Pre-op and Post-op care

Question 1

2 CV contraindications for surgery

besides those, what is the 1 other thing that’s signficiant in Goldman index for assessing operative risk?

Answer 1

EF <35% (increased JVD)
MI within 6 months

arrhythmia

Question 2

what is the single worst finding predicting high cardiac risk? how to treat this if you rlly must operate? (4 meds)

Answer 2

JVP distention

tx: ACEI’s, BB, Digoxin, diuretics

Question 3

if person has smoking or COPD, how do you assess their operative risk?
how do you decrease that risk?

Answer 3

start with FEV1. if abnormal -> blood gases.

need to stop smoking 8 weeks prior to surgery + intensive respiratory therapy

Question 4

the 2 clinical findings and 3 lab values used to predict hepatic risk of operative mortality

what is % mortality if any one of these are positive?

Answer 4

1. ascites
2. encephalopathy
3. bilirubin
4. albumin
5. PT/INR

40% mortality rate if any ONE is abnormal

Question 5

% operative mortality if MI within 3 months?

at 6 months?

Answer 5

40% at 3 months

6% at 6 mo

Question 6

malnutrition is defined as any one of the following: loss of body weight >20% within few months, serum albumin < 3, anergy to skin antigens, or serum transferrin <200 mg/dL. what is tx for this?

Answer 6

oral nutrition if possible (IV if not) 5-10 days. the longer the better.

Question 7

if pt has decreased albumin, what can you measure to determine if it’s nutritional problem vs liver problem?

Answer 7

prealbumin & CRP (other proteins in your body, albumin is a precursor).
if these are low, it’s nutritional problem (overall not enough protein)

if they are normal but albumin is low, it’s a liver problem (liver’s just not making enough albumin but you have enough protein overall in your body)

Question 8

so pt doesnt have any cardiac pulmonary hepatic or nutritional risk factors. WHATS THE OTHER THING YOU NEED TO CHECK THOUGH

Answer 8

blood glucose and blood gases.

anyone with increased blood glucose or in DKA can’t get surgery.

Question 9

malignant hyperthermia can develop after giving _______ or succinylcholine. what is tx? what do you have to watch out for?

Answer 9

IV dantrolene, 100% O2, cooling blankets, correction of acidosis. watch for development of myoglobinuria (f/u with UA)

Question 10

what complication if pt gets fever 30-45 mins (or even a few hours) after surgery?
tx?

Answer 10

bacteremia. you may have punctured bowel, or possibly gas gangrene in surgical wound
tx: get blood culture + start empiric abx

Question 11

pt has fever Post op day 5. what do you look for? what study? tx?

Answer 11

ultrasound legs/doppler studies of deep leg and pelvic veins. concern for DVT (if pt also in respiratory distress look at lungs for PE days 5-7)
tx: heparin bridge to warfarin

Question 12

post op day numbers for wind wind water walking wound wound?

Answer 12

1 wind (atelectasis) 
3 wind (pneumonia)
3 water (UTI)
5 walking (DVT/PE)
7 wound (wound infection)
10-15 wound (deep abscess)

Question 13

specific abx for catheter related UTI (CAUTI)

Answer 13

cepftriaxone

Question 14

take out catheters asap except when?

Answer 14

if they were there before the surgery

Question 15

prophylactic abx for hospital acquired pneumonia? (2)

Answer 15

vancomycin

pip/tazo

Question 16

what study to distinguish if abscess is present or not or if it’s just a wound infection? (post op day 7) tx?

Answer 16

ultrasound. tx is abx if just infection. need to drain too if abscess present (erythematous and BOGGY, plus ultrasound confirm)

note this is different from suspecting deep abscess. (post op fever day 10-15) in which CT would dx. pt probs needs to go back to surgery to drain it. or percutaneous drainage.

Question 17

what drugs are NOAC? (involved in heparin bridge to warfarin)

Answer 17

apixiban, rivaroxaban, apixiban

Question 18

what will you see on EKG when pt is having MI? (in this context, perioperative. within first 2-3 post op days)

what is most reliable dx test? tx?

Answer 18

ST depression
T wave flattening

dx by troponin levels

perioperatively canNOT use clot busters (tPA). must use angioplasty or stent + supportive tx

Question 19

dx and tx of PE

Answer 19

dx: CT angio (spiral CT with IV contrast)
tx: anticoag = heparinization. also need to add vena cava filter if PE recurs or if heparin/anticoag is contraindicated

Question 20

prophylaxis for DVT and PE (3)

Answer 20

1. scheduled heparin or other anticoagulation
2. sequential compression devices
3. WALKING

Question 21

intraoperatively, pt all of a sudden becomes more difficult to bag. BP declines. CVP rises.
what is next step? whats going on?

