NMS - Casebook Flashcards
What should blood glucose be in the immediate Preop period? What can be done to ensure this?
Between 100-250
Hold oral hypoglycemics, give 1/2 or 2/3 of NPH/insulin on day of surgery
What type of patient may not be a good candidate for laparoscopic surgery, and open surgery be preferred?
Patients with poor pulmonary function (specifically COPD with high pCO2), as CO2 from insufflation gas may be absorbed to blood stream in excess
Which five factors predict risk for cardiac complications after vascular surgery?
- Q waves on ecg
- History of ventricular ectopy requiring treatment
- Hx of angina
- DM requiring medical therapy
- Age > 70
When should aspirin and NSAIDs be stopped in the Preop period?
Aspiring 7-10 days before surgery, NSAIDs 2 days before, to ensure normal platelet function
What ECG finding is highly suggestive of underlying ischemic heart disease?
Left bundle branch block (never a normal variant)
What should be done for a patient who is found to have afib preoperatively?
- Find underlying cause
- Cardio version or beta blockers
- Oral anticoagulant
What is the main surgical risk in a cirrhotic patient?
Inability to tolerate even mild sedation
Check lab values and physical exam signs of cirrhosis
What factors need to be optimized in a patient with cirrhosis and as it’s to undergo surgery?
- Decrease ascites with K sparing diuretics and salt and water restriction
- Decrease Child risk classification
- Normalize PT with vitamin K
- Alcohol abstinence for 6-8 weeks
What should be done if ulceration is noted over a hernia?
Sign of pressure necrosis, thus increased risk of rupture
expedite surgery
What is the risk of hernia leaking ascitic fluid?
Risk of SBP, get cell count and culture of fluid and start IV Abx
Repair hernia urgently
What is the likely cause of capillary oozing in a chronic kidney failure patient and how can you treat this?
Platelet dysfunction due to uremia
- Desmopressin (ddAVP)
- FFP
- PostOp hemodialysis
What is the most likely cause of hypotension in a kidney transplant patient postop with no signs of hemorrhage? How can you treat?
Glucocorticoid deficiency, as patients are usually on steroids
Give hydrocortisone 25mg intraop and 100mg over 24 hrs
What should all patients with valvular abnormalities getting surgery receive?
Prophylactic Abx for prevention of subacute bacterial endocarditis
What is the equation for calculating intraop fluid requirements?
(EBL x 3 mL isotonic fluid / 1 mL blood loss) + UO - IVF given in OR = 700
What is the risk of continued IVF in the recovery period following surgery?
Fluid overload, edema, pulmonary edema (as 3rd spaced fluid goes back into IV space)
What is suppurative phlebitis and how do you treat it?
Infected thrombus in the vein and around indwelling catheter
Tx: remove catheter, surgical excision of infected vein
How do you treat enteric fistulas in patients without signs of peritonitis? Wha situations change this management plan?
NPO, TPN, replete electrolytes, close monitoring of fistula output: and in time fistula will close on its own
Will not close if FRIEND: foreign body, Radiation dmg, Infection or IBD, Epithelialization of fistulous tract, Neoplasm, Distal bowel obstruction
What is the cause of a very high fever (e.g. 105F) 12 hrs post op?
Major atelectasis (one whole lung or multiple lobes)
Or large abscess by gas forming bacteria (like after penetrating trauma)
How should wounds suspicious for gas gangrene (clostridium perfringens) be managed?
High dose penicillin G, wound debridement, hyperbaric O2, tetanus immunization
How do you treat hypertrophic scars and keloids?
Hypertrophic scars that are expanding and keloids should be revised and treated with steroid injection and pressure padding
What factors are involved in wound healing and how?
- Platelet derived GF - brings in macrophages, fibroblasts and PMNs
- TGF B - increases collagen synthesis
- FGF - hastens wound contraction
How can you differentiate malignant vs benign lesions on CXR?
Malignant - coin lesions in >50 yo, spiculated surface
Benign - calcification, bulls eye, popcorn shape
Besides size and stage of a tumor what is another important factor in determining the type of surgical resection for a lung cancer?
Location, if a main stem bronchus is affected Pneumonectomy may be required
What differentiates stage 2 vs 3 lung tumor? Treatment differences?
Stage2 affects hilar and peri bronchial LNs, can treat with surgical rsxn
Stage 3 - mediastinal LNs, requires chemo and RT, possible rsxn if tumor shrinks