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Surgery NBME > Pre and Post-OP Care > Flashcards

Pre and Post-OP Care Flashcards

1
Q

what are the standard preoperative tests?

A

CBC w/ electrolytes
ECG - if above 40 or with history of cardiac dz
CXR

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2
Q

what type of anesthesia has fewer pulmonary complications?

A

spinal anesthesia

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3
Q

what patients is spinal anesthesia dangerous in?

A

pts with CAD
marginal cardiac reserve w/ low EF
valvular heart dz
diabetic peripheral vascular disease w/ neuropathy

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4
Q

why is spinal anesthesia dangerous in pts with cardiac problems?

A

loss of peripheral vasoconstriction ability leads to hypotension and inability to increase CO

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5
Q

major drawbacks of general anesthesia

A

increased incidence of pulmonary complications

mild cardiodepression

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6
Q

how long before surgery should a patient stop taking.. Aspirin (1)? NSAIDs (2)?

A
  1. 7-10 days (irreversible)

2. 2 days (reversible effect)

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7
Q

what should be done prior to surgery in someone with history of previous MI?

A

cardiology consultation w/ possible exercise stress test and cardiac catheterization may be necessary prior to surgery

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8
Q

what pre-op precaution should be taken in a diabetic?

A

since pt is NPO after midnight, diabetics should receive IVF w/ dextrose

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9
Q

which drugs should not be given to a diabetic the morning of their surgery?

A

oral hypoglycemic drugs i.e. sulfonylureas

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10
Q

what do you do if an insulin-dep diabetic has a blood glucose > 250 mg/dL on morning of surgery? if glucose is < 250 mg/dL?

A
  1. give 2/3 of morning dose of NPH and regular insulin

2. give 1/2 of morning dose

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11
Q

what do you do pre-op if a pt has a low hematocrit?

A

reason for anemia must be determined and surgery post-poned until then

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12
Q

what do you do pre-op if a pt has a high hematocrit?

A

ensure proper hydration

tx. underlying cause before surgery

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13
Q

optimal perioperative blood glucose levels

A

100-250 mg/dL

- if higher than these values, should delay surgery until glucose under control

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14
Q

what are patients with poorly controlled DM at risk for post-op?

A

increased risk of wound infections

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15
Q

what do you do if a patient presents for surgery and on PE you find cellulitis from an infected hair follicle in his axilla?

A

elective surgery should be post-poned until acute infection is resolved, regardless of its location; otherwise, this significantly increases risk of wound infection

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16
Q

can you operate on someone who has a UTI?

A

no - surgery should be postponed until UTI has been treated w/ antibiotics and repeat UA and culture indicate resolution

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17
Q

what is diastolic BP > 110 a risk factor for?

A

development of CV complications such as malignant HTN, acute MI and CHF

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18
Q

how should you manage high BP perioperatively?

A

pt should continue on antihypertensive medications on the day of surgery - BB may reduce risk of cardiac complications following surgery

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19
Q

recommendations for a smoker about to undergo elective surgery?

A

6-8 weeks of abstinence can decrease post-op respiratory morbidity so patient should be advised to quit smoking prior to elective surgeries

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20
Q

what ABG results are associated with increased perioperative morbidity?

A

PaCO2 > 45 mmHg

PaO2 < 60 mmHg

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21
Q

can you do laparscopic surgery in a pt with compromised pulmonary status?

A

no… increased CO2 absorption through blood requires excretion from lungs and increases pulmonary work

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22
Q

five factors that are used to predict risk for cardiac complications after vascular surgery

A
  1. Q waves on ECG
  2. history of ventricular ectopy requiring tx
  3. hx of angina
  4. DM
  5. age > 70
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23
Q

MCC of post-op early death following LE revascularization

A

MI

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24
Q

if pt has prior history of MI and is being qualified for vascular surgery, what should be done?

A
  1. ECG
  2. persantine thallium stress test or dobutamine echo
  3. if reversible ischemia is present, pt should undergo cardiac catheterization prior to surgery
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25
Q

recent MI within what time frame poses a risk for cardiac complications in a non-cardiac surgery

A

MI w/in 30 days

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26
Q

pts pre-op ECG shows LBBB

A

pt should have careful evaluation for underlying cardiopulmonary disease as LBBB is highly suggestive of underlying ischemic heart disease

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27
Q

how does having a CABG in the past affect pre-op evaluation of cardiac risk/

A

CABG w/in last 6 months to 5 years has been shown to reduce the risk of cardiac complications in pts who are undergoing other surgery

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28
Q

what test should you do in a pt about to undergo surgery who had a CABG 10 years ago?

