Pre and Post-OP Care Flashcards
what are the standard preoperative tests?
CBC w/ electrolytes
ECG - if above 40 or with history of cardiac dz
CXR
what type of anesthesia has fewer pulmonary complications?
spinal anesthesia
what patients is spinal anesthesia dangerous in?
pts with CAD
marginal cardiac reserve w/ low EF
valvular heart dz
diabetic peripheral vascular disease w/ neuropathy
why is spinal anesthesia dangerous in pts with cardiac problems?
loss of peripheral vasoconstriction ability leads to hypotension and inability to increase CO
major drawbacks of general anesthesia
increased incidence of pulmonary complications
mild cardiodepression
how long before surgery should a patient stop taking.. Aspirin (1)? NSAIDs (2)?
- 7-10 days (irreversible)
2. 2 days (reversible effect)
what should be done prior to surgery in someone with history of previous MI?
cardiology consultation w/ possible exercise stress test and cardiac catheterization may be necessary prior to surgery
what pre-op precaution should be taken in a diabetic?
since pt is NPO after midnight, diabetics should receive IVF w/ dextrose
which drugs should not be given to a diabetic the morning of their surgery?
oral hypoglycemic drugs i.e. sulfonylureas
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?
- give 2/3 of morning dose of NPH and regular insulin
2. give 1/2 of morning dose
what do you do pre-op if a pt has a low hematocrit?
reason for anemia must be determined and surgery post-poned until then
what do you do pre-op if a pt has a high hematocrit?
ensure proper hydration
tx. underlying cause before surgery
optimal perioperative blood glucose levels
100-250 mg/dL
- if higher than these values, should delay surgery until glucose under control
what are patients with poorly controlled DM at risk for post-op?
increased risk of wound infections
what do you do if a patient presents for surgery and on PE you find cellulitis from an infected hair follicle in his axilla?
elective surgery should be post-poned until acute infection is resolved, regardless of its location; otherwise, this significantly increases risk of wound infection
can you operate on someone who has a UTI?
no - surgery should be postponed until UTI has been treated w/ antibiotics and repeat UA and culture indicate resolution
what is diastolic BP > 110 a risk factor for?
development of CV complications such as malignant HTN, acute MI and CHF
how should you manage high BP perioperatively?
pt should continue on antihypertensive medications on the day of surgery - BB may reduce risk of cardiac complications following surgery
recommendations for a smoker about to undergo elective surgery?
6-8 weeks of abstinence can decrease post-op respiratory morbidity so patient should be advised to quit smoking prior to elective surgeries
what ABG results are associated with increased perioperative morbidity?
PaCO2 > 45 mmHg
PaO2 < 60 mmHg
can you do laparscopic surgery in a pt with compromised pulmonary status?
no… increased CO2 absorption through blood requires excretion from lungs and increases pulmonary work
five factors that are used to predict risk for cardiac complications after vascular surgery
- Q waves on ECG
- history of ventricular ectopy requiring tx
- hx of angina
- DM
- age > 70
MCC of post-op early death following LE revascularization
MI
if pt has prior history of MI and is being qualified for vascular surgery, what should be done?
- ECG
- persantine thallium stress test or dobutamine echo
- if reversible ischemia is present, pt should undergo cardiac catheterization prior to surgery
recent MI within what time frame poses a risk for cardiac complications in a non-cardiac surgery
MI w/in 30 days
pts pre-op ECG shows LBBB
pt should have careful evaluation for underlying cardiopulmonary disease as LBBB is highly suggestive of underlying ischemic heart disease
how does having a CABG in the past affect pre-op evaluation of cardiac risk/
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
what test should you do in a pt about to undergo surgery who had a CABG 10 years ago?
graft patency is questionable at 10 years (esp. with saphenous grafts) therefore do a STRESS TEST to assess any reversible ischemia
pre-op evaluation in pt who had PCI with stent 2 years ago
cardiac evaluation with stress test needed
- PCI has higher rate of restenosis than CABG
pre-op evaluation in pt who had PCI 2 days ago
noncardiac surgery should be delayed for several weeks following coronary angioplasty due to high probability of coronary thrombosis
on pre-op evaluation you note your patient has angina on moderate exertion and uses nitroglycerin - what test should you run?
coronary angiography to see if pt would benefit from stent or revascularization
pre-op evaluation ECG shows 6 premature ventricular complexes per minute - what does this imply and what test should be done?
> 5 PVCs/min increased cardiac mortality
- assess ventricular dysfunction with stress test and echo
on preop evaluation you notice a loud right carotid bruit on your pt - what test should you do?
carotid duplex study to evaluate for carotid artery stenosis –> if high grade stenosis present, may need endarterectomy prior to surgery
what preop test should be done in pt who had a stroke 2 years ago…
carotid duplex study (if good neurologic recovery); no further tests needed if significant residual neurological deficit present
a pt being considered for umbilical hernia has a small ulcerated area on the hernia
the ulcer is due to pressure necrosis and has increased risk of rupture - should be repaired expediently
in an alcoholic patient, what is important pre-op?
that patient abstains from alcohol and has undergone withdrawl - alcoholic withdrawl is associated with high morbidity and mortality
a patient with cirrhosis has hemorrhoid that he would like removed - what are you worried about?
uncontrollable hemorrhage during surgical repair due to portal HTN
how do you manage bleeding in a patient with chronic kidney failure during surgery?
platelet dysfunction due to uremia can be managed with desmopressin
- FFP may also temporarily correct the defect
- postop hemodialysis may improve function
pt with chronic renal failure develops hypotension during surgery with no obvious cause or bleeding….
consider glucocorticoid deficiency
- give hydrocortisone 25 mg intraoperatively followed by 100 mg in next 24 hrs
normal ratio of replacement fluids for post-op
3 ml of isotonic fluid for every 1 ml of estimated blood loss
normal maintenance fluid for post-op
5% dextrose - 1/2 NS plus KCl 20 mEq/L
if patient loses a lot of blood during operation, what fluid should you opt for?
lactated Ringer’s or 0.9% NaCl for first 24 hours
calculation of intraoperative fluid requirements
(EBL x 3 mL isotonic fluid/1mL blood loss) + UO - IVF in OR
how do you estimate fluid replacement for fluids lost from drains or fistulas?
replace mL for mL
formula for estimation of maintenance fluid requirements
1500 mL for first 20 kg
20 mL/kg for every addition kg
normal urine output
0.5-1 mL/kg/hr
a post-op patient has a urine output of 10ml/hr for next 4 hours - what should you try first?
- catheter - irrigate and confirm position
2. dehydration - try volume resuscitation
MCC of fever in the immediate post-op period
atelectasis
- will hear fine crackles on lung auscultation
tx. of post-op atelectasis
pulmonary toilet
incentive spirometry
2nd MCC of post-op fever (on day 3)
UTI
tx. of post-op UTI
oral TMP-SMX or ciprofloxacin
what should you do if on wound exam you noticed fluctuance?
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
you notice that a patient’s indwelling IV has induration, edema and tenderness - what should you do?
remove the catheter and it should resolve
- rotate IV lines every 4 days to prevent this
you notice a patient as a drop of pus on the skin at the venipuncture exit site…dx?
suppurative phlebitis
- caused by presence of infected thrombus in the vein around the indwelling catheter
how do you tx. suppurative phlebitis
removal of catheter
excision of infected vein to first patent non-infected collateral branch
what do you do with a patient post-GI surgery that shows clinical signs of peritonitis post-op?
they require operative re-exploration
a 65 yo woman who had segment of necrotic bowel resected has intestinal contents draining from her wound on POD5 - what do you suspect?
leak at jejunostomy site
break in anastomosis site
missed enterotomy
what study should you do in someone with suspected enteric fistula post-op?
CT scan - to R/O intra-abdominal collection
- if present, should drain
how do you tx an enterocutaneous fistula post-op?
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
factors associated with a fistula that is failing to heal (6) - FRIEND
Foreign body in the wound Radiation damage to the area Infection or IBD Epithelialization of fistula tract Neoplasm Distal bowel obstruction
an extremely high fever in the immediate post-op period….
atelectasis - but would have to be entire lung
most probably is a serious wound infection with gas-forming bacteria
how does a wound infection caused by a gas forming appear?
erythematous with advancing edge of brown discoloration and bleb formation; there is thin watery discharge with foul odor and crepitus near the wound edge
management of suspected gas gangrene wound infection
wound should be opened and cultured immediately with high dose penicillin G, debridement and hyperbaric O2 treatment
Goldman’s Index (8)
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
how do you assess compromised ventilation pre-op in a smoker?
first measure FEV1; if abnormal, measure ABGs
- smoker will have low FEV1 and high PaCO2
how can you improve pulmonary risk in a smoker prior to elective surgery?
stop smoking for 6-8 weeks prior to operation
intensive respiratory therapy
which parameters increase mortality in a cirrhotic patient that needs surgery?
bilirubin > 2
albumin < 3
PT > 16
encephalopathy
contra-indications to a cirrhotic pt having surgery due to extremely high (100%) mortality
bilirubin > 4
albumin < 2
ammonia > 150 ng/dl
four indicators of severe nutritional depletion
weight loss > 20% of body weight
low albumin
anergy to skin test
serum transferrin < 200 mg/dl
tx of malignant hyperthermia
IV dantrolene
support measures: 100% O2, correct acidosis, cooling blankets, watch for myoglobinuria
45 min after cystoscopy a patient develops chills and a high fever
so early on after an invasive procedure indicates bacteremia - > take blood cultures 3x and start empiric antibiotics
MCC of post-op fever
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)
tx of post-op atelectasis
improve ventilation with deep breathing and coughing, postural drainage and incentive spirometry; ultimately, bronchoscopy if nothing
management of deep abscesses post-op
CT scans to find them and then drained percutaneously
when is post-op MI likely to occur? and how do you diagnose it?
either during the operation or up to POD3
- order ECG and troponin levels
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
post-op PE
first test to order in post-op PE
ABGs - hypoxemia, hypocapnia
follow with CT-angio
how can you prevent post-op PE?
pts w/o LE fractures - sequential compression stockings
high risk pts require anticoagulation
- age > 40, LE fractures, venous injury, femoral catheterization, prolonged immobilization
how do you manage pulmonary aspiration
lavage and removal of particulate matter (w bronchoscopy) followed by bronchodilators and respiratory support
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?
intraoperative tension PTX
- cant put chest tube in
- put hole in diaphragm or need placed in ant. chest under drape
major cause of post-op disorientation and first test to order?
hypoxia
- order ABGs
Tx of ARDS
PEEP
- in trauma patient, look for precipitating event ie. shock/sepsis
Tx of post op urinary retention
In and out bladder catheterization
-don’t do foley until atleast twice
Urinary sodium in dehydration
U-Na < 10-20
Urinary sodium in renal failure
U-Na > 40
XR finding in paralytic Ileus
Dilated loops of bowel without air fluid level
vs. mechanical obstruction which has fluid levels
What metabolic abnormality can prolong paralytic Ileus?
Hypokalemia
Paralytic Ileus of the colon
Ogilvie syndrome
