PERIOPERATIVE Flashcards
percentage of DVT patient’s go on to develop postphlebitic syndrome, a painful and debilitating chronic disorder
UP TO 30%
patients with nonfatal PE will develop chronic thromboembolic pulmonary hypertension and what percentage
5%
the recommended DVT prophylaxis for moderate risk procedure with no associated risk factors - EEG, 45-year-old male undergoing elective sigmoid colectomy for diverticular disease
pharmacologic prophylaxis with
low molecular weight heparin
or
low-dose unfractionated heparin is recommended.
The incidence of perioperative myocardial infarction after major noncardiac surgery in patients without evidence of cardiac disease is approximately
0.15%.
Functional capacity is considered excellent, good, vs poor with what criteria
excellent if the patient reaches greater than 10 metabolic equivalents (METs),
good if greater than 4 METs,
Climbing a flight or 2 of stairs, walking up a hill, walking at 4 mph (6.4 kph), running a short distance, mopping or scrubbing the floor, lifting heavy furniture, dancing, bowling, and playing doubles tennis are all examples of activities that require greater than 4 METs to perform.
poor if less than 4 METs.
The accepted accumulated dose of ionizing radiation during a pregnancy is
5–10 rad, with no single diagnostic study exceeding 5 rad.
A CT scan of the abdomen and pelvis has how much radiation to fetus
2–4 rad of exposure to a fetus;
Fetal radiation exposure during cholangiography is estimated to be
0.2–0.5 rad,
lain abdominal radiograph averages radiation doses of
p0.1–0.3 rad.
Radiopharmaceuticals, including technetium-99m, can be administered with fetal whole body radiation doses of less than
0.5 rad.
Epidural anesthesia/analgesia decreases rates of what complications
cardiac morbidity
heart failure,
myocardial infarction,
death.
Decreases in the incidence of acute renal failure, deep venous thrombosis, pulmonary embolism, decreased blood loss,
Epidural anesthesia/analgesia improves
pulmonary outcomes
reduced rates of pneumonia and hypoxemia.
reductions in vascular graft occlusions, transfusion requirements, intubation time, length of stay
Epidural anesthesia/analgesia supportive care needed
Routine bladder catheterization is not required for patients who have TEAA,
although if removed within 24 hours of placement, approximately 10% of patients will have urinary retention requiring at least 1 intermittent straight catheterization.
pneumothorax rate of subclavian vein central axis and morbidly obese patient versus ideal body weight
Although subclavian vein central access is more likely to be attempted in morbidly obese patients (47% vs. 15%), the incidence of pneumothorax is similar.
The incidence of perioperative myocardial infarction after major noncardiac surgery in patients without evidence of cardiac disease is approximately
0.15%.
In patients with a history of myocardial infarction, the risk ranges from
2.8% to 17.7%.
For patients with adequate functional capacity without symptoms or history of myocardial infarction, was recommended for cardiac preoperative evaluation
in-depth cardiac testing is not beneficial.
preoperative coronary revascularization is associated with its own morbidity and clearly does not fully protect the patient from a postoperative cardiac event.
Preoperative coronary revascularization may also significantly delay the planned noncardiac procedure, and in the case of coronary stent placement, continuation of antiplatelet agents such as aspirin and clopidogrel may be necessary for many months, further complicating matters.
Functional capacity is considered excellent if the patient reaches greater than
10 metabolic equivalents (METs),
good if greater than 4 METs, and poor if less than 4 METs. Climbing a flight or 2 of stairs, walking up a hill, walking at 4 mph (6.4 kph), running a short distance, mopping or scrubbing the floor, lifting heavy furniture, dancing, bowling, and playing doubles tennis are all examples of activities that require greater than 4 METs to perform.
This patient has no symptoms of cardiac disease. The patient has the risk factor of hypertension and, therefore, a 12-lead electrocardiogram is recommended. Because the patient performs at a moderate functional capacity (>4 METs), a 6-minute walk, stress test, or cardiac imaging exam is unnecessary.
In those patients without symptoms of cardiac disease who are of poor or unknown functional capacity, stress testing or cardiac imaging may be indicated. This would be determined by the number of active clinical risk factors and the surgery-specific cardiac risk of the procedure.
