Lecture 9 (Surgery)-Exam 4 Flashcards
InformedConsent
* Recognition of what?
Recognition of patient autonomy,there is a need to provide adequate information sothat informed decisions can be made.
InformedConsent
* What do patients need to understand? (6)
- the expected surgical procedure, as well as invasive monitoring devices used
- the disease process itself
- the natural course of the disease
- risks, benefits and potential alternatives
- most common and serious risks of the procedure
- and expected recovery time
InformedConsent
* What needs to be completed prior to any surgical procedure taking place?
* If the patient refuses, what needs to happen?
*
Documentation of informed consent by the patientshould be completed prior to any surgical procedure taking place.
If the patient refuses to have the surgical procedure, then itshould be thoroughly documented as well
* Usually this ismuch more involved and detailed then the consent to do the procedure
AdvancedDirectives
* What is it?
* What are the examples?
Legal documents that allow patients to provide specific instructions during times they cannot communicate wishes.
Examples include:
* Living wills: withdrawal of medical treatment, not nutrition or hydration.
* Durable Powers of Attorney: legally designate a surrogate or proxy
Preoperative Evaluationand Managment
* What needs to be done?
Specific Considerations in Preoperative Management
Cerebrovascular disease
* Majority are caused by what type of events?
* What are the risk factors?(5)
Majority, 80% of events are postoperative, caused by hypotension and atrial fibrillation.
Risk factors:
* previous CVA, hypertension as well as coronary artery disease
* diabetes and tobacco use
SpecificConsiderationsin Preoperative Management
* What is present?
* Recent what?
Asymptomatic carotid bruit
Recent transient ischemic attack
* symptomatic carotid artery stenosis should have stents placed
SpecificConsiderationsin Preoperative Management
Cardiovascular disease
* What are the RFs? (4)
* What index?
Risk factors
* age,recent MI,untreated CHF,diabetes
Revised cardiac risk index
* low, intermediate,high risk
SpecificConsiderationsin Preoperative Management
Cardiovascular disease
* What is the testing?
* What is the preoperative management?
Preoperative testing, intermediate risk requires additional such as
* ECG
* exercise stress testing
* invasive testing such as angiography
Preoperative management
* beta blocker medications
* may need to delayfor an extended periodsuch as after coronary angioplasty, stenting
SpecificConsiderationsin Preoperative Management
Pulmonary disease
* Who needs preoperative evaluation and screening? (4)
* What is the PE?(3)
Preoperative evaluation and screening
* COPD, smoking,advanced age and obesity
Physical exam
* chest X-ray
* arterial blood gas
* preoperative pulmonary function test
SpecificConsiderationsin Preoperative Management
Pulmonary disease
* What is the preoperative prophylaxis management?
- antibiotics
- incentive spirometry device
- cessation of smoking
- bronchodilators
SpecificConsiderationsin Preoperative Management
Renal disease
* What are the risk factors?
- underlying medical disease such as diabetes,HTN can increase creatinine levels,will have impact on medications used
- other electrolyte abnormalitiest hat could delay surgery or make a higher risk to undertake it
- the type of operative procedure can increase mortality and morbidity
SpecificConsiderationsin Preoperative Management
Renal disease
* What is the evaluation?
* What is the management?
Evaluation
* history
* physical examination
Management
* dialysis
* volume status, hypovolemia, volume overload poorly tolerated
* limited use of contrast/dyes and other nephrotoxins
SpecificConsiderationsin Preoperative Management
Diabetes:
* Target what?
* Assess what?
* Adjust or withold waht?
- target blood glucose levelsto help reducethe risk of perioperative hyperglycemia or hypoglycemia.
- assess the HbA1c levels to gaugelong-term glycemic control.Generally, should bebelow 7% for elective surgeries.
- adjust or withhold oral medications on the day of surgery. Metforminis withheld toavoid the risk of lactic acidosis.
SpecificConsiderationsin Preoperative Management
Diabetes:
* What therapy is modified?
