Pre-Op Evaluation & Sepsis

Question 1

Worst finding in Pre-Op Evaluation

Answer 1

JVD

Treat 1st w/ ACE-i, Diuretics, or Beta blockers

Question 2

Pt with recent ho MI, when is pt allowed to have surgery?

Answer 2

After 6 weeks since MI has elpased

Question 3

At what EF fraction is surgery contraindicated in?

Answer 3

EF <35% (normal EF is 55%)

↑ for post-op MI

Question 4

How many weeks before surgery should a pt quit smoking?

Answer 4

8 weeks (2 months)
with intensive respiratory pre-therapy 

Smoking compromises VENTILATION (High PCO2)
Evaluate FEV1 → ABGs

Question 5

What is an absolute contraindication to surgery unless a patient is septic?

Answer 5

Diabetic coma/ DKA

Pt must have normal:
Hydration & UOP
Partially corrected Acidosis & HYPERGLYCEMIA

Question 6

If possible how many days of nutrition should a patient be optimized with before surgery?

Answer 6

4-5d enterally, if possible

b/c villi blunting allows bacterial translocation → bacteremia.

Also low nutrition = poor wound healing

Question 7

List 4 forms of enteral nutrition

Answer 7

Nasogastric tube (NGT)
Nasoduodenal tube (Dobhoff)
Nasojejunal tube (NJT)
Percutaneous endoscopic gastrostomy tubes (PEG tube)

Question 8

List 3 routes of parenteral nutrition?

feeding nutrition intravenously

Answer 8

Feeding through central veins (subclavian & IJ)

Feeding through peripheral veins

Question 9

2 clinical findings and 3 lab findings used to predict operative mortality in patients with liver disease:

Encephalopathy & Ascites
Albumin & (2 more labs)

Answer 9

PT/INR

Bilirubin

Question 10

What is sepsis?

Answer 10

A body’s overactive immunologic response to an infection.

Question 11

What work up should be done if sepsis is suspected?

Initial labs (2)

Answer 11

Elevated lactate

2 sets of blood cultures

Question 12

What are the first steps in management of sepsis?

Answer 12

1. Initial fluid resuscitation (IVFs) → if, persistently hypotensive start Vasopressors (hemodynamic support)
2. Empiric broad-spectrum antibiotics

Question 13

What are the first steps in management of sepsis?

2-3

Answer 13

1. Initial fluid resuscitation (IVFs) → if, persistently hypotensive start Vasopressors (hemodynamic support)
2. Empiric broad-spectrum antibiotics

Question 14

Clinical features of Sepsis:

3 broad categories

Answer 14

1. Vitals →
   Fever, Tachycardia, Tachypnea
   +/- Hypotension; MAP < 65
2. Features of organ dysfunction →
   - Altered mental status (CNS)
   - ↑ Cr & BUN (Kidney failure)
   - ARDS (Respiratory failure)
   - ↑ Bleeding/clotting (Liver failure)
   - ↑ LFTs (Liver failure)
3. Features of infection

Question 15

Systemic inflammatory response syndrome
(SIRS)
Requires 2 or more of the following 4 criteria:

Reflects the systemic response to an infection or inflammatory process.

Answer 15

1) Temperature:
> 38ºC (100.4ºF)
< 36ºC (96.8ºF)

2) HR:
90+ bpm

3) RR:
> 20 breaths/min
PaCO2 < 32

4) WBC:
> 12k
< 4k
> 10% bands

Question 16

Severe Sepsis Criteria
Organ Dysfunction, Hypotension, or Hypoperfusion
(2)

Answer 16

↑ Lactate

SBP <90

Question 17

Septic Shock is defined as sepsis + hypotension (aka severe sepsis) despite ____

Answer 17

adequate fluid resuscitation

Question 18

qSOFA is used to identify patients with potential sepsis.

Consider positive if 2 or more of the following 3 are present:

Answer 18

Alteration in mental status

SBP ≤ 100

RR ≥ 22/min

Question 19

Hour-1 bundle for sepsis management:

4

Answer 19

Lactate
2 blood cultures
IVFs
Vasopressors: Levophed (NorEpi) or Vasopressin 
Antibiotics

Question 20

All surgeries (except for cataracts) require ____ as part of pre-op evaluation.

If it is concerning what exam is done next?

Answer 20

ECG

If concerning → stress test (exercise/dobutamine)

If concerning → echo

If concerning→ cath

If concerning→ stent (for stable angina)

Question 21

Most common cause of sepsis?

___ s/t ___

Answer 21

Pneumonia

Gram-positive bacteria
Strep pneumo, Staph A, etc.