Functional capacity is considered good if the patient reaches greater than
good if greater than 4 METs,
Functional capacity is considered poor if the patient reaches greater than
and poor if less than 4 METs.
activities that require greater than 4 METs to perform.
Climbing a flight or 2 of stairs, walking up a hill, walking at 4 mph (6.4 kph), running a short distance, mopping or scrubbing the floor, lifting heavy furniture, dancing, bowling, and playing doubles tennis are all examples of
vitamin D deficiency with early - 3 month post gastric bypass with symptoms of
had several weeks of intractable vomiting and unstable gait.
nystagmus.
classic signs of thiamine (Vitamin B1) deficiency (Wernicke encephalopathy) with intractable vomiting, unstable gait, and ocular motor dysfunction.
The continued vomiting serves to exacerbate the thiamine deficiency.
Neurological impairment may become permanent if treatment is not implemented.
Multiple mineral deficiencies are possible after bariatric surgery, such as
deficiencies of iron, calcium, copper, and zinc as well as Vitamins B1, B12, D, and E.
symptomatic deficiencies in the postbariatric surgery patient are generally limited to: posterolateral myelopathy (Vitamin B12 and copper deficiency)
acute encephalopathy (thiamine or Vitamin B1 deficiency).
treatment thiamine deficiency and bariatric
Thiamine deficiency can develop over a period of weeks; however, replacement therapy is effective within hours to days. In acutely ill patients, thiamine should be administered 3 times per day and given intravenously when possible. Dosages of 100–500 mg 3 times per day are described. Oral therapy generally consists of 50–100 mg twice daily.
bridge therapy in patients with atrial fibrillation, generally
bridge therapy in patients with atrial fibrillation, generally warfarin is discontinued 5–6 days before the procedure, and fractionated or unfractionated heparin is subsequently started within 2–3 days.
Heparin and warfarin are generally restarted within 12–24 hours after the procedure, and the heparin subsequently discontinued once the international normalized ratio (INR) reaches therapeutic range.
The American Society of Gastrointestinal Endoscopists defines low-risk procedures as
upper or lower endoscopy with or without mucosal biopsy, endoscopic retrograde cholangiopancreatography without sphincterotomy, and endoscopic ultrasound without biopsy.
In these patients, if the INR is within therapeutic range, it is safe to continue warfarin throughout the periprocedural period without interruption!
Data suggest that colonoscopy with polypectomy of lesions less than 1 cm in diameter can be performed safely in patients therapeutically anticoagulated on warfarin.
The American Society of Gastrointestinal Endoscopists defines Procedures deemed high risk for bleeding what is anticoagulation recommendations
endoscopic polypectomy,
sphincterotomy,
dilation of benign or malignant strictures,
percutaneous endoscopic gastrostomy tube placement,
endoscopic ultrasound with fine needle aspiration or core needle biopsy.
discontinuation or reduction of the warfarin dose and bridge therapy with heparin should be considered optimal.
The most effective method to reduce recurrence after operative closure of a small bowel enterocutaneous fistula (ECF) is
segmental resection with primary anastomosis.
that oversewing or wedge repair of established ECF had a recurrence rate of 32.7% versus 18.4% with resection and anastomosis or anastomotic revision.
No data indicate that ECF closure using layered sutures and bioabsorbable mesh reduces fistula recurrence rate.
Similarly, the use of fibrin glue, either as a primary closure method or an adjunct to suture closure of an ECF, does not reduce ECF recurrence.
Additional measures to reduce ECF recurrence rate include
drainage of septic foci, adequate nutritional support, skin protection, and patience.
The efficacy of octreotide in the management of fistulous
The efficacy of postoperative octreotide in the management of ECF is not clear.
Preoperatively, octreotide may help to reduce fistula output; however, there is little evidence that octreotide or somatostatin increases the overall probability of spontaneous fistula closure.
Early operative interventions for the management of fistulous
should be restricted to drainage of infection, and, when feasible, proximal defunctioning stoma with definitive ECF closure undertaken several months later.
Attempts at early closure of a high output ECF within 2 weeks have higher recurrence rates than delayed exploration several months later. This waiting period allows for control of infection, optimization of nutrition, and maturation of intra-abdominal adhesions.
use of perioperative antibiotics for laparoscopic cholecystectomy
no!
they do not reduce surgical site infection in low-risk patients undergoing laparoscopic cholecystectomy.
