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Surgery > Pestana- 3. Pre-Op and Post-Op Care > Flashcards

Pestana- 3. Pre-Op and Post-Op Care Flashcards

1
Q

What is the ejection fraction that prohibits noncardiac operations?

A
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2
Q

List the major findings that may predict cardiac risk during surgery?

A 
JVD
Recent MI
PVC or any rhythm other than sinus
Age >70
Emergency surgery
Aortic stenosis
Poor medical condition
Surgery within chest or abdomen
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3
Q

What should be used to treat a patient with JVD (marker of CHF) prior to surgery?

A

ACE Inhibitiors
Beta-blockers
Digitalis
Diuretics

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4
Q

How long should you wait after an MI to have surgery?

A

6 months (drops risk of mortality to around 6%)

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5
Q

What is the most common cause of increased pulmonary risk?

A

smoking

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6
Q

What does smoking do to increase pulmonary risk (what does it compromise)?

A

compromise ventilation (high PCO2, low FEV1) rather than oxygenation

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7
Q

What is the first test that should be used to evaluate pulmonary risk in a patient with risk factors (ex. COPD, smoking history, etc)?

A

FEV1 (do blood gases if this is abnormal)

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8
Q

What should you do for a patient at increased pulmonary risk before surgery?

A

Stop smoking for 8 weeks

Intensive respiratory therapy (PT, Incentive spirometry, expectorants, humidified air)

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9
Q

What two clinical findings are used to predict operative mortality in patients with liver disease?

A

Encephalopathy

Ascites

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10
Q

What 3 lab findings are used to predict operative mortality in patients with liver disease?

A

Serum albumin
Prothrombin time (INR)
Bilirubin

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11
Q

What are the 4 findings of severe nutritional depletion?

A
  • Loss of 20% of body weight over a couple of months

- Serum albumin

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12
Q

List the major findings that may predict cardiac risk during surgery?

A 
JVD
Recent MI
PVC or any rhythm other than sinus
Age >70
Emergency surgery
Aortic stenosis
Poor medical condition
Surgery within chest or abdomen
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13
Q

What should be used to treat a patient with JVD (marker of CHF) prior to surgery?

A

ACE Inhibitiors
Beta-blockers
Digitalis
Diuretics

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14
Q

How long should you wait after an MI to have surgery?

A

6 months (drops risk of mortality to around 6%)

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15
Q

What is the most common cause of increased pulmonary risk?

A

smoking

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16
Q

What does smoking do to increase pulmonary risk (what does it compromise)?

A

compromise ventilation (high PCO2, low FEV1) rather than oxygenation

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17
Q

What is the management of bacteremia?

A

Blood cultures X3

Empiric antibiotics

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18
Q

What should you do for a patient at increased pulmonary risk before surgery?

A

Stop smoking for 8 weeks

Intensive respiratory therapy (PT, Incentive spirometry, expectorants, humidified air)

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19
Q

What two clinical findings are used to predict operative mortality in patients with liver disease?

A

Encephalopathy

Ascites

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20
Q

What 3 lab findings are used to predict operative mortality in patients with liver disease?

A

Serum albumin
Prothrombin time (INR)
Bilirubin

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21
Q

What are the 4 findings of severe nutritional depletion?

A
  • Loss of 20% of body weight over a couple of months

- Serum albumin

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22
Q

What is the optimal length of time with preoperative nutritional support if a patient is severely nutritionally depleted?

A

7-10 days (but 4-5 will do)

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23
Q

What drugs can trigger malignant hyperthermia?

A

halothane

succinylcholine

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24
Q

What temperature is reached with malignant hyperthermia?