Answer 21

intraop tension pneumothorax (pt will have had recent lung trauma and/or broken ribs)
tx: decompression through diaphragm if abdomen is open. otherwise needle through chest wall. put in chest tube later.

Question 22

post op patient suddenly gets confused and disoriented. what is your #1 and #2 diff dx and thus what tests?

Answer 22

1. hypoxia. check blood gases and give respiratory support

Question 23

post op day 2-3 gets delirious, hallucinations, combative. what’s going on? (their blood gases and white count are normal) what is treatment?

Answer 23

delirium tremens. alcohol withdrawal.

tx: benzodiazepines. or IV alcohol (5% alcohol in 5% dextrose) or just oral alcohol

Question 24

giving IVF D5W to a postop or trauma patient. suddenly they get confusion, convulsions. maybe even fall into a coma. next step?

Answer 24

check electrolytes, may have hyponatremia bc you didn’t have Na in the IVF. give some hypertonic saline, +/-osmotic diuretics

Question 25

patient had hx of cirrhosis -> bleeding esophageal varices -> you do portocaval shunt to fix it -> pt goes into coma afterwards. what is happeninggg and what next

Answer 25

ammonium intoxication. it’s a thing.

give sodium glutamate

Question 26

treatment for post op ARDS

Answer 26

PEEP. or ECMO

Question 27

post op urinary retention treatment? (pt feels need to void but they can’t)

Answer 27

1. in and out catheter after 6 hours of not voiding
2. place Foley after 2nd time you have to put in in and out catheter
3. if absolutely no output, look for kink in catheter (true anuria post op is rare)

Question 28

pt has post op low urine output and doesn’t even feel need to void (so it’s not retention). what is next step?

Answer 28

do 500cc bolus challenge to differentiate between dehydration or renal failure. if problem is dehydration, urine output will at least slightly increase with the bolus. if it doesn’t increase = renal failure

alternatively you can do UA and look at urinary sodium. dehydrated pt UNa < 10-20. kidney failure UNa > 40

Question 29

pt has post op low urine output and doesn’t even feel need to void (so it’s not retention). you do UA and urinary sodium is < 10. what is problem, dehydration or renal failure?

Answer 29

dehydration (if renal failure, UNa >40)

Question 30

what electrolyte abnormality is a common cause of ileus?

Answer 30

hypokalemia

Question 31

what image do you order for abdominal distention that would show bowel obstruction or ileus or ogilvie syndrome (like ileus of colon)?

Answer 31

upright and flat KUB xray

Question 32

air fluid levels seen on KUB on a post op patient with abdominal distention. what study would you order next to confirm dx of bowel obstruction?

Answer 32

contrast swallow CT. it will find the transition point.

Question 33

who is at risk for ogilvie syndrome (paralytic ileus of the colon)? so you see dilated colon on flat and upright KUB. what is next step?

Answer 33

elderly sedentary patients who are then immobilized after surgery (so not necessarily abdominal surgery, it’s any surgery).

next step is colonoscopy, both to to rule out cancer and decompress the abdomen (tx). also leave a rectal tube in place

Question 34

what is treatment for wound dehiscence (dressings are soaked in salmon color fluid = peritoneal fluid. = fascia has failed)
what complications are you trying to avoid?

Answer 34

bind and bandage. elective surgery to repair. ELECTIVE. to prevent evisceration or later on ventral hernia

Question 35

post op patient coughs and bowel pops out of their incision. what is next step?

Answer 35

this is evisceration.

cover the bowel with warm saline dressings (WET) and GO TO OR EMERGENTLY. do NOT push bowel back in.

Question 36

if pt gets a post op fistula, you need to remove the fistula or put in suction + stoma and let nature/time heal it. however, you need to be aware of the things that could prevent the fistula from healing, which are? (FETID)

Answer 36

Foreign body
Epithelialization
Tumor
Infection, irradiated tissue, IBD
Distal obstruction

Question 37

when restoring volume with IV fluids, how to choose between NS or ringer lactate?

Answer 37

determine by acid base status.
NS for alkalosis
Ringer lactate for normal pH or acidotic

Question 38

hyperkalemia can occur rapidly if it’s being dumped from cells into blood (crushing injuries, dead tissue, acidosis). ultimate tx is dialysis, but what 3 things can we do to push K+ back into cells in the meantime? which one is fastest?

Answer 38

1 fastest is IV calcium which neutralizes K+ effect on cell membranes

2. 50% dextrose + insuline
3. NG suction and exchange resins (sucks K+ out of GI tract)