MISC (pre/post-op, endo, admin) Flashcards
Papaverine
vasodilator; also relaxes muscles of digestive system - good for diffuse mesenteric vasoconstriction
Pre-op: who gets EKG?
typically >50yo but not shown to predict cardiac risk peri-op
Pre-op: who gets CXR?
pts w/ cardiac or pulm sxs; need one within 6mo
Pre-op: who gets Hct/Hgb checked?
elderly w/ major organ dysfxn (liver) or known anemia, or pts undergoing surgery w/ possible signif blood loss
Pre-op: ACE inhibitors
HOLD - to avoid hypotension with an anesthesia
Risk factors for medication toxicity (even if within therapeutic range)
- low serum albumin (higher free drug concentrations)
- dehydration
- obesity (longer storage)
Highest risk delayed cx (bleeding, perf) in endoscopy pts
coag mode
What monopolar mode should be used (cut/coag) nearby cardiac devices?
cut mode - lowest voltage monopolar mode; transfers least amount energy
Absolute C/I to most robotic operations
- inability to tolerate pneumoperitoneum
- ascites
- gross contamination
Mgmt CO2 embolism
trendelenberg, left-side down, aspiration of gas thru central line
Mech CO2 embolism during laparoscopy
trocar insertion into vessel or direct absorption
Effect if give ACEI in pts with HTN 2/2 renal artery stenosis
decrease GFR -> acute oliguric or anuric renal failure (hence C/I)
Plain gut suture vs. chromic gut (tensile strength and absorption time)
tensile strength: plain 7-10d; chromic 10-14d
absorption: plain 70d; chromic >90d
* both absorbed by proteolytic enzymatic digestive process
Polyglactin 910 (coated vicryl)
copolymer slows water penetration
tensile strength: maintains >65% after 14d
absorption: min at 40d, complete at 56-70d
Polyglecaprone 25 (monocryl)
tensile strength: 50-60% at 7d, 20-30% at 14d, lost at 21d
absorption: complete at 91-119d
Polydioxanone (PDS)
tensile strength: 70% at 14d, 50% at 28d, 25% at 42d
absorption: minimal until 90d, complete within 6m
Silk
tensile strength: lost when exposed to moisture
absorption: nonabsorbable ~2yr
Fothergill sign
abdominal wall mass that does NOT cross midline + does NOT move with contraction of abdominal wall muscles -> if pos, then rectus sheath hematoma
Imaging presentation of Echinococcus
calcified cystic wall in the lungs and liver
Mgmt Echinococcal cysts
Staged procedure: all w/ lap pads soaked in hypertonic saline, which is toxic to parasite
- lobectomy
- nonanatomic rsection of liver lobe + entire cyst (avoid spilling)
When should pre-op SSI prophylactic Abx be given?
within 60 min of incision (except vanc)
When should do intra-op repeat of SSI prophylactic Abx?
if time of surgery > 2x half-life of drug or there is excessive blood loss during procedure
amp/sulb: 0.8-1.3 hrs
cefoxitin: 0.7-1.1 hrs
cefotetan: 2.8-4.6 hrs
Pregnant women have what alteration of PaCO2?
decreased @ 30mmHg (bc increase in minute ventilation)
Alpha-receptor cascade
GPCR -> phospholipase C -> inositol trisphosphate + diacylglycerol -> intracellular Ca -> vasoconstriction of vascular smooth muscle cells
Beta-receptor cascade
GPCR -> adenylate cyclase -> ATP to cAMP -> protein kinase A -> ion channels phosphorylated -> increase Ca2+ influx
Empiric Abx choice for GAS necrotizing SSI
penicillin (vanc, linezolid) + clindamycin (or zosyn, carbapenum, or ceftriaxone+metro)
New-onset a.fib after non-CT surgery is associated with increased risk of…?
stroke
Absolute C/I to ERAS (enhanced recovery after surgery)
- undergoing urgent operation
- ASA of 4+
- limited or no mobility
- severely malnourished
- noncompliant or reluctant to participate in protocol
In setting of hollow viscus injury, length of post-op Abx to decrease incidence of SSI?
24-hrs
When use vancomycin for pre-op prophylactic Abx?
for high-risk pts for MRSA, or have penicillin allergy (must be given over longer time than 60min bc required slow administration)
What does the APACHE score evaluate?
(acute physiology and chronic health eval) severity of disease classification system to estimate mortality in ICU
What is a quick test to quantify fraility?
Timed Up and Go - mobility instructions; prolonged if takes >12 seconds
What does the SOFA score evaluate?
