PERIOPERATIVE

Question 1

time course that malignant hyperthermia can present

Answer 1

up to 24 hours after anesthetic administration

Question 2

risk factors and diagnoses of concern for pulmonary embolism postoperatively

Answer 2

heart rate greater than 100 and
Hemoptysis
Recent surgery or immobilization
Malignancy
D-dimer
CTA

Question 3

findings consistent with prerenal azotemia

Answer 3

example this is dry after surgery
Low urinary sodium less than 20
Elevated urine osmolarityGreater than 500
FeNa less than one
BUN to plasma creatinine ratio greater than 40
BUN to plasma urea ratio of greater than 8
Dear and plasma are at mobile in the less than 1.5 a

Question 4

management of peristomal hernia

Answer 4

asymptomatic watch

Partial obstruction or worsening usually relocate the stoma

Question 5

postoperative parotitis

Answer 5

decreased saliva
Elderly poor hygiene male
Poor oral intake
Obstruction of salivary duct-can produce high fevers and erythema and edema
Can lead to life-threatening sepsis: Staphylococcus coverage warm compress
Rarely in advanced cases tracheostomy required

Question 6

toxic megacolon

Answer 6

Clostridium difficile

mortality up to 50%!

Question 7

Clostridium perfringens organism morphology

Answer 7

anaerobic gram-positive rod
produces exotoxin
produces dishwater pus

Question 8

treatment for V. tach

Answer 8

stable: With palpable carotid or femoral artery and normal blood pressure-
Amiodarone/lidocaine
Unstable: Cardioversion 200 J
If cardioverting stable but she synchronized started on her joules

Only epinephrine for pulseless V. tach

Question 9

treatment of rhabdomyolysis

Answer 9

maintain urine output of 100 or greater
Alkalinization of the urine-IV bicarbonate
Mannitol

Question 10

factors that cause fistulas this day open

Answer 10

FRIEND
Foreign body
Radiation
Inflammation/infection
Epithelialization
Neoplasia
Distal obstruction

Question 11

calculated maximum dose of lidocaine with and without epinephrine

Answer 11

without epinephrine kilogram x5
With epinephrine kilogram x7
70x5 equals 350 (35)

Question 12

treat lidocaine toxicity

Answer 12

Intralipid

Question 13

greatest risk factor for bowel ischemia with AAA repair open

Answer 13

prolonged hypotension preoperatively

(not well correlated with ligation of the inferior mesenteric artery)

Question 14

Clinical presentation of PE

Answer 14

at chest pain dyspnea
tachycardia
Decreased PaO2 line increased central venous pressure line

Question 15

complication of rapid infusion of vancomycin

Answer 15

red man syndrome
Caused by histamine release line where hypotension angioedema
Chills fever agitation dizziness
Onset 4-10 minutes after infusion

Question 16

treatment of red man syndrome

Answer 16

Can pretreat with antihistamine

Stop vancomycin

Question 17

over what period of time should vancomycin be administered for implants pre-incision

Answer 17

infused over at least 30 minutes

Question 18

most important amino acids for gluconeogenesis

Answer 18

ALANINE

gut a is major source

Question 19

zinc adeficiency

Answer 19

Alopecia
Poor wound healing
Immunosuppression
9 blindness/photophobia
Taste/smell
Neuritis
Skin problems

Question 20

copper deficiency

Answer 20

microcytic anemia
Pancytopenia
D. pigmentation
Osteopenia
 parenteral nutrition long term

Question 21

chromium deficiency

Answer 21

poor glucose control line sudden diabetic state
Peripheral neuropathy
Encephalopathy

Question 22

selenium deficiency

Answer 22

sling and deficiency CARDIAC! Cardiomyopathy
Skeletal myopathy
Loss of pigmentation
Erythrocyte macrocytosis

Question 23

time course that malignant hyperthermia can present

Answer 23

up to 24 hours after anesthetic administration

Question 24

risk of laparoscopic surgery versus open abdominal surgery for cardiac stress

Answer 24

Laparoscopic surgery is considered a similar risk as open surgery, because the cardiac stress evoked during these procedures is similar.

theThis 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.

Question 25

Current evidence demonstrates that beta-blockade decreases perioperative death

Answer 25

only in patients at high cardiac risk.

Ideally, beta-blockade should be started as early as possible in the preoperative period.

The Perioperative Ischemic Evaluation (POISE) trial was the largest randomized clinical trial evaluating the use of perioperative beta-blockade; it also included the largest number of vascular surgical patients. POISE demonstrated significant reduction in cardiovascular death, nonfatal myocardial infarction, and nonfatal cardiac arrest with perioperative beta-blockade, although this treatment was also associated with a higher overall risk of all-cause mortality and stroke.