* What is associated with an increased risk of infections?
* What can cause hyperglycemia?
- insulin therapy is modified to maintain appropriate glucose levels, short acting preferred.Glucoselevels will be maintainedwhile in hospital.
- poor glycemi ccontrol is associatedwith an increased riskof infections.
- surgical stresscan cause hyperglycemia.
Adrenal Insufficiency/ Steroid Dependence
* Requires what?
* Determine what?
* May require what?
- requires careful planning and coordination to avoid adrenal crisis and ensure hemodynamic stability during and after surgery.
- determine thetype, dose, and duration of steroidtherapy.
- may require”stress dose”steroids to mimicthe naturalincrease in cortiso production inresponse tosurgical stress.
Adrenal Insufficiency/ Steroid Dependence
* What do you for minor, moderate and major surgery?
minor surgery
* Continue usualdoseof steroids
moderate surgery
* Hydrocortisone 50-75 mg IV atthe induction of anesthesia, followed by25-50mg every6-8 hours for 24 hours.
major surgery
* Hydrocortisone100 mg IV at induction, followed by50 mgIV every6-8 hours for24-48 hours,gradually tapering backtotheir normal dose.
Anticoagulation
* Determine what?
* Assess the risk of what?
- determine the reason for anticoagulation such as atrial fibrillation, mechanical heart valve, venous thromboembolism.
- assess the riskof thromboembolism if anticoagulationis interrupted. Using a risk assessment score such as CHADS2to determine the risk of developing a stroke
Anticoagulation
* Evaluate what?
* What can assistinthe timing of discontinuation?
- evaluate thebleeding risk associated with the planned surgery.
- the type of anticoagulant and the timing of the last dose can assist inthe timing of discontinuation.
Anticoagulation
* when is warfarin stopped and restarted? DOCAS?
Warfarin
* typically stopped 5 daysbefore surgery to allowINR to dropbelow1.5
* restarted12-14 hoursat the patient’s usual dose
DirectOral Anticoagulants (DOACs) -Eliquis, Xarelto
* generally stopped 24-48 hoursbefore surgery, depending on half-life, renal function andbleeding risk of the procedure
* typically restarted 24-72 hours postoperatively, depending on bleeding risk
Anticoagulation
* when is Low MolecularWeight Heparin
stopped and restarted?
- usually stopped24 hoursbefore surgery
- can be restarted 24 hours after the procedure
Preoperative Evaluation
Preoperative Evaluation
* What are the coagulation studies? Results should be what?
* UA?
Preoperative Evaluation
* Who gets ECG? CXR?
Electrocardiography
* generally recommended if over 40 yoa
Chest radiography
* may be indicated if over the age of 60, little evidence supports routine chest radiography in patients without risk
Preoperative Evaluation
* Spirometry?
* Pregnancy?
Spirometry
* preoperative spirometry for patients being evaluated for thoracic and upper abdominal surgery and for those with a smoking history
Pregnancy
* indicated for all women of childbearing age who are to undergo surgery
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SurgicalProphylaxis
* Long story short, what antibiotic do you give for most cases?
Cefazolin
Surgical Nutrition:
* Malnourished patient is defined as what?
* Risks of malnutrition include what?
- Malnourished patient is defined as someone who has lost more than 10% of his or her mean body mass and/or has not had adequate nutritional intake for more than 7 days.
- Risks of malnutrition include greater incidence of infection, immune dysfunction, wound complications, and operative morbidly and mortality.
Surgical Nutrition: Clinical features
* What may be apparent?
* Decreased what?
* Subtile what?
- Weight loss, reduction of subcutaneous fat stores, and wasting may be apparent.
- Decreased cognitive function
- Subtle changes in skin, hair may occur
Surgical Nutrition: Physiologic impact
* Cardiovascular system will develop what?
* Respiratory system will undergo what?
* GI tract will develop what?
* Ultimately, what will develop? ⭐️⭐️⭐️
- Cardiovascular system will develop decreased myocardial mass, stroke volume and output.
