Pre-Op/Post-Op

Question 1

Ejection fraction

Answer 1

Normal 55%, under 35% = cardia risk in noncardio operations. Pero-op MI risk then 75085%, mortality between 55-90%

Question 2

Goldman’s index of cardia risk

Answer 2

11 pts for JVP, 10 for recent MI (in 6 mo), 7 for PMVC (5 or more/min) or non-sinus rhythm, 5 for >70 y/o, 4 for emergency surgery, 3 for aortic vasc stenosis, poor med condition, or surg within chest/abdoemn.
Total score 5 = 1% cardiac compication risk, 5% if 12 pts, and 11% if 25, and 22% if pts>25

Question 3

Jug venous distension

Answer 3

Indicates CHF. Worst singel finding for high cardiac risk. Tx w/ ACE-I, beta block, digitalis and diuretics pre-surgery

Question 4

Recent transmural or subedno MI

Answer 4

next worst predictor. Mort = 40% within 3 mo, but down to 6% after 6 mo. Defer surgery if possible, otherwise admit to ICU

Question 5

Severe progressive angina

Answer 5

means eval for coronary revasc before another operation

Question 6

Smoking

Answer 6

Increased pulm risk, compromised vent (high Pco2 and low FEV1). Presence of COPD or smoking hx? Eval! Look at FEV1, then blood gasses. Stop smoking for 8 weeks + intensive resp therapy before surgery

Question 7

Hepatic predictors

Answer 7

40% mortality if bili above 2 OR albumin below 3 OR PTT above 16 or encephalopathy
80-85% risk if three are present, or bili>4, alb <2, or blood ammonia at 150 or more

Question 8

Severe nutritional depletion

Answer 8

Loss of 20% body weight over few months, serum albumin below 3, anergy to skin antigens, or serum transfer level < 200. High operative risk, but 4-5 days preo-op nutrition via gut, and 7-10 days optimal!

Question 9

Diabetic coma

Answer 9

Absolute contraindication to surgery. Rehydration, return of urine, and partial acidosis/hyperglycemia correction first! Or treat sepsis first

Question 10

Malignant hyperthermia

Answer 10

Shortly after anesthetic (halothane or succinycholine), fever > 104! Yeek! Met acidosis + hypercalcemia too! Family hx? Tx = IV dantrolene, 100% o2, correct acidosis, cooling blankets. Watch for myglobinuria

Question 11

Bacteremia

Answer 11

Within 30-45 min of invasive procedures (UT instrumentation classic). Chills, temp spike to 104. Do blood cultures X3, start empiric abx

Question 12

PO fever (101-103)

Answer 12

Caused by (sequentially) atelectasis, pneumonia, UTI, DVT, wound infection, or deep abscesses

Question 13

Atelectasis

Answer 13

most common cause of post=op fever on PO day 1. Listen to lungs, CXR, improve ventilation. Bronchoscopy IF needed

Question 14

Pneumonia

Answer 14

in 3 days if atelectasis not resolved. Fever persists. CXR shows infiltrates. Do sputum culture, tx w/ appropriate abx

Question 15

UTI

Answer 15

On PO day 3. Do UA, cultures, tx w/ ab

Question 16

Deep thrombophlebitis

Answer 16

PO day 5, doppler of deep leg/pelvic eins for Dx (p/e is worthless). Anticoag w/ heparin

Question 17

Wound infection

Answer 17

PO day 7, p/e w/ warmth, red, tender. Tx w/ ab for cellultiis, open/drain if abscess. Sonogram to dx

Question 18

Deep abscess

Answer 18

Subphrenic, pelvic, subhepatic- fever po days 10-15. CT scan body cavity, percutaneous radiologically guided drainage therapeutic

Question 19

Periop MI

Answer 19

During operation (from hypotension), caught on EKG. When post-op, in PO day 2-3. 1/3 are chst pain, dx = troponin. Mort of 50-90% yeek! Tx the complications, can’t use clot busters post op

