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NU 737 > Module 3: Postoperative Principles > Flashcards

Module 3: Postoperative Principles Flashcards

1
Q

Admission to ICU

A
  • 15% surgical procudures requires ICU
  • Decision made by surgeon & anesthesiologist
  • **Elderly patients or significant comorbidities
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2
Q

Delivery of care

A

**Accurate Data collection: **
* Surgical Procedure
* Patient positioning
* Unexpected Events
**Efficient Among surgeon, Anesthesiologists & Intensivist: **
* Typically informal
Brief and Incomplete

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3
Q

Continue Medications

A

Eye drops (Glycoma)
Antiseizure
Bronchodilators
Thyroid Replaceement

DM agent: add Sliding Scale; levemir

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4
Q

Hold Medications

A

*** Glucorticoids **
* Should be given before Surgery
* Avoid Stress dosing:
* To Avoid : Hyperglycemia, Increased Infection Risk, and wound complications
* Talk to surgen ( ok to Hold )

  • Hold CCB, Diuretics, ACE : untile hemodynamically stable post up
  • Long Standing Insulin ( lantus or Levimir) , Metoforming, Glyburide: Hold Addd sliding scale SQ or IV, or Levemir
  • Maintain Glucose <180 mg/dl
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5
Q

Goal for Blood Surgar Post Up

A

< 180 mg/dl

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6
Q

Opiate Management :
**Fentanyl **

A

For Mechanically Vented Patients.
Analgesia Properities, Rapid Onset, short Sedation.

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7
Q

Opiate Management :
Other opiods

A

Morphine, Dilaudid, Oxycodone, MS Contin

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8
Q

Non-Opiate Management

A

Ketamine
Robaxin
Toradol (check Kidney Function)
Acetaminophed
and/or Gabaptin

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8
Q

Quantifying Pain and Sedation

A

*** Richmond Agitation Sedation Scale (RASSS) **
- Universal language to achieve adequite Sadation
* **Confusion Assessment Methord for the ICU (CAM-ICU) **
- check for delirium

Those scale help to avoid delirium, and shorter stay in ICU

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9
Q

Opiate Risk

A
  • Dependance and Withdrawal
    if on medication for > 7 days
  • Lethargy
  • Depressed Respitory Efforst
  • Vomiting and Ileus
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10
Q
A
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11
Q

Equivalent Dose

A

**Morphine **
Dose: 10 mg
Duration 4 to 5 HRS

**Dilaudid **
Dose: 1.5 mg
Duration : 4 to 5 hrs

**Fentanyl **
0.1 or 100 mcg
1 to 1.5 hrs

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12
Q

Fentanyl

A
  • Full-mu receptor agonist
  • High Potency, short duration of action, Rapid onset of action
  • Lipohilic- ideal drug for transdermal and transmucosal administration
  • Biovailability - 50 %
    > **25 mcg/hour trasdernal Fentanyl patch = 1mg/1 hour IV Morphine **
  • Ideal for childern and incooperative adults

Super POtent ( only in ICU )

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13
Q

Morphine

A

*** GOLD Standard - For Treatment of Moderate to Severe Pain **
* Full mu-receptor agonist
* Bioavailability: 30 % (PO: IV dose is 3: 1)
Easilty available is wide range of preparations
Most widely used opioids analgesic
CAVEAT : BID /TID : Active Morpphine metabolites

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14
Q

Hydromorphone

A

Semisynthetic opioid, Hydrogenated, of morphine
Full, Potent
Short duratio n

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15
Q

Oxycodone

A
  • **Most Utilized opiod worldwide **
  • *** IR and ER **
  • sustained Release Preperatio of Oxycontin : has 2 phase Release (Immediate and EXtended the the same pill)
    Chronic pain management
    Keep off IV madications
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16
Q

Hypothermia
Risk for ?

A

< 36 C
Riks of deloping
* Coagulopathy and
Hemorrhage

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17
Q

Mild Hypothermia

A
  • 32 to 36C or 89.6 to 96.8
  • **Passive External Rewarning **: warm Blankets
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18
Q

Moderate Hypothermia:

A

28 to 32 C or 82.4 to 89.6F
Active External Rewarning
Air Warming system

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19
Q

Severe Hypothermia

A

< 28 C
Active **core **rewarming
Warm IV fluids (Crystolids )
Do not warm Blood

20
Q

Assessemtn of Volume status

A
  • **Post Up (I/O ) **
    **Crystalloids : 0.9% +LR (keep eye on Na) **
    Change to NSS
    **MAP >65 **
    **UO >/= 0.5 mg/kg **

*** Echocardium : ** monitor resuscitatio efforts
**Maintenance Fluids : D5 1/2 NS (To prevent Catabolism) **

21
Q

Rapid Shallow Breathing (RSBI)

A

Predicts successful extubation and suctain off vent
GOAL : < 105 Value ( TV Devided by RR rate )

22
Q

Mechanical Vent

A

RR 12 to 16
PEEP: 5
FIO : 100% to 40%

**Tidal Volumes: 6ml/kg **

ARD: Neuro blockag (paralize; prone)

23
Q

Nutrition Requirment

A
  • 25 to 30 kcal /kg/day
    1.2 to 2.5 g/kg/day of protein
    24 to 48 hrs nurtrition
24
Q

Surgical Complications
Hemorrhage
Overwiew

A
  • **Frequent cause for ICU admission **
  • Persistent Postoperative Hypotension: ( early sigh for bleeding )
  • Early Identification can prevent :
    Prevent multi Organ Failure
    Hemodynamic monitoring
25
Q

Surgical Complications
Hemorrhage
Treatement Plan

A
  • blood
  • Fluid: Isotonic Crystalloids (Avoid
  • Hypovolic Shock ; MAP >65)
26
Q

