Pre-Op and Post-Op Care Flashcards
Pre-Op EF <35%
prohibitive cardiac risk for noncardiac operations.
incidence periop MI is 75-85%, morality 55-90%.
Goldman’s Index of Cardiac Risk
JVD = 11 pts MI within last 6 months = 10 pts PVC or arrhythmia = 7 pts >70yrs = 5 pts emergency surgery = 4 pts aortic valvular stenosis, poor medical condition, or surgery within chest/abd = 3 pts
Risk of cardiac complications: up to 5 pts = 1% up to 12 pts = 5% up to 25 pts = 11% over 25% = 22%
JVD
shows CHF, worst finding, predicts high cardiac risk
Tx: ACEI, beta blockers, digitalis, diuretics
Recent Transmural or subendocardial MI
40% risk of mortality within 3 months of surgery
Increased Pulmonary Risk
Cause: smoking
effect: compromised ventilation, high PCO2, low FEV1
Tx: stop smoking 8 wks before operation, resp therapy
Hepatic Risk
predictors: bilirubin, serum albumin, prothrombin time, ascites, encephalopathy
40% mortality: with either bilirubin >2, albumin 16, or encephalopathy
80-85% mortality: if three or more predictors present, bilirubin >4, albumin 150.
Severe Nutritional Depletion
loss of 20% of body weight in a few months, serum albumin <200.
Tx: 4-10 days perop nutritional support.
Diabetic Coma
absolute contraindication to surgery
Tx: rehydrate, increase urinary output, correct acidosis and hyperglycemia
Malignant Hyperthermia
after onset of anesthetic (halothane or succinylcholine)
temp >104F, metabolic acidosis, hypercalcemia.
May have family history.
Tx: IV dantrolene, 100% oxygen, correct acidosis, cooling blankets.
Watch for myoglobinuria.
Bacteremia
within 30-45 minutes of invasive procedures.
chills and temp >104F.
Dx: blood cultures
Tx: empiric antibiotics
Gas gangrene
rare cause of severe wound pain and high fevers within hours of surgery
Post-Op Fever 101-103F
from: atelectasis pneumonia UTI DVT wound infection deep abscesses
Atelectasis
most common post op fever POD1.
Dx: chest x-ray, improve ventilation
Tx: bronchoscopy
Pneumonia
POD3 fever if atelectasis not resolved.
Dx: infiltrates on CXR, sputum cultures
Tx: abx
UTI
POD3 fever
Dx: UA, urine cultures
Tx: abx
DVT
POD5 fever
Dx: Doppler studies of deep leg and pelvic veins
Tx: heparin
Wound Infection
POD7 fever
PE: erythema, warmth, tenderness.
Dx: sonogram
Tx: abx if cellulitis, open and drain abscess
Deep Abscess
subphrenic, pelvic, subhepatic
POD 10-15 fever
Dx: CT
Tx: drainage via radiology
Perioperative MI
During operation:
most commonly triggered by hypotension
Dx: EKG shows ST depression, T-wave flattening
Post-op:
POD 1-3 with chest pain.
Dx: troponin
Tx: for complications, emergency angioplasty, coronary stent
Pulmonary Embolus
POD7 in elderly or immobilized patients
Features: pleuritic chest pain, sudden onset, SOB, anxious, diaphoretic, tachycardic, prominent distended veins in neck and forehead.
Dx: arterial blood gases have hypoxia and hypocapnia, pulmonary angiogram, spiral CT/CT angio
Tx: heparin, IVC filter
Prevention: compression devices, anticoagulation
Risk factors: age >40yr, pelvic or leg fracture, venous injury, femoral venous catheter, anticipated prolonged immobilization.
Aspiration
hazard in awake intubations in combative patients with full stomach.
Can cause tracheobronchila tree injury, pulm failure, secondary pneumonia.
Prevention: NPO, antacids
Tx: lavage and removal of acid and particulates via bronchoscopy, bronchodilators, resp support
Intraoperative Tension PTX
in pt with traumatized lungs on positive pressure breathing.
Features: BP declines, CVP rises
Tx: needle decompression, chest tube.
