Pre-Op and Post-Op Care

Question 1

Pulmonary Risk

Answer 1

Smoking- Compromise ventilation, but not oxygenation.

• Assess FEV1, then if abnormal, blood gases.
• Cessation of smoking for 8 weeks and intensive respiratory therapy (PT, expectorants, incentive spirometry, humidified air) should precede surgery.

Question 2

Pre-Op: Hepatic Risk

Answer 2

Operative Mortality:

• Encephalopathy, ascites, serum albumin, prothrombin time (INR) and bilirubin.
• Mortality risk based on Child Risk.

Question 3

Pre-Op: Nutritional Risk

Answer 3

Severe nutritional depletion is identified by:

• Loss of 20% of body weight over 2 months.
• Serum albumin below 3.
• Anergy to skin antigens
• Serum transferrin level of less than 200 mg/dL

Question 4

Pre-Op: Metabolic Risk

Answer 4

Diabetic coma is absolute contraindication to surgery.

• Rehydration, return of UO, and partial correction of acidosis and hyperglycemia have to be achieved before surgery.
• Septic process will not resolve this.

Question 5

Post Op: Malignant Hyperthermia

Answer 5

Malignant Hyperthermia: Halothane or succinylcholine. >104 degrees, metabolic acidosis, hypercalcemia.
- Tx: IV dantrolene, 100% oxygen, correction of acidosis, and cooling blankets.

Question 6

Post Op: Bacteremia

Answer 6

Seen within 30-45 minutes of procedure. Chills and temperature spike to 104 degrees F.
- Blood culture x3 and start empiric ABX.

If severe wound pain and high fever within hours of surgery, gas gangrene in surgical wound.

Question 7

PO in 101-103F Causes

Answer 7

Atelectasis- 1 day
- Listen to lungs, chest xray, improve ventilation (deep breathing, coughing, postural drainage, incentive spirometry).

Pneumonia- 3 days if atelectasis does not resolve
- Fever will persist, chest xray will show infiltrates, do sputum culture and tx with ABX

UTI- 3rd day
- Urinalysis and urinary cultures. Tx with ABX.

Deep Thrombophlebitis- Day 5
- Doppler studies of deep leg and pelvic veins is best diagnostic modality. Anticoagulate with heparin.

Wound Infection- Day 7

• Erythema, warmth, and tenderness.
• Tx w/ ABX if only cellulitis. If abcess, drain. Can’t tell? Sonogram.

Deep Abscess- 10-15 days
- Ct scan is dx. Tx via percutaneous radiologically guided drainage.

Question 8

Perioperative Myocardial Infarction

Answer 8

Triggered most commonly by hypotension.
Detected by EKG (ST depression and t wave flattening).
Post-Op 2-3 days. Chest pain only in one third.
Troponin. Cannot use clot busters perioperatively, but can use emergency angiplasty and coronary stent.

Question 9

Pulmonary Embolism

Answer 9

Day 7- pleuritic pain, sudden onset, SOB, anxious, diaphoretic, and tachycardic with prominent distended veins.

Hypoxemia and hypocapnia. Spiral CT or CT angio is standard diagnosis test.

Tx: heparinization. Add greenfield if PEs recur while anticoagulated.

Question 10

Aspiration

Answer 10

Hazard in awake intubations in combative patients with full stomach. Lethal immediately or chemical injury of tracheobronchial tree and subsequent pulmonary failure.

Prevention: NPO and antacids before induction

Question 11

Intraoperative Tension Pneumothorax

Answer 11

Traumatized lungs once subjected to positive pressure breathing.

Decompression through diaphragm. If not needle, followed by chest tube.

Question 12

PO Pt is Confused and Disoriented

Answer 12

Hypoxia- check blood gases and provide respiratory support.

Question 13

ARDS- Adult Respiratory Distress Syndrome

Answer 13

Sepsis is precipitating event. Bilateral infiltrates and hypoxia with no evidence of CHF.

Tx: PEEP (Positive end expiratory pressure) taking care not to use excessive volume, otherwise barotrauma. Sepsis must be sought and corrected.

Question 14

Delirium Tremens

Answer 14

Drinking is interrupted by surgery. Confused, hallucinations, combative.

IV benzodiazepines, or intravenous alcohol (5% in 5% dextrose).