The data are less clear for high-risk patients undergoing laparoscopic cholecystectomy.
Positive bile culture and gallbladder rupture during laparoscopic cholecystectomy did not significantly increase the rate of surgical site infection!!!
Although prophylactic antibiotics reduce wound infection with elective OPEN cholecystectomy,
use of perioperative antibiotics for high-risk lap cholecystectomy patient’s
Factors contributing to high-risk patients include age older than 60 years, presence of acute cholecystitis, choledocholithiasis, biliary pancreatitis, jaundice, cholangitis, diabetes mellitus, and American Society of Anesthesiologists classification 3 or greater. Several authors recommend the selective use of prophylactic antibiotics in these high-risk patients.
In this patient, a Model for End-Stage Liver Disease (MELD) score of 15 predicts
an approximately 6% mortality in 3 months from his liver disease;
transjugular intrahepatic portosystemic shunt (TIPS) placement
. Effective portal decompression with TIPS will reduce the risk of bleeding esophageal varices and will aid in reducing ascites.
This intervention may allow selected cirrhotic patients to undergo major abdominal operations with acceptable morbidity and mortality within weeks after portal decompression.
In this case, available data support colectomy approximately 2–3 weeks after successful TIPS placement.
When patients on chronic corticosteroid supplementation require elective surgery how are they managed
their usual dose should continue uninterrupted whenever possible.
No published prospective trials have demonstrated benefit to treating steroid-dependent patients with supraphysiologic “stress dose” steroids compared with continuing their preoperative dose.
successful strategy for treating postoperative ileus
Gum chewing does appear to decrease postoperative ileus after both laparotomy and laparoscopy according to 2 meta-analyses of underpowered studies. The advantage of gum chewing is that it is relatively inexpensive and may be started in the postoperative period without specific preoperative alterations in care.
One successful strategy after OPEN laparotomy is using epidural analgesia, promoting early ambulation, and encouraging early oral intake.
These strategies do not translate when the laparoscopic approach is used!
use of epidural analgesia actually increases length of hospital stay after laparoscopic colectomy compared with spinal anesthesia and postoperative patient-controlled analgesia!
Erythromycin, which may have some role in the management of gastric dysmotility, does not decrease the rate of postoperative ileus after standard colectomy.
Alvimopan, a peripherally acting mu-opioid receptor antagonist, decreases postoperative ileus after open colectomy if administration begins PREoperatively and continues through the postoperative period.
With the laparoscopic approach, 4% of patients receiving alvimopan developed postoperative ileus compared with 12% of a matched cohort. Importantly, patients received alvimopan preoperatively to achieve this benefit, and overall length of stay was not shortened, unlike in the open approach.
increased mortality in patients randomized to achieve a blood glucose level of blank versus
81–108 mg/dL versus less than 180 mg/dL.
American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association guidelines
in-hospital intensive care unit targets to 140–180 mg/dL
general care medical and surgical wards 100–180 mg/dL and
Addressing the decision to delay surgery in an effort to optimize HbA1c preoperatively
Delay in surgery is not practical nor should it be recommended.
day of surgery management of hyperglycemia
use of perioperative glycemic control in the range of 150–200 mg/dL significantly reduces perioperative infections in diabetic patients undergoing open heart surgery.
There is insufficient evidence to support strict glycemic control versus conventional management (maintenance of glucose <200 mg/dL) for the prevention of surgical site infections in all surgical patients.
Smokers are at greater risk than nonsmokers for postoperative
wound healing complications,
postoperative pulmonary
cardiovascular complications.
significant reduction in wound healing complications associated with former smokers compared with current smokers.
makes the gastroesophageal sphincter incompetent, which allows reflux, with accompanying risks of pulmonary aspiration.
Smoking increases the production of what blood products
Hb, red blood cells, white blood cells, fibrinogen, platelets, platelet reactivity.
These increases result in an increase in the hematocrit and the blood viscosity, leading to an increased thrombotic tendency.
The result is an increased incidence of arterial thromboembolic disease in smokers.
Chronic hypoxia to the cardiac muscle and the increase in incidence of thromboembolic disease causes smokers to be at a 70% greater risk of coronary artery disease compared with nonsmokers, and the postoperative mortality in smokers is higher than in nonsmokers.
