Pestana Pre/Post-Op care Flashcards
5 categories of pre-op and post-op care
cardiac pulmonary hepatic nutritional metabolic
An ejection fraction of ________ poses prohibitive cardiac risk for non-cardiac operations (increases MI or mortality)
< 35%
What contributes to increased risk of cardiac complications?
Goldman’s index of cardiac risk
- JVD
- recent MI (within 6 months)
- PVC or rhythm other than sinus
- age >70
- emergency surgery
- aortic stenosis
- poor medical condition
- surgery within the chest or abdomen
2 worst factors that predicts high cardiac risk (ie predictor of cardiac complications) 2
JVD recent MI (within 6 months)
What should you treat a with JVD prior to surgery and why?
ACEi, ß blockers, digitalis, and diuretics
why? it is the single worst finding that predicts high cardiac risk
What should you do for someone who requires surgery, but had an MI 4 months ago?
admit to ICU day prior to surgery to optimize cardiac variables because a recent MI is the second worst factor that predicts cardiac mortality
What is the most common cause of increased pulmonary risk during surgery and why?
SMOKING. It compromises VENTILATION and results in high PCO2, low FEV1)
What should you recommend for a current smoker with COPD requires surgery?
quit smoking for 8 weeks with intensive respiratory therapy prior to surgery
What are some hepatic predictors of mortality?
bilirubin > 2 serum albumin < 3 PT > 16 ascites encephalopathy (blood ammonia >150)
(obviously the risk is higher if the values are higher)
How is severe nutritional depletion defined as?
> 20% loss of body weight over a couple of months, or serum albumin <200 mg/dL (or a combination of any of the above)
What is a metabolic risk that is absolutely contraindicated to surgery
diabetic coma - must rehydrate, resume urinary output, and at least partial correction of acidosis and hyperglycemia must be achieved before surgery
Patient develops 104˚F shortly after he was put under anesthesia.
What happened?
What other signs would you look out for? 3
What should you do? 4
think MALIGNANT HYPERTHERMIA, esp. with halothane or succinylcholine
Sx: metabolic acidosis + hypercalcemia + myoglobinuria
Tx: dantrolene, 100% O2, correct acidosis, cooling blankets
Patient develops chills and spikes to 104˚F shortly after he awakens from pyeloplasty
What happened?
What should you do? 2
think BACTEREMIA, esp since he underwent instrumentation of the urinary tract
Tx: blood culture x3 + empiric antibiotics
Patient experiences severe wound pain and T 104˚F a few hours after surgery.
What happened?
think GAS GANGRENE
Patient develops post op fever 103˚F after surgery. What is the differential? 6
atelectasis pneumonia UTI deep thrombophlebitis wound infection deep abscess
most common source of post-op fever and when does it occur?
Treatment?
atelectasis, day 1
tx: bronchoscopy (procedure that visualizes the tracheobronchial tree)
what happens if atelectasis is not resolved after 3 days? next best step in management?
increased risk of PNEUMONIA (fever, infiltrates on CXR)
Mgmt: sputum cultures + appropriate antibiotics
When does pneumonia, if present, typically produce fever post-op?
next best step in management?
day 3 (think - 3 syllables) Mgmt: sputum cultures + appropriate antibiotics
When does a UTI, if present, typically produce fever post-op?
next best step in management?
day 3 (think - 3 letters) Mgmt: UA, UC, antibiotics
When does thrombophlebitis, if present, typically produce fever post-op?
next best step in management?
day 5 (think - 5 syllables) Mgmt: doppler studies + heparin
When does infection, if present, typically produce fever post-op?
next best step in management?
day 7 (think - infection has 8 letters) Mgmt: abx if cellulitis, I&D if abscess
When does deep abscesses, if present, typically produce fever post-op?
next best step in management?
day 10-15 (think - deep abscesses has 13 letters)
Mgmt: percutaneous radiologically guided drainage
When does perioperative MI typically occur post-op?
next best step in management? What should you avoid?
day 2-3
Mgmt: troponin levels + angioplasty and coronary stent
avoid: clot busters/tPa in the perioperative setting (logical)
When does PE typically occur post-op?
next best step in management?
day 7
Mgmt: spiral CT (aka CT angio) + heparin
When is an IVC filter indicated? 2
if PEs recur while on anticoagulation
if anticoagulation is contraindicated
How do you prevent thromboembolism/PE?
SCDs + anticoagulation in high risk patients (>40yo, pelvic/leg fractures/anticipated prolonged immobilization, venous injury, femoral venous catheter)
When is anticoagulation indicated in the prevention of thromboembolism/PE? 4
> 40yo
pelvic/leg fractures/anticipated prolonged immobilization
venous injury
femoral venous catheter
How do you prevent aspiration? 2
NPO and antacids
How do you treat aspiration? 4
lavage
removal of acid/particulate matter
bronchodilators
respiratory support
When can intraoperative tension pneumothorax develop? What are the immediate signs of of this?
when patients with traumatized lungs are subjected to (+) pressure breathing
steady decline in BP + increase in CVP + becomes more difficult to “bag”
Ski trauma patient undergoing a surgery has a steady decline in BP, increase in CVP, and becomes more difficult to bag - what should you consider and what should you do immediately?
intraoperative tension pneumothorax
Tx insert needle through the anterior chest wall into the pleural space to relieve the pressure
What is the first thing you should consider if a post-op patient becomes confused and disoriented? What is the next best step in management?
