Pestana PeriOp Care

Question 1

What is the greatest Cardiac risk Factor for Surgery? Second greatest?

Answer 1

JVP Distension. Recent (6mo) MI.

Question 2

What is the greatest Pulmonary risk factor for surgery? How do you prepare for surgery?

Answer 2

Smoking. 8 weeks cessation and pulmonary therapy.

Question 3

What are the predictors of Hepatic risk for surgery?

Answer 3

Bilirubin. Albumin. Prothrombin time. Encephalopathy/Ascites.

Question 4

What are predictors of Nutritional risk for surgery?

Answer 4

Loss of 20% body weight, serum albumin <200mg/dL, anergy to skin antigens.

Question 5

Tachycardia, muscle rigidity, and Fever >104 developing after onset of anesthesia.
Treatment? What electrolyte is elevated?

Answer 5

Malignant Hyperthermia - IV Dantrolene, 100% O2, correction of acidosis, and cooling blankets. Calcium.

Question 6

Fever>104 developing during surgery.

Treatment? Potential complications?

Answer 6

Bacteremia (often during Urinary Tract procedure) - Blood Cultures x3 and empiric antibiotics. If severe wound pain develops post/op, consider gas gangrene.

Question 7

Fever on POD 1. Tests and treatment?

Answer 7

Atelectasis. Listen to the lungs, get CXR - if you see infiltrates, treat with spirometry (bronchoscopy if bad).

Question 8

Fever on POD 1-3. Tests and treatment?

Answer 8

Atelectasis progressed to pneumonia. CXR - will show infiltrates. Sputum cultures and treat with antibiotics.

Question 9

Fever on POD 3. Tests and treatment?

Answer 9

UTI. Urinalysis, urine cultures, and antibiotics.

Question 10

Fever on POD 5. Tests and treatment?

Answer 10

Deep Thrombophlebitis. Doppler studies of deep leg and pelvic veins. LMWH.

Question 11

Fever on POD 5-7. Tests and treatment?

Answer 11

Wound infection. CBC. Antibiotics for cellulitis. D&I for abscess.

Question 12

Fever on POD 7-15. Tests and treatment?

Answer 12

Deep abscess, usually subphrenic, pelvic, or subhepatic. Sonogram or CT scan and percutaneous drainage.

Question 13

Chest pain on POD 0-3. Symptoms? Tests?Treatment? Treatments to avoid?

Answer 13

MI. Crushing chest pain (not always), diaphoresis, dyspnea, syncope.
ST depression and T wave flattening on EKG. Elevated troponins (best test). PCI. DONT USE THROMBOLYTICS!

Question 14

Chest pain on POD 7. Symptoms? Tests?Treatment?

Answer 14

PE. Sudden pleuritic chest pain, dyspnea, diaphoresis, distended JVP.
ABG and CT angio. LMWH and greenfield filter.

Question 15

Combative, well fed patient during awake intubation develops pulmonary failure/pneumonia? Treatment?

Answer 15

Aspiration. Lavage and bronchoscopy. Bronchodilators, potentially ventilator.

Question 16

Post of patient becomes confused and disoriented? Tests and treatment?

Answer 16

Hypoxia. Check for sepsis, ABG, provide respiratory support.

Question 17

Septic post op patient develops respiratory distress? Tests and treatment? Complications with treatment?

Answer 17

ARDS. Check ABG and CXR. Correct sepsis. Ventilate with PEEP, but DON’T USE EXCESSIVE VOLUMES –> barotrauma.

Question 18

Alcoholic patient gets combative, confused, and hallucinates on POD 2-3? Treatment?

Answer 18

DT, which can be fatal. IV benzodiazopenes (Ativan).

Question 19

Post op patient develops confusion, convulsions, and coma. Charts note rapid weight gain and [Na]<120? Treatment?

Answer 19

Hypervolemic Hyponatremia. 500ml of 3% saline or mannitol.

Question 20

Neurological post op patient develops confusion, lethargy, and coma? Chart shows rapid weight loss, rising [Na]. Treatment?

Answer 20

Central Diabetes Insipidus. D5(1/2)NS to replace water.

Question 21

Cirrhotic patient undergoing a portocaval shunt falls into a coma?

Answer 21

Ammonium intoxication

Question 22

Patient voids zero urine after surgery? Treatment?

Answer 22

Mechanical issue. Unkink the catheter.

Question 23

Patient voids <0.5ml/kg/hr after surgery who is not in shock? Three diagnostic approaches?

Answer 23

Either Renal failure or low fluids.

1. Fluid bolus, renal failure will not respond.
2. Urinary [Na], renal failure will have >40mEg/L (high)
3. FeNa, >1 in renal failure

Question 24

Patient a few days after abdominal surgery has absent bowel sounds, no passage of gas/feces, and painless mild distension? Check what electrolyte? What medication exacerbates this issue?

Answer 24

Normal paralytic ileus, check his potassium. Morphine.

Question 25

Patient one week after surgery has absent bowel sounds, no passage of gas/feces, and painless mild distension? Tests and Treatment?

Answer 25

Bowel obstruction. Xray (dilated loops and air fluid levels in small bowel). CT scan. Correct surgically.

Question 26

Old patient who develops tense abdominal distension and massively dilated colon a few days after surgery for a broken hip? Tests and Treatment?

Answer 26

Ogilvie syndrome. Xray and CT scan to rule out obstruction. IV neostigmine and rectal tube.

Question 27

Pink fluid leaks out of wound on POD5-7 s/p open laparotomy? Treatment?

Answer 27

Wound dehiscence. Bound the abdomen and prepare for reoperation.

Question 28

Patient s/p open laparotomy gets out of bed and his guts fall out of his skin? Treatment?

Answer 28

Evisceration. Emergency abdominal closure.

Question 29

Do higher or lower GI fistulas leak greater volumes?

Answer 29

High

Question 30

Fistulas will heal by themselves unless…

Answer 30

They have F.R.I.E.N.D.S.

Foreign Body. Radiation. Infection. Epithelialization. Neoplasm. Distal obstruction. Patient is on steroids.