A study of current smokers who reduced their cigarette consumption before surgery demonstrated that
these patients had nearly seven times the risk of developing a postoperative pulmonary complication compared with those who did not reduce consumption, after adjusting for potential confounders!!
Among those who cut down within a month of surgery, those who stopped smoking closest to the surgery date were at the greatest risk of developing a postoperative pulmonary complication!
Esophageal stents percent success and most frequent complications
However, as experience improved, success rates approached 85%, even treating gastric problems.
Sleeve gastrectomy leaks from the staple line are preferentially treated with stents.
Stent migration is the main complication, especially in treating gastric leaks, mostly because of anatomical considerations.
Esophageal leaks treated by stents have a migration rate of about 20%.
Gastric leaks have a higher migration rate, about 40%, but these rates are decreasing as more experience is gained.
The Revised Cardiac Risk Index considers the following factors:
what is considered high risk
ischemic heart disease, congestive heart failure, cerebrovascular disease, diabetes, renal dysfunction, high-risk procedures.
Three or more factors denote patients at high risk for cardiac complications in the perioperative period.
Further studies have documented that inclusion of age older than 70 years and further stratification of surgical procedures into low risk, intermediate risk, and high-risk procedures improves the sensitivity of this risk index.
High-risk surgery includes
lower extremity revascularization
(open infrainguinal revascularization)
open aortic surgery.
This is because of increased intra-abdominal pressure and reduced venous return due to the pneumoperitoneum used during these procedures, leading to lower cardiac output and increased systemic vascular resistance.
The highest risk is during the first 72 hours after surgery.
Endovascular aortic aneurysm repair is considered what kind of cardiac risk
intermediate risk because of the reduced myocardial stress.
Current evidence demonstrates that beta-blockade
decreases perioperative death only in patients at high cardiac risk ( because of increase postoperative stroke risk)
The revised Lee Cardiac Risk Index categorizes the risk of a cardiac event in patients undergoing surgery. The Lee index uses 6 criteria:
high-risk surgery, ischemic heart disease, congestive heart failure, cerebrovascular disease, insulin-dependent diabetes, renal failure.
Intermediate risk includes 1–2 of these criteria,
high risk is greater than 3 criteria.
The risk of major cardiac complication is estimated to be
low 0.4%,
intermediate 0.9–7%,
high 11% !
.
considered for all intermediate and high risk cardiac risk surgeries
Perioperative statin therapy
Catheter-associated urinary tract infection Evidence-based recommendations for management to decrease infection rate and complications
silver impregnated catheter or antibiotic impregnation
Foley to gravity
Close system
Cleaning the meatus
hypercoagulable states by frequency
INHERITED
frequent-
factor V light and
hyper prothrombin - venous thrombosis
hyper ELEVATED homocystine
less frequent-
Protein C deficiency
Protein S deficiency
anti-thrombin 3 deficiency
Rare-
Dysfibringenemia
ACQUIRED
increased homocysteine due to deficient full passive, vitamin B12, B6
anticardiolipin antibody-lupus anticoagulant
DIC
acquired resistance activated protein C
a leading cause of adverse events in healthcare.
Poor communication
The benefits of preoperative briefings
are well established in the literature.
significantly improved rates of
proper antibiotic
thromboembolic prophylaxis.
3-fold reduction in observed communication failures,
Morbidly obese patients are more likely to have acute and chronic medical problems, including
insulin-dependent diabetes mellitus, hypertension, dyslipidemia, cardiovascular disease, cholelithiasis, cholecystitis.
Morbid obesity is an independent risk factor for acute lung injury, surgical site infections, postoperative gastroparesis. Pulmonary embolus cardiac failure
Electrocardiogram (ECG) changes in hyperkalemia can occur once the potassium level reaches
6.0 mEq/L.
The earliest ECG change hyperkalemia
peaked T-waves, which are most evident in the precordial V2 and V3 leads.
second EKG changes hyperkalemia
first-degree heart block (lengthening of the PR interval)
third EKG changes hyperkalemia and final EKG changes
widening of the QRS complex and eventual ventricular asystole.
Calcium directly antagonizes the cardiac effects of hyperkalemia by
altering the membrane actions of potassium
agents to decrease potassium level
Insulin/glucose and beta-agonists cause potassium to shift intracellularly.
