Medicine- Pre-op: Pulmonary, Cardio, & Testing Flashcards
What type of sx has the highest risk for pulmonary complications? Why?
- Upper abdominal sx
- Bc it causes splinting (which is a involuntary, rigid contraction of abd wall mm occuring due to post-op visceral pain) which limits the pts ability to take deep breaths=exacerbates pulmonary problems
T or F. Cardiac complications are > pulmonary complications.
F. 5-10% incidence of pulm comp’s in non-cardiac sx–>these comp’s include: atelectasis, pneumonia, bronchitis, bronchospasm (2ry to reactive airway dz, like asthma), hypoxemia, and resp failure
What is the % of post-op pulmonary complications across all types of sx (according to systematic review from 1980-2005)?
6.8%
What is the risk of putting a pt who has end-stage emphysema on a ventilator?
There’s a possibility they might die once you take them off bc when they’re on the vent they haven’t “breathed like that in 20 years” so it’s going to be hard for them to breath at all once they’re off.
What type of anesthesia is best for “pulmonary pts”?
Regional anesthesia
When is the ideal time to tell a pt to quit smoking prior to sx? Worst time to quit?
- 8 weeks. They will begin feeling better and everything will be cleared out of their bronchial tree
- 2 weeks pre-op
What are some pt related risk factors of Peri-op Pulm Comp’s (PPCs)?
Age, chronic lung dz, smoking, asthma, general health status, obstructive sleep apnea, pulm HTN, heart failure, upper resp infection, metabolic factors
Rales indicate what?
There’s FLUID in the lungs
Wheeze indicate what?
There’s an OBSTRUCTION in the bronchial tree
Ronchi indicate what?
There’s TURBULENT FLOW in the bronchi
Pt-related Risk Factors and PPCs:
Asthma is a risk only if what?
If it’s UNCONTROLLED or peak flow is <80%
Pt-related Risk Factors and PPCs:
Smoking is a risk if?
- Smoke >20 pk/yr, or
- Smoke past 8 weeks prior to sx
Pt-related Risk Factors and PPCs:
A surgeon will postpone sx if _____ is present/active.
URI
What are the procedure-related risk factors of PPCs?
Surgical site, duration of sx, type of anesthesia, and type of NM blockade
What is the most important procedure-related risk factor, in terms of PPCs?
Surgical site bc it’s related to distance of incision from diaphragm
In terms of procedure-related risk factors and PPCs, the longer the sx (i.e., >4h) the…
Greater chance of PPCs (40%). PPCs are around 8% in procedures lasting <2h
What type of anesthesia has less PPCs compared to general anesthesia (GA)?
Epidural (+/- GA)
What NMB incr risk of PPCs?
Pancuronium, bc it is long acting=residual blockade
What pre-op lab values, dependent upon other things, can be predictors to post-op respiratory failure?
-Albumin 30 mg/dL
What indices are used to predict PPCs?
- Arozullah Pneumoina Index
- Arozullah Respiratory Failure Index
What are the types of sleep apnea?
- Obstructive (OSA)
- Central (rare)
- Mixed
What questionnaire is used to assess sleep apnea?
STOP-BANG Questionnaire: Snoring Tired Observed blood Pressure BMI (> 35 kg/m2) Age (> 50yo) Neck circumference (> 40cm) Gender (Male)
Who is considered a ‘Vasculopath’?
The person w/ arterial insufficiency…no palpable pedal pulses; sitting in bet a lot; wounds
What tests will you order for the vasculopath pt?
- ABI
- Arterial Duplex Doppler
- Angiogram
- MRA
- Also heel protection because they will have incr risk of pressure wounds due to poor blood flow in decr healing potential
What tests will you order for someone who has ‘post-op fever’?
- CXR–>atelectasis/pneumonia
- UA–>UTI
- CBC–>infection
- LE venous Doppler–>DVT
What orders/tests will you order for a ‘pre-op’ pt?
- NPO past midnight
- Meds w/ sips in a.m.
- Hold oral glycemic meds
- Accucheck in a.m.: if >200mg/dL=cancel sx
- Signed and witnessed consent
- Hold lovenox or equivalent
- CBC, CMP, INR in a.m.
- Hold other meds depending on condition
What tests will you order for a pt who has an ‘infection’ in their foot?
- Wound culture
- Blood culture x2
- CBC, BMP
- ESR, CRP
- Xray, MRI, Bone scan, WBC scan, CT
What are the two forms of metabolism?
- Anabolism
- Catabolism
What are the Normal Tissue Repair phases?
- Inflammation
- Proliferation
- Maturation/Redmodeling
What happens during the Inflammatory phase?
Vasodilation–>Cells contain injury–>Scavengers cells clean up
What happens during the Proliferative phase?
Repair–>Cells migrate and proliferate–>Crude organization of CT
What happens during the Maturation/Remodeling phase?
Tissue organization–>Restore S&F
What is apoptosis?
Programmed cell death with NO inflammation
What is necrosis?
Death from inside out that produces EXTREME inflammation
Why does a pts skin look dry and flaky after taking a cast off after 30 days?
Because it takes skin cells 28d to migrate to the surface and slough off
What is the difference between:
- Atrophic scar
- Hypertrophic scar
- Keloid
- Depressed scar
- Enlarged scar that remodels w/ time
- Hyperproliferative scar that does not resolve with time
What is the goal of debridement?
To stimulate bleeding which brings GFs and nutrients to the wound and decr healing time while incr healing potential
A pt needs “cancer sx”, but just had a DES put in 4 months ago. What do you do?
Take off plavix for 1 week, and infuse with IV antiplatelet (i.e., integrilin). Stop the IV 2h prior to sx. After sx, start plavix again
What is the triad of sysmptoms for Aoritc Stenosis?
- Angina
- Syncope
- Dyspnea
What is the most common valvular dz in the elderly?
Aortic stenosis
For pts who can’t reach the target HR, what type of pre-op cardiac test will you perform?
- Dipyridamole stress imaging (use in pts w/ arrhythmias), or
- Dobutamine ECHO (use in pts w/ bronchospams or severe carotid stenosis)
What differentiates T1 and T2 diabetes?
T1 DM=ABSOLUTE insulin deificiency
T2 DM=progressive insulin secretory defect
If I have a HbA1c of 8, what is my BG?
~183 mg/dL
