Pre Peri and Postop Care Flashcards
Prophylactic Abx:
- when are these administered?
- MC abx given
- which Abx are good for gram negative anaerobic pathogens?
When: administered 60 min before incision
MC abx is Cefazolin (Ancef)
Gram negative, anaerobic: cefotetan, cefoxitin, ceftizoxime
*Each of these with or w/o metronidazole.
What is the MC preventable cause of death peri-post operatively?
What is the Caprini score used for?
Pulmonary embolism.
Caprini used in assessment of Thromboembolic dz, based upon scoring it places you in either very low, low, moderate, or high risk.
how do we prevent thromboembolic events in: -very low -low risk -moderate -high -very high patients?
Very Low: early and frequent ambulation
Low: mechanical methods (teds, compression stockings, foot pumps)
Moderate & high: pharmacological
Very high: pharmacological and mechanical
Which medications are commonly used in thromboembolic dz prophylaxis?
T/F, IVC filter can be used in thromboembolic dz prophylaxis?
LMW heparin preferred in high risk pts
Low dose UFH
Warfarin
Aspirin
True. Only used with absolute CI to anticoagulation or failure to adequate anticoagulation.
Definition of Surgical site infection.
Risk factors of surgical site infection?
Presentation of surgical site infection?
SSI: an infection related to an operation that occurs at or near the surgical incision within 30days of the procedure or within 90 if an implant is used.
RIsk factors:
- surgical technique
- prolonged surgery time
- instrument sterilization
- preop prep
- thermoregulation/glycemic control
- Medical condition of pt
- surgical environment (traffic, cautery, prosthesis, blood transfusion)
Presentation:
- localized erythema
- induration
- warmth
- pain
Surgical site infection Tx
Tx: prophylactic abx
- debride infected wounds & give abx
- Abx usually - clindamycin, vancomycin, ampicillin
Wound complications: Hematoma/Seroma
- what is this?
- consequences
- presentation
- tx
- prevention
What: collection of blood or serum under the incision
Consequences: wound separation and infection
Presentation:
-pain and swelling a few days after surgery
Tx:
- percutaneous drains
- wound exploration (packed and healed by secondary intention)
Prevention:
- closure of dead space
- meticulous hemostasis
Wound Complications: Fascial Dehiscence -what is this? -complication -risk factors -cause -presentation -tx -prevention
What: abdominal wall tension overcoming tissue or suture strength THIS IS AN EMERGENCY
Complication: incisional hernia
Risk factors:
- age
- males
- COPD (coughing)
- ascities
Cause:
failure to remain anchored, knot failure, or large stitch intervals.
Presentation:
- profuse serosanguinous drainage
- popping sensation with abd buldge
Tx: closure in the OR.
Prevention: internal or external retention sutures.
What is primary intention wound healing?
Secondary intention?
Primary Intention: wound closed with stitches or staples and covering it with sterile dressing.
Secondary intention: epidermis and dermis not closed. Packed daily to every other day w/ saline moistened gause and covered with a sterile dressing.
Pulmonary complications of surgery?
- Hypoventilation
- Pneumonia (infection)
- Atelectasis
- Prolonged mechanical ventilation & resp failure
- Exacerbation of underlying chronic lung dz
- Bronchospasm
Who is high risk for pulmonary complications after surgery?
Procedure-related risk factors associated with Pulmonary complications?
- Greater than 50YO
- COPD
- Asthma
- Smoking greater than 20 pack year hx
- general health status:
- -CHF increases risk
- -URI- best to postpone elective surgery until resolved.
Risk facotrs:
- surgical site: abdominal and thoracic
- duration of surgery: greater than 3-4hrs
- Type of anesthesia: general
- Type of neuromuscular blockade: using long acting agent
Post-op Fever:
- considered fever at what temp?
- cause
- -what are the 5Ws?
- -how many days post op can you expect each of the Ws?
Fever greater than 38C in the 1st few days after major surgery
Cause: most are caused by inflammatory stimulus of surgery and resolves spontaneously
5W:
- wind (d1-2) (pna, aspiration)
- water (d3-5) (urinary tract, indwelling catheter)
- walking (d4-6) (venous thrombosis, PE)
- wound (d5-7) (site infections)
- wonder drugs (d7+) (drug fever, infection related to IV lines)
What are some medications that cause fever?
Antimicrobials: PCN, Cephalosporins, FQ…all of them.
CV meds:
- Thiazide
- Lasix
- Hydralazine
Anticonvulsants:
-Phenytoin
Other:
- UFH
- salicylates
- NSAIDS
Treatment of post-op fever?
Remove unnecessary tx including medications and catheters
Suppress fever with tylenol
Abx per clinical judgement
Malignant Hyperthermia:
- what is this?
- cause
- signs of hypermetabolism
What: an uncommon and sometimes life-threatening rxn to some anesthetic agents
Cause:
- deploarizing muscle relaxants (Anectine)
- gases in anesthetic machine (halothane, isoflurane, enflurane, desflurane, sevoflurane)
Signs:
- hypercarbia (most sensitive indicator of potential MH in the OR)
- skeletal muscle rigidity (most specific sign)
- tachycardia
- tachypnea
- high temperature (usually late sign)
- hypertension
- cardiac dysrrhthmias
- acidosis
- hypoxemia
- hyperkalemia
- myoglobinuria
Malignant HTN:
- pathophys
- what is the most dangerous triggering agent?
- tx
Pathophys:
- genetic predisposition
- increased intracellular calcium
- continuous muscle contraction
Succinylcholine is the most dangerous.
Tx:
- call for help
- Stop triggering agents
- hyperventilate pt with 100% O2
- Finish or abort procedure
- Administer dantrolene (muscle relaxer)
- Cool patient
- Monitor and treat acidosis
- Promote urine output (lasix, mannitol)
- Treat hyperkalemia (Insulin + D50W)
- Treat dysrhythmias with procainamide and calcium chloride
- Monitor creatinine kinase, urine myoglobin, and coagulation for 24-48hrs
Surgical Care Improvement Project (SCIP)::
-goal
goal: reduce preventable surgical morbidity and mortality
What are the SCIP measures:
- 1
- 2
- 3
- 4
- 6
- CARD-2
- VTE-2
- 9
- 10
1: pre-op abx given within 1hr before incision
2: must recieve SCIP recommended prophylactic abx (ancef or possibly vanco if gut)
3: d/c abx within 24hrs of anesthesia end time
4: Controlled 6am postoperative serum glucose (Cardiac only)
6: appropriate hair removal (Clipping)
CARD 2: perioperative beta blocker therapy for pre B blocker Rx
VTE2: VTE prophylaxis within 24hrs prior to or after anesthesia end time.
9: remove urinary catheter by postop day 2
10: temperature greater than 96.8 (36C) 15 minutes after anesthesia end time.