A

graft patency is questionable at 10 years (esp. with saphenous grafts) therefore do a STRESS TEST to assess any reversible ischemia

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29
Q

pre-op evaluation in pt who had PCI with stent 2 years ago

A

cardiac evaluation with stress test needed

- PCI has higher rate of restenosis than CABG

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30
Q

pre-op evaluation in pt who had PCI 2 days ago

A

noncardiac surgery should be delayed for several weeks following coronary angioplasty due to high probability of coronary thrombosis

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31
Q

on pre-op evaluation you note your patient has angina on moderate exertion and uses nitroglycerin - what test should you run?

A

coronary angiography to see if pt would benefit from stent or revascularization

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32
Q

pre-op evaluation ECG shows 6 premature ventricular complexes per minute - what does this imply and what test should be done?

A

> 5 PVCs/min increased cardiac mortality

- assess ventricular dysfunction with stress test and echo

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33
Q

on preop evaluation you notice a loud right carotid bruit on your pt - what test should you do?

A

carotid duplex study to evaluate for carotid artery stenosis –> if high grade stenosis present, may need endarterectomy prior to surgery

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34
Q

what preop test should be done in pt who had a stroke 2 years ago…

A

carotid duplex study (if good neurologic recovery); no further tests needed if significant residual neurological deficit present

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35
Q

a pt being considered for umbilical hernia has a small ulcerated area on the hernia

A

the ulcer is due to pressure necrosis and has increased risk of rupture - should be repaired expediently

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36
Q

in an alcoholic patient, what is important pre-op?

A

that patient abstains from alcohol and has undergone withdrawl - alcoholic withdrawl is associated with high morbidity and mortality

37
Q

a patient with cirrhosis has hemorrhoid that he would like removed - what are you worried about?

A

uncontrollable hemorrhage during surgical repair due to portal HTN

38
Q

how do you manage bleeding in a patient with chronic kidney failure during surgery?

A

platelet dysfunction due to uremia can be managed with desmopressin

  • FFP may also temporarily correct the defect
  • postop hemodialysis may improve function
39
Q

pt with chronic renal failure develops hypotension during surgery with no obvious cause or bleeding….

A

consider glucocorticoid deficiency

- give hydrocortisone 25 mg intraoperatively followed by 100 mg in next 24 hrs

40
Q

normal ratio of replacement fluids for post-op

A

3 ml of isotonic fluid for every 1 ml of estimated blood loss

41
Q

normal maintenance fluid for post-op

A

5% dextrose - 1/2 NS plus KCl 20 mEq/L

42
Q

if patient loses a lot of blood during operation, what fluid should you opt for?

A

lactated Ringer’s or 0.9% NaCl for first 24 hours

43
Q

calculation of intraoperative fluid requirements

A

(EBL x 3 mL isotonic fluid/1mL blood loss) + UO - IVF in OR

44
Q

how do you estimate fluid replacement for fluids lost from drains or fistulas?

A

replace mL for mL

45
Q

formula for estimation of maintenance fluid requirements

A

1500 mL for first 20 kg

20 mL/kg for every addition kg

46
Q

normal urine output

A

0.5-1 mL/kg/hr

47
Q

a post-op patient has a urine output of 10ml/hr for next 4 hours - what should you try first?

A
  1. catheter - irrigate and confirm position

2. dehydration - try volume resuscitation

48
Q

MCC of fever in the immediate post-op period

A

atelectasis

- will hear fine crackles on lung auscultation

49
Q

tx. of post-op atelectasis

A

pulmonary toilet

incentive spirometry

50
Q

2nd MCC of post-op fever (on day 3)

A

UTI

51
Q

tx. of post-op UTI

A

oral TMP-SMX or ciprofloxacin

52
Q

what should you do if on wound exam you noticed fluctuance?

A

this suggests a fluid collection beneath the skin, some sutures should be removed and pus should be drained followed with wet-to-dry dressings (BID) and irrigation

53
Q

you notice that a patient’s indwelling IV has induration, edema and tenderness - what should you do?

A

remove the catheter and it should resolve

- rotate IV lines every 4 days to prevent this

54
Q

you notice a patient as a drop of pus on the skin at the venipuncture exit site…dx?

A

suppurative phlebitis

- caused by presence of infected thrombus in the vein around the indwelling catheter

55
Q

how do you tx. suppurative phlebitis

A

removal of catheter

excision of infected vein to first patent non-infected collateral branch

56
Q

what do you do with a patient post-GI surgery that shows clinical signs of peritonitis post-op?

A

they require operative re-exploration

57
Q

a 65 yo woman who had segment of necrotic bowel resected has intestinal contents draining from her wound on POD5 - what do you suspect?

A

leak at jejunostomy site
break in anastomosis site
missed enterotomy

58
Q

what study should you do in someone with suspected enteric fistula post-op?

A

CT scan - to R/O intra-abdominal collection

- if present, should drain

59
Q

how do you tx an enterocutaneous fistula post-op?

