hx of >3 week course of 20mg
  3. significant history of chronic topical steroid use >2g/day on large area of skin
17
Q

Thyrotoxicosis must be corrected to avoid _____________. Significant hypothyroid can induce __________ and ___________ collapse(IV doses may be higher to replete).

A

thyroid storm, hypothermia, CV

18
Q

You want to be cautious with CT with IV contrast in patients with significant goiter because it may cause ____________

A

thyrotoxicosis

19
Q

________________ increases the risk for surgical site infections by 5x

A

hypoalbuminemia (alb <3.0 mg/dl)

20
Q

What meds do you want to use for the acute treatment of prevention/treatment of withdrawl for alcohol?

A

ativan/lorazepam

21
Q

What is the pre op protocol for a patient with cancer

A

tumors have to be restaged before resection
certain chemo agents may affect wound perfusion/healing(best to wait 4-6 weeks before surgery)

22
Q

Preop instructions: Medications with Sips

A

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?

23
Q

What are the 3 phases of post op?

A
  1. immediate, post anesthetic phase
  2. intermediate-hospitalization
  3. convalescent phase-post d/c
24
Q

What are the primary causes of early complications and death following major surgery?

A

acute pulmonary, cardiovascular, fluid derangements

25
Q

What are the 5 W’s of post op fever?

A
  1. 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)
  2. Wound- look at surgical wound- bowel smell, make sure skin is intact
  3. Water- urination, could fever come from UTI- place catheter so risk for infection
  4. 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)
  5. Walking- DVT or PE could cause fever.
26
Q

When is a fever concerning? If _______ or more are present: nearly 100% sensitive for bacterial infection.

A
  1. pre-op trauma
  2. ASA > class 2
  3. FEVER >48 HRS POST OP
  4. Initial temp above 38.6C (101.4F)
  5. Post op WBC >10k
  6. Post op BUN>15mg/dl

3

27
Q

What can a post op fever <48 hours indicate?

A

atelectasis

28
Q

What can a day 2 post op fever indicate?

A

phlebitis
pneumonia
UTI

29
Q

> 5 days post op: fever is rare without infection. What do you want to consider?

A

wound infection, anastomosis breakdown, intra abd abscess/leak
consideration for CT E/P +/- chest CT

30
Q

What are the 3 classifications of surgical site infections and what are the risks?

A
  1. superficial incisional
  2. deep incisional
  3. organ space

age, nutritional status, DM, smoking, obesity, co-existing infection/colonization, altered immune response, duration of stay, steroid use, operative technique

31
Q

Seroma (wound complication)

A

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

32
Q

Hematoma(wound complication)

A

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

33
Q

Dehiscence (wound complication)

A

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

34
Q

What are the risk factors associated with dehiscence and what are ways to prevent it?

A

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

Emed/Surg (13 decks)

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