Question 15

Hyponatremia

Answer 15

Quickly induced by liberal administration of sodium free IV fluids with high levels of ADH (triggered by the response to trauma). Central Pontine Myelinolysis.

Question 16

PreOperative Assessment- Cardiac Risk

Answer 16

Ejection Fraction-

Question 17

Hypernatremia

Answer 17

Rapidly induced by large, unreplaced water loss.

Surgical damage to posterior pituitary with unrecognized diabetes insipidus. Use less saline like D51/2 or D51/3.

Question 18

Ammonium Intoxication

Answer 18

Common source of coma in cirrhotic patient with bleeding esophageal varices who undergoes portocaval shunt.

Question 19

Postoperative Urinary Retention

Answer 19

Feels need to void but can’t.

In and out bladder catherization should be done at 6 hours post-op if no spontaneous voiding has occurred.

Question 20

Zero Urinary Output

Answer 20

Typically mechanical; look for plugged or kinked catheter.

Question 21

Low Urinary Output

Answer 21

Less than 0.5 mL/kg/h in presence of normal perfusing pressure.

Fluid deficit or acute renal failure? Fluid challenge of 500 mL of IV fluid infused over 10 min. Can also measure urinary sodium, 10-20 mEq/L vs 40 in kidney disease (FeNa > 1 in renal failure)

Question 22

Paralytic Ileus

Answer 22

Bowel sounds absent, no passage of gas, mild distention, no pain.
Will be prolonged by hypokalemia.

Question 23

Early mechanical bowel obstruction

Answer 23

Adhesions can happen during the PO period. Paralytic ileus will resolve 5, 6, 7 days. If not, obstruction.

Surgical Intervention

Question 24

Ogilvie Syndrome

Answer 24

Paralytic ileus of colon that does not follow abdominal surgery.

Old and AD from surgery due to broken hip or something.
Massive, dilated colon. Fluid and electrolyte correction, follwed by colonoscopy to get air out and place long rectal tube.

Question 25

Wound Dehiscence

Answer 25

5th PO following open laparoscopy.
Salmon colored fluid.
Prompt reoperation

Question 26

Evisceration

Answer 26

Catastrophic complication of wound dehiscence, where skin opens and abdominal contents rush out.
Emergency closure.

Question 27

Wound Infections

Answer 27

7th Post Op day

Question 28

Fistulas of GI Tract

Answer 28

Bowel contents will leak through wound or drain site. Sepsis, fluid electrolyte loss, nutritional depletion, erosion and digestion of belly wall.

Suction tubes of ostomy bags to protect abdominal wall until fistula heals. Will heal if no foreign body, epithelialization, tumor, infection, irradiated tissue, IBD, or distal obstruction. FETID.

Question 29

Hypernatremia

Answer 29

Every 3 mEq/L that the serum sodium concentration is above 140 = 1 L of water loss.
D51/5.
If more rapid development of hypernatremia, CNS symptoms and correction should be done with more dilute fluid.

Question 30

Hyponatremia

Answer 30

ADH or not receiving appropriate replacement of isotonic fluids.

Ns for alkalosis or Ringer Lactate for acidotic pts and whose pH is normal.

Question 31

Hypokalemia

Answer 31

Happens when potassium is lost from GI tract or urine and not replaaced.
Speed limit of IV potassium id 10eEq/h.

Question 32

Hyperkalemia

Answer 32

Occurs slowly when kidney cannot excrete, or rapidly if K is being dumped from cells into blood.

Tx: hemodialysis, or can help by pushing potassium into the cells. (50% dextrose and insulin).
Or neutralize its effect with IV calcium (quickest protection).

Question 33

Metabolic Acidosis

Answer 33

Production of acids, loss of buffers, inability for kidney to secrete fixed acids.

If abnormal acids are piling up, anion gap. Serum sodium exceeds more than 10 to 15 the sum of cholirde and bicarbonate.
Administration of bicarbonate would temporarily help correct the pH.

Question 34

Metabolic Alkalosis

Answer 34

Loss of acid gastric juice, or excessive bicarb.

KCL intake to correct

Question 35

Respiratory Acidosis or Alkalosis

Answer 35

Impaired ventilation or abnormal hyperventilation.