Question 20

Pulm Embo

Answer 20

PO day 7 in oldies or immobilized. Pleuritic pain, sudden, w/ SOB. Pt = anxious, sweaty, tachy, prom distented neck veins/ forehead. Low CVP = excludes dx! ABG show hypoxemia and hypocapnia. Gold standard = pulm angiogram, but real standard = spiral CT w/ iv contrast (CT angio!). Dx, then tx w/ heparinization, or IVC filter if recurrent

Question 21

Aspiration

Answer 21

Awake intubation w/ fully fed combative pts. Lethal immediately, or chem injury in tracheo/bronch tree => pulm failure or 2ndary pneumonia. Prev w/ NPO/antacids before induction. Tx = lavage + remove acid + stuff w/ bronchoscope, then bronchodilators and resp support. No steroids :(

Question 22

Intraop tension pneumo

Answer 22

Pts w/ weak/trauma lungs (chronic TB or trauma), with pos pressure breathing, the get harder to bag. BP down, CVP up. If abdomen open, decompress thru diaphragm, otherwise, put in needle to pleural space. Chest tube lata

Question 23

Hypoxia

Answer 23

First choice if confused/disoriented patient, maybe 2ndary to sepsis. Check abg, give resp support

Question 24

ARDS

Answer 24

Complicated post-op, sepsis as precipitating event. Bilat pulm infiltrate, hypoxia, but NO CHF. Give PEEP, but not excessive volume (too much means barotrauma). Find the source of sepsis!

Question 25

Delirium Tremens

Answer 25

Alcoholic whose drinking is stopped by surgery. PO 2 or 3, get confused, hallucinations, combative. IV benzos = tx, or IV alcohol at some places

Question 26

Hyponatremia

Answer 26

If you give too much D5W or other fluid to post-op pt w/ high ADH => confusion, convulsions, coma and death. Chart review shows large fluid intake, quick weight gain, super fast Na down. Prevent it by putting soidum in fluid. Therapy controversial, mortality high…give hypertonic saline (5% in 100 ml or 500 ml of 3%), add diuretics

Question 27

Hypernatremia

Answer 27

Confusion, lethargy, coma…induced by large unreplaced water loss. Damage to post pit => diabetes insipidus, or unrecog osmotic diuresis. Chart review shows large, unreplaced UO, weight loss, rapid rising Na conc. Do rapid fluid replacementbut cushion w/ D51/2 or D51/3 instead of D5W

Question 28

Ammonium intoxication

Answer 28

Coma in cirrhotic patient w/ bleeding esophageal varices who gets portocaval shunt

Question 29

Postop Urinary Retention

Answer 29

Common post abdomen, pelvis, perineum, or groin surgery. Patient wants to pee but can’t. In/out bladder cath done at 6 hours post op if no pee. Foley if you have to do 2-3 caths

Question 30

Zero UO

Answer 30

Mechanical problem (not biologic). Look for plugged/kinked catheter

Question 31

Low UO (less than .5ml/kg/h)

Answer 31

If pressure normal, rep either fluid def or acute renal fail, low-tech dx test = fluid challenge. Give 500 ml IV…dehydrated patient will pee more, renal fail won’t. Or measure Na in urine 40 in renal fail. Or do FeNa- renal failure if >1

Question 32

Paralytic ileus

Answer 32

First few days post op. Bowel sounds absent, no farts. Mild distension, but no pain. Prolonged by hypokalemia

Question 33

Early mechanical bowel obstruction

Answer 33

Adhesions during post-op period. Assumed to be paralytic ileus, but then doesn’t resolve after a week. Xray shows dilated loops of small bowel + air-fluid levels. Dx w/ CT scan showing proximal dilation + distal collapsed. Do surgical intervention

