Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

CT surgery March 2022 > Post Operative complciations of CT surgery > Flashcards

Post Operative complciations of CT surgery Flashcards

1
Q

Increased Risk Stratification – Patient-Related Variables

6

A
  1. Genetic factors
  2. Older patients
  3. Females/smaller body mass index
  4. Known coagulopathies (Von Willebrand’s dz, uremia)
  5. Comorbidities (Diabetes, hepatic and renal dysfunction, PVD, infection, hypersplenism, ITP, preoperative anemia)
  6. Advanced cardiac disease (shock, poor ventricular function)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Increased Risk Stratification – Preop Medications

7

A
  1. High dose aspirin
  2. Clopidogrel/prasugrel
  3. Emergency surgery after llb/llla inhibitors
  4. Low-molecular-weight heparin within 18 hours
  5. Fondaparinux within 48 hours
  6. Incomplete reversal of INR off warfarin
  7. Direct thrombin inhibitors, Thrombolytic therapy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Increased Risk Stratification – Procedure-Related Variables

A
  1. Complex operations (valve-CABG, thoracic aortic surgery, esp. deep hypothermic circulatory arrest cases)
  2. Urgent/emergent operations
  3. Reoperations
  4. Use of bilateral ITA grafting
  5. Long durations of CPB time (qualitative and quantitative platelet defects, coagulation factor depletion, increased fibrinolysis)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What do you give in a post op CT surgery patient if their fibrinogen is low?

A

We give cryo

you can also give FFP

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Management of Postoperative Bleeding

8

A
  1. Ensure chest tubes remain patent
  2. Warm patient to normothermia
  3. Control hypertension, agitation, and shivering
  4. Support/optimize hemodynamics, oxygen-carrying capacity, tissue perfusion
  5. Consider use of 10 cm PEEP with caution
  6. TTE/TEE if concerned about tamponade
  7. Urgent exploration for significant ongoing bleeding or tamponade
  8. Emergency exploration for exsanguinating hemorrhage/tamponade/near arrest
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Return to the OR for surgical exploration should be considered when:

2 scenerios

A

Acute onset of rapid bleeding (>300mL/h) after minimal blood loss

> 400mL/h for 1 hour
300mL/h for 2-3 hours
200mL/h for 4 hours

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Management of Coagulopathic Bleeding

  1. if PTT elevated?
  2. if hematocrit < 26%
  3. Other options? 3
  4. if platelet dysfunction from uremia, aspirin
  5. for severe coagulopathy?
A
  1. Protamine 25mg IV x two doses
  2. Packed red cells
    • Platelets (1 -2 “five or six packs”)
    • Fresh Frozen Plasma, 2-4 units
    • Cryoprecipitate, 6-10 units
  4. Desmopressin (DDAVP) 0.3 ug/kg IV
  5. Recombinant factor VIIa 60 ug/kg
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

PTT > 1.5 x nl?

ACT > 130 sec?

A

Protamine (consider FFP)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Platelet count <100,000

Platelet dysfunction?

A

Platelets (consider desmopression)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

INR greater than 1.5

A

FFP

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Fibrinogen less than 100?

A

Cryo

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Elevated FSP or D dimer

?

A

Lytics

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Why do we transfuse packed RBCs?

A

Increase oxygen-carrying capacity and avoid end-organ ischemia and dysfunction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q 
Minimum Hematocrit to maintain tissue oxygenation
?
Healthy pt?
stable post op pt?
bleeding post op pt?
A
  1. Healthy patients: 18 – 21%
  2. Stable postoperative patient: 22 – 24%
  3. Bleeding postoperative patient: 26% keep up with bleeding
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

One unit of RBCs typically raises the Hct of a 70kg male __%?

A

3

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Indications for post op PLT transfusion:

2

A
  1. In setting of excessive bleeding, give platelets when count is less 100,000/uL
  2. When platelet dysfunction is likely (preop meds, uremia, post CPB) and bleeding persists, platelets should be given even if plt count > 100,00/uL
    (Platelets are not indicated in nonbleeding patient unless count drops to <20-30,000/uL)
17
Q

PLT: Each 6-pack unit should increase the platelet count ~ ?

A

7000 – 10,000/uL

18
Q

FFP Contains what?