- Respiratory system will undergo catabolism of major muscles for respirations.
- GI tract will develop atrophy of villa, with overgrowth of bacteria.
- Ultimately poor wound healing will develop, with an increased incidence of wound infection, dehiscence, and evisceration (cannot stay together)
Surgical Nutrition: Dx studies
* What are the measures?
- Serum creatinine, albumin, prealbumin.
- BMI, arm circumference, and nitrogen balance are useful parameters to measure overall status.
Surgical Nutrition:
* What is the treatment?
- Replacement of caloric and nitrogen requirements necessary to maintain nutritional homeostasis or prevention of catabolism.
- Preferred nutritional replacement is always via the enteral route to maintain GI viability and aid in the prevention of multisystem organ dysfunction.
- Another option is the use of peripheral or central catheters.
Surgical Nutrition:
* What are the complications?
- Diarrhea caused by osmotic loading is a common complication and can be controlled by limiting concentration or rate of infusion.
- Never assume that diarrhea is solely from enteral feeding, and always consider Clostridium difficile as a potential etiology.
Truma:
Primary Survey:
* Asssuring what?
* What is the next priority?
* Tension pneumothorax?
* What should never be completely occluded?
Assuring a patient has a functioning airway is the priority.
Breathing is the next priority in the trauma patient
* Tension pneumothorax – lack of breath sounds on affected side, hyperresonance on the affected side and subcutaneous emphysema – chest decompression
Open chest wounds should never by completely occluded.
Primary Survey
* flail chest is characterized by what? What is the main problem?
* What should be assessed after airway and breathing have been secured? What may be needed?
Flail chest is characterized by paradoxical breathing.
* main problem is the lung contusion
Circulation status should be assessed after airway and breathing have been secured.
* CPR may be necessary, two angiocatheters and initial infusion of balanced solutions such as Ringers lactate or normal saline.
Truma
Secondary Survey
* Focus on what?
Focus on is to identify any occult injuries the patient may have sustained.
Trauma
* Penetrating chest trauma? (2)
- most cases of penetrating chest trauma can by managed by tube thoracostomy alone.
- remaining must be evaluated regarding clinical indications for operative intervention.
Trauma: Blunt abdominal trauma
* What exam?
* Look for what?
* What may be added?
- FAST exam has largely replaced diagnostic peritoneal lavage.
- looks for air or fluid collection present
- CT may be added as needed to clarify the FAST results
Trauma
* Penetrating abdominal trauma: What is indicated?
* Penetrating flank trauma: Work up? What is difficult?
Penetrating abdominal trauma
* immediate laparotomy is indicated if patient exhibits signs of shock, peritoneal irritation, or evisceration.
Penetrating flank trauma
* workup in stable patient includes CT with oral and IV contrast.
* trauma is difficult to assess because many injuries in this region may be retroperitoneal.
Trauma: vascular trauma
* Look for signs of what?
* Presence of what?
- look for signs of arterial injury, such as a pulsatile mass or hemorrhage, expanding hematoma, significant hemorrhage, presence of thrill or bruit, or acute ischemia to the involved extremity.
- presence of a pulse distal to the injury does not rule out significant vascular injury.
Trauma: Head trauma
* What should be calculated?
* initial GCS correlates to what?
* Avoidance of what?
- GCS should be calculated on all patients.
- initial GCS correlates to the severity of the brain injury.
- avoidance of secondary insults to the brain caused by hypotension and hypoxemia is paramount.
Trauma
* Fasilar skull fx: May be associated with waht? Evaluate what?
* Epidural hematoma: Caused by what? Brief period of what?
Basilar skull fractures
* may be associated with rhinorrhea, otorrhea, or ecchymosis of the lids (racoon eyes)
* evaluate for ecchymosis behind the ears (Battle’s sign)
Epidural hematoma
* caused by injuries to the middle meningeal artery
* brief period of unconsciousness is followed by a lucid interval
Trauma: Subdural hematomas
* Results from what
* Associated with what?