Question 26

The revised Lee Cardiac Risk Index categorizes the risk of a cardiac event in patients undergoing surgery. The Lee index uses 6 criteria:

Answer 26

high-risk surgery, ischemic heart disease, congestive heart failure, cerebrovascular disease, insulin-dependent diabetes, and renal failure.

Intermediate risk includes 1–2 of these criteria, and

high risk is greater than 3 criteria.

The risk of major cardiac complication is estimated to be 0.4%, 0.9–7%, and 11% for low-, intermediate-, and high-risk categories, respectively. Perioperative statin therapy should be considered for all intermediate- and high-risk patients undergoing vascular surgical procedures.

Although cirrhosis is a significant comorbid condition, it is not a predictor of major cardiac complications in patients undergoing vascular surgical procedures.

Question 27

high risk cardiovascular event vascular procedures

Answer 27

High-risk vascular surgical procedures include open aortic surgery and open infrainguinal revascularization.

Question 28

Evidence-based recommendations for CA-UTI prevention

The most effective way to reduce the incidence of CA-UTI is

Answer 28

The most effective way to reduce the incidence of CA-UTI is

(1) to reduce the use of urinary catheterization by restricting its use to patients who have clear indications and
(2) to remove catheters as soon as they are no longer necessary.

 other recommendations include:
Clean meatus
Keep Foley to gravity
Closed system
 Silver or antibiotic coated catheter

NOT systemic antibiotics

Question 29

thromboembolic events that should prompt workup for hypercoagulability

Answer 29

clots occurring in patients younger than 50 years;

clotting in an unusual site
(i.e., mesenteric vein, cerebral vein, or axillary vein);

a history of venous and arterial thromboses or recurrent venous thrombosis,
particularly if unprovoked;

history of multiple miscarriages or stillbirths.

Question 30

list hypercoagulability inherited disorders

Answer 30

frequent:
Factor V Leiden
hyperprothrombinemia
hyper homocystinemia

Less frequent:
protein C deficiency
protein S deficiency
anti-thrombin 3 deficiency

Rare:
Dysfigringenemia

Lupus anticoagulant or anti-cardiolipin antibody
chronic DIC coagulation - associated with cancer

required resistance to activated protein C

Question 31

The benefits of preoperative briefings he was

Answer 31

are well established in the literature. A 2-minute operating room briefing was introduced at 1 institution. The briefing significantly reduced the perceived risk of wrong-site surgery among team members as well as increased their perceived team collaboration. Researchers commented that demonstrating a statistically significant decrease in actual wrong-site surgery would be difficult, given the rarity of the events. A preoperative briefing at the Houston Veterans Administration hospital demonstrated significantly improved rates of proper antibiotic and thromboembolic prophylaxis. Finally, in another study, the use of a preoperative briefing resulted in a 3-fold reduction in observed communication failures, reducing the number of visible negative consequences. Such communication was observed as being proactive, enhancing the collaborative interaction of the team. is

Question 32

Morbidly obese patients are more likely to have acute and chronic medical problems, including

Answer 32

insulin-dependent diabetes mellitus, 
hypertension, 
dyslipidemia, 
cardiovascular disease, 
cholelithiasis, and 
cholecystitis.

Question 33

morbidly obese patients admitted to the intensive care unit with those with morbid obesity had a higher

Answer 33

mortality (30% vs. 17%),

Morbid obesity is an independent risk factor for

acute lung injury,
surgical site infections,
postoperative gastroparesis.

Pulmonary embolus and cardiac failure are the 2 most common postoperative complications, occurring at nearly twice the rate observed in nonobese patients.

Although subclavian vein central access is more likely to be attempted in morbidly obese patients (47% vs. 15%), the incidence of pneumothorax is similar.

Question 34

Electrocardiogram (ECG) changes in hyperkalemia can occur once the potassium level reaches

Answer 34

6.0

Question 35

the earliest ECG change is

Answer 35

peak T waves

which are most evident in the precordial V2 and V3 leads.

Question 36

second EKG change and hyperkalemia

Answer 36

first-degree heart block

lengthening of the PR interval

Question 37

would do EKG changes progressed to after lengthening of the PR interval with hyperkalemia

Answer 37

progressing to widening of the QRS complex

Question 38

once there is widening of the QRS complex and hyperkalemia what can occur next

Answer 38

eventual ventricular asystole.

Question 39

list management and agents at lower potassium in hyperkalemia with their mechanisms

Answer 39

intravenous insulin/glucose - cause potassium to shift intracellularly

inhaled beta-agonists also cause potassium to shift intracellularly

sodium polystyrene sulfonate - a cation exchange resin, reduces total body potassium via the gastrointestinal mucosa.

Hemodialysis,