(sequential organ failure assessment) predicts ICU mortality based on lab/clinical data
MC organism causing VAP and SSI
S.aureus
MC (#1, #2) organism causing central-cath-associated bloodstream infection
#1: S. epidermidis #2: S. aureus
VitC vs. VitD: decreased resus volumes in burns
VitC
VitC vs. VitD: antioxidant effect
VitC
VitC vs. VitD: decreased MOF after trauma and burns
both
PPI decreases absorption of what oral AC?
dabigatran
What oral AC has high oral bioavailability?
rivaroxaban, apixaban, edoxaban
Renal vs. hepatic elimination: rivaroxaban, dabigatran
rivaroxaban: both
dabigatran: renal
What is inspiratory resistance training?
inhalation exercise against progressively increasing inspiratory resistance - those who improved pre-op have decreased post-op pulm operation
Time of onset, half-life: Oral factor Xa inhib
Time of onset: 2-4hr
Half-life: 7-15hr
Time of onset, half-life: Oral direct thrombin inhib
Time of onset: 2-3hr
Half-life: 12-14hr
Which pts should receive extended DVT ppx beyond their inpatient stay?
- total hip replacements
- total knee replacements
- major cancer resections
- high-risk gyn resections
What does the Frailty Index estimate?
- risk for post-op Cx
- length of stay
- discharge to SNF
Half-life fondaparinux (SubQ)
12-17 hrs
RF for periop cardiac events
- increasing age
- increasing ASA status
- decreasing functional status
Ultrasound surgical energy instruments: highest temp, thermal spread, cooling time
Tmax: 200 C
Highest thermal spread
Longest cooling time (>40sec)
Bipolar surgical energy: highest temp, thermal spread, cooling time
Tmax: 90 C (same as monopolar)
Least amt thermal spread
Cool quickly
Neck circumference associated with CAP
> 40cm
Post-op mgmt for COPD pt s/p thoracic surgery
thoracic epidural pain control + removal of urinary cath POD#1
Abx with cross-reactivity for penicillin
cephalosporin, carbapenem (beta-lactam ring)
When should warfarin be held pre-operatively for low-risk pts?
5 days
After bridging AC to LMWH before surgery, when should LMWH be held pre-operatively? When can you give it post-operatively?
held 24-hours pre-op
held 48-72 hours post-op after high-risk bleeding procedures
After drug-eluting coronary stent, at what point can anti-plt therapy be held so these pts can have elective surgery?
at least 6 months - to allow for stent endothelialization
Pre-op bundle for pts having colorectal surgery (and possibly intra-op colonoscopy)
PO Abx + mechanical bowl prep (reduces rate SSI) + IV abx
When and how give TXA for trauma pt?
Within 3 hours as bolus, then continue for 8-hrs as gtt - can still give even if closed head injury
Pre-op anemia is strongly associated ? in pts undergoing noncardiac surgery
mortality (2x greater odds dying within 90d surgery)
Promethazine MOA, interaction with metoclopramide?
MOA: H1-R antag in vomiting center of medulla, vestibular nucleus, and chemo-R trigger zone
Interaction: blocks cholinergic-R on intestinal muscle fibers -> decreased tone and peristalsis of gut SM (counteracts prokinetic drugs)
Ondansetron MOA, best used for…?
MOA: serotonin antag -> effect on 5HT3-R
peripheral effects: via enterochromaffin cells of enteric nervous system
central effects: via nucleus tractus solitaries + chemo-R trigger zone
best used for: chemotherapy-induced emesis
Anti-emetic for cerebral edema (2/2 brain mass)
corticosteroids
Scopolamine MOA, best used for…?
MOA: anticholinergic via M1-5 R antag
best used for: movement-related nausea, bowel obstruction
Elimination of methadone
two-phase: alpha (8-12hr) and beta (30-60h)
analgesic effect correlates with alpha-phase.
withdrawal sxs held abay with beta-phase.
MCC immune deficiency worldwide
malnutrition
First cell present during inflammatory phase of wound healing
Neutrophils
Laparoscopic insufflator initial flow rate? To obtain pressure of…? Pneumoperitoneum is maintained by constant gas flow of…?
Initial flow rate = 4-6L/min
Obtain pressure = 10-20 mmHg
Constant gas flow = 200-400 L/min-1
Dominant feature of remodeling phase of wound healing
Collagen remodeling (collagen III replaced with collagen I) and scar formation
Types of collagen
1 = MC; main type in healed wounds (scars) 2 = cartilage 3 = blood vessels, fetal skin, uterus 4 = basement membrane 5 = cornea
What is Palmer’s technique?
method of abdominal Veress access though left subcostal margin - Palmer’s point is 3cm below left subcostal margin @ midclavicular line - C/I hepatosplenomegaly
What is Hasson’s technique?
open cutdown and direct visualization before placement of primary trocar
Bipolar can be used to seal vessels of max. what diameter?
7mm