A

104 F

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25
What electrolyte abnormalities are to be expected in malignant hyperthermia?
metabolic acidosis | hypercalcemia
26
How do you treat malignant hyperthermia?
IV dantrolene 100% oxygen Cooling blankets Correction of acidosis
27
What should you expect if patient develops 104F temperature and chills 30-45 minutes after an invasive procedure (urinary tract instrumentation)?
bacteremia
28
What is the management of bacteremia?
Blood cultures X3 | Empiric antibiotics
29
Postoperative fever (101-103) is usually caused by what (be time sequential)?
``` Atelectasis (POD1) Pneumonia (POD3) UTI (POD3) Deep venous thrombophlebitis (POD5) wound infection (POD7) deep abscess (POD 10-15) ```
30
How do you work up possible post-op pneumonia?
- CXR - Sputum cultures - Abx
31
How do you work up post-op deep venous thrombophlebitis?
Doppler studies | Anticoagulate with heparin
32
How do you treat aspiration?
- Lavage - Removal of acid/particulate matter with bronchoscopy - Bronchodilators - Respiratory support
33
How do you work up a potential post-op deep abscess?
CT scan with percutaneous IR guided drainage
34
What is the most common trigger for perioperative MI?
hypotension
35
When do most post-op MIs occur?
between POD2 and 3
36
What is the most reliable diagnosticc test for MI?
troponing
37
What are your treatment options for peri or post-op MI?
emergency angioplasty and coronary stent (no thrombolytics!!!)
38
When do most post-op PEs occur?
POD7
39
If you expect a PE and the CVP is low, what should you suspect?
NOT a PE (will have distended veins in neck and forehead with PE)
40
What is the gold standard to diagnose PE?
pulmonary angiogram
41
What is more commonly used to diagnose PE?
spiral CT (with contrast = CT angio)
42
How do you prevent aspiration during intubation?
NPO and antacids
43
How do you treat aspiration?
- Lavage - Removal of acid/particulate matter with bronchoscopy - Bronchodilators - Respiratory support
44
What should you expect if your patient with chest trauma that is intubated suddenly becomes more difficult to "bag", the BP drops and CVP rises?
tension pneumothorax
45
What should you always suspect first if a patient gets confused and disoriented after surgery?
hypoxia
46
What is the centerpiece of ARDS therapy?
PEEP
47
What must you be careful of when treating ARDS?
not to use excessive ventilatory volumes (can result in barotrauma)
48
What is the DOC for delirium tremens?
IV benzodiazepines
49
Why do patients given lots of D5W quickly after surgery develop hyponatremia?
ADH is high (triggered by stress of surgery)
50
How do you treat D5W induced hyponatremia?
- always include sodium in IV fluids | - may use small amounts of hypertonic saline
51
Brain surgery followed by hypernatremia should be suggestive of what?
damage to posterior pituitary and DI
52
How do you treat post-op hypernatremia?
D5(1/2) or D5(1/3) normal saline (rather than D5W)
53
What is a common source of coma in cirrhotic patient with bleeding esophageal varices who undergoes portocaval shunt?
ammonium intoxication
54
When should you in-an-out cath a patient who has post-op urinary retention?
at 6 hours post-op
55
When should you put in an indwelling cath a patient who has post-op urinary retention?
after the 2nd or 3rd consecutive in-and-out cath
56
Low UOP in presence of normal perfusing pressure represents what 2 potential things?
- Fluid deficit | - Acute renal failure
57
What is the fluid challenge?
Bolus of 500mL IV fluid over 10-20 minutes (will see temporary increase in UOP in dehydrated patient but not in patient with ARF)
58
What does the urinary sodium look like in a dehydrated v. ARF patient?
Dehydrated (40 mEq/L ; FENA >1)
59
What is the physical exam like in a patient with paralytic ileus?
No Bowel Sounds No flatus Mild distension No pain
60
What might prolong paralytic ileus?
hypokalemia
61
What fluid replacement should be used in a patient with low sodium and alkalosis?
normal saline
62
What is another way to explain Ogilvie syndrome?
"paralytic ileus of the colon"
63
How do you treat Ogilvie syndrome?
- Fluid and electrolyte correction - Colonoscopy to suck out air - Place long rectal tube
64
Why should you not use neostigmine to stimulate colon motility in Ogilvie syndrome?
it is lethal if given to someone who is actually obstructed
65
What must you always remember to do when correcting acidosis?
replace K (renal loss of K occurs with long-standing acidosis)
66
What is a complication of wound dehiscence where the skin opens up and abdominal contents rush out?
evisceration
67
What is counted as a low-volume GI fistula?
200-300 mL/day
68
What things prevent closure of fistulas?
``` FETIDS Foreign body Epithelialization Tumor Infection/ Irradiated tissue, IBD Distal obstruction Steroids ```
69
What is the rule for how much water is lost in hypernatremia?
every 3 mEq/L that serum sodium is >140 is 1L of water lost
70
How do you treat SIADH (or slowly developing hyponatremia)?
water restriction
71
What fluid replacement should be used in a patient with low sodium and acidosis or normal pH?
ringer lactate
72
What fluid replacement should be used in a patient with low sodium and alkalosis?
normal saline
73
What is the "speed limit" for IV potassium administration?
10 mEq/h
74
What trauma may lead to hyperK?
crush injuries
75
What is the treatment for hyperK?
- IV calcium gluconate - 50% dextrose and insulin - NG tube/exchange resins (suck out of GI tract)
76
What must you always remember to do when correcting acidosis?
replace K (renal loss of K occurs with long-standing acidosis)
77
What can be used to treat metabolic alkalosis?
5-10 mEq/h of KCl

Surgery (13 decks)

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