* What is dx?
* What is used?
- result from injuries to bridging veins.
- associated with severe head injuries and can result in significant axonal injury even after evacuation.
- CT is diagnostic
- anticoagulant use are at increased risk of intracranial bleeding even with minor trauma.
Post op
Wound complications: Hematoma
* Collection of what?
* Higher risk when?
* What happens with small hemaotomas?
* Txt?
- collection of blood and clot in the wound, usually caused by inadequate hemostasis.
- higher risk when receiving aspirin or low dose heparin
- small hematomas may resorb but increase the incidence of wound infection
- treatment may involve evacuation and repeat closure
Post op
Wound Complications: Hemoperitoneum
* MCC of what?
* usually result of what?
* Apparent what?
* High index of what?
* Txt?
- most common cause of shock in first 24 hours
- usually result of a technical problem of hemostatic factors
- apparent within 24 hours after operation, tachycardia, hypotension, decreased urine output.
- high index of suspicion needed and frequent examination of patients.
- treatment involves fluid resuscitation.
Post-op
Wound Complications:Seroma
* What is it?
* Delay what?
* Txt?
- fluid collection in the wound other than pus or blood
- delay healing and increase risk of infection
- treatment involves compression dressings or persistent ones are treated with repeated evacuation
Post op ⭐️⭐️⭐️⭐️
Wound Complications: Wound dehiscence
* What is it?
* Common in who?
* Local risk factors are usually from what?
partial or total disruption of all layers of the operative wound
in systemic risk factors, common in patients with DM, immunosuppression, jaundice, sepsis, corticosteroids and other comorbidities
local risk factors are usually a result of combination and not one isolated cause
* closure - result of too few stitches and placing them close to edge
* intra-abdominal pressure - distended bowel
* deficient wound healing - infections
post op
Wound Complications: Anastomotic leask
* Systemic factors?
* Local risk factors can include what?
* ID what?
* SXS?
* TXT?
- systemic factors include age, malnutrition, vitamin deficiencies and comorbid conditions such as diabetes, smoking, previous radiation/chemotherapy
- local risk factors can include poor blood flow, hypotension, contamination
- identified clinically, radiographically and/or intraoperatively
- S/S include pain, fever, peritonitis and drainage, bilious or fecal material
- treatment consists of bowel rest, antibiotics, percutaneous drainage
Common Postoperative Surgical Emergencies: Altered mental status/combative patient
* Postoperative day 0:
* Postoperative day 2 and 3:
* Elderly have what?
- Postoperative day 0, recovering from general anesthesia
- Postoperative day 2 and 3, consider alcohol withdrawal
- Elderly have less neurologic reserve and largest population to suffer mental status changes
Common Postoperative Surgical Emergencies: AMS/combative patient
* What should you do if sudden mental status changes in previously stable patient occur? (3)
- should be emergently worked up
- CBC, CMP, EKG, full set of vital signs
- diagnostic imaging such as CT scan
Common Postoperative Surgical Emergencies
* What is oliguria?
low urine output, can be organized by postoperative day
Common Postoperative Surgical Emergencies: Oliguria
* What can happen on postop day one?
- low blood volume, hypovolemia
- mechanical causes by Foley
- ureteral injury during pelvic surgery
Common Postoperative Surgical Emergencies: Oliguria
* What happens on post op day 1, 2, 3
postoperative day 1 and 2
* fluid mobilization
* Ileus and small bowel obstruction
* nephrotoxic agents
* delayed hemorrhage, started on anticoagulants
postoperative day 3
* ileus recurrence with fluid sequestration
Common Postoperative Surgical Emergencies: Postoperative hypotension
* Ensure what?
* Severe hypovolemia can cause what?
* If febrile, could also be what?
* What are common sources?
