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Pestana Surgery > Pestana Pre/Post-Op care > Flashcards

Pestana Pre/Post-Op care Flashcards

1
Q

5 categories of pre-op and post-op care

A 
cardiac
pulmonary
hepatic
nutritional
metabolic
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2
Q

An ejection fraction of ________ poses prohibitive cardiac risk for non-cardiac operations (increases MI or mortality)

A

< 35%

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3
Q

What contributes to increased risk of cardiac complications?

A

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
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4
Q

2 worst factors that predicts high cardiac risk (ie predictor of cardiac complications) 2

A 
JVD
recent MI (within 6 months)
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5
Q

What should you treat a with JVD prior to surgery and why?

A

ACEi, ß blockers, digitalis, and diuretics

why? it is the single worst finding that predicts high cardiac risk

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6
Q

What should you do for someone who requires surgery, but had an MI 4 months ago?

A

admit to ICU day prior to surgery to optimize cardiac variables because a recent MI is the second worst factor that predicts cardiac mortality

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7
Q

What is the most common cause of increased pulmonary risk during surgery and why?

A

SMOKING. It compromises VENTILATION and results in high PCO2, low FEV1)

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8
Q

What should you recommend for a current smoker with COPD requires surgery?

A

quit smoking for 8 weeks with intensive respiratory therapy prior to surgery

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9
Q

What are some hepatic predictors of mortality?

A 
bilirubin > 2
serum albumin < 3
PT > 16
ascites
encephalopathy  (blood ammonia >150)

(obviously the risk is higher if the values are higher)

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10
Q

How is severe nutritional depletion defined as?

A

> 20% loss of body weight over a couple of months, or serum albumin <200 mg/dL (or a combination of any of the above)

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11
Q

What is a metabolic risk that is absolutely contraindicated to surgery

A

diabetic coma - must rehydrate, resume urinary output, and at least partial correction of acidosis and hyperglycemia must be achieved before surgery

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12
Q

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

A

think MALIGNANT HYPERTHERMIA, esp. with halothane or succinylcholine
Sx: metabolic acidosis + hypercalcemia + myoglobinuria
Tx: dantrolene, 100% O2, correct acidosis, cooling blankets

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13
Q

Patient develops chills and spikes to 104˚F shortly after he awakens from pyeloplasty
What happened?
What should you do? 2

A

think BACTEREMIA, esp since he underwent instrumentation of the urinary tract

Tx: blood culture x3 + empiric antibiotics

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14
Q

Patient experiences severe wound pain and T 104˚F a few hours after surgery.
What happened?

A

think GAS GANGRENE

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15
Q

Patient develops post op fever 103˚F after surgery. What is the differential? 6

A 
atelectasis
pneumonia
UTI
deep thrombophlebitis
wound infection
deep abscess
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16
Q

most common source of post-op fever and when does it occur?

Treatment?

A

atelectasis, day 1

tx: bronchoscopy (procedure that visualizes the tracheobronchial tree)

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17
Q

what happens if atelectasis is not resolved after 3 days? next best step in management?

A

increased risk of PNEUMONIA (fever, infiltrates on CXR)

Mgmt: sputum cultures + appropriate antibiotics

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18
Q

When does pneumonia, if present, typically produce fever post-op?
next best step in management?

A 
day 3 (think - 3 syllables)
Mgmt: sputum cultures + appropriate antibiotics
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19
Q

When does a UTI, if present, typically produce fever post-op?
next best step in management?

A 
day 3 (think - 3 letters)
Mgmt: UA, UC, antibiotics
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20
Q

When does thrombophlebitis, if present, typically produce fever post-op?
next best step in management?

A 
day 5 (think - 5 syllables)
Mgmt: doppler studies + heparin
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21
Q

When does infection, if present, typically produce fever post-op?
next best step in management?

A 
day 7 (think - infection has 8 letters)
Mgmt: abx if cellulitis, I&D if abscess
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22
Q

When does deep abscesses, if present, typically produce fever post-op?
next best step in management?

A

day 10-15 (think - deep abscesses has 13 letters)

Mgmt: percutaneous radiologically guided drainage

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23
Q

When does perioperative MI typically occur post-op?

next best step in management? What should you avoid?

A

day 2-3
Mgmt: troponin levels + angioplasty and coronary stent
avoid: clot busters/tPa in the perioperative setting (logical)

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24
Q

When does PE typically occur post-op?

next best step in management?

A

day 7

Mgmt: spiral CT (aka CT angio) + heparin

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25
Q

When is an IVC filter indicated? 2

A

if PEs recur while on anticoagulation

if anticoagulation is contraindicated

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26
Q

How do you prevent thromboembolism/PE?

A

SCDs + anticoagulation in high risk patients (>40yo, pelvic/leg fractures/anticipated prolonged immobilization, venous injury, femoral venous catheter)

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27
Q

When is anticoagulation indicated in the prevention of thromboembolism/PE? 4

A

> 40yo
pelvic/leg fractures/anticipated prolonged immobilization
venous injury
femoral venous catheter

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28
Q

How do you prevent aspiration? 2

A

NPO and antacids

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29
Q

How do you treat aspiration? 4

A

lavage
removal of acid/particulate matter
bronchodilators
respiratory support

30
Q

When can intraoperative tension pneumothorax develop? What are the immediate signs of of this?

A

when patients with traumatized lungs are subjected to (+) pressure breathing
steady decline in BP + increase in CVP + becomes more difficult to “bag”

31
Q

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?

A

intraoperative tension pneumothorax

Tx insert needle through the anterior chest wall into the pleural space to relieve the pressure

32
Q

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?

