MP&S - Pre/Post Op Management Flashcards
When do you choose surgery?
– Re-think surgery → high risk & low benefit
– Surgery → High benefit & low risk
– Operate → Even if risk is high, the risk of not operating is certain death
What are some RED FLAGs for surgery?
- Cardiac/Vascular/Lung/Liver/ Endocrine Dz
- Bleeding d/o
- Infection
- DM
- (NPO pre op –> hold or reduce hypoglycemic agents – better if the glucose is high rather than low)
What labs should you order before Surgery?
- CBC/BMP (lytes/BUN/Creat/glucose)
- LFT’s (in older pts or when indicated)
- CXR if indicated
- Surgical Consent
- Clotting studies (only if indicated)
- EKG (pts w/ cardiac Hx or > 40yo)
- Type & Cross PRN (should include number of units & should be >2unit min)
What is the Difference between T&C vs T&S?
- T & C (Type & Cross):
- Determines blood type & blood is made available before the surgery begins - T & S (Type & Screen):
- Determines blood type, but blood is not made available, it as to be ordered after.
What are some of the risks of GENERAL Anesthesia?
- ↓Sys vascular resistance
- ↓Myocardial contractility
- ↓Stroke volume
- ↑Cardiac irritability
What the key difference between general and local anesthesia?
Local anesthesia carries the least risk
What is the most problematic Post-Op Cardiac Risk?
Post-op MI carries a 50% mortality risk
- Related to age & pre-existing conditions
What are some HIGH Post-Op Cardiac Risks?
- Emergent surgery in elderly pt,
- Aortic surgery,
- Periph vascular surgery,
- Procedures w/prolonged blood loss
> 5% risk of MI or death
What are some INTERMEDIATE Post-Op Cardiac Risks?
- Carotid endarterectomy,
- GU
- Ortho
- Uncomplicated abd
- H&N
- Thoracic surg
What are some MINOR Post-Op Cardiac Risks?
- Cataracts
- Endoscopy
- Superficial procedures
Cardiac tests prior to Surgery?
- EKG
- Dobutamine → stress echo
- Dipyridamole thallium imaging
- Coronary angiography
- Exercise stress testing not always used
What group of drugs can reduce Absolute risk of cardiac event Po-Op by ~15%?
BB
What is dangerous about post op Ischemia?
It can be asymptomatic in up to 90% of cases
It usually occurs 1-2 days post-op
What is THE MC Post-Op complication?
Pulm Complication
What ARE MC Pulm Post-Op complicates?
Atelectasis & PNA
What IS MC Pulm Post-Op complicates?
Atelectasis
- MC post-op complication in pts who have received GENERAL anesthesia
What are some of the Post-Op Pulm Risk Factors?
o Age, Obesity
o Smoking/COPD/Asthma
o Sleep apnea
o Thoracic or upper abd surgery
*****2X higher in smokers even w/o COPD
How do you reduce plum risks?
o Stop smoking > 8 wks prior to surgery
o Delay elective surgery in pts w/ poorly ctrl COPD
o Prevention of MC pulm complication (atelectasis)
- Deep breathing - Incentive spirometry - Preoperative teaching - Avoid supine positioning
Post-Op - Resp/Cardiac Status?
o Good pulmonary toilet
- use of spirometer
o Good cough/deep breathing techniques
o D/C vents & ET tubes ASAP
o Chest PT PRN
o CXR PRN
- r/o atelectasis, PNAWhy is there a high risk of DVT Post-OP?
o Blood loss during surgery
o Combined w/ decreased activity
How does Anemia cause complications during surgery?
Extensive blood loss & HCT < 28 will increase MI risk
→ might want to transfuse
What surgeries carry higher risk of infection?
- Oral,
- Trauma,
- Bowel,
- Vaginal
How to prevent infection during surgery?
o Abx admin prior to surgery
o Prophylactic abx used if risk is >2%
What RFs do pts w/ DM present Post-Op?
o ↑Risk for:
• Stroke, MI, Inf, DKA, Wound dehiscence
How do you manage DM pts going to surgery?
NPO pre op
- Hold or reduce hypoglycemic agents – better if the glucose is high rather than low
- Use of sliding scale rather than regular oral hypoglycemic agents or regular insulin dosing UNTIL pt is taking
BS – Q6H (post- prandial & HS)
Liver Dz Post-Op complications?
o LFT’s
- pts w/hx of liver Dz or ETOH abuse
o Narcotics/sedatives metabolized in liver so consider that when ordering meds
o Coagulopathy occurs w/liver Dz
o Ascites
How does Malnutrition/Drug Dependency effect Post-Op pts?
o Vit K def, Hepatic dys, Poor wound healing, lyte abnml’ties (tx Hyponatremia slowly – 3% Saline last resort)
o Poor social/family support often the case
o Pain relief in light of drug dependency
o Drug withdrawal
How do Steroids effect Post-Op pts?
o Chronic steroid → suppress bodies’ endogenous steroid production
o Doses as small as 7.5mg Prednisone per day (or Hydrocortisone 30 mg/day) can be a suppressive dose
o Partial adrenal insufficiency may be present for these pts as long as 9 mos after d/cing
o Solution:
- GIVE Solu-Cortef 100mg IV
- immediately pre-op & repeat that night and/or next AM
Post-Op 5 P’s?
o Pain control
- PCA/Epidural/IM/IV/PO PRN
o Prevent Pus
- Post op abx prophylaxis
o “Pillow”
- Sleeper PRN
o “Poop”
- Narcotics + inactivity = constipation
o Previous Meds
- Co-morbidities
Fever Post-Op?
o Common post op → often resolves spontaneously
o Fevers in 1st 24 hrs are rarely wound infections
o Can be caused by atelectasis
o If pt has Foley → check for UTI & Rx PRN
o Could be PE/PNM/drug induced
o C/S, blood cults, CXR, U/A & C/S
Post-Op Mobilization?
o Get pt OOB & ambulating ASAP
o Get the pt moving any way you can → chair or cardiac chair if can’t ambulate
o Complications, → pressure sores, PNM etc
Post-Op Oversedation/Confusion causes?
o Elderly pts
o Narcotics
o Multi factorial:
- Polypharmacy,
- Sundowning,
- unfamiliar surroundings
How do you reduce Post-Op infections?
o Prophylaxis of wound infection.
o D/C drains/tubes as soon as possible
o Higher risk w/implants or immuno-compromised pts
Post-Op Pain Control?
o 5th vital sign → Pre-emptive pain ctrl reduces post op narcotic use most effectively
o Risk of over sedation/confusional states
o Narcotics can make you itchy (side effect) → not a true allergy unless rash forms
o Taper a pt appropriately & no worries about “addiction”
Post Op - Wound Healing?
o Compromised in the
- elderly,
- chronically ill,
- DM,
- immunocompromised.
o Check wound QD or QOD at least
o Remove stitches/staples when ready & steri strip wound PRN
o Watch for signs of infection
- Redness
- Calor
- Drainage (esp purulent)
- Dehiscence
Post-Op Fluids/Electrolytes
o Check lytes, BUN, Creat PRN
o Older pts tend to be dehydrated when they come in
o Pts can lose fluid/blood intra-op → get a lot of fluids IV intra-op
o Daily weights/I & O PRN – QD weights can help Dx CHF / fluid retention
Pt / Family Communication
o Maintain communication (i.e. phone #’s of family members)
o Prepare pre-op – avoid surprises
o Address family concerns even if you think they are minor
o Obtain informed consent from pt or legal guardian, family member etc
What do you do when Brainscape tells you to take a break?
Fuck off
