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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

How well did you know this?
1
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2
3
4
5
Perfectly
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
Q

What electrolyte abnormalities are to be expected in malignant hyperthermia?

A

metabolic acidosis

hypercalcemia

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26
Q

How do you treat malignant hyperthermia?

A

IV dantrolene
100% oxygen
Cooling blankets
Correction of acidosis

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27
Q

What should you expect if patient develops 104F temperature and chills 30-45 minutes after an invasive procedure (urinary tract instrumentation)?

A

bacteremia

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28
Q

What is the management of bacteremia?

A

Blood cultures X3

Empiric antibiotics

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29
Q

Postoperative fever (101-103) is usually caused by what (be time sequential)?

A 
Atelectasis (POD1)
Pneumonia (POD3)
UTI (POD3)
Deep venous thrombophlebitis (POD5)
wound infection (POD7)
deep abscess (POD 10-15)
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30
Q

How do you work up possible post-op pneumonia?

A
  • CXR
  • Sputum cultures
  • Abx
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31
Q

How do you work up post-op deep venous thrombophlebitis?

A

Doppler studies

Anticoagulate with heparin

32
Q

How do you treat aspiration?

A
  • Lavage
  • Removal of acid/particulate matter with bronchoscopy
  • Bronchodilators
  • Respiratory support
33
Q

How do you work up a potential post-op deep abscess?

A

CT scan with percutaneous IR guided drainage

34
Q

What is the most common trigger for perioperative MI?

A

hypotension

35
Q

When do most post-op MIs occur?

A

between POD2 and 3

36
Q

What is the most reliable diagnosticc test for MI?

A

troponing

37
Q

What are your treatment options for peri or post-op MI?

A

emergency angioplasty and coronary stent (no thrombolytics!!!)

38
Q

When do most post-op PEs occur?

A

POD7

39
Q

If you expect a PE and the CVP is low, what should you suspect?

A

NOT a PE (will have distended veins in neck and forehead with PE)

40
Q

What is the gold standard to diagnose PE?

A

pulmonary angiogram

41
Q

What is more commonly used to diagnose PE?

A

spiral CT (with contrast = CT angio)

42
Q

How do you prevent aspiration during intubation?

A

NPO and antacids

43
Q

How do you treat aspiration?

A
  • Lavage
  • Removal of acid/particulate matter with bronchoscopy
  • Bronchodilators
  • Respiratory support
44
Q

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?

A

tension pneumothorax

45
Q

What should you always suspect first if a patient gets confused and disoriented after surgery?

A

hypoxia

46
Q

What is the centerpiece of ARDS therapy?

A

PEEP

47
Q

What must you be careful of when treating ARDS?

A

not to use excessive ventilatory volumes (can result in barotrauma)

48
Q

What is the DOC for delirium tremens?

A

IV benzodiazepines

49
Q

Why do patients given lots of D5W quickly after surgery develop hyponatremia?

A

ADH is high (triggered by stress of surgery)

50
Q

How do you treat D5W induced hyponatremia?

A
  • always include sodium in IV fluids

- may use small amounts of hypertonic saline

51
Q

Brain surgery followed by hypernatremia should be suggestive of what?

A

damage to posterior pituitary and DI

52
Q

How do you treat post-op hypernatremia?

A

D5(1/2) or D5(1/3) normal saline (rather than D5W)

53
Q

What is a common source of coma in cirrhotic patient with bleeding esophageal varices who undergoes portocaval shunt?

A

ammonium intoxication

54
Q

When should you in-an-out cath a patient who has post-op urinary retention?

A

at 6 hours post-op

55
Q

When should you put in an indwelling cath a patient who has post-op urinary retention?

A

after the 2nd or 3rd consecutive in-and-out cath

56
Q

Low UOP in presence of normal perfusing pressure represents what 2 potential things?

A
  • Fluid deficit

- Acute renal failure

57
Q

What is the fluid challenge?

A

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
Q

What does the urinary sodium look like in a dehydrated v. ARF patient?

A

Dehydrated (40 mEq/L ; FENA >1)

59
Q

What is the physical exam like in a patient with paralytic ileus?

A

No Bowel Sounds
No flatus
Mild distension
No pain

60
Q

What might prolong paralytic ileus?

A

hypokalemia

61
Q

What fluid replacement should be used in a patient with low sodium and alkalosis?

A

normal saline

62
Q

What is another way to explain Ogilvie syndrome?

A

“paralytic ileus of the colon”

63
Q

How do you treat Ogilvie syndrome?

A
  • Fluid and electrolyte correction
  • Colonoscopy to suck out air
  • Place long rectal tube
64
Q

Why should you not use neostigmine to stimulate colon motility in Ogilvie syndrome?

A

it is lethal if given to someone who is actually obstructed

65
Q

What must you always remember to do when correcting acidosis?

A

replace K (renal loss of K occurs with long-standing acidosis)

66
Q

What is a complication of wound dehiscence where the skin opens up and abdominal contents rush out?

A

evisceration

67
Q

What is counted as a low-volume GI fistula?

A

200-300 mL/day

68
Q

What things prevent closure of fistulas?

A 
FETIDS
Foreign body
Epithelialization
Tumor
Infection/ Irradiated tissue, IBD
Distal obstruction
Steroids
69
Q

What is the rule for how much water is lost in hypernatremia?

A

every 3 mEq/L that serum sodium is >140 is 1L of water lost

70
Q

How do you treat SIADH (or slowly developing hyponatremia)?

A

water restriction

71
Q

What fluid replacement should be used in a patient with low sodium and acidosis or normal pH?

A

ringer lactate

72
Q

What fluid replacement should be used in a patient with low sodium and alkalosis?

A

normal saline

73
Q

What is the “speed limit” for IV potassium administration?

A

10 mEq/h

74
Q

What trauma may lead to hyperK?

A

crush injuries

75
Q

What is the treatment for hyperK?

A
  • IV calcium gluconate
  • 50% dextrose and insulin
  • NG tube/exchange resins (suck out of GI tract)
76
Q

What must you always remember to do when correcting acidosis?

A

replace K (renal loss of K occurs with long-standing acidosis)

77
Q

What can be used to treat metabolic alkalosis?

A

5-10 mEq/h of KCl

Surgery (13 decks)

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