Disorientation/Coma Post op
- hypoxia secondary to sepsis.
a. check blood gases, provide resp support. - ARDS when complicated post op course usually with sepsis.
a. bilat pulm infiltrates, hypoxia, no CHF.
b. tx is PEEP, treat sepsis - delirium tremens in alcoholics on POD 2-3
a. have hallucinations, become combative.
b. tx: IV benzos, IV alcohol - hyponatremia if fast infusion of sodium free IVF in postop pt with high ADH.
a. confusion, convulsions, coma/death
b. large fluid intake, weight gain, low serum Na
c. prevent by Na in IVF
d. high mortality
e. tx: small amounts hypertonic saine, osmotic diuretics - hypernatremia if large water loss from osmotic diuresis.
a. large urinary output, weight loss, high serum sodium
b. tx: rapidly replace fluid with D5 1/2 or D5 1/3 normal saline. - ammonium intoxication in cirrhotic pt with bleeding varices and portocaval shunt
Post Op Urinary Retention
usually from surgery in abd, pelvis, perineum, groin.
Features: feels like need to void but can’t.
Tx: in and out catheterization at 6hr post op, foley if still can’t after 3 catheterizations.
No output: mechanical problem. look for plugged or kinked catheter.
Low output: (40 in renal failure, FENa >1 in renal failure.
Paralytic Ileus
in first few days post op.
neg BS, neg flatus, mild distension, no pain.
prolonged by hypokalemia.
Early Mechanical Bowel Obstruction
from adhesions during post op.
Usually assumed paralytic ileus that doesn’t resolve by POD5-7.
Dx: x-ray shows dilated loops of small bowel and air-fluid levels, CT abd shows transition btw proximal dilated bowel and sital collapsed bowel.
Tx: surgery
Ogilvie Syndrome
paralytic ileus of colon.
in elderly sedentary patients.
Features: large abd distention with massively dilated colon.
Dx: x-ray shows dilated colon
Tx: after rule out obstruction and correct fluid and electrolytes, do endoscopy and then give IV neostigmine to restore motility.
Wound Dehiscence
POD5 after laparotomy
Features: large amounts pink, salmon colored fluid on dressing, wound looks intact.
Tx: tape wound securely, bind abd, reoperate.
Evisceration
complication of wound dehiscence.
skin opens up and abd contents rush out when pt coughs, strains, gets out of bed.
Tx: keep in bed, large sterile dressings soaked in saline, emergency closure.
Fistulas of GI Tract
bowel contents leak out through wound or drain.
Can cause sepsis, needing drainage.
Drain freely leads to fluid and electrolyte loss, nutritional depletion, erosion/digestion of belly wall.
Hypernatremia
Cause: lost water or developed hypertonicity.
Happens slowly = brain adapts and will show volume depletion.
a. tx: volume repletion slowly using D5 1/2 NS.
Rapid = from osmotic diuresis or diabetes insipidus, causes CNS symptoms.
a. tx: correct with D 1/3 NS or D5W
Hyponatremia
- high ADH from post op water intoxication or inappropriate ADH secretion by tumor.
a. tx: water restriction if slow. rapid = hypertonic saline - losing large amounts of isotonic fluids retains water if doesn’t get enough isotonic fluids.
a. tx: isotonic fluids
water intoxication causes CNS symptoms
Hypokalemia
slowly when lost through GI tract or in urine and not replaced.
rapidly when moves into cells (DKA correction).
Tx: potassium replacement 10mEq/h.
Hyperkalemia
slowly when kidneys can’t excrete potassium (renal failure or aldosterone antagonists.
rapidly when dumped into blood (crushing injries, dead tissue, acidosis).
tx: hemodialysis, 50% dextrose and insulin, NG suction, IV calcium.
Metabolic Acidosis
from excessive production of fixed acids (DKA, lactic acidosis, low-flow states), loss of buffers, or inability of kidney to eliminate fixed acids.
Features: pH <25, base deficit.
a. anion gap if abnormal acids build up.
Tx: give bicarb/lactate/acetate, treat underlying condition.
a. watch K+ and replace if necessary
Metabolic Alkalosis
loss of acid gastric juice or giving too much bicarb.
Features: pH >7.4, serum bicarb >25, base excess.
Tx: KCl, ammonium chloride, 0.1 HCl
Respiratory Acidosis and Alkalosis
impaired ventilation = acidosis
abnormal hyperventilation = alkalosis
Features: abnormal PCO2 (low in alkalosis, high in acidosis), abnormal pH.
Tx: acidosis = improve ventilation; alkalosis = reduce ventilation.