Sodium polystyrene sulfonate, a cation exchange resin, reduces total body potassium via the gastrointestinal mucosa.
Hemodialysis is particularly effective at removing potassium.
World Health Organization subsequently developed and disseminated the surgical safety checklist 3 phases:
before induction of anesthesia,
before skin incision,
before the patient leaves the operating room.
who has responsibilities / active role with World Health Organization surgical safety check list and what are they
The surgeon, anesthetist, and operating room nurse
Ensuring that the anesthesia machine is functional
surgical site is marked are done before induction.
The surgeon’s estimate of anticipated blood loss is announced before skin incision.
A debriefing pertaining to the concerns for recovery of the patient among the surgeon, anesthetist, and nurse is done before patient leaves the operating room.
Confirming that the antibiotic was given within 60 minutes of the incision is done before incision;
Extended surgical timeouts are advocated to include the parameters of the Surgical Care Improvement Project, such as
prophylactic antibiotics, normothermia, euglycemia, venous thromboembolism prophylaxis, beta-adrenergic blockage
Mechanical thromboprophylaxis
reduce the risk of deep vein thrombosis,
they have been studied much less than pharmacologic thromboprophylaxis.
Mechanical thromboprophylaxis has not been evaluated as a strategy to reduce the risk of death from pulmonary embolus.
Studies demonstrate an additive effect of combining mechanical and pharmacologic thromboprophylaxis in patient groups, and current guidelines for high-risk general surgery patients recommend a pharmacologic method of prophylaxis be COMBINED with a mechanical method of prophylaxis.
Current recommendations for prevention of venous thromboembolism in nonorthopedic surgical patients are based on
stratification to groups of very low risk, low risk, moderate risk, and high risk.
The Caprini scoring system
thrombotic event - cumulative risk score.
It is intended for surgical and medical patients
captures congenital and acquired risks in addition to factors associated with the clinical setting.
postoperative Infarcted liver management
is conservative!
fluid resuscitation,
maintenance of electrolytes and blood glucose,
replenishment of phosphate,
sodium polystyrene sulfonate to decrease ammonia levels and reverse encephalopathy.
complications of post operative liver infarction and their management
abscess formation is successfully treated with percutaneous drainage.
The intravenous administration of prostaglandin E1 is used for the treatment of fulminant hepatic failure.
Prostaglandin E1 is known to increase hepatic blood flow and improve clinical outcome in various settings such as liver dysfunction or ischemia/reperfusion injury. Intravenous prostaglandin E1 might be considered for hepatic infarction patients with stable blood pressure, because it may exacerbate hypotension.
Liver resection is NOT advocated.
The Surgical Care Improvement Project (SCIP) provides
evidence-based guidelines that decrease surgical site infections.
These guidelines include
prophylactic antibiotics within 1 hour before surgical incision,
avoiding the use of razor removal of hair from the surgical site,
perioperative avoid hypothermia.
discontinuation of antibiotics within 24 hours after the surgery end time.
Perioperative normothermia Current recommendations
forced-air warming for 30 minutes preoperatively,
forced-air warming intraoperatively for major abdominal procedures more than 30 minutes,
intravenous fluid warming for major abdominal surgery procedures more than 60 minutes
maintaining ambient operating room temperature greater than 23°C for adults
at least 26°C for infants.
NOT - Passive heating of ventilator circuits - has a trivial effect on maintaining core temperature.
BMS thrombosis is most common in what time period
first 2 weeks after stent placement
exceedingly rare after more than 4 weeks.
generally administered after BMS placement for how long
double therapy 4 wks: A thienopyridine (ticlopidine or clopidogrel) is with aspirin for 4 weeks
delaying surgery 4–6 weeks after BMS placement allows proper thienopyridine use to reduce the risk of coronary stent thrombosis.
In patients with BMSs, daily antiplatelet therapy with aspirin should NOT be stopped perioperatively.
DES antiplatelet therapy recs
dual antiplatelet therapy f
or 12 months after DES!!
For patients treated with DESs who are to undergo subsequent procedures that mandate discontinuation of thienopyridine therapy, aspirin should be continued, if at all possible, and the thienopyridine should be restarted as soon as possible after the procedure.
Elective procedures for which there is significant perioperative or postoperative bleeding should be deferred until patients have completed 12 months of dual antiplatelet therapy for DESs and 1 month for BMSs.
