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Surgery: PESTANA Shelf > Pestana Pre/Post-Op care > Flashcards

Pestana Pre/Post-Op care Flashcards

1
Q

5 categories of pre-op and post-op care

A
  1. cardiac
  2. pulmonary
  3. hepatic
  4. nutritional
  5. 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%

(Normal = 55%)

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3
Q

What contributes to increased risk of cardiac complications? (8)

A

Goldman’s index of cardiac risk -

  1. JVD
  2. recent MI (within 6 months) -
  3. PVC or rhythm other than sinus -
  4. age >70 -
  5. emergency surgery -
  6. aortic stenosis -
  7. poor medical condition -
  8. Chest/Abd surgery
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4
Q

What 2 factors are the greatest predictors for cardiac complications during surgery?

A

JVD

recent MI (within 6 months)

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5
Q

What should you treat JVD with prior to surgery (4)

A

ACEi, ß blockers, digitalis, and diuretics

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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

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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 tht requires surgery?

A

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

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9
Q

Hepatic predictors of mortality during surgery? (5)

A

[Albumin < 3] or Ascites

[Bilirubin > 2]

encephalopathy (NH3 >150)

[PT > 16]

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10
Q

How is severe nutritional depletion defined as? (3)

A
  1. >20% wt. loss over couple months
  2. [Albumin < 3]
  3. [Transferrin < 200]
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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: DACO (Dantrolene/Acidosis correction /Cooling blankets/O2 100%)

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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 abx

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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? (5)

A

Post-Op Fever:

  1. atelectasis—> pneumonia
  2. UTI
  3. Deep thromboplebitis
  4. Deep Abscess
  5. wound infection
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16
Q

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

A

atelectasis, day 1

Dx: bronchoscopy

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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 Post Op] (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 Post Op] (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 Post Op] (think - 5 syllables)

Mgmt: doppler + heparin

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21
Q

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

A

[day 7 Post Op] (think - infection has 8 letters)

Mgmt: [cellulitis=abx] vs. [Abscess=IND]

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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 (2)? Cx?

A

day 2-3 Mgmt: troponin levels + [Coronary stent: angioplasty].

tPA in perioperative setting = Cx!

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24
Q

When does PE typically occur post-op? Dx? Tx?

A

[day 7 Post Op]

Dx: [spiral CT angio]

Tx: heparin

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25
Q

When is an IVC filter indicated (2)?

A
  1. Recurring PE even while on AntiCoag
  2. AntiCoags are cx
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26
Q

How do you prevent thromboembolism/PE? What rules out PE dx?

A

[SCD (Sequential Compression Devices)] + AntiCoag

low CVP excludes PE

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27
Q

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

A
  1. [Venous damage/catheter (especially femoral)]
  2. LE Fracture (Pelvis / Leg)
  3. immobilization
  4. > 40 yo
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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 (3)?

A
  • Lavage removal
  • BronchoDilators
  • Respiratory Support
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30
Q

When can intraoperative tension pneumothorax develop? What are the immediate signs of of this (3)?

A

when patients with traumatized lungs are subjected to (+) pressure ventilation

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? Dx method? Tx?

A

HYPOXIA / [Dx: blood gases] / [Tx: Respiratory Support]

Also Check Na+ and NH3

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 (2)?

A

[PEEP (Positive End Expiratory Pressure)] + Treat Sepsis

35
Q

Alcoholic Pt who becomes [confused + combative + hallucinations]. What is the usual precipitating event? Next best step in management?

A

DELERIUM TREMENS

IV benzodiazepines

36
Q

Which Electrolytes are associated with confusion post-op?

A

imbalance of Na+ vs. NH3

37
Q

What typically causes hypOnatremia post op? What are some sign to look out for in the chart (3)?

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

What causes hypernatremia post op? 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 (2)?

A

cirrhotic patients with bleeding esophageal varices who undergoes TIPS surgery

Tx:

Lactulose (converts NH3 –> NH4+)

RifaXimin (DEC intraluminal NH3)

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 from a catheter is typically caused by….

A

mechanical problem (plugged or kinked catheter)

45
Q

Low urinary output from a catheter is typically caused by…. ___ or ____

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

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 slow 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 (insulin drives K+ into cells)

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 (diarrhea)
3) Renal failure (DEC elimination of fixed acids)

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 alkalosis

A

loss of gastric juice excess intake of bicarbonate

72
Q

treatment of metabolic ALKolosis

A

KCl (5-10 mEq/hr)

73
Q

Breakdown for Lung Physical findings

A

Surgery: PESTANA Shelf (14 decks)

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