Pre-Op and Post-Op Care Flashcards
Pulmonary Risk
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.
Pre-Op: Hepatic Risk
Operative Mortality:
- Encephalopathy, ascites, serum albumin, prothrombin time (INR) and bilirubin.
- Mortality risk based on Child Risk.
Pre-Op: Nutritional Risk
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
Pre-Op: Metabolic Risk
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.
Post Op: Malignant Hyperthermia
Malignant Hyperthermia: Halothane or succinylcholine. >104 degrees, metabolic acidosis, hypercalcemia.
- Tx: IV dantrolene, 100% oxygen, correction of acidosis, and cooling blankets.
Post Op: Bacteremia
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.
PO in 101-103F Causes
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.
Perioperative Myocardial Infarction
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.
Pulmonary Embolism
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.
Aspiration
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
Intraoperative Tension Pneumothorax
Traumatized lungs once subjected to positive pressure breathing.
Decompression through diaphragm. If not needle, followed by chest tube.
PO Pt is Confused and Disoriented
Hypoxia- check blood gases and provide respiratory support.
ARDS- Adult Respiratory Distress Syndrome
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.
Delirium Tremens
Drinking is interrupted by surgery. Confused, hallucinations, combative.
IV benzodiazepines, or intravenous alcohol (5% in 5% dextrose).
Hyponatremia
Quickly induced by liberal administration of sodium free IV fluids with high levels of ADH (triggered by the response to trauma). Central Pontine Myelinolysis.
PreOperative Assessment- Cardiac Risk
Ejection Fraction-
Hypernatremia
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.
Ammonium Intoxication
Common source of coma in cirrhotic patient with bleeding esophageal varices who undergoes portocaval shunt.
Postoperative Urinary Retention
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.
Zero Urinary Output
Typically mechanical; look for plugged or kinked catheter.
Low Urinary Output
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)
Paralytic Ileus
Bowel sounds absent, no passage of gas, mild distention, no pain.
Will be prolonged by hypokalemia.
Early mechanical bowel obstruction
Adhesions can happen during the PO period. Paralytic ileus will resolve 5, 6, 7 days. If not, obstruction.
Surgical Intervention
Ogilvie Syndrome
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.