Question 34

Ogilvie syndrome

Answer 34

Paralytic colon ileus in old immobile people (mayb hip surgery). Large tense nontender abdomen, xray showing huge colon. Colonscopy to suck out gas, decompress, and rule out mechanical cause. Leave in long rectal tube…if cecum is gonna blow up, do a cecostomy/colostomy

Question 35

Wound dehiscence

Answer 35

Day 5 post ex-lap. Intact wound, looks pink, slamon-colored fluid soaking dressings (peritoneal fluid!) Tape wound securely, bind abdomen, and don’t move or cough. Gotta re-op to avoid ventral hernia, but not emergency

Question 36

Evisceration

Answer 36

Catostrophic complication, if patient couhgs strains or gets outta bed. Cover bowels sterily and do emergency abdominal closure

Question 37

Wound infections

Answer 37

Seen at Post op day 7

Question 38

Fistulas of GI tract

Answer 38

Bowel contents leak out through wound or drain site. Could leak into a cesspool, then sepsis. if drain freely (afebrile, no periotnitis), then its- fluid/electrolyte loss, nutritional depletion, or erosion/digestion of belly. Dep on location/volume of fistula. Nonexistent in distal colon, present/manageable in low-volume high GI fistulas, and daunting in high-volume fistulas in GI tract.Tx = fluid/electrolyte, nutritional support (elemental diet delivered beyond fistula), compulsive ab wall protection (suction, ostomy bag). Nature heals fistula, if no foreign body, radiation, infection, epithelization, neoplasm, distal obstruction (FRIEND)

Question 39

Hypernatremia

Answer 39

Patient has lost water, is hypertonic. Every 3 meq/L above 140 means 1L water lost. Slowly? then brain can adapt. tx = volume repletion, but correct volume fast while just nudging tonicity. Use D51/2S (not D5W). Fast development? (DI or osmotic diuresis), you get CNS symptoms, correct with more diluted solution…D51/3W and D5W

Question 40

Hyponatremia

Answer 40

Water has been retained. Two options 1- Normal fluid volume then retains water b/c of extra ADH. 2- patient losing isotonic fluids from GI tract forced to retain h20 if not adequately replaced. Rapid hyponat has CNS symptoms, requires careful hypertonic saline use. In slow hyponat, brain adapted, so just do water restriction. If hypovolemic dehydrated pt, do volume retoration w/ isotonic fluid

Question 41

Hypokalemia

Answer 41

Slowly develops, when K lost from GI tract or in urine and not replaced. Rapidly develops when K igoes into cells, if DKA corrected. Tx with potassium, follow IV speed limit of 10 mEq/h

Question 42

Hyperkalemia

Answer 42

Slowly if kidney can’t excrete potassium, rapidly if potassium dumped out of cells (crush, dead tissue, acidosis). Tx = hemodialysis, or wait it out by doing 50% dextrose and insulin + NG suction/exchange resin and neutralize with IV calcium (quickest heart protection)

Question 43

Metabolic acidosis

Answer 43

From excessive acid production (DKA, lactic acidosis, low-flow state), or loss of buffers(from GI), or from inability of kidney to eliminate fixed acids. Low blood pH, low bicarb, based deficit. If abornal acids pile up, anion gap (Na > Cl + bicarb by 10-15 or more), but not if loss of buffers. Tx underlying cause, could administer bicarb temporarily, but only if initial problem is bicarb loss, otherwise could make a rebound alkalosis. If long-standing acidosis, renal loss of K obvious after acidosis corrected

Question 44

Metabolic alkalosis

Answer 44

Loss of acid gastric juice or from excessive admin of bicarb. High pH, high bicarb, base excess. Tx = abundant KCL (5-10 mEq/h), allow kidney to correct. Rarely, use ammonium Cl or .1N HCl

Question 45

Resp acidosis/alkalosis

Answer 45

From impaired vent (acidosis) or hypervent (alkalosis). recog by abnormal Pco2 (low in alk, high in acid), + abnormal blood pH. Treat logically