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perioperative care Flashcards

1
Q

what conditions may lead to immune compromise in the perioperative patient

A 
malnutrition 
old age
severe trauma or burns
renal failure
cancer
immunosuppressive meds (corticosteroids, chemo, prolonged abx)
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2
Q

how do you manage hypertension meds perioperatively

A

patient should take ACEi and ARBs until DAY BEFORE operation

patients should continue beta blockers, CCBs and alpha-2 agonists until and INCLUDING day of surgery

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3
Q

how do you manage diuretics perioperatively

A

taken until day before operation

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4
Q

how do you manage anticoagulants perioperatively

A

patients on aspirin or clopidogrel should be discontinued at least 1 WEEK prior to operation if bleeding is a significant risk or concern (at surgeons discretion)

patients on oral anticoagulants (warfarin) should be discontinued at least 5 DAYS before operation unless otherwise stated

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5
Q

why do we worry about patients with compromised preoperative pulmonary function

A

susceptible to post op complications like hypoxia, atelectasis, pneumonia

monitor degree of post op impairment

do a CXR, blood gasses, ECG, PFTs

patients with resp compromise should be planned for preop smoking cessation (at least 48 hours), bronchodilator use, postural drainage, instruction in coughing and deep breathing and maybe supplemental O2

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6
Q

what is the 1/3rds–2/3rds rule for fluids

A

water is about 60% of body weight

of that 1/3 is ECF, 2/3 is ICF

of the ECF, 1/3 is intravascular, 2/3 is interstitial fluid

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7
Q

what physical signs can indicate fluid status

A

tachycardia–> 15% volume loss

hypotension–30% volume loss

mucous membranes

urine output

sunken orbits

decreased skin turgor

capillary refill

pulse strength

skin temp

orthostatic BP

JVP

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8
Q

how do you determine how much fluid you should replace?

A

% body weight lost x body weight in kg equals liters to replace

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9
Q

what is a short cut to calculate maintenance fluids for an adult

A

weight plus 40 equals ml/hr

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10
Q

what are the electrolyte derangements that can be caused by diarrhea

A

metabolic acidosis

hypokalemia

hypernatremia

hypovolemia

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11
Q

what electrolyte derangements are caused by vomiting

A

hypochloremic alkalosis

hypokalemia

hypomagnesemia

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12
Q

what electrolyte derangements can be caused by NG drainage

A

hypokalemia

hypochloremia

hypomagensemia

metabolic alkalosis

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13
Q

what is third spacing

A

when fluid moves out from the intravascular space into the interstitial space

can be cause by burns (fluids pool at burn site), ascites (pancreatitis, peritonitis, ileus etc), pleural effusions, long/difficult surgical procedures, increased overall fluid volume, increased capillary hydrostatic pressure (i.e right and left heart failure), hyponatremia, albumin loss, increased capillary permeability (inflammation, trauma etc) and lymphatic obstruction

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14
Q

what fluids are commonly given post op

A

D5NS or D5 in ringers (dont add K in first 24 hours)

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15
Q

how much fluid is usually lost via NG and how can this be replaced

A

less than 500 ml/day

replace by increasing maintenance infusion with 20meq of K added to each liter

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16
Q

define shock

A

state of cellular and tissue hypoxia due to reduced oxygen delivery and/or increased oxygen consumption or inadequate oxygen utilization

most commonly due to circulatory failure manifested as hypotension (i.e reduced tissue perfusion)