Surgical Complications:
Pulmonary Embolus

Manifestation
Hemodynamic Instability

A
  • Origin: Femoral, Iliac, Popliteal Veins

**Manifestation: **
* SOB, chest pain, ST. DVT (s/s )
* Altered Ventilation Perfusion RAtio

  • **Hemodynamic Instability **:
  • Blockage of main or major branch of PA –> Resulting - in Increase PVR (Increase Pulmonary Vascular Resistance)
    -Leads to RT Heart Dialation leading to
    -LV Dysfunction
  • Rt Heart comprase Left Heaert –> decrease Preload and Decrease CO
27
Q

DX : PE

A

*** D-Dimer : Will be elevated post-up **
* **DD is protein fragment of blood clot that been dissolved in a body. **
Therefore, D-D elevated with present of PE.

CTA (Gold Standard DX for PE )

**VQ Scan : Miss Match

  • For pt Kidney Issues; or Allergy to Diy
  • VQ Not Reliable in ICU pt with Disorders: ( COPD, Cystic Fibrosis, Bronchiectasis, Interstadial Lung Diseas)

**ECHO **

28
Q

TX PE

A

Heparing ( PTT 60 to 90 seconds): ICU
Lovenoz 1mg/mg BID
NOAC
IVC Filter (if down leg)

29
Q

Surgical Complications
Anastomotic Leak

A

Most Devistating Surgical Complication Result in Mortality and Morbility

30
Q

**Anastomotic Leak

Clinical Findings:**

A

*** fever, **
**Elevated WBC,
**ST,
**Hypotension
* Enteric Contents in Perianastomotic drain

31
Q

Anstomotic Leak
**Diagnosis : **

A

* CT W/PO Or IV contrast (not Always ask colorectal Surgery )
* Identify leak
* Detect other Pathologies

32
Q

Anatomotic Leak
Treatment Plan

A

**Septic shock and Generalized Peritonitis **
Surgical Revision

Hemodynamically Stable

  • **Antibiotics and Percutaneous Drainage (zosy +Microfungil (Antifungal ) **
  • Endoscopy with Stent Depoyement
  • Consult: ID, GI, Surgery
33
Q

Intraabdominal Compartment Syndrome
Causes

A
  • Severe Abdominal TRauma
  • Abdominal Surgery
  • Deep Burns
  • Obesety
  • Intraabdoninal or Retroperitoneal Hemorrhage
  • Excessive Crystalloid or Blood Products **
34
Q

Intraabdominal Hypertension (IAH)

A

Intraabdominal Pressure > 12mmHG

35
Q

Abdominal Compartemetn Syndrome (ACS)

A

Incraabdonial Pressure > 20
New or Worseing organ Dysfunction

36
Q

Intraabdominal Compartment Syndrome
Clinical Findings

A
  • Tense and distended abdomen
  • Increased peak airway pressure
  • or Decrased Tidal Volume
  • Postoperative persistent** metabolic Acidosis and Shock: Suggest Bowel Ischemia
37
Q

Intraabdominal Compartment Syndrome
Diagnosis

A

CT scan or endoscopy
Abdominal pressure measurement

38
Q

Intraabdominal Compartment
Treatment : IAH or early ACS?

A
  • N0n Surgically
  • Decreasing volume resuscitation
  • Sedation and Neuromuscular blockage
39
Q

Intraabdominal Compartment: ACS

A

Surgical Decompression via **Celiostomy **
Negative Pressure dressing

40
Q

Surgical Complications
Acute Kidney Injury

A

Increases mortality and Morbidity
Emergen or high-risk surgeries

41
Q

Surgical Complications
Acute Kidney Injury:

**Prerental AKI **

A

Hypovolemia d/t bleeding
Impaired cardiac Function
* Cardiac Renal Syndrome

42
Q

Surgical Complications
Acute Kidney Injury:

**Intrarenal **

A

**Acute tubular necrosis: **
* Hypovolemia
* Shock
* nephrotoxic agents

43
Q

Postrenal AKI

A

**Obstruction to urine Flow

Damage to ureters
Urinal drainage obstruction **

**non obstructive **
Have urge cannot go
enlarge Prostate : Flomax

44
Q

Surgical Complication
Malignant Hyperthermia (MHS_ )
**Overview **

A
  • Severe reaction to anesthesia
  • Genetic Mutation
    (Autosoma Dominant : one gene from parent to be affected
    50% chanses
  • Fatall if not treated Promptly
45
Q

Surgical Complication
**Malignant Hyperthermia **

Clinical Manifestations

A
  • High body temperature (crasy high)
  • Rigid muscles or spasms
  • Tachycardia
  • Rhabdomyolysis
  • Acute renal failure
  • Coagulation issues (clotting and bleeding )
46
Q

Surgical Complication
**Malignant Hyperthermia **

Risk Factors :

A

**Inherited Gene Affected **
Malignant Hyperhtermia Susceptibiltity (MHS)

    ****RYR1 Mutation: RYR 1 mutation ** **Rarely affected genes **: CACNA1S and STAC 3
47
Q

Surgical Complication
Malignant Hyperthermia (MHS)
Diagsosis

A
  • Genetic Testing
  • Muschle Biopsy **
    (Tissue subjected to triggering Chemicals )
48
Q

Surgical Complication
Malignant Hyperthermia (MHS)
Treatment

A

**Dantrolene **
* 2.5 mg/kg IV bolus
TO
10 mg/kg PRN
**maintenace OPtion: **
* 1mg/kg IV Q 4 to 6 hrs
0.25 mg/kg /hr IV infusion
Oxygen
IV fluids x
body cooling

NU 737 (8 decks)

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