A

HYPOXIA

Mgmt: blood gases, provide respiratory support

33
Q

Patient with bilateral pulmonary infiltrates, hypoxia, with no evidence of CHF. What is the usual precipitating event?

A

ARDS - usually due to sepsis

34
Q

Management of ARDS?

A

PEEP + source of sepsis must be sought out and corrected

35
Q

Patient becomes confused and combative with evidence of hallucinations. What is the usual precipitating event?
Next best step in management?

A

DELERIUM TREMENS

IV benzodiazepines

36
Q

Electrolyte abnormalities that are associated with disorientation/confusion post-op? 3

A

hyponatremia
hypernatremia
ammonium intoxication

37
Q

How does hyponatremia usually develop in a post-op patient?

What are some sign to look out for in the chart?

A

liberal administration of sodium-free IVF

chart review: large fluid intake, quick weight gain, rapidly lowering serum Na concentration (hours)

38
Q

Prevention of hyponatremia in a post-op patient

A

Always include Na in IVF

39
Q

Treatment of hyponatremia in a post-op patient?

A

small amounts of hypertonic saline + osmotic diuretics

40
Q

How does hypernatremia usually develop in a post-op patient?
What are some sign to look out for in the chart?

A

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

41
Q

Treatment of hypernatremia in a post-op patient?

A

D5 1/2 NS

42
Q

What type of post-op patients would you normally see ammonium intoxication? Tx?

A

cirrhotic patients with bleeding esophageal varices who undergoes TIPS surgery
Tx: lactulose

43
Q

Management of a post-op patient who complains of the need to void, but cannot do it

A

bladder catheterization at 6 hrs post-op or foley catheter after 2 or 3 days of consecutive catheterization

44
Q

Zero urinary output is typically caused by….

A

mechanical problem (plugged or kinked catheter)

45
Q

Low urinary output is typically caused by…. 2

A

fluid deficit or acute renal failure

46
Q

What are 3 different ways to differentiate between fluid deficit or acute renal failure that is causing low urinary output

A

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

47
Q

signs of paralytic ileus

A

decreased/absent bowel sounds
no passage of gas
MILD distension, but no pain

48
Q

paralytic ileus can be prolonged by this electrolyte abnormality

A

hypokalemia

49
Q

if normal bowel function does not resume within 5-7 days post-op, what should you consider? next best step management?

A

mechanical bowel obstruction

Tx: abdominal CT (transition point noted at site of obstruction), surgical intervention

50
Q

What is ogilvie syndrome? What patient population is it normally seen in?

A

paralytic ileus of the colon - typically in elderly, sedentary patients who have become further immobilized owing to surgery elsewhere

51
Q

Sx ogilvie syndrome? Management of these patients?

A

LARGE abdominal distension

Mgmt: correct fluid/electrolytes, r/o mechanical obstruction PRIOR to IV neostigmine to restore colonic motility

52
Q

sequelae of GI fistulas that do not drain completely (leaks into a cesspool that then leaks out)

A

sepsis

53
Q

3 sequelae of GI fistulas that do not drain completely (pt is afebrile + no signs of peritoneal irritation)

A

fluid + electrolyte losses
nutritional depletion
erosion + digestion of abdominal wall

54
Q

Management of GI fistulas

A

FEN support

suction tubes and ostomy bags until nature heals the fistula

55
Q

What will prevent fistulas from healing?

A

F.E.T.I.D.S

Foreign bodies
Epithelialization
Tumor
Infection, Irradiated tissue, IBD
Distal obstruction 
Steroids
56
Q

a serum sodium of 143 represents how much water lost from body?

A

1 L of water

rule of thumb: every 3mEq that serum sodium [ ] is above 140 represents roughly 1 L of water lost

57
Q

Rapid development of hypernatremia should be treated with:

A

D5 1/2NS (rapid volume repletion with minimal changes in tonicity)

58
Q

Slow development of hypernatremia should be treated with:

A

D5 1/3NS or D5W

59
Q

Rapid development of hyponatremia (ie water intoxication) should be treated with:

A

hypertonic saline

60
Q

Slowly developing hyponatremia (ie SIADH) should be treated with:

A

water restriction

61
Q

Hypovolemic, dehydrated patients losing large amounts of GI fluids become hyponatremic. Why is that? How are these patients managed?

A

they are forced to retain H2O

Mgmt: isotonic saline or LR solution

62
Q

3 main causes of rapid development of hypokalemia

A 
GI losses (massive diarrhea, since GI fluids have high K content)
excess loop diuretics 
excess aldosterone
63
Q

Main cause of rapid development of hypokalemia

A

correction of DKA

64
Q

How fast should you replete K?

A

10 mEq/h

65
Q

2 main causes of slow development of hyperkalemia

A

renal failure

aldosterone antagonists

66
Q

Main causes of rapid development of hyperkalemia

A

K is dumped from the cells into blood (cell lysis secondary to crush injuries or dead tissue, acidosis)

67
Q

Treatment of hyperkalemia 5

A

1) hemodialysis
2) dextrose + insulin
3) NG suction
4) kayxelate
5) IV Calcium

68
Q

3 main causes of metabolic acidosis

A

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)

69
Q

treatment of metabolic acidosis 3

A

treat underlying cause
+/- HCO3 administration ( if the etiology is HCO3 loss)
replace K

70
Q

Why is it that bicarbonate administration in the treatment of metabolic acidosis is not

A

it’s a temporary measure and may cause rebound alkalosis once the underlying problem is corrected

71
Q

2 main causes of metabolic acidosis

A

loss of gastric juice

excess intake of bicarbonate

72
Q

treatment of metabolic acidosis

A

KCl (5-10 mEq/hr)

Pestana Surgery (13 decks)

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