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17
Q

list the 4 overarching types of shock

A

distributive

cardiogenic

hypovolemic

obstructive

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18
Q

list the types of distributive shock

A 
septic shock 
SIRS
neurogenic shock 
anaphylactic shock 
drug and toxin-induced
endocrine shock
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19
Q

list the types of cardiogenic shock

A

cardiomyopathic shock
arrhythmic shock
mechanical shock

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20
Q

list the types of hypovolemic shock

A

hemorrhagic shock

non hemorrhagic shock

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21
Q

list the types of obstructive shock

A

pulmonary vascular shock

mechanical shock

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22
Q

how many classes of hemorrhagic shock are there

A

4

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23
Q 
list the 
1. blood loss in mL
2. blood loss in % volume
3. pulse rate 
4. BP
5. resp rate 
6. urine output
7. CNS/mental status
for class I hemorrhagic shock
A
  1. blood loss in mL–up to 750mL
  2. blood loss in % volume–up to 15%
  3. pulse rate–less than 100
  4. BP–normal
  5. resp rate–14-20
  6. urine output–above 30mL/hr
  7. CNS/mental status–slightly anxious
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24
Q 
list the 
1. blood loss in mL
2. blood loss in % volume
3. pulse rate 
4. BP
5. resp rate 
6. urine output
7. CNS/mental status
for class II hemorrhagic shock
A
  1. blood loss in mL–750-1500 mL
  2. blood loss in % volume–15-30%
  3. pulse rate–100-120
  4. BP–normal
  5. resp rate–20-30
  6. urine output–20-30 ml/hr
  7. CNS/mental status–mildly anxious
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25
``` list the 1. blood loss in mL 2. blood loss in % volume 3. pulse rate 4. BP 5. resp rate 6. urine output 7. CNS/mental status for class III hemorrhagic shock ```
1. blood loss in mL--1500-2000mL 2. blood loss in % volume--30-40% 3. pulse rate--120-140 4. BP--decreased 5. resp rate--30-40 6. urine output--5-15ml/hr 7. CNS/mental status--anxious, confused
26
``` list the 1. blood loss in mL 2. blood loss in % volume 3. pulse rate 4. BP 5. resp rate 6. urine output 7. CNS/mental status for class IV hemorrhagic shock ```
1. blood loss in mL--above 2000 mL 2. blood loss in % volume--above 40% 3. pulse rate--above 140 4. BP--decreased 5. resp rate--above 35 6. urine output--negligible 7. CNS/mental status--confused, lethargic
27
descibe an approach to fluid resuscitation in an acutely hypotensive patient
1. assess ABCDEs and call for help 2. ask for vitals, ABGs, oximetry, O2 by NP or other, and ECG 3. ask for IV access (large bore x2) 4. bolus 1-2L NS or ringer's 5. CBC with type and crossmatch 6. O neg blood 7. stop any bleeding * patients need referral to ICU if remains uncompensated, and if there are signs/symptoms of organ dysfunction (persisted tachy, dyspnea, hypotension, diaphoresis, oliguria, cold/pale, metabolic acidosis, decreased LOC
28
what are the 4 classes of wounds
1. clean wounds 2. clean-contaminated wounds 3. contaminated wounds 4. dirty/infected wounds
29
define clean wound
uninfected, no inflammation, no orifices are entered during surgery likely no abx needed
30
define clean-contaminated wound
an orifice or cavity has been entered under controlled conditions and without unusual contamination
31
define contaminated wounds
open, fresh, accidental wounds with major break in sterile technique possible gross spillage from GI tract or something similar possible non purulent inflammation present
32
define dirty/infected wound
clinical infection perforated viscera infection may have been present preoperatively feculent
33
is there published evidence for prophylactic abx therapy for wounds without clinical evidence of infection?
no signs include--cellulitis, pus, malodor, wet gangrene, fever, chills, nausea, leukocytosis, hypotension, confusion etc
34
what is first line for surgical prophylaxis and cellulitis tx
cephalexin/keflex is first line
35
what abx should be used for the gut
need to cover gram negatives and anaerobes anaerobes--flagyll gram negatives--ceftriaxone or cipro
36
what are the primary causes of early post op complications and death
acute pulmonary, CV and fluid derangements