HYPOXIA
Mgmt: blood gases, provide respiratory support
Patient with bilateral pulmonary infiltrates, hypoxia, with no evidence of CHF. What is the usual precipitating event?
ARDS - usually due to sepsis
Management of ARDS?
PEEP + source of sepsis must be sought out and corrected
Patient becomes confused and combative with evidence of hallucinations. What is the usual precipitating event?
Next best step in management?
DELERIUM TREMENS
IV benzodiazepines
Electrolyte abnormalities that are associated with disorientation/confusion post-op? 3
hyponatremia
hypernatremia
ammonium intoxication
How does hyponatremia usually develop in a post-op patient?
What are some sign to look out for in the chart?
liberal administration of sodium-free IVF
chart review: large fluid intake, quick weight gain, rapidly lowering serum Na concentration (hours)
Prevention of hyponatremia in a post-op patient
Always include Na in IVF
Treatment of hyponatremia in a post-op patient?
small amounts of hypertonic saline + osmotic diuretics
How does hypernatremia usually develop in a post-op patient?
What are some sign to look out for in the chart?
rapidly induced by large, unreplaced water loss (ie surgical damage to posterior pituitary, unrecognized osmotic diuresis)
chart review: large, unreplaced urinary output, rapid weight loss, rapidly rising Na concentration
Treatment of hypernatremia in a post-op patient?
D5 1/2 NS
What type of post-op patients would you normally see ammonium intoxication? Tx?
cirrhotic patients with bleeding esophageal varices who undergoes TIPS surgery
Tx: lactulose
Management of a post-op patient who complains of the need to void, but cannot do it
bladder catheterization at 6 hrs post-op or foley catheter after 2 or 3 days of consecutive catheterization
Zero urinary output is typically caused by….
mechanical problem (plugged or kinked catheter)
Low urinary output is typically caused by…. 2
fluid deficit or acute renal failure
What are 3 different ways to differentiate between fluid deficit or acute renal failure that is causing low urinary output
1) fluid bolus of 500mL infused over 10-20min - dehydrated patients will respond with temporary increase in UO while patients with ARF will not
2) UNa - dehydrated patient 40mEq/L
3) FENa - dehydrated patients < 1, ARF > 1
signs of paralytic ileus
decreased/absent bowel sounds
no passage of gas
MILD distension, but no pain
paralytic ileus can be prolonged by this electrolyte abnormality
hypokalemia
if normal bowel function does not resume within 5-7 days post-op, what should you consider? next best step management?
mechanical bowel obstruction
Tx: abdominal CT (transition point noted at site of obstruction), surgical intervention
What is ogilvie syndrome? What patient population is it normally seen in?
paralytic ileus of the colon - typically in elderly, sedentary patients who have become further immobilized owing to surgery elsewhere
Sx ogilvie syndrome? Management of these patients?
LARGE abdominal distension
Mgmt: correct fluid/electrolytes, r/o mechanical obstruction PRIOR to IV neostigmine to restore colonic motility
sequelae of GI fistulas that do not drain completely (leaks into a cesspool that then leaks out)
sepsis
3 sequelae of GI fistulas that do not drain completely (pt is afebrile + no signs of peritoneal irritation)
fluid + electrolyte losses
nutritional depletion
erosion + digestion of abdominal wall
Management of GI fistulas
FEN support
suction tubes and ostomy bags until nature heals the fistula
What will prevent fistulas from healing?
F.E.T.I.D.S
Foreign bodies Epithelialization Tumor Infection, Irradiated tissue, IBD Distal obstruction Steroids
a serum sodium of 143 represents how much water lost from body?
1 L of water
rule of thumb: every 3mEq that serum sodium [ ] is above 140 represents roughly 1 L of water lost
Rapid development of hypernatremia should be treated with:
D5 1/2NS (rapid volume repletion with minimal changes in tonicity)
Slow development of hypernatremia should be treated with:
D5 1/3NS or D5W
Rapid development of hyponatremia (ie water intoxication) should be treated with:
hypertonic saline
Slowly developing hyponatremia (ie SIADH) should be treated with:
water restriction
Hypovolemic, dehydrated patients losing large amounts of GI fluids become hyponatremic. Why is that? How are these patients managed?
they are forced to retain H2O
Mgmt: isotonic saline or LR solution
3 main causes of rapid development of hypokalemia
GI losses (massive diarrhea, since GI fluids have high K content) excess loop diuretics excess aldosterone
Main cause of rapid development of hypokalemia
correction of DKA
How fast should you replete K?
10 mEq/h
2 main causes of slow development of hyperkalemia
renal failure
aldosterone antagonists
Main causes of rapid development of hyperkalemia
K is dumped from the cells into blood (cell lysis secondary to crush injuries or dead tissue, acidosis)
Treatment of hyperkalemia 5
1) hemodialysis
2) dextrose + insulin
3) NG suction
4) kayxelate
5) IV Calcium
3 main causes of metabolic acidosis
1) excess production (DKA, lactic acidosis, low-flow states)
2) loss of buffers (vomiting, diarrhea)
3) inability of kidneys to eliminate fixed acids (renal failure)
treatment of metabolic acidosis 3
treat underlying cause
+/- HCO3 administration ( if the etiology is HCO3 loss)
replace K
Why is it that bicarbonate administration in the treatment of metabolic acidosis is not
it’s a temporary measure and may cause rebound alkalosis once the underlying problem is corrected
2 main causes of metabolic acidosis
loss of gastric juice
excess intake of bicarbonate
treatment of metabolic acidosis
KCl (5-10 mEq/hr)
