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Surgery > perioperative care > Flashcards

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
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 III hemorrhagic shock
A
  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
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26
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 IV hemorrhagic shock
A
  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
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27
Q

descibe an approach to fluid resuscitation in an acutely hypotensive patient

A
  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
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28
Q

what are the 4 classes of wounds

A
  1. clean wounds
  2. clean-contaminated wounds
  3. contaminated wounds
  4. dirty/infected wounds
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29
Q

define clean wound

A

uninfected, no inflammation, no orifices are entered during surgery

likely no abx needed

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30
Q

define clean-contaminated wound

A

an orifice or cavity has been entered under controlled conditions and without unusual contamination

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31
Q

define contaminated wounds

A

open, fresh, accidental wounds with major break in sterile technique

possible gross spillage from GI tract or something similar

possible non purulent inflammation present

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32
Q

define dirty/infected wound

A

clinical infection

perforated viscera

infection may have been present preoperatively

feculent

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33
Q

is there published evidence for prophylactic abx therapy for wounds without clinical evidence of infection?

A

no

signs include–cellulitis, pus, malodor, wet gangrene, fever, chills, nausea, leukocytosis, hypotension, confusion etc

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34
Q

what is first line for surgical prophylaxis and cellulitis tx

A

cephalexin/keflex is first line

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35
Q

what abx should be used for the gut

A

need to cover gram negatives and anaerobes

anaerobes–flagyll

gram negatives–ceftriaxone or cipro

36
Q

what are the primary causes of early post op complications and death

A

acute pulmonary, CV and fluid derangements

37
Q

how should the patient be positioned post op

A

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
Q

when does peristalsis return to the small intestine post op

A

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
Q

how should G, J or GJ tubes be manages in the first 24 hours post op

A

low intermittent suction or dependent drainage

40
Q

what is the post op WHO analgesia ladder

A
  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
Q

what is prealbumin

A

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
Q

what are the current indications for nutritional support

A

weight loss over 10%

anticipated prolonger post op recovery period during which the patient will not be fed orally

43
Q

what is enteral support

A

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
Q

what is parenteral support and when is it indicated

A

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
Q

what is refeeding syndrome

A

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
Q

what % of patients get post op fever

A

40%

47
Q

what can cause fever hours post op to POD1

A

inflammatory reaction in response to surgery

reaction to blood products

malignant hyperthermia

resolving sepsis or infection from pre op conditions

48
Q

what causes fever in POD 1-2

A

atelectasis (old wives tale)

early wound infection (clostridium, GAS)

aspiration pneumonitis

addisionian crisis, thyroid storm, transfusion rxn

49
Q

what causes fever in POD 3-7

A

infections are more likely

UTI, surgical site, IV site, septic thrombophlebitis infections

leakage at bowel anastamosis

DVT

PE

50
Q

signs of leakage at bowel anastamosis

A

tachycardia

hypotension

oliguria

adbo pain

51
Q

what does dehiscence mean

A

wound coming apart

52
Q

what does wound evisceration mean

A

big gush of fluid, popping/gross sensation, appearance of bowels–> put something warm and wet on it

53
Q

what causes fever in POD 8 and beyond

A

intraabdominal abscesses

DVT/PE

drug fever

also...
cholecystitis
perirectal abscess
URTI
infected seroma/biloma/hematoma
parotitis 
c diff 
sinusitis from NG
endocarditis
54
Q

what are the 5 Ws of post op fever

A 
Wind
Water
Wound
Walking
Wonder drugs
55
Q

what are the 5 As of periooperative meds

A 
Antiemetics
Antibiotics
Analgesics
Anticoagulants
Antecendent (home meds)
56
Q

what patients are at a higher risk of wound complications

A

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
Q

when should dressings over closed wounds be removed

A

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
Q

define wound dehiscence

A

partial or total disruption of any or all layers of the operative wound

59
Q

what is fascial dehiscence

A

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
Q

treatment for fascial dehiscence

A

ound exploration

debridement

mass closure with continuous slowly absorbable suture (with possible external sutures)

61
Q

what is superficial dehiscence

A

only superficial reopening of the tissue

signs include open wound, broken sutures without healing, pain, bleeding, pus or drainage at the site

62
Q

why do we care about dehiscence

A

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
Q

what are some warning signs of necrotizing soft tissue

A 
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
Q

what does a history of mucocutaneous bleeding suggest

A

vWD

thrombocytopenia

functional platelet disorders

65
Q

how do you treat anaphylaxis

A

IV epinephrine

66
Q

how do you treat tension pneumo

A

chest tube

67
Q

what does an elevated serum lactate suggest

A

shock

68
Q

ddx for post op oliguria

A

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
Q

treatment for post op oliguria

A

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
Q

ddx post op chest pain

A

MI

PE

pneumothorax

gastric/GI

MSK

71
Q

ddx post op abdo distension

A

infection

leak

inflammation

hydrostatic/oncotic changes and 3rd spacing

hemorrhage

ileus

constiptation**

obstruction**

72
Q

define hypertonic crystalloid

A

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
Q

define isotonic crystalloid

A

same osmolality as serum

NS, D5W, ringers

generally we bolus with NS or ringers

74
Q

define hypotonic crystalloid

A

less osmotic than serum

1/2 NS, D5W

75
Q

give an example of a colloid

A

albumin –in liver failure

76
Q

what is the best measure of adequacy of volume resucitation

A

THIRST

then Hr, urine output, skin turgor, BP, cap refill

77
Q

most likely pathogen upper GI

A

gram +

78
Q

most likely pathogen lower GI

A

gram -

79
Q

what does ancef conver

A

gram + and some gram -

80
Q

what can you use for penicillin allergy

A

clinda

81
Q

what does cipro cover

A

gram -

82
Q

what does flagyll cover

A

anaerobes

83
Q

common risks for blood products

A

infection

giving wrong type–hemolytic reactions

84
Q

approach to shock

A

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
Q

list discharge criteria

A

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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