37
how should the patient be positioned post op
patient should turn from side to side hourly for the first 8-12 hours to prevent atelectasis early ambulation is encouraged to reduce venous stasis upright positioning helps to increase diaphragmatic excursion
38
when does peristalsis return to the small intestine post op
within 24 hours function returns to right colon by 48 hours returns to left colon by 72 hours however it can take up to 3-4 days NG tubes in place should be left in for 203 days or until evidence that normal peristalsis has returned
39
how should G, J or GJ tubes be manages in the first 24 hours post op
low intermittent suction or dependent drainage
40
what is the post op WHO analgesia ladder
1. non opioid like NSAID with or without another non opioid like tylenol with or without adjuvant 2. opioid for mild to moderate pain (i.e codeine) plus other shit 3. opioid for moderate to severe pain (i.e morphine) plus other shit
41
what is prealbumin
transport protein for thyroxine decreased in many of same conditions as serum albumin but has much shorter half life so changes faster with response to changes in nutritional status and liver function can be used to monitor nutritional status over time
42
what are the current indications for nutritional support
weight loss over 10% anticipated prolonger post op recovery period during which the patient will not be fed orally
43
what is enteral support
preferred because it is simple, safe and has reduced complications cheaper, helps maintain mucosal barrier function high protein oral supplements are most suitable for patients with wounds and those with malignancy prethickened supplements and puddings are helpful for support to individuals with dysphagia and those with neuro conditions early enteral support may be appropriate in patients who are malnourished at baseline
44
what is parenteral support and when is it indicated
indicated in post op patients who are anticipated to be unable to receive adequate enteral nutrition by post op day 10-14 or those with IBD where a period of bowel rest is helpful dextrose, protein, amino acids, electrolytes, vitamins, minerals, trace elements, fatty acids etc can be supplemented enterally or parenterally
45
what is refeeding syndrome
clinical complications that can occur as a result of fluid and electrolyte shifts during aggressive nutritional rehabilitation (oral, enteral or parenteral) or malnourished patients marked by HYPOPHOSPHATEMIA, HYPOKALEMIA, vitamin deficiencies (thiamine), CHF, peripheral EDEMA, rhabdomyolysis, seizures and hemolysis with carbs and glucose, insulin is released which triggers cellular phosphate and Mg uptake and production of ATP and other molecules requiring phosphate--> this further depletes low phosphate stores--> lack of phosphorylated intermediates causes tissue hypoxia and myocardial dysfunction and resp muscle failure
46
what % of patients get post op fever
40%
47
what can cause fever hours post op to POD1
inflammatory reaction in response to surgery reaction to blood products malignant hyperthermia resolving sepsis or infection from pre op conditions
48
what causes fever in POD 1-2
atelectasis (old wives tale) early wound infection (clostridium, GAS) aspiration pneumonitis addisionian crisis, thyroid storm, transfusion rxn
49
what causes fever in POD 3-7
infections are more likely UTI, surgical site, IV site, septic thrombophlebitis infections leakage at bowel anastamosis DVT PE
50
signs of leakage at bowel anastamosis
tachycardia hypotension oliguria adbo pain
51
what does dehiscence mean
wound coming apart
52
what does wound evisceration mean
big gush of fluid, popping/gross sensation, appearance of bowels--> put something warm and wet on it
53
what causes fever in POD 8 and beyond
intraabdominal abscesses DVT/PE drug fever ``` also... cholecystitis perirectal abscess URTI infected seroma/biloma/hematoma parotitis c diff sinusitis from NG endocarditis ```
54
what are the 5 Ws of post op fever
``` Wind Water Wound Walking Wonder drugs ```
55
what are the 5 As of periooperative meds
``` Antiemetics Antibiotics Analgesics Anticoagulants Antecendent (home meds) ```
56
what patients are at a higher risk of wound complications
protein depletion ascorbic acid deficiency marked dehydration or edema chronic diuretic therapy severe anemia DM smoking steroid use cytotoxic drugs past irradiation obesity myocardial dysfunction CVD and poor ability to maintain adequate BV/perfusion (poor perfusion means delayed wound healing or increased infection risk)
57
when should dressings over closed wounds be removed
day 3 or 4 skin suture or staples removed by day 5 and replaced by tapes (should be left in for 2 weeks for wounds that cross creases, were closed under tension or were in some extremities)
58
define wound dehiscence
partial or total disruption of any or all layers of the operative wound
59
what is fascial dehiscence
separation of the fascial closure of the abdominal wound with exposure of the abdominal contents to the external environment, due to failure of suture, shear forces from tension or fascial necrosis from infection and/or ischemia signs include profuse serosanguinous drainage, popping sensation, incisional bulge, gush of fluid
60
treatment for fascial dehiscence
ound exploration debridement mass closure with continuous slowly absorbable suture (with possible external sutures)
61
what is superficial dehiscence
only superficial reopening of the tissue signs include open wound, broken sutures without healing, pain, bleeding, pus or drainage at the site
62
why do we care about dehiscence
all wound dehiscence is a surgical emergency, treated as a new wound with abx therapy and surgical debridement, frequent dressing changes and close monitoring
63
what are some warning signs of necrotizing soft tissue
``` swelling erythema pain tachycardia tense edema outside the area of compromised skin pain disproportionate to appearance skin discoloration and eccymosis blisters/bullae and necrosis subcutaneous gas fever hypotension shock ```
64
what does a history of mucocutaneous bleeding suggest
vWD thrombocytopenia functional platelet disorders
65
how do you treat anaphylaxis
IV epinephrine
66
how do you treat tension pneumo
chest tube
67
what does an elevated serum lactate suggest
shock
68
ddx for post op oliguria
failure of staff to appreciate fluid losses during procedure and in the immediate post op period urinary retention poor renal perfusion (pre renal failure... hypovolemia and/or pump failure) renal failure (tubular necrosis) renal tract obstruction (post renal)
69
treatment for post op oliguria
treat with fluid replacement if pre renal hypovolemia or diuretic therapy is pump failure --consider inotropes etc for cardiac function improvement if renal failure, match input to output and correct electrolytes (may need dialysis) treat any renal tract obstruction
70
ddx post op chest pain
MI PE pneumothorax gastric/GI MSK
71
ddx post op abdo distension
infection leak inflammation hydrostatic/oncotic changes and 3rd spacing hemorrhage ileus constiptation** obstruction**
72
define hypertonic crystalloid
greater osmolality than serum--> i.e D5NS, D5 1/2NS D5 1/2NS with KCl is pretty common perioperatively because glucose is good for muscle stores and organ function, especially since they arent eating much and since giving sugar stimulates insulin which will stimulate K uptake into cells
73
define isotonic crystalloid
same osmolality as serum NS, D5W, ringers generally we bolus with NS or ringers
74
define hypotonic crystalloid
less osmotic than serum 1/2 NS, D5W
75
give an example of a colloid
albumin --in liver failure
76
what is the best measure of adequacy of volume resucitation
THIRST then Hr, urine output, skin turgor, BP, cap refill
77
most likely pathogen upper GI
gram +
78
most likely pathogen lower GI
gram -
79
what does ancef conver
gram + and some gram -
80
what can you use for penicillin allergy
clinda
81
what does cipro cover
gram -
82
what does flagyll cover
anaerobes
83
common risks for blood products
infection giving wrong type--hemolytic reactions
84
approach to shock
call for help ``` start a "MOVIE" Monitors Oxygen Vitals Investigations and IV fluids Extras (ECG, CXR, environment) ``` Volume resuscitation with evaluation of end points treat underlying pathology
85
list discharge criteria
good mobilization adequate oral intake for liquids and solids GI transit for gas normal urinary function no wound problems pain control no fever patient knows about possible complications and their detection patient feels comfortable with discharge (stoma etc)

Surgery (20 decks)

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