* After what/
- ensure that the blood pressure is accurate, get manual to confirm, in addition get full set of vitals
- severe hypovolemia can cause hypotension accompanied by tachycardia
- if febrile also, could lead down sepsis pathway
- anesthetics and analgesics are common sources, cause hypotension
- after restarting home medications
Common Postoperative Surgical Emergencies: Tachycardia
* Mild sinus tach due to what? (3)
* Consider what?
- mild sinus tachycardia often due to postoperative pain, atelectasis and hypovolemia
- consider pulmonary embolism or progressive stages of shock
Common Postoperative Surgical Emergencies: N/V
* Attributable to what?
* Txt?
* Possibe what?
* If NG tube placed and nauseous, then do what?
attributable to anesthesia
aggressive management with antiemetics
possible ileus requiring NG tube placement
if NG tube in place and nauseous, then adjust until functioning properly
* X-ray to confirm placement
* placement of a larger bore NG tube
Common Postoperative Surgical Emergencies: SOB
* What can happen?
* Reactive what?
* PEs accompanied with what?
* Pneumonia with what?
* Possible result of what?
- atelectasis, volume overload, begins on postoperative day 2
- reactive airways such as smokers and asthmatic
- pulmonary embolism accompanied with tachycardia or pleuritic chest pain
- pneumonia with accompanied with fever, elevated WBC and productive cough
- possible result of a MI, intra-abdominal complications, sepsis and fever
Common Postoperative Surgical Emergencies: CP
* Mirroes what?
* MI, consider what orders?
* PE should be considered with what?
* What are some other causes?
mirrors work-up in emergency department with added consideration of incisional pain
myocardial infarction, consider serial troponins, ECG, current set of electrolytes and hemoglobin levels
pulmonary embolism should be considered with the following
* shortness of breath
* low oxygen saturation
pleural effusion and musculoskeletal pain
Postoperative Fever: General characterisitcs
* Most early postoperative fever is caused by what?
* What is the nmemonic?
most early postoperative fever is caused by an inflammatory response to tissue trauma and resolves without intervention.
mnemonic of the five W’s is useful to aid in determining cause of fever
Mnemonic of the Five Ws
* Wind: When does the fever occur? Exam may reveal what?
* Water: Commonly develops when? Many casues are what? Patient may complain about what?
Mnemonic of the Five W’s: Wound infections
* MCC of postoperative fever after what?
* What is the MC pathogen?
* Mild changes in what?
* superficial infections involve what?
- most common cause of postoperative fever after 72 hours
- Staphylococcus aureus is the most common pathogen
- mild changes in the vital signs is seen early, and pain may or may not be present at the site of the infection
- superficial infections involve the skin and subcutaneous tissue; deep infections involve areas below the fascia
Mnemonic of the Five W’s: Walking (thrombophlebitis)
* superficial thrombophlebitis most commonly is associated with what?
* deep thrombophlebitis can be associated with what?
* thrombophlebitis of the lower extremity may be associated with what?
- superficial thrombophlebitis most commonly is associated with intravascular catheters. Purulent drainage around an indwelling catheter with induration of the vein may be detected on physical exam.
- deep thrombophlebitis can be associated with indwelling central lines or DVT.
- thrombophlebitis of the lower extremity may be associated with Homan’s sign; however, this test has very low specificity. Unilateral edema of an extremity is a more specific indicator of DVT.
Mnemonic of the Five W’s: Wonder drugs
* What are often are implicated in drug fever that develops one week postoperatively?
* this is a diagnosis of exclusion and should be considered when?
- wonder drugs, such as anesthetics, sulfa-containing antibiotics, and others, often are implicated in drug fever that develops one week postoperatively.
- this is a diagnosis of exclusion and should be considered when faced with a negative sepsis workup in a postoperative patient with fever.
Mnemonic of the Five W’s: Whopper
* Refers to what?
* in the case of intra-abdominal fluid collections, what may happen?
* Blood cultures may be what?
- refers to the presence of a postoperative abscess
- in the case of intra-abdominal fluid collections, an ileus may develop as a sequela of an occult abscess.
- blood cultures may be polymicrobial, indicating anastomotic leakage.