A

NPO, give pt TPN and measure fistula output daily - most will heal on their own w/in a few weeks
- if it does not close w/in 5-6 weeks and pt is free of infection, definitive repair should be planned

60
Q

factors associated with a fistula that is failing to heal (6) - FRIEND

A 
Foreign body in the wound
Radiation damage to the area
Infection or IBD
Epithelialization of fistula tract
Neoplasm
Distal bowel obstruction
61
Q

an extremely high fever in the immediate post-op period….

A

atelectasis - but would have to be entire lung

most probably is a serious wound infection with gas-forming bacteria

62
Q

how does a wound infection caused by a gas forming appear?

A

erythematous with advancing edge of brown discoloration and bleb formation; there is thin watery discharge with foul odor and crepitus near the wound edge

63
Q

management of suspected gas gangrene wound infection

A

wound should be opened and cultured immediately with high dose penicillin G, debridement and hyperbaric O2 treatment

64
Q

Goldman’s Index (8)

A

predictors of operative cardiac risk

  • JVD: 11 pts
  • recent MI w/in 6 months: 10 pts
  • age >70: 5 pts
  • PMBs or arrhythmias: 7 points each
  • aortic stenosis: 3 pts
  • poor general condition: 3 pts
  • chest/abdominal surg: 3 pts
  • emergency surgery: 4 pts
65
Q

how do you assess compromised ventilation pre-op in a smoker?

A

first measure FEV1; if abnormal, measure ABGs

- smoker will have low FEV1 and high PaCO2

66
Q

how can you improve pulmonary risk in a smoker prior to elective surgery?

A

stop smoking for 6-8 weeks prior to operation

intensive respiratory therapy

67
Q

which parameters increase mortality in a cirrhotic patient that needs surgery?

A

bilirubin > 2
albumin < 3
PT > 16
encephalopathy

68
Q

contra-indications to a cirrhotic pt having surgery due to extremely high (100%) mortality

A

bilirubin > 4
albumin < 2
ammonia > 150 ng/dl

69
Q

four indicators of severe nutritional depletion

A

weight loss > 20% of body weight
low albumin
anergy to skin test
serum transferrin < 200 mg/dl

70
Q

tx of malignant hyperthermia

A

IV dantrolene

support measures: 100% O2, correct acidosis, cooling blankets, watch for myoglobinuria

71
Q

45 min after cystoscopy a patient develops chills and a high fever

A

so early on after an invasive procedure indicates bacteremia - > take blood cultures 3x and start empiric antibiotics

72
Q

MCC of post-op fever

A 
day 1 - Wind } atelectasis, pneumonia
day 3 - Water } UTI
day 5 - Walking } DVT/ PE
day 7 - Wound } infection
day 10 - Wonder where } deep abscess
late - wonder drugs (medication induced)
73
Q

tx of post-op atelectasis

A

improve ventilation with deep breathing and coughing, postural drainage and incentive spirometry; ultimately, bronchoscopy if nothing

74
Q

management of deep abscesses post-op

A

CT scans to find them and then drained percutaneously

75
Q

when is post-op MI likely to occur? and how do you diagnose it?

A

either during the operation or up to POD3

- order ECG and troponin levels

76
Q

on 7th POD after hip surgery, pt suddenly develops severe pleuritic chest pain and SOB; he is anxious, diaphoretic and tachycardic and has prominent distended veins in neck and forehead

A

post-op PE

77
Q

first test to order in post-op PE

A

ABGs - hypoxemia, hypocapnia

follow with CT-angio

78
Q

how can you prevent post-op PE?

A

pts w/o LE fractures - sequential compression stockings
high risk pts require anticoagulation
- age > 40, LE fractures, venous injury, femoral catheterization, prolonged immobilization

79
Q

how do you manage pulmonary aspiration

A

lavage and removal of particulate matter (w bronchoscopy) followed by bronchodilators and respiratory support

80
Q

halfway through surgery, the anesthesiologist notes it is becoming progressively harder to bag the pt and his BP is steadily declining while CVP is rising; no evidence of intraabdominal bleeding - dx and tx?

A

intraoperative tension PTX

  • cant put chest tube in
  • put hole in diaphragm or need placed in ant. chest under drape
81
Q

major cause of post-op disorientation and first test to order?

A

hypoxia

- order ABGs

82
Q

Tx of ARDS

A

PEEP

- in trauma patient, look for precipitating event ie. shock/sepsis

83
Q

Tx of post op urinary retention

A

In and out bladder catheterization

-don’t do foley until atleast twice

84
Q

Urinary sodium in dehydration

A

U-Na < 10-20

85
Q

Urinary sodium in renal failure

A

U-Na > 40

86
Q

XR finding in paralytic Ileus

A

Dilated loops of bowel without air fluid level

vs. mechanical obstruction which has fluid levels

87
Q

What metabolic abnormality can prolong paralytic Ileus?

A

Hypokalemia

88
Q

Paralytic Ileus of the colon

A

Ogilvie syndrome

Surgery NBME (16 decks)

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