A

all clotting factors at normal concentrations with a slight reduction in factors V and VIII

19
Q

Only ___% of the normal level of most clotting factors is required to provide hemostasis ( INR >1.5 before clinically significant factor deficiency exists)

A

30

20
Q
  1. Single unit ~ ___mL total volume
  2. Typical “dose” 2-4 units (4 units increase level of clotting factors by ~___%)?
  3. Contains what? which is useful in ATIII-deficient patients
A
  1. 250
  2. 10
  3. ATIII (antithrombin III)
21
Q

Cryprecipitate:
Provides what?
5

A
  1. Provides concentrated levels of
    - factor one (fibrinogen) and
    - factor VIII:C,
    - von Willebrand’s factor,
    - factor XIII (fibrin-stabilizing factor) and
    - fibronectin (tissue integrin involved in wound healing.)
22
Q

Both factors _____ are essential for proper platelet aggregation and adherence to endothelium
Especially beneficial for patients with von Willebrand’s disease or hypofibrinogenemia

A

I and VIII

23
Q

Recombinant Factor VII (rFVIIa)

Used successfully in arresting bleeding in patients with severe uncontrollable coagulopathy

Combines with tissue factor at the site of vessel injury and to the surface of activated platelets, activating factor X

What does this result in?

A

Results in thrombin generation, platelet activation and an explosive “thrombin burst” that promotes localized hemostasis at the site of tissue injury

Systemic thrombosis may occur – beware!

24
Q

Causes of Low Cardiac Output Syndrome

8

A
  1. Decreased preload
  2. Decreased contractility
  3. Tachy-Bradyarrythmias
  4. Increased Afterload
  5. Diastolic dysfunction
  6. Sepsis
  7. Anaphylaxis
  8. Protamine Reactions
25
Q

Treatment Approach to low cardiac output syndrome?

5

A
  1. Look for non-cardiac causes
  2. Treat ischemia or coronary spasm
  3. Optimize preload
    PCWP or LA pressure 18-20mmhg
  4. Optimize heart rate
    Pace if necessary to a HR around 90 bpm
  5. Control Arrhythmias
26
Q

Low cardiac output syndrome

  1. Assess Cardiac output and start inotropic support if cardiac index is?
  2. Calculate SVR and start vasodilator if SVR over ?
  3. If BP is low with a low SVR?
    - marginal CO?
    - satisfactory CO?
  4. What if these two fail?
  5. Transfuse to keep HCT greater than?
A
  1. less than 2.0
  2. 1500
    3.
    - Norepinephrine if marginal cardiac output
    - Phenylephrine (neo) if satisfactory cardiac output
  3. Vasopressin if the first two fail
  4. 26%

Surgeon specific. Be sure to check what the threshold is for transfusion in your particular service

27
Q

Actions of dopamine:

  1. At 3-5mcg/kg/min?
  2. 5-10mcg/kg/min?
  3. > 10mcg/kg/min
A
  1. renal vasodilator
  2. vasodilator/inotropy
  3. vasoconstrictor
28
Q

Actions of dobutmaine?

5-20mcg/kg/min

A

Vasodilator > Inotropy

29
Q

Actions of Milrinone?

0.25- 0.75mg/kg/min

A

Vasodilator > Inotropy

30
Q

actions of Epinephrine
1-20mcg/min?
>20?

A

inotropy/vasodilator

vasocontrictor

31
Q

actions of Norepinephrine?
1-2 mcg/min
>2mg/min

A

inotropy

vasoconstrictor

32
Q

actions of Isoproterenol?

1-10 mcg/min

A

chronotropy >inotropy

33
Q

What is the definition of acute renal failure?

A

Defined as a 50% increase in the serum creatinine concentration above baseline

34
Q

Risk Factors for Acute Renal Failure:

6

A
  1. Pre-operative Cardiac performance
  2. Advanced atherosclerotic vascular disease
  3. Reduction in creatinine clearance pre-op
  4. Increase CPB time
  5. Presence of perioperative hemodynamic instability
  6. Use of radiocontrast agents immediately before surgery
35
Q
  1. When should you use Continuous Renal Replacement Therapy:
  2. What is CVVH?
  3. CVVHD
  4. CVVHDF:
A
  1. Utilized with hemodynamic instability
  2. : Continuous venovenous hemofiltration
  3. : Continuous venous venous hemodialysis
  4. Continuous venous venous hemodiafiltration
36
Q

Risk factors for the development of mediastinitis include the following?
10

A
  1. Pedicled bilateral internal mammary artery (BITA) grafts.
    - This risk is even higher among patients with diabetes, thus rendering many surgeons reluctant in using BITA grafting in this subgroup of patients.
  2. Emergency surgery
  3. External cardiac compression (conventional cardiopulmonary resuscitation)
  4. Obesity (>20% of ideal body weight)
  5. Postoperative shock, especially when multiple blood transfusions are required
  6. Prolonged bypass and operating room time.
  7. Reoperation
  8. Reexploration following initial surgery
  9. Sternal wound dehiscence
  10. Surgical technical factors (eg, excessive use of electrocautery, bone wax, paramedian sternotomy)
37
Q

Arogatroban in HIT until PLT are? and INR is?

A
  1. over 100,000

2. 4

38
Q

HIT: Do not start Coumadin until PLT are?

A

Over 100k

CT surgery March 2022 (3 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions