Pre-op and Post-op care Flashcards
What are the components of Goldman’s index of cardiac risk?
- JVD** (worst one)
- recent MI* (within 6 months)
- PVCs (>5 per minute) or any other non-sinus rythm
- age>70
- emergency surgery
- aortic stenosis
- existing medical conditions
- chest/abdomen surgical hx
Ejection fraction of under _______% poses prohibitive cardiac risk for non-cardio surgeries, and has a perioperative MI incidence of >75%.
35
Pre-op treatment for pt with JVD?
Acei’s, Beta-blockers, digitlis, and diuretics
If recent MI in a pre-op patient, and waiting is not an option…..what should you do?
Admit to ICU for optimization of “cardiac variables”
What is the most common cause of increased pre-operative pulmonary risk?
Smoking
-Compromised ventilation (high PCO2, low FEV 1), not oxygenation
How do you evaluate a pre-op patient with pulmonary risk (e.g smoking or COPD)
start with FEV1….if abnormal –> blood gases
- in a smoker –> cessation for 8 weeks pre-op and intensive respiratory therapy
What Hepatic findings give a pre-op patient 40% mortality? Which ones give you 80%?
40%:
-EITHER Bilirubin > 2, Albumin < 3, PT > 16, or encephalopathy
80%:
-3 of the above present, or with either Bili >4, Albumin < 2, blood ammonia >150
In pt with severe nutritional depletion (>20% wt loss over a couple of months), how should they be managed pre-operatively?
- Nutritional support (preferably via the gut) for 7-10 days ideally…..although as few as 4-5 may be sufficient
What metabolic/endocrine complication is an absolute contraindication to surgery?
Diabetic coma
In a patient with diabetic coma….What steps should be taken before you can operate?
Rehydration, return of urine output, at least partial correction of acidosis and hyperglycemia
What is the cause, and what are the characteristics of Malignant hyperthermia?
Cause: Anesthetics (halothane or succinylcholine)
Charac: -temp > 104 degF -Metabolic acidosis -Hypercalcemia -May have a FHx -Can potentially develop myoglobinuria -
What is the treatment for malignant hyperthermia?
Dantrolene, 100% O2, correction of acidosis, cooling blankets
Severe wound pain and very high fever within hours of surgery…..
gas gangrene (very rare)
Post-op fever causes in order of occurance are…..
- Atelectasis - PO day 1
- UTI - PO day 3
- DVT - PO day 5
- Wound infection - PO day 7
- Antibiotics, Heparin, etc — PO day 10+
- Deep abcess - PO day 10-15
*Pneumonic: Wind, water, walking, wounds, wonder drugs
When does postoperative Mi typically occur?
2-3 days postop. 2/3 of time there is no chest pain. Most reliable test = troponin
-Higher mortality than regular MI
How long after surgery does PE occur?
usually around PO day 7 in elderly and/or immobilized patients.
Pts considered “high risk” for PE can be treated with anticoagulation prophylactically to prevent PE. WHat factors make a pt “high risk”??
- Age > 40
- pelvic or leg fractures
- venous injury
- femoral venous catheter
- anticipated prolonged immobilization
How do you treat a patient who aspirated?
lavage and removal of acid and particulate matter (w/ help of bronchoscopy), followed by bronchodilators and resp support.
Characteristics of Intraoperative tension pneumothorax?
- patients with traumatized lungs (blunt trauma etc), once they are subjected to positive pressure breathing
- Become progressively more difficult to bag
- BP steadily declines, CVP steadily rises
What is the first thing you should suspect when a post-op patient gets confused/disoriented?
Hypoxia
-may be secondary to sepsis. check blood gases and provide resp support
What is the primary therapy for ARDS?
- High PEEP on ventilation, avoid high volumes (barotrauma)
- treat underlying condition, ex: Abx for sepsis
Alcoholic who becomes confused, hallucinates, becomes combative about 3 days after an emergency surgery?
Delerium tremens
- Drinking was interrupted by surgery
- Tx = Benzos IV
Symptoms of post-op Hyponatremia?
confusion, convulsions, eventually coma
Causes of, and Correction of Post-op hypernatremia?
Causes: intra-operative pituitary damage –> Diabetes insipidus, osmotic diuresis
Correction: D5 1/2 NS
What is a common cause of coma in cirrhotic patients with bleeding varices who undergo porto-caval shunts?
Ammonium intoxication
-Shunt bypasses liver –> less ammonia metabolized –> worsened encephalopathy –> coma
When should you do in-and-out bladder catheterization in a post-op patient?
If no spontaneous voiding by 6 hours post-op
Most likely causes of low urine output (less than 0.5 ml/Kg/hr) in setting of normal perfusion?
Fluid deficit or acute renal failure
Describe a Fluid challenge test:
- Give a bolus of 500 mL IV fluid infused over 10-20 minutes. Dehydrated pts will respond with incr in Urine output, ARF pts will not respond
- alternate ways of differentiating = Urine Sodium( una< 20 if dehydrated), FENa (>1 arf)
What is most likely present in a post-op patient with absent bowel sounds, no passage of gas, mild abd distension, no pain?
Paralytic ileus
- Prolonged by hypokalemia
- worsened by opiate meds
If ileus doesn’t resolve after 5-7 days, it is most likely ______, and imaging would show _________
Bowel obstruction
- Xrays: dilated loops of small bowel with air-fluid levels
- CT: confirms Diagnosis –> transition point between proximally distended bowel and distal collapsed bowel.
*Tx = surgical intervention
Ogilvie syndrome
- Paralytic ileus of the colon
- does not follow surgery
- seen in elderly sedentary patients who are further immobilized due to surgery elsewhere.
- Large abdominal distention (tense, not tender), with massively dilated colon on Xray
Treatment of Ogilvie syndrome?
- Fluid and electrolyte correction
- rule out mechanical obstruction with imaging
- Neostigmine IV to restrore colonic motility
- Long rectal tube also used commonly
When does wound dehiscence typically occur?
about PO day 5
Characteristics of wound dehiscence:
- Wound looks intact
- Large amounts of serosanguinous fluid soaking through dressings
Treatmet of wound dehiscence…
- Tape wound securely
- bind the abdomen
- avoid exertion etc
- **Ultimately –> re-operation to fix fascial layer in order to prevent evisceration or ventral hernia
Evisceration management:
-Stay in bed –> cover bowel with large sterile dressings soaked in warm saline –> Emergency abdominal closure in OR
Management of a post-op GI fistula
-FLuid and e-lytes replacement, nutritional support (delivered beyond fistula), protection of abdominal wall
all this done until nature heals fistula (as long as no foreign body, epithelialization, tumor, infection, irridated tissue, IBD, distal obstruction) *F.E.T.I.D pnemonic
Friend pneumonic- foreign body, radiation, infection/ inflammation, neoplasia, distal obstruction
Every ____ mEq/L that the serum sodium concentration goes above 140 represents roughly 1 L of water lost
3
Symptoms of hypernatremia when caused rapidly vs slowly:
Slowly (diarrhea over several days, lack of access to water, etc) = manifestations of volume depletion
Rapidly (DKA, DI) = Sx of volume depletion + CNS symptoms from brain shrinkage
- Correct with D5 1/2 NS
- correct rapid more quickly with D51/3NS or even D5W
Therapy for Hyponatremia:
Rapidly developed: 3% Saline
Slowly developed: water restriction, then NS if needed.
What is the safe rate of K+ replacement for Hypokalemia?
10 mEq/hour
What are the most common causes of hypokalemia?
- GI losses = develops over a few days
- Cellular shift = correction in DKA
Hyperkalemia: when does it develop slowly vs. when does it develop rapidly?
Slowly = kidney failure, aldosterone antagonists
Rapidly = dumped from cells (crush injuries, dead tissue, acidosis)
Fastest treatment for hyperkalemia is _______
IV calcium gluconate
Describe “rebound alkalosis” with Bicarb treatment…
Pt with acidosis not caused by bicarb loss –> bicarb admin. temporarily raises pH –> underlying cause corrected –> now you have excess bicarb –> Alkalosis
What electrolyte might need to be replaced in long-standing acidosis? Why?
K+
-long-standing acidosis –> renal K+ loss not evident until acidosis corrected
KCl can be used to help correct ______
metabolic alkalosis
Risk of operative mortality 3 mths after mi____%
Risk of operative mortality 6 mths after mi _____%
40%–>6%
What are three indicators of severe nutritional depletion?
Serum albumin < 3, anergy to skin antigens, serum transferrin < 200
An arterial blood gas for a pt that is having a pe must show?
Hypoxemia and hypocapenia
If concerned for a post op abscess what imaging modality would you chose? How do you treat it?
CT and percutaneous drainage
How can a wound infection be distinguished from abscess if you are not sure?
Ultrasound
If the pt has zero urine output post op, what is the most likely etiology?
Mechanical-kinked or plugged cath
